Annals of Long Term Care

alzheimer’s association
Best Practices in Nursing Care for Hospitalized Older Adults with dementia
from The John A. Hartford Institute for Geriatric Nursing and the Alzheimer’s Association

Issue Number D2, Revised 2007
Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing

WHY: There is no evidence that older adults with dementia physiologically experience less pain than do other older adults (American Geriatrics Society (AGS), 2002). Rather than being less sensitive to pain, cognitively-impaired elders may

As with all older adults, those with dementia are at risk for multiple sources and types of pain, including chronic pain from conditions such as osteoarthritis and acute pain. Untreated pain in cognitively impaired older adults can delay healing, disturb sleep and activity patterns, reduce function, reduce quality of life, and prolong hospitalization.

BEST TOOLS:
Several tools are available to measure pain in older adults with dementia. Few have been comprehensively evaluated and each has strengths and limitations (Herr, Decker, & Bjoro, 2006). The American Medical Directors Association has endorsed the Pain Assessment in Advanced Dementia Scale (PAINAD) (Warden, et al, 2003).

We recommend the following:
• Ask older adults with dementia about their pain. Even older adults with mild to moderate dementia can respond to simple questions about their pain (American Geriatrics Society, 2002).
• Use a standardized tool to assess pain intensity, such as the numerical rating scale (NRS) (0-10) or a verbal descriptor scale (VDS) (Herr, 2002; See also Try This: Pain Assessment). The VDS asks participants to select a word that best describes their present pain (e.g., no pain to worst pain imaginable) and may be more reliable than the NRS in older adults with dementia.
• Use an observational tool (e.g., PAINAD) to measure the presence of pain in older adults with dementia.
• Ask family or usual caregivers as to whether the patient’s current behavior (e.g., crying out, restlessness) is different from their customary behavior. This change in behavior may signal pain.
• If pain is suspected, consider a time-limited trial of an appropriate type and dose of an analgesic agent. Thoroughly investigate behavior changes to rule out other causes. Use the PAINAD to evaluate the pain before and after administering the analgesic.

TARGET POPULATION: Older adults with cognitive impairment who cannot be assessed for pain using standardized pain assessment instruments. Pain assessment in older adults with cognitive impairment is essential for both planned or emergent hospitalization.

VALIDITY AND RELIABILITY: The PAINAD has an internal consistency reliability ranging from .50 (for behavior assessed at rest) to .67 (for behaviors assessed during unpleasant caregiving activities). Interrater reliability is high (r - .82 - .97). No test-retest reliability is available.

STRENGTHS AND LIMITATIONS: Pain is a subjective experience and there are no definitive, universal tests for pain. For patients with dementia, it is particularly important to know the patient and to consult with family and usual caregivers.

BARRIERS to PAIN MANAGEMENT in OLDER ADULTS with DEMENTIA: There are many barriers to effective pain management in this population. Some common myths are: pain is a normal part of aging; if a person doesn’t verbalize that they have pain, they must not be experiencing it; and that strong analgesics (e.g., opioids) must be avoided.