Download - Book Pain Older People
-
7/29/2019 Book Pain Older People
1/17
CONCISE GUIDANCE TO GOOD PRACTICE
A series of evidence-based guidelines for clinical management
NU M BER 8
The assessment of pain in older people
NATIONAL GUIDELINES
Octob er 2007
-
7/29/2019 Book Pain Older People
2/17
Guideline Developm ent Grou p
These guidel ines were prepared by B Col let t
FRCA, S OMahon y FRCP, P Schofield Ph D ,
SJ Closs Ph D and J Potter FRCP o n b e h a l f o f
the mu l t id isc ip l inary Gu ide l ine Deve lopment
Group convened by t he Br i t i sh Ger ia t r ics
Society and t he Br i t ish Pain Society in
con jun c t ion w i th t he Cl in i cal Standards
Depar tm ent o f the Royal Co l lege o f
Physicians.
Professor S Jos Closs Ph D (Nursing)
Chair of N ur sing Research, Uni versi ty of
Leeds, Leeds
Dr Beverly Collett FRCA (Pa in m ed ic ine)
Consu l tan t in Pa in Management andAnaesthesia, Univers i ty Hospita ls
of Leicester
Mrs Jean Giffin Patient representat ive
Mrs Joanna Gough (Adm in is t ra t ive supp or t )
Br i t ish Geriatr ics Society, London
Dr Danielle Harari (Geriatr ic medic ine)
Con sul tan t Physic ian/Senio r Lecturer,
St Thomas Hospi ta l , London
Mr Lester Jones (Physiotherapy)
Senior Lecturer, Kingston Univers i ty and
Univers i ty o f Londo n
Dr Sinead OMahony FRCP (Geriatr ic
medic ine) Senior Lecturer/ConsultantPhysic ian, L landough NHS Trust, Penarth,
South Glam organ
Dr Jonathan Potter FRCP Clin ical Director,
Cl in ical Effect iveness and Evaluat ion Unit ,
Royal Col lege of Physic ians; Con sul tan t
Acknowledgements
The Gu id e l ine Deve lopm ent Group (GDG) wou ld l i ke to t hank and
acknow ledge the supp or t rece ived f rom Jo Gough fo r h er adm in is t ra t ive
he lp in o rgan ising th e ac t iv i t ies o f th e GDG and in assist ing w i th the
dra f t in g o f the gu id ance.
The GDG are gratefu l to the Br i t ish Pain Society and the Br i t ish
Geriatr ics Society for the provis ion of fac i l i t ies for meet ings, and to
the peer reviewers who took th e t im e to p rov ide va luab le and
considered feedback.
Clinical Standards Depart m ent
The a im o f th e Cl in ica l Standards Depar tm ent o f the Royal Co l lege o f
Physic ians is to im prove pa t ien t care and hea l thcare p rov ision by
se t t ing c l in i ca l standards and m on i t o r ing t he i r u se . We have exper t ise
in t he deve lopm ent o f ev idence-based gu ide l ines and the o rgan isat ion
and repor t ing o f mu l t i cen t re compara t ive per fo rmance da ta . The
depar tm ent h as th ree core s t ra tegic ob jec t ives: to defines tandards
around the c l in ica l work o f ph ysic ians, to measureand eva lua te the
imp lementa t ion o f s tandards and i ts impac t on pa t ien t care and to
effect ively implement th ese standard s.
Our p ro gramm e invo lves co l labora t ion wi t h spec ia l i st socie t ies, pa t ien t
g roups and n a t iona l bod ies inc lud i ng : the Nat iona l Ins t i tu te fo r Hea l th
and Cl in ical Excel len ce (NICE), th e Health care Com m ission and th e
He a l t h Fo u n d a t i o n .
Con cise Guidance to Go od Practice series
The conc ise gu ide l ines in t h is ser ies a re in tend ed to in fo rm those
aspec ts o f p hysic ians c l in ica l p rac t ice wh i ch m ay be ou t side t he i r own
specia l is t area. In many instances, the guidance wi l l a lso be useful for
other c l in ic ians inc luding GPs, and other heal thcare professionals.
