It’s a cold and snowy day. You receive a call for a 50-year-old woman who’s fallen on ice in her driveway. She gives you and your partner a half-smile when you greet her. She’s alert and oriented, slightly pale. After a quick visual assessment, it’s easy to see she’s in pain, and when you palpate her hip, the resulting grimace and yell all but confirm a hip fracture. She’s quickly extricated with a scoop stretcher and given ample pain medication to make her ride as comfortable as possible.
Later the same day, you receive a call for an 85-year-old male who fell in an assisted living facility. Upon arrival, you find your patient sitting on a chair waiting to be taken to the hospital. Unlike the woman you treated earlier, he has severe dementia and isn’t able to participate in his examination in the ways you’re accustomed. He doesn’t respond to your greeting and he punctuates nearly every attempt at palpation anywhere on his body with an “ouch.”
Staff report he fell 30 minutes ago, and they had helped him off of the floor and walked him about 20 feet over to a chair. He doesn’t have any obvious injuries, and he’s clearly ambulatory. Staff wants him “checked out” at the hospital according to their facility policy. It’s later determined he has a hip fracture.
In the first instance, your quick visual assessment is an example of “flying by the seat of your pants”–you quickly judged that your patient was in pain. And you were right. In the second instance, however, with only limited input from the patient, your task was much more difficult. The ability to conduct a quick visual assessment and the need for pain management was unclear.
PREHOSPITAL PAIN MANAGEMENT
Studies repeatedly demonstrate prehospital providers rarely provide the level of pain medication to appropriately relieve a patient’s pain. In a 2013 study of paramedics’ attitudes about providing pain medications, there were a number of psychological barriers: the reluctance to give medications without objective signs (e.g., obvious broken bones or abnormal vital signs), the fear of hiding diagnostic symptoms, and a lack of understanding about how much pain medication to give.1
A study looking specifically at pain management for suspected extremity fractures reported that only 1.8% of the patients received pain medication in the prehospital setting.2 A similar study examining pain management in lower-extremity fractures indicated only 18% of the patients were given pain medications, but when the patients arrived at the hospital, a full 91% received pain medications–an indication prehospital pain management was significantly lacking. Most disturbing, of the 18% who received pain medications, there was a bias toward younger patients.3 In other words, paramedics were more likely to adequately medicate younger patients in pain vs. older patients.
Pain management in dementia patients is challenging even in the hospital setting. A study of patients with hip fractures divided into two groups (with and without cognitive impairment), and the amount of postoperative pain medication was tracked. Following surgery, it was determined 50% of the patients with no cognitive deficits received inadequate pain medication–and these patients were given an average of 300% more pain medication than the group with dementia.
So, if 50% of the patients who had no trouble describing and rating their pain were under-medicated, then the group of dementia patients–who couldn’t articulate their pain adequately–were most likely in significant pain.4
This bias toward under-medicating cognitively impaired patients was shown again in the assisted living environment when a study positively demonstrated pain management decreased with the patient’s ability to articulate and communicate.5
Because the number of patients with dementia is only going to continue to increase, it’s imperative we understand how to manage their pain more effectively. A study using data from the 2000 census projected a three-fold increase (from 4.5 to 13.2 million) in the number of people 65 years of age and older who will be diagnosed with some type of cognitive decline by the year 2050.6
DEFINING DEMENTIA
In a broad sense, dementia is the loss of brain function. Typical symptoms are forgetfulness, communication problems, loss of control over bodily functions and inability to care for oneself. Dementia is a general medical category describing a set of symptoms and isn’t a disease, and the category contains several different types.7 (See Table 1, above.) The most common are Alzheimer’s and vascular, however, there are many subtypes and mixtures such as Lewy body, frontotemporal and Parkinson’s with similar presentations.8
There’s no known cure for dementia, but scientists have identified several causes– mostly related to either misshaped or excessive proteins in the brain that interfere with communication, but it can be caused by stroke, trauma or disease.
Further complicating this condition is the presumption that every episode of forgetfulness, noncompliance with medical orders, or plain stubbornness is a case of dementia. Contrary to popular belief, older adults don’t have substantial declines in intelligence and memory, but rather the process of memory recall slows. Just because grandpa doesn’t want to eat broccoli or take another dose of medication doesn’t make him demented. Because of this bias, it’s not uncommon for family or facility staff to report a patient has dementia despite not having been diagnosed by a physician.
PAIN ASSESSMENT PREDICAMENT
As discussed earlier, the visual tools we’re most accustomed to when assessing pain–initial presentation and vital signs–are unreliable when examining patients with impairments that don’t allow two-way communication.9 An examination of some of the most recent research reveals a novel method to appropriately gauge a patient’s pain.
