NASHVILLE, TENN. – Pain assessment is moving beyond listening for a patient to say “ouch.”
One possible way to estimate pain in all patients is to apply an observational scale that was first used on patients with advanced dementia.
“Pain behavior is helpful for assessing all patients, not just those who can't communicate,” Gail H. Reiner said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
A structured, itemized, pain-assessment tool might also work better than an unstructured, subjective impression when caregivers and family members attempt to gauge a patient's pain, said Dr. Anne C. Mosenthal, chief of surgical critical care at the University of Medicine and Dentistry of New Jersey-University Hospital in Newark.
Ms. Reiner and her associates tested the Pain Assessment in Advanced Dementia (PAINAD) scale on a convenience sample of 98 communicative patients. The scale was first reported in 2003 by researchers from Bedford, Mass. (J. Am. Med. Dir. Assoc. 2003;4:9–15). The scale scores five observational elements on a scale of 0–2, with 0 being normal and 2 being the most affected. (See box.) The result is a 0–10 score that's similar to an Apgar score, said Ms. Reiner, a nurse and director of staff education at San Diego Hospice and Palliative Care. The tool is “very user friendly” and can be applied in about 1 minute, she said.
The tested patients were either at the San Diego Hospice or in the hospice unit of a San Diego nursing home during June and July 2005. Their ages ranged from 32–98, with a mean age of 71 years, and 83% of patients were English speakers. Gender was evenly divided between women and men. Patients were assessed using the PAINAD tool, and they also underwent two interviews with verbal pain-assessment tools.
A statistical analysis of the results is still in progress. On a qualitative level, the older a patient was, the lower the intensity of described pain. But the patients' pain behaviors were stable across all ages. “Seemingly, the PAINAD scoring was not altered by age,” Ms. Reiner said.
Gender and English-language ability also appeared to be linked with verbal pain reporting, with women and English speakers more likely to report higher levels of pain. But these effects were not seen in the PAINAD scores.
The limitations of subjective impressions of pain were examined in a separate study by Dr. Mosenthal and her associates. They had critical care nurses, surgical residents, and family members rate the pain and symptom severity of 28 patients in the surgical ICU of University Hospital. Nurses and residents also rated the pain and symptoms of another 36 patients who did not have a family member available.
The observers rated pain using a 10-point scale (10 = severe), and symptoms using a four-point scale (4 = severe). Nine different symptoms were assessed and added for a total symptom score. Patients' self-ratings of pain and symptom severity were measured by an interview using the Edmonton Symptom Assessment Scale. Of the 64 patients, 37 were being treated for trauma and 27 had recent surgery. All patients were treated with either an opioid or sedative.
The average total symptom score was 22 by patient self-rating, 21 as gauged by family members, 13 when assessed by nurses, and 15 when estimated by physicians. The differences between the nurse and physician ratings and those of the patients were statistically significant, Dr. Mosenthal reported.
The average pain score among patients with no family members present was 4.7 by patient self-assessment, compared with 2.4 by nurses and 2.6 by physicians; those were statistically significant differences. When family members were present, the average pain score was 4.5 when measured by patients, 6.0 when estimated by family members, 2.2 according to nurse assessments, and 3.8 based on physician ratings.
“I was surprised. I thought nurses would do best,” Dr. Mosenthal said. All patients were receiving treatment for their pain, so their caregivers may have assumed that the pain was controlled.
“I think the PAINAD scale might work better.” They plan to test it and see if it improves results, she said.
A third study reported at the meeting tried to analyze the range of factors that contributed to chronic pain. The study included 50 patients with nonmalignant pain from arthritis, 50 patients with cancer-associated pain and hope for recovery, and 50 patients with terminal cancer pain. The patients were tested using a battery of pain-assessment tools that examined seven aspects of pain: physiologic, sensory, affective, cognitive, behavioral, sociocultural, and spiritual.