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Assessing Pain in Persons with Impaired Cognition and Communication. Michael Craine, Ph.D. Eastern Colorado Health Care System. Polytrauma. Two or more injuries to physical regions or organ systems, one of which may be life threatening. Results in Physical, Cognitive, Psychological,

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assessing pain in persons with impaired cognition and communication

Assessing Pain in Persons with Impaired Cognition and Communication

Michael Craine, Ph.D.

Eastern Colorado Health Care System

  • Two or more injuries to physical regions or organ systems, one of which may be life threatening.
  • Results in Physical,
  • Cognitive,
  • Psychological,
  • or Psychosocial Impairments
  • and Functional DisabilityVHA HANDBOOK 1172.1, 2005
  • Traumatic Brain Injury frequently occurs in polytrauma in combination with:
  • Amputation,
  • Auditory impairments,
  • Visual impairments,
  • Spinal Cord Injury,
  • Posttraumatic Stress Disorder and other mental health conditions VHA HANDBOOK 1172.1, 2005
  • Injuries often caused by an explosive blast
  • Primary blast injury– concussive overpressure to gas-containing organ systems: injury to lung, bowel, and inner ear, amputation
  • Secondary blast injury – penetrating fragments and other missiles can cause head and soft tissue trauma
  • Tertiary blast injury - displacement of the whole body by combined pressure loads (shock wave and dynamic overpressure)
  • Miscellaneous blast injuries - burns, crush, soft tissue, fractures, and amputations VHA HANDBOOK 1172.1, 2005
polytrauma brain injury
Polytrauma Brain Injury
  • 60% or more of polytrauma survivors have some degree of brain injury VHA HANDBOOK 1172.1, 2005
  • Brain injury is the most frequent problem treated at Polytrauma Rehabilitation Centers
  • Injury to the brain primarily guides the course of rehabilitation
polytrauma brain injury7
Polytrauma Brain Injury

polytrauma brain injury8
Polytrauma Brain Injury
  • Brain Injury Symptoms include:
    • Attention and Concentration Deficit
    • Memory Problems
    • Problems with New Learning
    • Problems in Higher Order Reasoning
    • Impaired Problem-solving
    • Reduced Cognitive Flexibility
polytrauma and pain
Polytrauma and Pain
  • Pain is a multidimensional phenomenon
  • Unpleasant sensory experience
  • Emotional suffering
  • Commonly associated with disability and emotional distress
  • Pain is always subjective
polytrauma pain assessment
Polytrauma Pain Assessment
  • Effective pain management requires a comprehensive assessment
  • Particular challenges are associated with assessment and management of pain in the cognitively-impaired veteran, and with efforts to balance optimal pain management with rehabilitation goals VHA HANDBOOK 1172.1, 2005
polytrauma pain assessment11
Polytrauma Pain Assessment
  • Problems with attention, comprehension and memory can affect patient report
  • Neuropsychological and Speech/Language testing can be helpful to define patient’s abilities to provide self-report and the best way of obtaining patient report
  • Testing can identify specific deficits to consider when assessing pain
cognitive impairment and pain
Cognitive Impairment and Pain
  • The inability to communicate well does not mean that a person is not experiencing pain
  • Patients with difficulty in communication due to cognitive impairment can suffer pain and need to be assessed
  • Caregivers have difficulty knowing when these patients are in pain and when they are experiencing pain relief
cognitive impairment and pain13
Cognitive Impairment and Pain
  • Impaired patient is vulnerable to under-treatment and over-treatment
  • Severe cognitive impairment is often associated with fewer complaints (Parmalee, 1996)
  • Failure to report does not mean absence of pain
assessment guidelines
Assessment Guidelines
  • Assessing Pain in the Patient with Impaired Communication: A Consensus Statement from the VHA National Pain Management Strategy Coordinating Committee
  • VHA Pain Management Webpage

assessment guidelines15
Assessment Guidelines
  • Pain Assessment in the Non-verbal Patient: Position Statement with Clinical Practice Recommendations
  • American Society for Pain Management Nursing

assessment guidelines16
Assessment Guidelines
  • Assessment guidelines are based on studies in the elderly, children and persons who are intubated or unconscious
  • Younger adults with brain injuries and related pain assessment challenges have not been studied
  • Prevalence of pain after traumatic brain injury has been estimated at 44% or more (Martelli et al, 2004; Sherman, et al, 2006)
recommendations for assessment
Recommendations for Assessment
  • Assess using multiple assessment strategies to identify presence and intensity of pain
  • Patient’s report of pain
  • Reports of patient’s pain by surrogates, caregivers
  • Patient’s behaviors
  • Physiological parameters – most useful in acute pain
  • Empirical analgesic trials
patient s report of pain
Patient’s Report of Pain
  • Pain is a subjective experience
  • Best source of pain presence and pain intensity is patient report
  • But remember lack of report does not mean lack of pain
  • Even persons with mild to moderate impairment can often learn to use self-report methods(Chibnall, 2001; Ware et al, 2006)
patient s report of pain19
Patient’s Report of Pain
  • Initially try different types of pain intensity scales then consistently use one that patient prefers
  • Scale examples are 0-10 NRS, Wong-Baker Faces, VAS, Verbal Descriptor Scales, vertical and horizontal thermometers
  • Patients can improve in reporting skill with practice
patient s report of pain20
Patient’s Report of Pain

