Pain in the elderly. How to better understand and rate it.


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It is often difficult to determine the amount of pain an elderly person is experiencing.This is complicated by dementia and verbal impairment. This presentation describes helpful methods to assess pain in the elderly.

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Pain in the elderly. How to better understand and rate it.

  1. 1. Measure of Pain in Elderly People with Dementia Ross Finesmith M.D. Abstract The care of the elderly patient suffering from dementia is complex, particularly when the nurse employs patient-centred, individualised approaches to care. Pain assessment in such cognitively impaired individuals is made much more difficult by their condition. Pain is frequently experienced by elderly patients, with reported prevalence rates as high as 45–84% among patients in healthcare settings. Cognitive impairment is also common in the elderly, with studies showing that approximately half of patients in nursing homes or palliative care settings are affected to some degree The Doloplus-2 method of clinical evaluation has been used to assess pain in elderly and those with dementia for 15 years. This paper will examine the published literature on the Doloplus-2 scale, evaluate the clinical utility and psychometric properties of this instrument through critical appraisal, and discuss how Doloplus-2 may be used in pain management for elderly patients with dementia. Perspective This article presents a critical review of a behavioural pain assessment scale, the Doloplus-2. The Doloplus-2 is a rating scale completed by nursing staff to categorize patient’s behavioral responses to acute pain. This measure could potentially help clinicians more effectively identify the extent of pain in elderly who are unable to verbalize their painful symptoms. Page 1
  2. 2. Key words: Pain scales, Doloplus, Alzheimer’s, Pain assessment. Elderly pain scale Index Introduction ………………………………………………………………………4-5 Critical Appraisal …………………..…………………………………………………5 - The Doloplus-2 scale ……………………………..………………………………..6 - Clinical Utility …………………………………………...………………………6-8 - Psychometric Properties …………………………..…………………...…………..8 - Validity…………………. …………………………………………………….8-9 - Reliability………..………………………………...…………………………9-10 - Responsiveness………………………………………………...……………10-11 2
  3. 3. - Other factors to consider …………………………………………………………..11 Conclusion ……………………………………………………………………….12-13 Appendices ……………………………………………………………………….14-16 References………………………………………………………………………...17-20 3
  4. 4. Introduction Evidence based practice is an essential aspect for all health care professionals because it is becoming fundamental for practice clinical decision making. Macnee and McCabe18 stress the importance of the evidence base in delivering care quality improvement. Although the nature of evidence based practice continues to be debated, especially from the differing ideological positions of nurses, medical staff and other professions, the use of evidence to inform and change practice is an important function of any nurse and requires the ability to apply critical evaluation to key areas of care as Melnyk and Fineout-Overholt 21 emphasise. The care of the elderly patient suffering from dementia (any one of the spectrum of disorders which produce dementia) is complex, particularly when the nurse employs patient-centred, individualised approaches to care. Elderly patients often present with complex healthcare needs, yet from some evidence available it is suggested that the elderly nursing care standards continue to be less than optimal.14 Over 50% of nursing home residents, and a similar number of elderly patients admitted to acute care hospitals, have dementia.11 Pain assessment in such cognitively impaired individuals is made much more difficult by their condition3 . Pain can result in behavioral changes in any person and should always be considered as a potential cause in patients with dementia, especially in those that are non-verbal. Failure to recognize pain in older adults can have serious effects on cognitive performance, quality of life; increase symptoms of depression and functional ability29 . An evaluation of pain measurement would serve many purposes, including identifying how consistently measurement tools or instruments are used by nursing staff (or other staff), identifying how effective the tools are in actually identifying pain, or how effective they are in reduced negative outcomes or behaviours in patients such as those with dementia whose cognitive impairments limit their ability to communicate pain levels. Davies et al6 identify that altered cognitive patients are unable to inform others of their pain. This essay examines one method of clinical evaluation applied to the clinical setting; the clinical evaluation method chosen is outcome measurement Pain assessment is the 4
