LAS VEGAS — Assessing pain in older adults — particularly older adults with a cognitive impairment — can be a challenge, but it is a surmountable challenge, according to Keela Herr, PhD, RN, who spoke on this topic at a session this week.
Dr. Herr, who is a professor and co-director of the Iowa Hartford Center of Geriatric Nursing Excellence at The University of Iowa, explained that assessing pain in older adults can be challenging for two reasons: patients may be reluctant to report their pain, and clinicians may assume that those older adults with cognitive impairment are unable to adequately report their pain. The key to getting over these challenges, she said, is “don’t assume anything.”
Dr. Herr urged clinicians to question all adults about the presence of pain, instructing them to use words like “ache,” “hurt,” and “discomfort” if the patient responds negatively to a question if they have “pain.” A comprehensive assessment should then follow that gathers information to understand the cause of pain and establish an appropriate plan for treatment.
“Some patients with cognitive impairment may be able to self-report with appropriate instruction and time,” she said, noting two studies that demonstrated how some patients with mild cognitive impairment can respond and report their pain using pain scales.1-2
Behavioral pain tools have been developed and validated in the last decade, according to Dr. Herr, and can be used with those patients who have moderate to severe dementia and who may be unable to verbally report their pain.
“Although there is no one tool that can be recommended across all settings and populations, valid and reliable tools exist that can help raise awareness of potential pain in those most vulnerable,” Dr. Herr said.
Clinicians also have a number of clinical practice guidelines as resources when treating older patients.
There are numerous consensus recommendations that provide tools to help clinicians identify and evaluate the possibility of pain in people with dementia who are unable to communicate the cause of their suffering.3 One of the key challenges to improving pain care in older adults, including those with dementia, is the consistent implementation of these existing recommendations, Dr. Herr explained.
She noted that when evaluating pain indicators, it is important for clinicians to ensure that basic comfort needs are being met, to determine the presence of treatable etiologies, to employ and recommend nonpharmacologic comfort strategies, and, where necessary, to recommend analgesics.
Concluding her session, Dr. Herr noted that there are several areas of research on assessing pain in older patients that need to be further explored, including determining the best tools across cultures; determining tool sensitivity in response to treatment; and finding a way to interpret nonverbal pain scores using newer digital techniques.
1. Ferrell BA, Ferrell BR, Rivera L, et al. Pain in cognitively impaired nursing home patients. J Pain Symptom Manag. 1995;10(8):591-598.
2. Feldt K, Ryden M, Miles S. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip fracture. J Amer Geriatr Soc. 1998;46:1079-1085.
3. Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: Position statement with clinical practice recommendations. Pain Manag Nurs. 2011;12(4):230-250.