Interrater Variability in Pain Assessment of Long-term Care Residents with Dementia

Abstract

People with dementia are at great risk of their pain being undetected. In long-term care facilities, certified nursing assistants are on the front-line to detect whether a resident with dementia is experiencing pain, but research on certified nursing assistants' abilities to accurately assess pain are scarce. This study aims to examine certified nursing assistants' pain assessment skills using a simulated standardized video context. Design: A cross-sectional study was conducted. Methods: Fifty certified nursing assistants and 40 individuals with no professional experience in the field of care (controls) watched the same video of an older adult woman with dementia experiencing pain. Afterwards, they completed visual analog scales (pain intensity, affective distress), an observational pain assessment scale (Algoplus), and a set of questionnaires. Results: In both groups, pain intensity assessment and empathic reaction scores showed important interrater variability. Moreover, certified nursing assistants and controls did not differ in detecting the presence of pain or assessing its intensity. But certified nursing assistants displayed lower empathic reactions and dispositions. Certified nursing assistants pain assessment scores decreased with experience and expertise. Conclusions: The practice of pain assessment is challenging for certified nursing assistants in long-term care facilities. Their professional status does not prevent inter-personal inconsistency and tends to lower their empathic dispositions. Personal determinants may interfere with their assessment behaviors and must be considered to enhance pain management for residents with dementia.

The influence of Alzheimer’s disease stigma on pain assessment in older persons

“…Indeed, using the Algoplus, the observer is asked to report explicit behaviors that can signal the presence of pain thus limiting the influence of subjective impression. Then, the high inter-rater variability found in the Algoplus scores in both part of this research and in previous works (Vitou et al, 2021) may more originate in the difficulty of assessing pain on the base of facial expressions than in the influence of personal beliefs and experience (Lautenbacher et al, 2013).…”

“…It displayed no blood, no wound, no sign susceptible to elicit disgust or physical discomfort. The video has been validated in a prior study as representing a standard painful situation experienced by an older adult woman with an inconspicuous cognitive status (Vitou et al, 2021).…”

“…Based on the modified labeling theory (Link & Phelan, 2001) and on previous studies on the influence of stigma on pain assessment (Azevedo et al, 2014; De Ruddere & Craig, 2016; Decety et al, 2010), we designed an experimental vignette/label protocol to manipulate different disease conditions. A unique video stimulus, validated as displaying a standard painful situation of the daily care practice of certified nursing assistants (Vitou et al, 2021), was proposed in order to control sources of bias related to the assessed person and the assessment context. Pain was assessed using two complementary measures: a visual analog scale (VAS) to collect the subjective clinical impression of the observer (Apinis et al, 2014) and then a structured observational tool, the Algoplus, recommended for the assessment of older people with communication difficulties, to provide a more objective evaluation (Rat et al, 2014).…”

“…Studies on physicians and nurses have shown that personal characteristics such as seniority (Prkachin et al, 2007), empathy (Goubert et al, 2009; Green et al, 2009), and burnout (Gleichgerrcht & Decety, 2014) may influence the pain assessment ratings of the observers. A recent study that focused on certified nursing assistants in long term care facilities showed that their pain assessment scores decreased with experience and expertise (Vitou et al, 2021). Studies about the influence of the observers’ sex and age in a care context are scarce and show inconsistent results (Gingras et al, 2021; Ruben et al, 2018).…”

Knowledge and Attitudes towards Palliative Care: Validation of the Spanish Version of Questionnaire on Palliative Care for Advanced Dementia

“…Despite this, however, the facial expression of pain in people with dementia is very homogeneous in both presence and intensity, thus allowing us to detect it using validated scales [63][64][65]. This may be partly attributed to knowledge deficits and negative attitudes of health care staff and informal caregivers towards pain, its assessment, and management in dementia [66]. Healthcare professionals should gain confidence and be able to distinguish signs and symptoms of pain from dementia-related behavioral changes.…”