  5. 5. chosen intervention for elderly people who suffer dementia. The outcome measure tool is the Doloplus-2 (see appendix 1). This paper will examine published literature on the Doloplus-2 scale, evaluate the clinical utility and psychometric properties of this instrument through critical appraisal, and discuss how Doloplus-2 may be used in pain management for elderly patients with dementia (see appendix 2). The critical appraisal checklist as Jerosch-Herold16 guide is followed in this paper because it is rigorous and comprehensive. It is hoped that the evidence gathered will allow informed decision-making on the acceptability of this scale for use by nurses and other care providers in everyday clinical practice. Critical appraisal Pain is frequently experienced by elderly patients, with reported prevalence rates as high as 45–84% among patients in healthcare settings.12,19 Cognitive impairment is also common in the elderly, with studies showing that approximately half of patients in nursing homes or palliative care settings are affected to some degree. 8,20,22 Regular assessment is vital in order to manage pain effectively. Elderly patients who had mild cognitive impairment might be able to communicate well enough to understand and use simple self-report tools for pain assessment such as the (VAS) tool, which is Visual Analogue Scale, (VRS) Verbal Rating Scale, (NRS) Numeric Rating Scale or (FPS) Facial Pain Scale. However, patients with moderate or severe impairment are frequently unable to understand or answer even simple questions.8 These patients present a challenge for nurses and other care providers and evidence shows that their pain management is frequently suboptimal, often as a result of inadequate assessment and diagnosis.22,37 Behavioural pain assessment instruments must be used with this group for their pain assessment. It is important to note that the behavioural pain assessment tools do not measure pain directly, but are based on observations of behaviour related to sleep patterns, level of appetite, patterns of physical activity and mobility, and expression of body language .37 Assessment of physiological indicators for example: the heart rate (Pulse) or blood pressure (BP) may also be included.37 There are many scales of behavioural pain assessment that have been developed for use including Doloplus-2, 5
  6. 6. Pain Assessment in Advanced Dementia (PAINAD), Pain Assessment in Dementing Elderly (PADE), Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Abbey Pain Scale.9,1,34,33,35 Glendinning 10 defines the outcomes as “Outcomes refer to the impact or the end results of services on the person’s life”. Therefore it is important to evaluate and appraise the tools used to measure them as Melnyk and Fineout-Overholt21 define the “outcomes measurement is a generic term used to describe the collection and reporting of information about an observed effect in relation to some care delivery process or health promotion action. It requires the careful identification of reliable and valid outcome indicators, the selection of appropriate measurement methods, and the assurance of timeliness of data collection and reporting”. Using these tools is intended to improve the elderly people quality of life and monitoring the effectiveness of the intervention as well as for the professional development by discovering who needs training as Corr and Siddons 5 say. Those tools which form part of models of care planning and management of pain, underline and reinforce continuous reassessment of pain in the light of changes in the patient’s condition due to medical procedures, movement, activities of daily living, and the administration of methods of pain relief. This kind of approach reflects the essence of nursing care. As such, pain assessment must also be considered an essential component of the nursing care of these individuals, because with the cognitive impairments that are caused by dementia, they are some of the most vulnerable patients that nurses will have in their care. The Doloplus-2 scale Clinical utility The clinical utility of an instrument is an important factor in determining if the instrument will be acceptable in clinical practice.28 To date, there are a lack of published data on all of the available behavioural pain assessment tools demonstrating their clinical utility, but the Doloplus-2 scale is the most widely tested scale.37 6
