Although several types of pain assessment tools are available to help clinicians evaluate pain in older people, too often the sole initial emphasis is to gauge pain intensity instead of determining how the pain affects function and the need for treatment, according to research presented at the American Pain Society Annual Scientific Meeting, www.americanpainsociety.org.
In a plenary session address, Keela Herr, RN, Ph.D., professor and associate dean for faculty, University of Iowa School of Nursing, said persistent pain affects 50 percent of individuals 65 and older, and decisions regarding appropriate pain management strategies should rely on patient responses about how pain impacts daily life and activities, instead of simply asking 'how much does it hurt?'
"The pain intensity number scales do not provide information about pain tolerability, interference with daily activity, or need for treatment and don't address the uniqueness in each person's pain experience," said Herr. "In patients who do not have dementia and are able to communicate verbally, the goal should be to understand how tolerable or manageable the everyday pain really is, but these assessments take time and staff time is short."
Herr added that innovative approaches to advance initial pain assessment incorporating probes for the emotional and physical impact of pain are being tested in the VA and at the University of Utah, and may benefit older adults in similar care settings. The University of Utah has developed a protocol in which clinicians engage in guided conversations to assess pain changes, tolerability, impact on function and sleep, and satisfaction with pain control. "Just knowing how bothersome pain can be is very valuable for deciding whether or not to modify a pain management strategy," said Herr.
When treating patients with dementia who cannot communicate verbally, Herr said pain often is unrecognized or undertreated. "There are known pain behaviors that provide non-verbal cues, such as grimacing, moaning and bracing. However, not all persons with dementia exhibit these signs and their pain indicators might be more subtle," she explained.
Herr highlighted future challenges for improving tools for identifying and monitoring pain in this vulnerable population. She noted that considerable research has emphasized development of pain behavior tools to support decision-making about pain in those who cannot speak for themselves. Although over 35 tools are now available, some with good psychometric support, unanswered questions remain about their application in the clinical setting.
Tools for pain assessment in older adults have been available and recommended in clinical practice guidelines, but their use in practice is not consistent. Herr added that good pain assessments require foundational knowledge about pain in older people.
"The number of people over the age of 65 is expected to double in the United States by 2050, so health care providers must be prepared for a huge surge in demand for medical services, especially pain management. Education and training to manage pain in the elderly right now is insufficient and clinician training programs must address this serious deficiency," said Herr. "Establishing core pain competencies as essential content in pre-licensure programs would be an important next step."
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