Differences in Staff-Assessed Pain Behaviors among Newly Admitted Nursing Home Residents by Level of Cognitive Impairment

Abstract

<b><i>Objective:</i></b> Pain is common among nursing home residents with cognitive impairment and dementia. Pain is often underdiagnosed and undertreated, which may lead to adverse health outcomes. Nonverbal behaviors are valid indicators of pain, but the extent to which these behavioral expressions vary across levels of cognitive impairment is unknown. This study sought to examine differences in the prevalence of pain behaviors among nursing home residents with varying levels of cognitive impairment. <b><i>Methods:</i></b> The Minimum Data Set, version 3.0, was used to identify newly admitted nursing home residents with staff-assessed pain (2010–2016, <i>n</i> = 1,036,806). Staff-assessed pain behaviors included nonverbal sounds, vocal complaints, facial expressions, and protective body movements or postures over a 5-day look-back period for residents unable or unwilling to self-report pain. The Cognitive Function Scale was used to categorize residents as having no/mild, moderate, or severe cognitive impairment. Modified Poisson models provided adjusted prevalence ratios (aPR) and 95% CIs. <b><i>Results:</i></b> Compared to residents with no/mild cognitive impairments (any pain: 48.1%), residents with moderate cognitive impairment (any pain: 42.4%; aPR: 0.94 [95% CI 0.93–0.95]) and severe cognitive impairment (any pain: 38.4%; aPR: 0.86 [95% CI 0.85–0.88]) were less likely to have any pain behavior documented. Vocal pain behaviors were common (43.5% in residents with no/mild cognitive impairment), but less so in those with severe cognitive impairment (20.1%). Documentation of facial expressions and nonverbal pain behaviors was more frequent for residents with moderate and severe cognitive impairment than those with no/mild cognitive impairment. <b><i>Conclusions:</i></b> The prevalence of behaviors indicative of pain differs by level of cognitive impairment. Pain evaluation and management plays an important role in treatment and care outcomes. Future work should examine how practitioners’ perceptions of pain behaviors influence their ratings of pain intensity and treatment choices.

Pain Behaviors and Pharmacological Pain Management Among Newly Admitted Nursing Home Residents

“…Four pain behaviors shown to be valid indicators of pain were assessed (Saliba & Buchanan, 2008). Vocal complaints of pain—the most common pain behavior documented among residents with staff-assessed pain (Morrison et al, 2020)—includes complaints such as “that hurts,” “ouch,” or “stop.” Nonverbal sounds are characterized by “crying, whining, gasping, moaning, or groaning.” Facial expressions include “grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth, or jaw.” Protective body movements or postures include “bracing, guarding, rubbing or massaging a body part/area, and clutching or holding a body part during movement.” We hypothesized that vocal pain behaviors may be associated with the greatest likelihood of pharmacological pain management. We also hypothesized that residents with multiple pain behaviors would be more likely to receive pharmacological management of pain.…”

“…Four pain behaviors shown to be valid indicators of pain were assessed (Saliba & Buchanan, 2008). Vocal complaints of pain-the most common pain behavior documented among residents with staff-assessed pain (Morrison et al, 2020)includes complaints such as "that hurts," "ouch," or "stop." Nonverbal sounds are characterized by "crying, whining, gasping, moaning, or groaning."…”

Commentary on Pain Behaviors in Dementia: Letter to the Editor with Reference to the Article by Morrison et al. (2020)

“…We read with keen interest the recent study by Morrison et al [ 1 ], entitled “Differences in Staff-Assessed Pain Behaviors among Newly Admitted Nursing Home Residents by Level of Cognitive Impairment,” published in the journal Dementia and Geriatric Cognitive Disorders . In the period 2010–2016, the research examines differences in the prevalence of pain behaviors among US nursing home residents ( n = 1,036,806) with varying levels of cognitive impairment (CI) [ 1 ].…”

“…In this study, there are a number of interesting findings: The association between the level of CI and the frequency of documentation of pain behaviors, established using modified Poisson models. Of particular note, newly admitted residents with moderate-to-severe CI were less likely to have their pain documented/assessed by aged care staff compared to those with no or mild CI [ 1 ]. This may explain the undertreatment of pain in the residential aged care setting, particularly in those living with later stages of dementia [ 2 ].…”

“…This may also be an evolutionary and compensatory mechanism for partial or complete loss of verbal communication of pain [ 3 ]. Compared to those with no or mild CI, facial expressions of pain are more commonly documented for residents with moderate-to-severe CI, independently of the effect of covariates, such as depression and anxiety [ 1 ]. This finding is not surprising and aligns well with previous literature [ 4 , 5 , 6 ].…”