Ask the patient if they are experiencing any pain using questions like the following. Show
If the older person has no pain on admission, record ‘0’ as the pain score and advise them to let staff know if pain develops. If the older person does report pain during the initial screening interview, then further assessment of pain intensity, location, quality and symptoms is needed to guide diagnosis and treatment. Assessing for painThere are two main methods for identifying pain in older people: self-report and observational. Self-reportSelf-report is the most reliable source of information on pain. Use it with all older people, including those with a cognitive or communication impairment.1,2 Self-report of pain may be obtained by:
All self-reports should be taken seriously, including those from older people with a cognitive impairment.4 Self-reported pain from people with a severe cognitive impairment or non-communicative patients should be cross-validated with an observational pain assessment and, where appropriate, discussed with the patient’s family or carer. However, take care when using family or carer reports of pain in an older person, as pain intensity may be over- or under-estimated.2 Self-report pain assessment toolsMultidimensional tools are used for an initial comprehensive pain assessment. They evaluate the sensory component of pain (what the person is feeling), the emotional response to pain (impact on the person’s function and relationships, and the meaning of the pain) and quality of life (activities, mood, sleep). The following tools may be used.
Unidimensional pain assessment tools are used for ongoing evaluation of pain intensity and response to treatment. They evaluate only the sensory component of pain. Examples include:
Some patients prefer to use numbers to describe their pain, while others prefer words. If you are not successful in using one type of self-report tool with an older person, try a different tool. ObservationalIn older people who have severe cognitive impairments or communication difficulties, their behaviour may be the only external indicator of pain.2 Pain behaviours are individual, so identifying pain requires clinical judgement and familiarity with the older person. Involving family and carers can help with identifying and confirming observational pain.2 The following observation scales are recommended for older people with severe cognitive or communication difficulties.5
Pain should be assessed at rest and during activity, such as movement or transfer. Behavioural and autonomic signs of painFacial expressions
Vocalisation
Body movement
Social interaction
Activities
Mental status
Autonomic signs
Autonomic signs of pain are only observable during a severe acute pain episode.2 They may reflect active nociception and may assist with identifying pain in older people who are intubated or unconscious following surgery but need to be used carefully, because the absence of autonomic signs does not indicate the absence of pain. Barriers to identifying painSeveral factors may interfere with an older person disclosing pain, including:
Comprehensive pain assessmentWhen an older person is identified as being at risk of pain or experiencing pain, a comprehensive geriatric-focused pain assessment should be conducted. The assessment should include the following elements.1,5,6 General medical historyInclude prior and coexisting medical conditions, pain and treatment outcomes. Pain history
Physical examination
Functional assessment
Psychosocial function
Cognitive function
Previous pain treatments
1 The American Geriatric Society, The management of persistent pain in older persons: American Geriatric Society panel on persistent pain in older persons. Journal of American Geriatric Society, 2002. 50: pp. S205-S224. 2 British Pain Society and British Geriatrics Society, Guidance on: The assessment of pain in older people., 2007, British Pain Society and British Geriatrics Society. 3 Royal College of Physicians, British Geriatrics Society, and British Pain Society, The assessment of pain in older people: national guidelines. Concise guide to good practice series, No 8., L. Turner-Stokes and B. Higgins, Editors. 2007, Royal College of Physicians: London. 4 Herr, K., Pain assessment in the older adult with verbal communication skills, in Pain in Older Persons, S. Gibson and D. Weiner, Editors. 2005, IASP Press: Seattle. pp. 111-133. 5 Zwakhalen, S.M., et al., Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatrics, 2006. 6. 6 The Australian Pain Society, Pain in residential aged care facilities: Management strategies, 2005, The Australian Pain Society: Sydney. 7 International Association for the Study of Pain. IASP Taxonomy 2012. 2012 [cited 2015 April 15]; Available from: . 8 Commissioner for Senior Victorians. Ageing is everyone’s business: a report on isolation and loneliness among senior Victorians, 2016, State of Victoria: Melbourne. |