Pain Screening
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INCLUDE COGNITIVELY IMPAIRED RESIDENTS
Because "pain is subjective and lacks objective biological markers," self-report of pain by residents "is generally held to be the gold standard of pain assessment" (7). In other words, "pain is whatever the person says it, existing whenever (the person) says it does" (6, 7).
But what if the person is cognitively impaired, as 50% of nursing home residents are? Will this person's self-report be meaningful? So much is made of this concern that even most studies that have examined pain prevalence in nursing homes have excluded residents with marked cognitive impairment on the assumption that their responses would be unreliable. Among the minority of studies that included cognitively impaired individuals, some have reported a low prevalence of pain among these residents. These findings provide another reason to exclude cognitively impaired residents from further research.
One disturbing consequence of this oversight is that cognitively impaired residents may be short-changed on pain management. In a recent study, we found that as cognitive impairment increased among residents with pain, the nursing staff were increasingly less likely to document pain presence. This finding suggests that nursing staff tend to disregard reports of pain by residents with more severe cognitive impairment.
As it turns out, cognitively impaired residents are remarkably trustworthy reporters. This conclusion is based on a recent study we conducted in 33 nursing homes with 893 residents (7). No one was excluded based on cognitive impairment.
What we found contradicts assumptions and findings from previous studies. First, we found a higher prevalence of pain among cognitively impaired residents than previous studies have reported. We also found that the vast majority of residents, including the most cognitively impaired residents, could provide us with meaningful self-reports of pain when asked four simple YES/NO questions.
We designed this study to determine whether a cognitive performance measure derived from the Minimum Data Set (MDS) could accurately identify residents capable of responding to our pain screening interview. Specifically, we used residents' MDS recall scores, which are calculated from four items on the MDS. Lower scores indicate greater cognitive impairment.
Our findings? Among the 79% of residents (n=709) with recall scores between 1 and 4, 83% to 97% answered all four questions. Yet even among the most cognitively impaired residents--the 21% with recall scores of 0--52% were able to complete the interviews.
This latter finding is in keeping with Parmelee's assertion that "self reports [of pain in cognitively impaired elderly] are…no less valid than those of cognitively intact individuals," a conclusion that Manz et. al concurred with as well (8, 9).
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