The gu ide l ines are designed to a l lo w c l in ic ians to m ake rap id ,
informed decis ions based wherever possib le on synthesis of the best
avai lab le ev idence and exper t consensus ga thered f rom prac t ising
cl in i c ians and serv ice users. A key feature of th e ser ies is to p rovid e
b th d t i f b t t i d h ib l t i l
-
7/29/2019 Book Pain Older People
3/17
Contents
Guideline Development Group ii
Foreword 1
Methodology 2
Background 2
The challenge of impaired cognition and
communication 2
Assessment 3
Types of scales used to assess pain
Implications and implementation 4
SUMMARY OF THE GUIDELINES 5
Appendices
1 Gu i d el i n e d ev el o pm e n t p r o ce ss 7
2 A lgo r i t h m f o r a sse ssm e n t o f p ai n i n o l d e r p eo p l e 8
3 Pain m ap 9
4 Exa m p l es o f p ai n sca le s
A N u m er ic r at i ng scal e 10
B Ve r b al d e scr i p t i ve r at i n g sca l e 10C Ve rb al n u m er i ca l r at i n g sca le 11
D Pai n Th er m om et er 11
E Ab b ey Pa in Scal e 12
References 14
Foreword
Pain is so un iversal that it is essential that it is
recognised by all people working with older people.
It places a blight on daily life, limiting functional
ability and imp airing the qu ality of life. The symptom
manifests itself in m any ways, not on ly as a sensory
experience but also by causing psychological distress.
It may be difficult for some to articulate their pain,for examp le those with d ementia, some forms of
stroke or Parkinsons disease. The non -verbal
m anifestations of p ain m ust be recognised and
interpreted so th at the distress caused to th ese m ost
vulnerab le mem bers of society can be alleviated.
The Nation al Service Framework ( NSF) for Older
People placed great emphasis on t he dignity of older
people. The appropriate management of pain is
essential to en sure the dignity and well-being of older
people. This important need has been reiterated in
my review of progress with t he NSF and p lans for t he
next ph ase in A new am bit ion for old age.*
It is timely therefore that the British Pain Society has
worked with the British Geriatrics Society and the
Royal College of Physicians t o r eview th e cur rent
evidence in the literature and to produ ce sound
guidan ce to help all practitioners in assessing for the
presence of pain.
I fully com men d t he guidance presented here, and
hope that health and social practitioners will takeheed an d u tilise it in their everyday practice.
October 2007 Ian Philp
National Director for Older People,
D t t f H lth
-
7/29/2019 Book Pain Older People
4/17
Methodology
The guidance has been developed in accordance with
the requ iremen ts for concise guidelines as detailed at
www.rcplondon.ac.uk/college/ceeu/conciseGuideline
DevelopmentNotes.pdfDetails are shown in Appendix 1.
Background
mu ltidimensional and m ay be described at several
levels:
sensory dimension: the intensity, location and
character of the pain sensation
affective dim ension: th e emotion al com pon ent o f
pain and how pain is perceived
imp act: the disabling effects of pain on the
persons ability to fun ction an d participate in
society.
The purpose of this guideline is to provide
professionals with a set of practical skills to assess
pain as the first step towards its effective
man agemen t. The guidance does not seek to
differentiate between acute and persistent pain as the
literature relating to pain in older people shows that
such a distinction is impractical.
For m ore detailed guidance and evaluation of th e
supp or ting literatur e, please see the full guideline.4, 5
The challenge of impaired
cognition and communication
Assessing pain becom es even m ore challenging in the
presence of severe cognitive imp airm ent,
comm un ication d ifficulties or language and cultural
barr iers. However, even in the p resence of severe
cognitive and communication impairment, many
individuals m ay have their pain assessed u sing
appropriate observational scales.
Verbal and nu m erical ratin g scales best quan tify the
intensity of pain in older p eople with n o
cognitive/comm un ication imp airment and can also
be used with ap propr iate assistance in many p atients
Pain is under-recognised and under-treated inolder people. It is a subjective, personal
experience, only known to the person who
suffers. The assessment of pain is particularly
challenging in the presence of severe cognitive
impairment, communication difficulties or
language and cultural barriers.
These guidelines set out the key components
of assessing pain in older people, together
with a variety of practical scales that may be
used with different groups, including those
with cognitive or communication impairment.
The purpose is to provide professionals with a
set of practical skills to assess pain as the first
step towards its effective management. The
guidance has implications for all healthcare
and social care staff and can be applied in all
settings, including the older persons own
home, in care homes, and in hospital.
http://www.rcplondon.ac.uk/college/ceeu/conciseGuidelineDevelopmentNotes.pdfhttp://www.rcplondon.ac.uk/college/ceeu/conciseGuidelineDevelopmentNotes.pdfhttp://www.rcplondon.ac.uk/college/ceeu/conciseGuidelineDevelopmentNotes.pdf -
7/29/2019 Book Pain Older People
5/17
Scales shou ld use large clear letters/nu m bers and be
presented u nder good lighting. Once the mostappropriate scale has been chosen to suit the
ind ividual persons strengths, staff shou ld contin ue
to use this for sequential assessment in order to
observe the response to treatment .
