Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care

Abstract

BackgroundThe purpose of this study was to determine the relationship between hypothesized pain behaviors in the elderly and a measurement model of pain derived from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0 items.MethodsThis work included a longitudinal cohort recruited from Medicare-certified longterm care facilities across the United States. MDS data were collected from 52,996 residents (mean age 83.7 years). Structural equation modeling was used to build a measurement model of pain to test correlations between indicators and the fit of the model by cognitive status. The model evaluates the theoretical constructs of pain to improve how pain is assessed and detected within cognitive levels.ResultsUsing pain frequency and intensity as the only indicators of pain, the overall prevalence of pain was 31.2%; however, analysis by cognitive status showed that 47.7% of the intact group was in pain, while only 18.2% of the severely, 29.4% of the moderately, and 39.6% of the mildly cognitively impaired groups were experiencing pain. This finding supports previous research indicating that pain is potentially under-reported in severely cognitively impaired elderly nursing home residents. With adjustments to the measurement model, a revised format containing affective, behavioral, and inferred pain indicates a better fit of the data to include these domains, as a more complete measure of the pain construct.ConclusionPain has a significant effect on quality of life and long-term health outcomes in nursing home residents. Patients most at risk are those with mild to severe cognitive decline, or those unable to report pain verbally. Nursing homes are under great scrutiny to maintain standards of care and provide uniform high-quality care outcomes. Existing data from federally required resident surveys can serve as a valuable tool to identify indicators of pain and trends in care. Great responsibility lies in ensuring pain is included and monitored as a quality measure in long-term care, especially for residents unable to communicate their pain verbally.

Ethnic Differences in Nonverbal Pain Behaviors Observed in Older Adults with Dementia

“…With the chronic progressive decline of cognition and loss of function that occurs in dementia (Corbett et al, 2014), the expression of pain becomes more challenging (Corbett et al, 2014; Flo, Gulla, & Husebo, 2014; Shega et al, 2008). Consequently, as dementia progresses, these older adults tend to report fewer painful conditions (Burfield, Wan, Sole, & Cooper, 2012), even though they may suffer from the same painful diagnoses as cognitively intact older adults (Closs, Cash, Barr, & Briggs, 2005; Husebo et al, 2008; Reynolds, Hanson, DeVellis, Henderson, & Steinhauser, 2008). Burfield et al (2012) found that 47.7% of cognitively intact older adults reported experiencing pain daily, while only 39.6% of those older adults with mild dementia, 29.4% of the moderately impaired, and 18.2% of older adults with severe dementia reported painful experiences despite similar painful diagnoses.…”

“…Consequently, as dementia progresses, these older adults tend to report fewer painful conditions (Burfield, Wan, Sole, & Cooper, 2012), even though they may suffer from the same painful diagnoses as cognitively intact older adults (Closs, Cash, Barr, & Briggs, 2005; Husebo et al, 2008; Reynolds, Hanson, DeVellis, Henderson, & Steinhauser, 2008). Burfield et al (2012) found that 47.7% of cognitively intact older adults reported experiencing pain daily, while only 39.6% of those older adults with mild dementia, 29.4% of the moderately impaired, and 18.2% of older adults with severe dementia reported painful experiences despite similar painful diagnoses. These findings suggest that pain is less likely detected and treated in persons with dementia, particularly as the dementia worsens.…”

Characteristics Associated with Quality of Life in Long-Term Care Residents with Dementia: A Cross-Sectional Study

“…Although some studies confirm a relationship between pain and a lower psychological wellbeing in dementia, the exact relationship between pain and the various domains and the effect on QOL remains unclear [20,21,22,23]. In addition, although chronic diseases can have an impact on QOL, information is lacking on their relationship with QOL in persons with dementia [24,25].…”

The relationship between pain and disruptive behaviors in nursing home resident with dementia

“…Therefore, pain is often under-reported in NH residents with dementia. These residents may express pain through disruptive behaviors [3], because they cannot appropriately verbalize their pain experience.…”