Assessment of Pain in the Nonverbal or Cognitively Impaired Older Adult

https://doi.org/10.1016/j.cger.2007.12.001Get rights and content

The inability of nonverbal older adults to communicate pain represents a major barrier to pain assessment and treatment. This article focuses on nonverbal older adult populations with dementia, delirium, and severe critical illness. A comprehensive approach to pain assessment is advocated encompassing multiple sources of information. Selected behavioral tools for nonverbal pain assessment are critiqued. Although there are tools with promise, there is currently no standardized behavioral tool that may be recommended for broad adoption in clinical practice and continued concerted effort to this end is needed.

Section snippets

Challenge of dementia for pain assessment

Dementia is one of the most frequent causes of cognitive impairment in older adults with a forecast worldwide increase in incidence from 25 million in 2000 to 114 million by 2050 [4]. Dementia involves the development of multiple cognitive deficits manifested by impaired memory and involving cognitive disturbances, loss of language, ability to recognize or identify objects, and executive function [5]. As dementia progresses to advanced stages individuals become increasingly dependent in all

Challenge of delirium for pain assessment

Delirium is a form of transient cognitive impairment often accompanied by loss of ability to communicate effectively. The incidence of delirium in older adults ranges from 16% to 62% with hip fracture [24], 62% in the ICU [25], 25% to 45% in older cancer patients [26], and approximately 22% in nursing home residents [27].

Delirium is characterized by recent onset of fluctuating awareness and inability to focus attention, change in cognition (eg, memory deficit, disorientation), or perceptual

Challenge of severe critical illness for pain assessment

Older adults have increased prevalence of comorbid illness and trauma and account for more than 60% of all ICU days [40]. During episodes of severe critical illness older people may lose the ability to speak because of unconscious state, presence of an endotracheal tube, or fatigue.

Many older adults die in the ICU [41]. Patients able to report the ICU experience in retrospect have indicated that endotracheal intubation, mechanical ventilation, and consequent inability to speak are extremely

Approaches to pain assessment in nonverbal older adults

Assessment of pain is a critical component of a comprehensive approach to pain management in all populations. The purpose of pain assessment is to detect the presence and source of pain, identify any comorbidities requiring attention, determine the effect of pain on function, and collect data on which to base individual treatment plans [6]. Achievement of these goals is challenging in nonverbal older adults. Nevertheless, general principles can guide approaches to pain identification,

Behavioral pain assessment tools for use with older adults

During the past 10 years, a number of standardized tools for pain assessment based on observation of behaviors have been developed for use with nonverbal older adult populations. Several reviews of available tools [53], [69], [70], [71], [72] have indicated that although there are tools with potential, there is currently no tool that has sufficiently strong reliability and validity to support recommendation for broad adoption in clinical practice. Moreover, reviews have called for further tool

Summary

Pain is an important health problem for nonverbal older adults with dementia, delirium, and during episodes of severe critical illness requiring appropriate strategies for these vulnerable populations. A comprehensive approach to assessment is advocated including multiple sources of information to ensure a valid and reliable basis on which to make treatment decisions. Behavioral observation and surrogate report are essential components of a multifaceted approach to assessment that may include

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