People with very severe cognitive/com mun ication
impairm ent m ay not be able to self-report pain even
with fu ll assistance. Clinicians m ay need to rely on
behavioural responses, but these can be hard to
interpret.
Assessment
The key components of an assessment for anyone
suffering from pain are shown in Box 1.
It is particularly important to use observations for
signs of pain in older p eople with cognitive or
communication impairment (Table 1).
For an algorith m for assessm ent, see Append ix 2. For
an example of a pain map, see Appendix 3.
Table 1. Observational changes associated with pain.
Type Description
Autonom ic changes Pa l lo r, sweat ing , tachypnoea, a l te red b rea th ing pa t te rns , tachycard ia , hyper tens ion
Faci al exp ressi on s Gr im a ci ng, w i nci ng, f ro wn in g, r ap id bl in ki ng, b ro w r ai si ng, b ro w l ow er in g, ch eek rai si ng,
eyel id t igh ten ing , nose wr in k l ing , l ip corner pu l l ing , ch in r a ising , l ip pucker ing
Bo dy m o vem en ts Al tered gai t p aci ng ro ck in g h an d w ri ngi ng rep et it ive m o vem en ts i ncreased ton e
Box 1. Key components of an assessment of pain.
Direct enqu iry ab out t he presence of pai n
i nc lud ing the u se o f a l te rna t ive words to descr ibe pa in
Observation for signs of pain
espec ia l l y in o lder peop le w i th cogn i t i ve /
c om m u n i c at i o n i m p a i rm e n t
Descript ion of pain t o i n c l u d e :
sensory d im ens ion t h e n at u re o f t h e p ai n (eg sh ar p, d u l l , b u r n i n g et c)
p ai n l oca t i on an d r ad i at i o n (b y p at i en t s p o i n t i n g t o
the pa in o n th emse lves o r by us ing a pa in m ap)
i n t en si t y, u si n g a st an d ar d i sed p ai n asse ssm en t sca l e
af fec t ive d im ens ion
em o t i o n al r esp o n se t o p ai n (eg fea r, an xi et y,
depress ion)
im pac t : d isab l ing e f fec ts o f pa in a t the leve ls o f
fu n ct i o n al ac t i vi t ies (eg ac t i vi t i es o f d ai l y l i vi n g)
p ar t i ci p at i o n (eg w o rk , so ci al ac t i vi t ies, r el at i o n sh i p s)
Measurement of pain
us ing s tandardised scales in a format that is access ib le
t o t h e i n d i v i d u a l
Cause of pain
examin a t ion an d in vest iga t ion to estab l ish the cause
o f pa in
-
7/29/2019 Book Pain Older People
6/17Types of scale used to assess pain Imp lication s and implementation
Table 2. Types of scale for assessing pain.
Type of pain assessment Practical suggestions Comments and references
for scale selection
Self-report
High va l id i t y and re l iab i l i t y in
o l d e r p e o p le911
Can be used in m i ld /modera te
c o gn i t i v e im p a i r m e n t 9,12
Ver t ica l as opposed t o h or izon ta l
o r i e n t a t i o n m a y h e lp t o a vo id
m is in te rp re ta t ion in t he p resence o f
v isuo-spa t ia l neg lect , eg in pa t ien ts
w i t h st r o k e
High va l id i t y and re l iab i l i t y in
o l d e r p e o p le911
Older peop le w i t h m odera te to severe Pa in Thermom eter6 Easy to use
co gn i t i ve/ co m m u n i cat i o n im p ai rm en t (Ap p en d ix 4 ) Val i d i t y h as n o t b een fu l l y evalu at ed 6
Colou red Visual Anal ogue Scale7 Wel l un ders tood in ear ly and m id-stage
stage Alzhei m ers di sease8
Observati ona l p ain assessm entOl d er p eo p le w i th se ver e co gn i ti ve/ Ab b ey Pai n Sca le Sh o rt an d ea sy t o ap p ly scal e13
c o m m u n i c a t i o n im p a i r m e n t (n o si n g l e (Ap p e n d i x 4 )13,14 Requ i res mo re de ta i led eva lua t ion
recommendat ion cur ren t ly poss ib le )
Multidimensional assessment
Ol der p eo pl e w it h m i ni m al co gn it ive Br ief Pai n In ven to r y15,16 15- i tem scale assessin g: sever i ty, im pact
im p ai r m en t o n d ai l y l i vi n g, im p act o n m o o d an d
e n jo y m e n t o f l i f e
Older peop le w i th no s ign i f i can t
c o g n i t i v e / c o m m u n i c a t i o n im p a i r m e n t
and
O ld er p e o p le w i t h m i l d t o m o d e r a t e
c o g n i t i v e / c o m m u n i c a t i o n im p a i r m e n t
Num er ic g raph i c ra t ing sca le
(Append ix 4 )
Verbal rat in g scale or
num er ica l ra t ing scale (010)
(Append ix 4 )
-
7/29/2019 Book Pain Older People
7/17
Recommendation Grade
1 Pain awareness C
Al l hea l thcare p ro fessiona ls shou ld be a le r t to the possib i l i t y o f pa in i n o ld er peop le , and to t he fac t tha t o ld er
peop le a re o f ten reluc tan t to acknow ledge and repor t pa in .