  7. 7. The Doloplus scale was originally developed as a 15-item scale in 1992 as a tool to assess pain in elderly patients with cognitive failure, then refined to the present Doloplus-2 scale in 1999.36 The scale comprises 10 items across 3 domains: somatic (5 items), psychomotor (2 items) and psychosocial (3 items), and records observations of various aspects of patient behaviour that may be indicative of pain. Items assess pain-related behaviours such as facial expressions, disturbed sleep, verbal reaction, protective body postures and functional impairment in daily activities, as well as psychosocial reactions and changes in patterns of communication (see appendix 1). Items are scored at one of four different levels which correspond to pain intensity levels rising (where 0 = normal behaviour and 3 = high level of pain-related behaviour).14,17 A final score ≥ 5 out of thirty (where 30 = maximum score of pain) confirms that the patient is suffering pain.37 The final score obtained is not a measure of the pain experienced by the patient at a particular point in time, rather a reflection of the progression of pain experienced.37 Research has shown that scales, which can be used effectively not including an in- depth knowledge of the patient, are of greater value than those which require the user to be familiar with the patient which they are assessing.30 A possible limitation of this scale is that it appears that the nurse or other care provider needs to know the patient well in order to attain the most accurate results. A further limitation is that although instructions for use are provided, certain items may be difficult to understand or interpret.37 Therefore, additional training may be required to ensure competency in those nurses wishing to use this scale with their patients, which will incur additional cost, thus making the scale less cost-effective. There is no available information about how long the scale takes to complete. There is limited evidence to date on the portability of the Doloplus-2 scale. The published literature that is available documents the findings of studies involving pain assessment in elderly patients in hospitals and nursing homes, which was the patient population for which this instrument was developed.14 Psychometric properties of the Doloplus-2 scale 7
  8. 8. Three psychometric properties are of particular importance when assessing a given outcome measure, namely validity, reliability and responsiveness. Holen and colleagues assessed the validity and reliability of the Doloplus-2 scale in a study in 2007. Their paper clearly defines the purpose of the study – to test the Doloplus-2 scale criterion validity and inter-rater reliability in elderly patients recruited from nursing homes.14 The study was conducted in a total of 73 patients with a mean age of 84 years. Within this sample, 50% of patients were reported to have severe cognitive impairment and 36% were classed as moderately impaired (Mini Mental State Examination [MMSE] scores of 0–10 and 11–20, respectively). It must be noted that this is a small sample size and no power calculation was reported in the paper. The study sample was representative of the patient population in whom the instrument would be used (i.e. elderly patients with cognitive impairment). The scale description is briefly included in the methods section of the paper, with full referencing of earlier studies. User competency is demonstrated by the inclusion of a statement indicating that the nurses who would be administering the instrument were either trained or familiar with the patient.14 Although this study was conducted in a small number of patients, it can be considered suitable for inclusion in this evidence-based investigation of the Doloplus-2 scale. Validity Validity relates to two factors: whether an instrument measures what it is intended for, and how much confidence users can have in the results obtained when using the instrument.5 Three different types of validity must be considered: face, content and criterion validity. The Doloplus-2 scale is meaningful to both the patient and the nurse as a behavioural pain assessment tool, thus demonstrating the face validity of this instrument. Furthermore, this scale provides a comprehensive assessment of changes in pain-related behaviour across three different domains, confirming content validity.37 Criterion validity examines the extent to which a particular scale corresponds with another well-established measure, typically considered the ‘gold standard’. However, in the case of behavioural pain assessment, no gold standard currently exists and other pain measures must therefore be used for comparison. In an observational study of a 8
