Assessment and Management of Pain in Older Adults: A Review of the Basics

Patricia Bruckenthal, PhD, RN, ANP; Yvonne M. D'Arcy, MS, CRNP, CNS

Disclosures

Topics in Advanced Practice Nursing eJournal. 2007;7(1) 

In This Article

Clinical Assessment of Pain

The goals of a clinical assessment for pain in older adults are the same as those established for younger patients. Older individuals may be reluctant to report pain for several reasons:

  • Many older people think that pain is a normal part of aging;

  • They do not want to be a nuisance; and

  • They fear the consequences of acknowledging pain, such as expensive testing or hospitalization.

Nurses must be aware of the potential for underreporting pain and make every effort to pursue an evaluation of pain in this population. A comprehensive assessment includes:

  • Detailed history, including characterization of the present pain complaint, pain-related history, and the impact of the pain on the patient's quality of life;

  • Physical exam; and

  • Appropriate diagnostic assessment.

Medical History

The initial history should include detailed questioning about all known medical conditions and physical limitations. There are several possible sources for persistent pain related to a host of pathologic conditions, including:

  • Peripheral vascular disease;

  • Diabetes;

  • Poststroke syndrome;

  • Decubitus ulcers;

  • Oral/dental problems;

  • Contractures;

  • Degenerative joint disease;

  • Rheumatoid arthritis;

  • Previous fractures; and

  • Osteoporosis.

A history of liver, gastrointestinal, and kidney dysfunction is important to elicit because these may have an impact on pharmacologic treatment options. A complete medication history, including prescribed, over-the-counter, and herbal remedies, and alcohol consumption are necessary and will be considered in analgesic choices.

Present Pain Complaint

To evaluate the present pain complaint, characterize an individual's pain by:

  • Type;

  • Quality;

  • Location;

  • Intensity; and

  • Etiology.

Included is an evaluation of what factors make the pain better, worse, and what treatments have been used as well as the patient's response to treatments.

The type of pain that the patient describes may be caused by actual or potentially damaging stimuli to tissue (skin, muscle, bone, organs), or nociceptive pain. If it is caused by a primary lesion or dysfunction in the nervous system, it is referred to as neuropathic pain. Some patients may have both types, or pain of mixed etiology.

Individual self-report remains the most reliable indicator of pain, even for patients with mild cognitive impairment. For all older adults, the language used for assessment may need to be modified to include pain descriptors used by the patient, such as a pinching or squeezing type of pain or what the term "discomfort" means to the patient.

Pain is often thought of as being "high" on a continuum of discomfort, and a patient may respond that he or she does not have "pain" when questioned. However, patients may respond to words, such as achy, sore, or discomfort. Once a term to describe an individual's pain has been identified, it is recommended that this term be used throughout the assessment and reassessment of that individual's pain.

Assessment Tools

Several assessment tools are available to evaluate the intensity and location of the pain complaint. Older adults can use typical 1-dimensional scales, such as[3]:

  • The Numeric Rating Scale;

  • Verbal Rating Scale;

  • Visual Analog Scale; and

  • FACES Pain Rating Scale.

The Numeric Pain Rating Scale, the most commonly used pain rating scale, is a line with 0 (no pain) at one end and 10 (worst pain possible) at the opposite end. The patient is asked to rate pain intensity by picking the number that most closely represents the level of pain that the patient is experiencing.

The Verbal Rating Scale uses verbal descriptors -- such as mild, moderate, and severe -- or quality descriptors -- such as ache, agonizing, or discomfort -- to describe the pain. The FACES Pain Rating Scale uses a series of faces that range from happy to sad with tears. The patient is asked to pick the face that best represents the pain that he or she is experiencing.

For patients who have acute pain in which pain intensity is the key for assessment, or for trying to determine the efficacy of pain management intervention, the simple 1-dimensional scales work best. Older patients, especially those with mild cognitive impairment, may need extra time to respond and require larger print versions. It may be helpful to have a few different versions of 1-dimensional scales available, because the preference or ease of use of a scale may differ among older persons.[4]

Multidimensional scales, such as the Brief Pain Inventory, are helpful because they include a body map so that the patient can mark the area that hurts as well as elicit information in regard to the impact of pain on functioning.[5] The Brief Pain Impact Questionnaire is a practical tool for clinicians especially in assessment of older adults.[5,6] When patients have chronic pain, the use of a multidimensional scale is indicated.

Assessment in the Cognitively Impaired

When assessing pain in severely cognitively impaired patients, the clinician must rely on behavioral indicators. These include[7,8]:

  • Nonverbal cues, such as restlessness and guarding;

  • Verbal cues, such as crying, moaning, and groaning; and

  • Facial expressions, such as grimacing.

Changes in usual activity may also be an expression of pain.

There is tremendous variability in pain behavior, and often certified nursing assistants will be the first to notice behavioral changes, including[9,10]:

  • Combativeness;

  • Resisting care;

  • Decreased social interactions;

  • Increased wandering;

  • Difficulty sleeping; and

  • Refusing to eat.

Several pain assessment tools have been developed for cognitively impaired long-term care residents.[11,12] Assessment tools vary greatly in their reliability, validity, and applicability for easy clinical use. The Pain Assessment in Advanced Dementia (PAINAD) scale has been designed for use in patients with Alzheimer's disease. It is clinically very popular, but as with all tools in this category, the reliability and validity of the tools are an evolving process. The reader is encouraged to review these prior to adoption in clinical practice to see whether the tool is appropriate to the work setting.

A comprehensive assessment will enable the clinician to establish an appropriate plan of care. Some interventions will result in rapid improvement in pain, whereas others will require an interdisciplinary approach and a greater length of time for resolution. Reassessment at frequent intervals will serve as a guide as to whether chosen interventions are successful.

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