2 Pain enquiry C
Any hea l th assessm ent shou ld inc lud e enqu i ry about pa in , u sing a range o f a l te rna t i ve descr ip to rs
(eg sore, hu r t i ng, achin g).
3 Pain description C
Where pa in is p resen t , a de ta i led c l in ica l assessm ent o f t he m u l t i d im ensiona l aspects o f pa in shou ld be
u n d e r t a k e n i n c l u d i n g :
sensory dim ension: the na tu re , loca t ion and in tens i ty o f pa in affective dimension: t h e e m o t i o n a l c o m p o n e n t a n d r e sp o n s e t o p a in impac t : on fu nc t ion in g a t the level o f ac t iv i t ies and par t i c ipa t ion .
3.1 Pain location C
An a t t e m p t t o l o c at e p a in s h o u ld b e m a d e b y :
ask ing the pa t ien t to po in t to th e a rea on them se lves the use o f pa in m aps to de f ine th e locat ion an d the ex ten t o f pa in .
3.2 Pain intensity C
Pain assessm ent shou ld rou t in e ly inc lud e the use o f a s tandard ised in ten si ty ra t in g sca le, p re fe rab ly a
simple verbal descr iptor scale or a numer ic rat ing scale, i f the person is able to use these.
4 Communication C
Every ef fo r t shou ld be m ade to faci l i ta te comm un ica t ion par t i cu la r ly w i th those peop le w i th sensory
im pair m ents (use of hear i ng aid s, g lasses etc).
Sel f - report assessment scales should be of fered in an accessib le format to sui t the strengths of the indiv idual .
5 Assessment in people with impaired cognition/communication C
Peop le w i th m odera te to severe comm un ica t ion p rob l ems shou ld be o f fe red add i t io na l assistance wi th
se l f - repor t th rou gh th e use o f su i tab ly adapt ed sca les and fac i l i ta t ion by sk i l led p ro fessiona ls .
In peop l e w i th very severe im pa i rm ent , and in s i tua t ion s wh ere p rocedures m igh t cause pa in , an
b t i l t f i b h i i ddi t i l l i d ( T bl 1)
SUM MARY OF TH E GUIDELINES
-
7/29/2019 Book Pain Older People
8/17
The prop er evaluation of pain in older people does
require staff training and the add itional tim erequired to u ndert ake a proper evaluation will
inevitably im pact on staff time in already over-
pressed services. However, if pain is sought ou t,
addressed and relieved, the lot of older people would
be greatly enh anced. Moreover, relief from the
disabling effects of pain may potentially save staff
time in o ther areas such as the p rovision of suppo rt
for basic self-care activities etc.
These basic guidelines should be a routine part of the
training and care provision of all healthcare
professionals.
References
1 National Statistics Online. Self-reported health problems: by
gender and age, 199697: social trends dataset.
www.statistics.gov.uk/StatBase/xsdataset.asp?More=Y&vlnk=
670&All=Y&B2.x=86&B2.y=13 (accessed 22 M ay 2007).
2 Helme RD, Gibson SJ. The epidemiology of pain in elderly
people. Clin Geriatr Med2001;17:41731.
3 Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing
home.J Am Ger iat r S oc 1990;38;40914.
4 British Geriatrics Society, 2007. www.bgs.org.uk/Publications/
Clinical%20Guidelines/clinical_guidelines_index.htm
5 Bri tish Pain Society, 2007. www.britishpainsociety.org
6 AGS Panel on Persistent Pain in Older Persons. The
man agement of persistent pain in older person s.J Am
Geriatr Soc 2002;50:S20524.