  9. 9. convenience sample of 73 patients by Holen and colleagues,14 a pain specialist nurse evaluated patients’ pain levels using a Numerical Rating Scale (a widely used pain measure with favourable psychometric properties). Results of univariate regression analyses showed no correlation between results obtained using the Doloplus-2 scale and the expert’s pain ratings (R2 = 0.02). Interestingly, when results obtained with Doloplus-2 were compared with pain ratings on a subset of patients (n = 16) assessed by a geriatric expert nurse, a considerable higher rating of R2 = 0.54 was obtained. It must therefore be debated whether pain ratings determined by a pain expert who was unfamiliar with the patients provides an acceptable means of comparison. A prospective observational study by Pautex and colleagues25 in 2007 conducted in 180 hospitalised patients (mean age = 83.7 years; mean MMSE = 18.0) also investigated the criterion validity of the Doloplus-2 scale. It improved on the previous study with a larger sample size and by comparing observed pain to patient-reported pain. The self-report VAS was employed as the gold standard in this study.27,15 Findings showed moderate correlation of Doloplus-2 with the VAS (Spearman coefficient=0.46).25 Results of a small-scale study (n = 16 participants) conducted using a French language version of the scale reported a correlation between Doloplus- 2 and both the VAS and L’Echelle Comportementa le Pour Personne Agées (ECPA) (r = 0.67 using Pearson correlation coefficients).37 Torvik et al32 designed a study to assess the reliability (internal consistency) of Doloplus-2 and compare registered nurses’ estimations of pain to the findings on the Doloplus-2 assessment. A total of 77 non-verbal patients with a mean age of 86 were included from 7 nursing homes in Norway. The patient’s primary registered nurse administered the Doloplus-2 following an instructional session. Concordance (90%) was found between proxy rating and Doloplus-2 scores with respect to estimating ‘pain’ with the two different assessment methods, suggesting that the two measures are addressing the same pain construct. The Cronbach’s alpha score for the total questionnaire was 0.71 9
  10. 10. In this study, 52% of the patients were rated by nurses to be experiencing pain, compared with 68% when using Doloplus-2 (p = 0.01). In one-third of the patients the nurses could not determine whether the patients were in pain while the Doloplus-2 score represented pain. These findings support the use of Doloplus-2 as a supplement to proxy rating. Reliability Reliability relates to the consistency and stability of a particular outcome measure. There are two types of reliability, which must be considered in any evaluation: test- retest reliability (i.e. a measure of how consistent the instrument is in producing the same results at repeated intervals with the same user) and inter-rater reliability (i.e. how consistent the instrument when used by different people). A systematic review carried out in 2006 by Holen and colleagues about behavioural pain assessment tools that reports adequate test – retest and inter - rater reliability of the Doloplus-2 scale. The study shows, an inter-rater reliability of 0.77 (CI, 0.47–0.92) was obtained using intra-class correlation coefficients. 14 An observational study conducted in a non-probability sample of 128 residents in three nursing homes investigated pain during influenza and care situations using a Dutch translation of the Doloplus-2 scale.38 Test-retest reliability of this scale was measured using Cronbach’s alpha (where values ≥7.0 are considered high).26 An alpha coefficient of 0.74 was obtained for the total scale and a range of 0.58–0.80 was obtained for individual subscales. These findings therefore demonstrate good test- retest reliability of Doloplus-2 in this population. In the development and reliability assessment of the Doloplus-2 Japanese version, non-verbal patients with AD were assessed for pain following surgery for a hip fracture. In this study, 31 nurses monitored 6 patients during post-surgical rehabilitation sessions. The intraclass correlation coefficient for inter-rater reliability for the Version 2 administrators was 0.90 (P < 0.001), with a 95% confidence interval of 0.88–0.92; the degree of agreement by items (0.67–0.90) was excellent.2 Nurses' reported that while utilizing the Doloplus-2 there were no difficulties scoring Japanese expressions and facial expressions. Analysis of individual patient case 10
  11. 11. studies indicated that pain scores were high only when the patients clearly were experiencing pain, such as full weight bearing on the surgical hip. These results were used to finalize the Japanese Doloplus-2. This was a small sample size and a similar designed larger cohort still must be studied to confirm these findings. The reliability, validity and clinical feasibility of Chinese version of the Doloplus-2 scale were supported in a study of institutional older people with moderate and severe dementia. In this study the internal consistency for the total scale, was alpha 0.74 and the subscales range was 0.67–0.87. The intra-class correlation coefficient of the scale was 0.81 and of the subscales ranged from 0.60 to 0.81.4 The mean score of clinical feasibility assessed by 14 RNs was 4.14 (S.D. 0.77; range 3–5), supporting the clinical usefulness of Chinese-Doloplus-2 scale. The mean scores of the total