Probable Pain on the Pain Assessment in Impaired Cognition (PAIC15) Instrument: Assessing Sensitivity and Specificity of Cut-Offs against Three Standards

Abstract

Observational pain scales can help to identify pain in persons with dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) covers 15 items that indicate pain, but it is unclear how probable pain is, for each summed score (range 0–45). We aimed to determine sensitivity and specificity of cut-offs for probable pain on the PAIC15 against three standards: (1) self-report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut-off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with re-assessment after 2 months in 137 residents. The area under the ROC curve was excellent against the PAINAD cut-off (≥0.8) but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, PAIC15 scores of 3 and higher represent possible pain for screening in practice, with sensitivity and specificity against self-report in the 0.5 to 0.7 range. While sensitivity for screening in practice may be too low, a cut-off of 4 is reasonable to indicate probable pain in research.

Could negative behaviors by patients with dementia be positive communication? Seeking ways to understand and interpret their nonverbal communication

“…For timely pain management, caregivers are in desperate need of a way to interpret the nonverbal communications of patients with dementia. 13 Pain is highly prevalent in patients with dementia who are nonverbal. Chronic pain is still undertreated in such patients because of changes in their perception and expression of pain.…”

“… 14 Near the end of life, patients with dementia might have increased pain when resting. 13 Pain severity could predict a decline in daily living functioning for those patients. 15 A systematic review showed strong scientific evidence for five body movements as pain indicators in older adults who had cognitive impairments and who could not self‐report pain: physical aggression, agitation (restlessness), guarding, rubbing, and rigidity.…”

“…In any care setting, family and professional caregivers can use validated observational tools to help identify probable pain in patients with dementia who have limited ability to self‐report pain. 13 , 17 , 18 , 19 For example, the Pain Assessment in Advanced Dementia scale 17 is a five‐behavior‐item observational tool with a total score ranging from 0 to 10 (0 = no pain, 10 = presenting pain behavior). Caregivers score what they see and hear with respect to breathing patterns, negative vocalization, facial expression, body language, and consolability for up to 5 min during and after active movement.…”

Towards a Better Understanding on How Cognitive Impairment Affects Pain

“…The articles included in this Special Issue focus on pain outcomes and pain responses in varies types and pathologies of cognitive impairments, ranging from individuals with intellectual disabilities [ 1 , 2 , 3 ] to older adults with varying degrees of cognitive impairments [ 4 , 5 , 6 , 7 ] and more severe forms of dementia [ 8 ]. Moreover, about half of the articles have a clear clinical perspective, with investigations focused on the reliability [ 9 ] and clinical cut-off scores [ 8 ] of observational pain assessment scales as well as reflections on the pain management and pharmacological treatment of pain in younger and older individuals with cognitive impairments [ 1 , 7 ]. Other articles applied controlled experimental pain stimuli to compare pain sensitivity between different pathologies of cognitive impairments [ 2 , 4 ].…”

“…Across all articles, it becomes evident that pain is still often overlooked in individuals with cognitive impairments and that observational pain assessment tools are necessary to improve this situation in these vulnerable individuals. The articles included also show promising findings, namely that these observational pain assessment scales allow for a reliable pain assessment that is relatively consistent across different regions in Europe, across different language versions, and across different pathologies [ 3 , 4 , 8 , 9 ]. Moreover, it also becomes apparent across articles that cognitive impairment is not necessarily associated with a decrease in pain responsiveness to noxious stimuli; in contrast, several articles point to an increase in pain responses in individuals with cognitive impairments [ 2 , 4 , 5 ].…”