7 Scherder EJA, Bouma A. Visual analogue scales for pain
assessmen t in Alzheimers disease. Gerontology
2000;46:4753.
8 Hadjistavropoulos T, Herr K, Turk D et al. An
interdisciplinary expert consensus statemen t on assessmentof pain in older person s. Clin J Pain 2007;23:S143.
9 Chibnall JT, Tait RC. Pain assessment in cognitively impaired
and u nim paired older adults: a com parison of four scales.
Pain 2001;92:17386.
10 Herr KA, Spratt K, Mobily PR, Richardson G. Pain intensity
assessm ent in older adu lts. Clin J Pain 2004;20:20719.
11 Kaasalainen S, Crook J. An exploration of seniors ability to
report pain. Clin Nurs Res 2004;13:199215.
12 Stolee P, Hillier L, Esbaugh J et al. Instruments for the
assessm ent of p ain in older person s with cognitiveimpairment. J Am Ger iat r S oc 2005;53:31926.
13 Abbey J, Piller N, De Bellis A et al. The Abbey pain scale:
a 1-minu te num erical indicator for people with end-stage
dementia.In t J Pallia t N urs 2004;10:613.
14 Abbey J, De Bellis A, Piller N et al. Abbey pain scale. In: The
Royal Austr alian Co llege of Gen eral Pr actition ers Silver
Book Nation al Taskforce.M edical ca re of older p erson s in
residential aged care facilities.
www.racgp.org.au/silverbookonline/4-6.asp
15 Keller S, Bann CM, Dodd SL et al. Validity of th e brief paininventor y for use in docum enting the outcom es of patients
with noncancer pain. Clin J Pain 2004;20:30918.
16 Pain Research Group, University of Wisconsin-Madison.
Brief pain inventory. In: The Royal Australian College of
Gener al Practition ers Silver Book Nation al Taskforce.
M edi cal care of older p erson s in resid en tial aged care faci lit ies.
/ il b k li /4 7
http://www.statistics.gov.uk/StatBase/xsdataset.asp?More=Y&vlnk=670&All=Y&B2.x=86&B2.y=13http://www.statistics.gov.uk/StatBase/xsdataset.asp?More=Y&vlnk=670&All=Y&B2.x=86&B2.y=13http://www.statistics.gov.uk/StatBase/xsdataset.asp?More=Y&vlnk=670&All=Y&B2.x=86&B2.y=13http://www.bgs.org.uk/Publications/Clinical%20Guidelines/clinical_guidelines_index.htmhttp://www.bgs.org.uk/Publications/Clinical%20Guidelines/clinical_guidelines_index.htmhttp://www.bgs.org.uk/Publications/Clinical%20Guidelines/clinical_guidelines_index.htmhttp://www.britishpainsociety.org/http://www.racgp.org.au/silverbookonline/4-6.asphttp://www.racgp.org.au/silverbookonline/4-7.asphttp://www.racgp.org.au/silverbookonline/4-7.asphttp://www.racgp.org.au/silverbookonline/4-6.asphttp://www.britishpainsociety.org/http://www.bgs.org.uk/Publications/Clinical%20Guidelines/clinical_guidelines_index.htmhttp://www.statistics.gov.uk/StatBase/xsdataset.asp?More=Y&vlnk=670&All=Y&B2.x=86&B2.y=13 -
7/29/2019 Book Pain Older People
9/17
Appendix 1. Guideline development process
The fu l l gu ide l ines4, 5 have been d eveloped in accordance wi th the p r i nc ip les la id dow n b y the Appra isa l o f Gu ide l in es fo r
Research and Eva lua t ion co l labora t ion . 17
Scope and purpose
Overa l l ob jec t ive o f To p rov ide sim p le and p ragmat ic adv ice fo r c l in ic ians w i th regard to screen in g and
t h e gu id el in es assessm en t o f p ai n in o l d er ad u l t s
Th e p a t i e n t g r o u p c o ve r ed A l l o l d e r p e o p le co m in g i n t o c o n t a c t w i t h h e a l t h ca r e p r o f essi o n a l s
Target aud ience Al l hea l thcare p ro fessiona ls , inc lud i ng those in p r im ary care, hosp i ta ls and care hom e se t t ingsCl in i ca l ar ea s co ver ed Th e assessm e n t of p ai n
Stakeholder involvement
The Gu ide l in e A m u l t id iscip l in ary Gu id e l ine Deve lopm ent Group (GDG) was convened by the Br i t i sh
D e ve l op m e n t Gr o u p Ge r ia t ri cs So ci e ty an d t h e Br i t i sh P ai n So ci e ty i n co n j u n ct i o n w i t h t h e Cl i n i ca l St a n d ar d s
Depar tm ent o f th e Roya l Co l lege o f Physic ians, w i t h represen ta t ives f rom:
n u r si n g
p ai n m e di ci ne
p at ien t gr ou p ge ri at r ic m e d i ci n e
p h ysi o th e ra py.