C-Doloplus-2 demonstrated that older people with moderate and severe dementia had low levels of behavioral expressions of pain. In an eloquently designed study, Pickering et al24 examined the reliability of the Doloplus-2 scale across 5 different languages. The languages were English, Italian, Portuguese, Spanish and Dutch. Nine teams (one for Dutch and two for each of the other languages) were been developed on the basis of experience and competence in geriatrics and in pain evaluation of elderly patients with communication disorders. Each team tested the scale in their native language with at least 40 elderly persons. There were 40 patients per team and each patient was assessed by two trained physicians independently. Physician 1 evaluated the patient and physician 2 rated the patient again 4 hours later without any treatment in between. Each physician assessed the patients by observing for a few minutes prior to scoring the Doloplus-2® scale. The raters were blind to previous ratings. The aim of the present study was to validate the translation of the Doloplus-2 scale in five languages, with regard to test–retest and inter-rater reliability. Pearson and intra- 11
  12. 12. class correlation coefficients reveled good to excellent results for the four languages, English, Italian, Portuguese and Spanish. The Pearson correlation coefficient ranges from 0.95 to 0.99 for test–retest reliability and from 0.92 to 0.97 for inter-rater reliability; the intra-class correlation coefficient ranges from 0.83 to 0.98 for test– retest reliability and from 0.84 to 0.97 for inter-rater reliability. Dutch correlations are fair to moderate, inter-rater reliability is 0.75 and test–retest reliability is 0.57 (Pearson) or 0.62 (intra-class). These results establish that reliability tests and correlations are good to excellent for the English, Italian, Portuguese and Spanish versions, while the reliability correlations are fair to moderate and more heterogeneous for the Dutch scale. Responsiveness This relates to how sensitive a particular instrument is at detecting meaningful and clinically important changes over time. The first clinical trial using the Doloplus-2 scale has recently been published. A randomised, crossover, open label study was carried out in 34 inpatients (aged 53–96 years) at hospitals in France to investigate the use of nitrous oxide-oxygen mixture for pain relief while taking care of bedsores and painful ulcers.23 Patients were randomised to receive: morphine only, nitrous-oxide- oxygen mixture only, or a mixture of morphine plus nitrous oxide-oxygen mixture. Results showed statistically significant differences between the morphine only and nitrous oxide-oxygen mixture only treatment groups using the Doloplus-2 scale (p<0.01). Similar findings were also obtained using the ECPA and VAS scales. This study serves to demonstrate the responsiveness of the Doloplus-2 scale. However, further studies are needed to confirm these findings. It should also be noted that the Doloplus-2 is not designed to detect subtle changes in pain-related behaviour and focuses mainly on indicators such as facial expressions.37 A number of other early validation studies have also been carried out on the Doloplus- 2 scale and the findings of these are discussed in the systematic review of behavioural pain assessment tools carried out by Zwakhalen and colleagues in 2006.37 These 12
  13. 13. studies were conducted on patients in geriatric centres and palliative care settings and investigated validity, test-retest reliability and inter-rater reliability.37 However, in these studies, only a small proportion (1–5%) of the overall study sample was unable to communicate verbally. Results confirmed the criterion validity of the scale, demonstrating significant correlations between Doloplus-2 and the VAS (p<0.001). Furthermore, Doloplus-2 showed good responsiveness. A test-retest reliability of 0.82 (using Cronbach’s alpha) was reported and correlation testing as a measure of inter- rater reliability found no significant differences between different users. While these results are undoubtedly encouraging, it must be remembered that the patient population in these studies were largely able to communicate verbally which may have had some bearing on the results obtained. The Doloplus-2 is available in a number of languages including English, French, Norwegian and Dutch but further investigation of the psychometric properties of each of these different language versions is still needed. Other factors to consider In any evaluation of a particular outcome measure, it is important to consider whether the instrument is user-centred. Assessment of pain in elderly patients with moderate or severe cognitive impairment is challenging because of their lack of understanding and verbal communication. By necessity, the Doloplus-2 scale is completed entirely