Wong-Baker FACES Pain Rating Scale

Numeric Rating Scale (NRS)

0 1 2 3 4 5 6 7 8 9 10

No Pain Mild Moderate Severe Worst Possible

patient s report of pain21
Patient’s Report of Pain
  • Examples of scales can be found in the Pain as the Fifth Vital Sign Toolkit and Pain Outcomes Toolkit
  • VHA Pain Management Webpage

patient s report of pain22
Patient’s Report of Pain
  • Ask the patient for a description of pain
  • “Pain is what the person says it is.” (McCaffery and Pasero, 1999)
  • Inquire about:
    • sensory – pain quality
    • emotional – suffering, anxiety, depression
    • behavioral components – activity, guarding
patient s report of pain23
Patient’s Report of Pain
  • Focus assessment on specific concrete, here and now experience of pain
  • “How much pain do you feel now?” Not “how much pain have you had the lately?”
  • Compare report to experiences like needle sticks that occur commonly
report by surrogates
Report by Surrogates
  • Caregivers and family members can provide information about pain
  • Surrogates should be asked to describe specific behaviors
  • Inquire about sensory, emotional and behavioral components
  • Surrogates can underestimate and overestimate pain presence and intensity
observation of behaviors
Observation of Behaviors
  • Facial Expressions
  • Verbalizations/Vocalizations
  • Body movements
  • Interpersonal behavior change
  • Change in activity pattern
  • Mental status change – anxiety, agitation, depression (American Geriatrics Society, 2002)
observation of pain behaviors
Observation of Pain Behaviors
  • Patients with cognitive impairment may not show any specific behavior associated with pain
  • Patients with severe impairment may appear stoic when they are actually displaying a frozen mask in response to pain
observation of pain behaviors27
Observation of Pain Behaviors
  • Pain behaviors should be assessed at rest and during movement
  • Pain Behaviors have not been well-examined in younger veterans with cognitive impairment
physiological parameters
Physiological Parameters
  • Changes in vital signs can provide some indication of acute distress
  • Not a good indicator of chronic problem
  • Vital changes do not discriminate pain from other sources of distress
  • Absence of physiologic indicators does not mean absence of pain
empirical analgesic trials
Empirical Analgesic Trials
  • Use in conjunction with other assessment strategies
  • Consider other sources of distress that could be masked by analgesic trial
  • PTSD is very common in this population and should receive specific treatment
  • PTSD can be present even in the instance of a loss of consciousness at time of injury (Bryant et al, 1999)
empirical analgesic trials30
Empirical Analgesic Trials
  • Consider impact of analgesic on cognitive status
  • Identify functional/behavioral indicators to determine efficacy
  • Use an adequate titration schedule (25% - 50%) to assure dose efficacy
pain assessment tools
Pain Assessment Tools
  • Numerous tools have been developed
  • Tools are designed for use with elderly with dementia or children
  • No tools have been validated for polytrauma patients with cognitive impairment
  • All tools need further refinement
pain assessment tools32
Pain Assessment Tools
  • Noncommunicative Patient’s Pain Assessment Instrument (NOPPAIN)
  • Checklist of Nonverbal Pain Indicators (CNPI)
  • Discomfort in Dementia of Alzheimer’s Type (DS-DAT)
  • Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
  • Doloplus 2
  • Others
pain assessment tools33
Pain Assessment Tools
  • There is no standardized tool based on nonverbal pain indictors that can be recommended for broad adoption in clinical practice (Herr et al, 2006)
  • State of the Art review of tools used with elderly with dementia is available at City of Hope Website

  • Only patient self-report of pain intensity can be entered in CPRS vital sign section
  • Pain tool scores cannot be substituted for patient self-report even if they provide a 0-10 number, e.g. PAINAD
  • All other pain assessment is documented in progress note with appropriate title
re assessment
  • Pain assessment is an ongoing process
  • Pain should be re-assessed regularly with other vital signs
  • Pain assessment should always occur after new interventions or changes in health status
polytrauma pain
Polytrauma Pain
  • Treat the Person – Not the Pain! Dennis Turk, Ph.D.
  • Always address pain in context of the individual patient
  • This requires extra attention in cases of cognitive impairment and impaired communication.