Fu n d in g Br i t i sh Pain So ciet y
Br i t i sh Ger iatr ics Society
Co n fl i ct s o f in t erest No n e d eclared
Rigour of development
Evidence gather ing Search strategy: Re levan t fu l l len g th a r t i c les were iden t i f ied us ing e lect ron i c searches in M ed l ine ,PubMed, OVID Medline, CINAHL, EMBASE, AMED, SciSearch & Cochrane. Evidence-based reviews
were i den t i f i ed f r om OVID, Cochran e, ACP Jou rnal Clu b, DARE and CCTR. Psychological and socia l
science l i t eratu re was sought th rou gh PsychINFO and ASSIA. Conf erence pap ers were searched via
IASP, the Br i t ish Pain Society and the European Pain Society. Relevant publ icat ions were included.
Inclusion criteria: Papers descr ib in g or ig inal stud ies, evidence-based guid el ines or system at ic reviews
Stud ies inc lud i ng o lder peop le (65 and over ) w i t h o r w i t hou t cogn i t i ve impa i rm ent
Pa in was de f ined as bo th acu te and pers isten t , accord in g to th e In te rna t ion a l Assoc ia t ion fo r t he
Stud y of Pain (IASP) def in i t ions, but the fo cus was on persistent pain (www.iasp-pain.org/ terms-p.html ).Studies including pain assessment
Papers pub l ished a f te r 1990
Exclu sion criteria :Paed ia t r ic l i te ra tu re
Search terms:Com bin a t ion o f search te rm s used in c luded:
pa in o r d iscomfor t o r ag i ta t ion and assessm ent o r sca les o r measurement o r behav iou ra l
http://www.iasp-pain.org//AM/Template.cfm?Section=Home&WebsiteKey=ab2d1c7a-069c-4ec9-a5b4-022117666cddhttp://www.iasp-pain.org//AM/Template.cfm?Section=Home&WebsiteKey=ab2d1c7a-069c-4ec9-a5b4-022117666cdd -
7/29/2019 Book Pain Older People
10/17
8
The
asses
sm
entof
pain
in
older
people
Observe for potential indicators of pain: f a ci a l e xp r essi o n s v er b a l i sa t i o n s/ v o ca l i sa t i o n s b od y m ovem e nt s a l t e re d i n t e r p e r so n a l i n t e r a ct i o n s c h a n ge s i n a c t i vi t y p a t t er n s o r r o u t i n e s m e n t a l st a tu s c h an g es p h y si o l o g i ca l c h a n ge s.
N o i m m e d i a t e t r e at m e n t n e e d e d .
Co n t i n u e t o m o n i t o r .
Ask wh ether the p erson h as pa in a t r es t o r on m ovemen t . Use a l te rna t ivedescr iptors such as sore, hur t ing or aching.
Observe fo r po ten t ia l i nd ica to rs o f pa in .
Is pain reported/apparent?
Assess pain int ens i ty u s ing a sim ple scale such as averba l r a t ing scale o r n um er ic ra t ing sca le .
Ask the person to show wh ere the i r pa in is(p o i n t i n g o r p a i n m a p ).
Is pain present?
Ta k e a d et a i l ed p a i n h i st o r y . Ex am i n e t h e p at i en t . Tr ea t c au se . Tr e at sy m p t o m s i f c au s e i s n o t i d e n t i f i a b l e . Co n si d e r r ef er r al .
T rea t mo rb id i t y .
Do potential painindicators persist?
N o i m m e d i a t e a ct i o nneeded.
Co n t i n u e t o m o n i t o r .
N o i m m e d i a t e a ct i o n n e e d e d .
Co n t i n u e t o m o n i t o r a n dt rea t as requ i red .
N o i m m e d i at e
ac t ion needed.
Cont in ue tom o n i t o r .
Re l u c t an t t o c o m p l a i n o fp a i n . Evidence of morbidity that may
be causing pain?
Can t he p erson com m un icate successfu l ly?*
Appendix 2. Algorithm for the assessment of pain in older people
*If there is doubt ab out ability to com mu nicate, assess and facilitate as indicated in Recom m endation s 4 and 5 o f the Guidelines.