by the user with little or no input from the patient. As previously discussed, if the nurse is unfamiliar with the patient or inexperienced in using this tool, it may not be possible to make an accurate assessment. Behavioural pain assessment instruments such as Doloplus-2 cannot therefore be considered as user-centred as self-reported pain assessment measured such as the VAS which patients complete themselves. Torvik et al32 compared reported pain scale ratings between a cohort verbal and non- verbal elderly patients. The study was a cross-sectional, interviewer-assisted and proxy-rated survey using the Doloplus-2. The patients were divided into two groups depending on their cognitive functioning. Patients who were able to verbally respond appropriately during the Mini-Mental Status Examination (MMSE) were classified as self-reporting and those unable to respond verbally were entered into or the proxy- 13
  14. 14. rated group. Of the 214 patients in the study, 128 were classified, and able to, self- report symptoms and 86 were unable to self-report and therefore assessed with the Doloplus-2. In the self-report group, 80% were rated mildly or moderately impaired on the MMSE. The group assessed with the Doloplus-2, none of the selected variables were significantly related to pain. The variables included Barthel index, pain-related diagnosis, receiving pain medication, age and gender. There was no difference between the groups with or without pain and therefore raises questions about the whether the Doloplus-2 scale was used in the correct way or if it is sensitive enough to discriminate between pain and other observed behaviors. The limitation o=f the study was the criteria for stratification of the patients. The verbally responsive group was assessed with the MMSE and by default those that could not appropriately respond where classified in the other group. The degree of their dementia is not clear. Additional research comparing cognitively equal verbal and non-verbal groups are needed to study the raised questions. Conclusions Assessing pain for elderly patients with cognitive impairment presents a considerable challenge for nurses and other care providers. Accordingly, reports suggest that pain is frequently unrecognised and under treated among in this patient group.13 To date, there is a lack of published literature on all of the behavioural pain assessment tools which are available. This paper examined the available evidence of the clinical utility and psychometric properties of the Doloplus-2 scale. Available studies are limited in number and offer inconclusive evidence about the validity, reliability, and responsiveness of the Doloplus-2 scale to measure pain in older adults. Without a valid, reliable, and responsiveness tool, measuring improvements in care quality is impossible. While the problem of unrecognised pain in cognitively impaired individuals is a serious one, the evidence does not support implementing the Doloplus-2 behavioural pain assessment tool in the clinical setting. Evidence suggests that the Doloplus-2 14
  15. 15. scale requires knowledge of the patient in order to assess the patient accurately. The information gathered by the scale may not always be easily interpreted by the nurse or other care provider without the need for training to ensure competency, thus increasing the costs associated with using this scale. While the face and content validity of the Doloplus-2 scale are confirmed, there is insufficient evidence to confirm the criterion validity of the Doloplus-2 scale in this patient population. It must be noted that as there is no gold standard behavioural pain assessment tool, either self-report instruments or expert pain ratings are currently used for comparison which may not be ideal for comparison and thus limit the accuracy of the information obtained on the criterion validity of Doloplus-2. Test-retest reliability of Doloplus-2 was shown to be high in one study but again; further investigation of this property is required to confirm these findings. Only one randomised clinical trial has so far been published which employs the Doloplus-2 scale and although findings demonstrated the sensitivity of this scale, it should be noted the sample size in this study was small. Behavioural pain assessment tools cannot be considered as user-centred as self- reported pain measures but offer the only way of assessing pain in patients with limited ability to communicate. To conclude, following this review of the published literature on the Doloplus-2 scale, currently the evidence to recommend the implementation of the Doloplus-2 in everyday clinical practice are insufficient, particularly for inexperienced users or those who are unfamiliar with the patients which they are assessing. Appendices Appendix 1 15
  16. 16. 16
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