Yes
Yes
Yes
Yes
N o
Yes
N o
N o
Yes
N o
N o
No
N o
Cons ider empir ical analges ict r ia l o r o ther pa in - re l iev ingi n t e r v e n t i o n .
Mon i to r r esponse care fu l l y .
A t t em p t t o i n t e r p r et m e a n i n g o f b e h a vi o u rw i th he lp o f ca reg ivers fami l ia r w i th theperson . Provide in d iv idu a l ised care .
Ensure bas ic com for t n eeds are m et .
Prov ide reassurance i f behav iour suggestsfear.
Cons ider prov id ing analges ics pr ior tom o v e m e n t .
Do potential pain indicators persist?
Yes
-
7/29/2019 Book Pain Older People
11/17
Appendix 3. Pain m ap
Where is your pain? Please mark where you feel pain on the drawings below.
Right Left Left Right
-
7/29/2019 Book Pain Older People
12/17
Most severe
pain imaginable
No pain at all
Say to the patient:
This is a scale to m easure p ain.
0 ind ica tes no pa in a t a l l .
The num bers on th e sca le ind ica te inc reasing leve ls o f pa in ,
up to 10 w h ich is the mo st severe pa in im ag inab le . Which po in t on th e sca le show s how m uch pa in you h ave today?
To the administrator:
In your op in ion was the person ab le to u nders tand th is sca le?
Yes N o
Co m m e n t :
10
9
8
7
6
5
4
3
2
1
0
Reproduced with permission from Professor Lynne Turner-Stokes, Concise Guidance Series Editor, Royal Col lege of Physicians, London.
Append ix 4. Examples of pain scales
4A Numeric rating scale
The Numeric Graphic Rating Scale (NGRS)
-
7/29/2019 Book Pain Older People
13/17
On a scale of 0 to 10, please tell me how severe your pain is today.
4C Verbal numerical rating scale
4D Pain Thermometer
Pain as bad as it could be
Extreme pain
Severe pain
Moderate pain
Mild pain
Slight pain
No pain
-
7/29/2019 Book Pain Older People
14/17
4E Abbey Pain Scale
Use of the Abbey Pain Scale
The Abbey Pain Scale is best u sed as par t o f an overa l l pa in m anagem ent p lan . Som e pa in m anagem ent s t ra tegies can
be foun d in the w ebsi te c i ted in Ref 19 .
Object ive
The Pain Scale is an instrument designed to assist in the assessment of pain in residents who are unable to c lear lyar t i cu la te the i r needs.
Ongoin g assessm ent
The Scale does not d i f ferent iate between distress and pain, so measur ing the ef fect iveness of pain-re l iev ing
intervent ions is essent ia l .
Recent work by the Austra l ian Pain Society 20 recom m ends tha t th e Abbey Pain Scale be u sed as a m ovement -based
assessm ent . The s ta f f record ing th e sca le shou ld there fo re observe th e residen t wh i le th ey a re be ing m oved, eg dur in gpressure area care, whi l e sho weri ng etc.
Com ple te the sca le im m edia te ly fo l lowin g the p rocedure and record the resu l ts in th e residen t s no tes . Inc lude th e
t im e o f com ple t ion o f th e sca le, the score , sta f f m em ber s signa ture and ac t ion ( i f any) taken in response to resu l ts o f
the assessm ent , eg pa in m ed ica t ion o r o ther therap ies.
A second eva lua t ion shou ld be condu c ted one hou r a f te r any in te rven t ion taken in respon se to th e f i rs t assessm ent , to
de te rm ine th e e f fect iveness o f any pa in - rel iev ing in t e rven t ion .
I f , at th is assessm ent, th e score on th e pain scale is th e sam e, or wor se, consider fu r th er int ervent ion and act as
appropr ia te . Com ple te the pa in sca le hou r ly , un t i l th e residen t app ears comfor tab le , then four -hour ly fo r 24 h ours ,
t rea t ing pa in i f i t recurs . Record a l l the p a in - re l iev ing in te rven t ion s under taken. I f p a in /d ist ress persists , un der take a
com prehens ive assessm ent o f a l l facets o f residen t s care and m on i t o r c losely over a 24-hou r p er iod , in c lud ing any
fu r t h e r i n t e r v e n t i o n s u n d e r ta k e n . I f t h e re i s n o im p ro v em e n t d u r i n g t h a t t im e , n o t i f y t h e me d i c al p ra c t i t i o n e r o f t h e
pa in scores and th e ac t ion /s taken.
Jenn y Abbey
Apr i l , 2007
-
7/29/2019 Book Pain Older People
15/17
Ad d scores fo r Q1 t o Q6 an d reco rd h ere Tot al p ain sco re
The Abbey Pain Scale
Fo r m e asu re m e n t o f p a i n i n p e o p l e w i t h d e m e n t i a w h o c a n n o t v e rb a l i se
How to u se scale: Whi le ob serv in g the resident, score qu est io ns 1 to 6.
Nam e of residen t: ............................................................................................................................................................
Nam e and designat io n of per son com pl eti ng th e scale: .................................................................................................
Date: ............................................................................. Tim e: ........................................................................................
Latest p ain reli ef given w as ........................................................................................................................... at .......hrs.
Q1. Vo cal isat io n
eg wh imper ing , g roan ing , c ry ing
Absen t 0 M i ld 1 M oderate 2 Severe 3
Q2 . Fa ci al ex pr essi o n
eg look ing tense , f rown in g , gr im acing , look in g f r igh tened
Absen t 0 M i ld 1 M oderate 2 Severe 3
Q3 . Ch a n ge i n bo d y l an gu a ge
eg f idget ing , rock ing , guard in g par t o f body , wi t hdr awn
Absen t 0 M i ld 1 M oderate 2 Severe 3
Q4 . B eh avi ou r al ch an ge
eg inc reased con fus ion , re fus ing to ea t , a l te ra t ion in usua l pa t te rns
Absen t 0 M i ld 1 M oderate 2 Severe 3
Q5 . Ph ysi o lo gi ca l ch a n ge
eg tempera tu re , pu lse o r b lood pressure ou t side norm al l im i ts , persp i r in g ,
f lush ing o r pa l lo r
Absen t 0 M i ld 1 M oderate 2 Severe 3
Q6 . Ph ysi ca l ch an ges
eg skin tears, pressure areas, arth r i t is , contr actures, previo us in ju r ies
Absen t 0 M i ld 1 M oderate 2 Severe 3
Q1
Q2
Q3
Q4
Q5
Q6
-
7/29/2019 Book Pain Older People
16/17
-
7/29/2019 Book Pain Older People
17/17
CAN BE PHOTOCOPIED FOR STAFF USE
Observe for potential indicators of pain: fac ial expressions ve rbal i sa t i ons/vocal i sa t i ons b o dy m o vem e n t s a l te red i n te rpersona l i n te ract i ons changes in ac t i v i ty pa t te rns o r rou t i nes m e n ta l st a tu s c h an g es physio log i ca l changes.
No imm ed ia te t rea tment needed .
Con t inue to m on i to r .
Ask wh ether th e person h as pain at rest or on m ovemen t. Use a l ternat ivedescr iptor s such as sore, hu rt in g or achin g.
Observe fo r po ten t i a l i nd i ca to rs o f pa in .
Is pain reported/apparent?
Assess pain int ensity u sing a sim ple scale such as a
verbal rat in g scale or num eric rat ing scale.
Ask th e person to show w here thei r p ain is (poin t ingor pa in m ap).
Is pain present?
Take a de ta i l ed pa in h i s to ry. Ex am i n e t h e p at i e n t . Treat cause . Treat sympt oms i f cause i s no t i den t i f i ab le . Cons ider re fer ra l .
No im m ed ia te act i onneeded.
Con t inue to m on i to r .
No im m ed ia te ac t i on needed .
Con t inue to m on i to r andtreat as requi red.
N o i m m e d i ateact ion needed.
Continue tom o n i t o r .
Re luc tan t to com p la ino f p ai n .
Evidence of morbidity that maybe causing pain?
Can th e p erson com m un icate successfu l ly?*
Algorithm for the assessm ent of pain in older people
* I f there is doubt abou t abi l i ty to comm unicate, assess and fac i l i ta te as indicated in Recom m endat ions 4 and 5 of the Guidel ines (over leaf) .
Yes
Yes
Yes
Yes
No
No
NoNo
No
No
No
Yes
Yes
Treat morbid i ty.
Do potential painindicator s persist?
Consider emp ir ica l an algesict r i a l o r o the r pa in - re l i evingin te rven t ion .
Mon i tor respon se carefu l l y.
A t t em p t t o i n te r p r et m e an i n g o f b e h av i ou rw i th he lp o f caregive rs fami l i a r w i th th eperson. Provide indi v idual ised care.
Ensure basic comfo rt n eeds are m et.
Provide reassuran ce i f behaviour suggestsfear.
Consider p rovid in g analgesics pr ior t om o v e m e n t .
Do potential pain indicators persist?
Yes
Copyright 2007 Royal College of Physicians