A 2014 research paper that systematically examined 441 systematic reviews of over 28 different pain scales concluded there was none that could be recommended as the “best assessment” for use in cognitively impaired individuals.10 These reviews were based on criteria related to validity (i.e., does the pain scale cover all important items/dimensions?); reliability (i.e., if two different people evaluated the same person, did they get the same score?); and homogeneity (i.e., if a pain scale was used in two different locations, can the results from those two locations be combined and show the same results?).
Furthermore, none of these scales were prepared with the thought of prehospital use in mind. Most of them looked at a vast array of elements (some as high as 80 items), and most considered behavioral characteristics that only could be assessed based on familiarity with the patient–a luxury not available in the prehospital environment.
Because many of these 28 pain scales had promising characteristics, they were examined again to determine which would be most beneficial (and with the highest validity) for prehospital use. Each was considered for various elements: length (scales that were too long were eliminated), familiarity (scales that required judgment based on familiarity with the patient were excluded), and performance (scales that didn’t have high reliability were removed as nonviable).
THE PAINAD SCALE
When the filtering was complete, one scale rose to the top–the Pain Assessment in Advanced Dementia (PAINAD) scale developed by Warden, Hurley and Volicer.11 (See Table 2, above.) It was specifically developed for use in patients with cognitive impairment and is brief, simple to use, and fits in with the assessment prehospital providers routinely perform.
The PAINAD scale uses the familiar 0—10 pain scale, but is directed specifically at patients who are unable to participate in their own examination. It considers:
- Breathing;
- Negative vocalization;
- Facial expression;
- Body language; and
- Consolability.
Compared with a normal patient, it’s interesting to note that an expressionless, noncommunicative patient staring blankly into space would be considered pain-free in the realm of cognitive impairedness. According to the originators of the scale, you’re supposed to observe the patient without interacting–something that may not be entirely possible in the prehospital setting. However, if we encounter a patient we suspect is cognitively impaired, instead of immediately walking up and introducing ourselves, try a few moments of quiet observation with only minimal interactions.
In the case of our 85-year-old male patient, using the PAINAD scale reveals he was in a significant amount of pain, despite his ability to “stand up and walk to a chair.” When approached, there was no immediate reaction to your presence–something which seems normal for a dementia patient. Based on the report from staff, it seemed unlikely someone with a broken hip would have been able to walk, so your initial impression was he had been uninjured in the fall and would simply need a quick ride to the hospital.
After a few minutes, however, it became clear his breathing was slightly labored– despite being reported as normal by the staff because of ongoing chronic obstructive pulmonary disease (COPD). When attempting to palpate, he moaned, and made limited physical attempts to resist cooperating with your examination. When asked questions such as, “Does this hurt?” he would confusingly alternate between yes and no–clearly a symptom of his dementia, providing no obvious clue to his pain. The expression on his face was tense and matched the rigidity in his body, as if he was about to give you a lecture, but couldn’t. Caregivers interpreted this as his “normal attitude,” shrugging it off as being related to dementia.
Finally, because of the wide range of medications the patient was taking, the patient’s vital signs were fairly stable, with normal heart, blood pressure, oxygen saturation and respiratory rates.
Unfortunately, even caregivers who interacted with the patient on a daily basis were unable to recognize his behavioral changes and instead provided you with viable reasons for nearly every pain-related sign/symptom. He walked, he has COPD, he has an “attitude,” and he has dementia. You could have easily substantiated a BLS transport, and with his limited verbal ability, the receiving hospital would have accepted your assessment–until the X-rays came back.
By substituting your typical approach to pain assessment with the PAINAD scale, you have a simple, easy-to-use method to evaluate your cognitively impaired patient’s pain. This patient would have scored 8/10 on the PAINAD score (breathing = 1, negative vocalization = 2, facial expression = 2, body language = 1, and consolability = 2), and as such you discover he’s an excellent candidate for pain control. The administration of the appropriate dosage of pain medication reduces his PAINAD scale considerably to a 4/10 (breathing = 0, negative vocalization = 1, facial expression = 1, body language = 1, and consolability = 1). It’s better, but indicates there’s still room for improvement.
CONCLUSION
Flying by the seat of your pants can be dangerous. For the pilot who suddenly flies into cloudy weather, the solution is simple: switch from looking out the window to watching your flight instruments. Although not as easy, the alternative view enables the pilot to keep the plane flying straight and level. Similarly, for the prehospital provider who finds themselves with a non-communicative patient, simply switch to the PAINAD scale and you’ll be able to keep your patient comfortable and pain free.
REFERENCES
1. Walsh B, Cone DC, Meyer EM, et al. Paramedic attitudes regarding prehospital analgesia. Prehosp Emerg Care. 2013;17(1):78—87.
2. White LJ, Cooper JD, Chambers RM, et al. Prehospital use of analgesia for suspected extremity fractures. Prehosp Emerg Care. 2000;4(3):205—208.
3. McEachin CC, McDermott JT, Swor R. Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia. Prehosp Emerg Care. 2002;6(4):406—410.
4. Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage. 2000;19(4):240—248.
5. Reynolds KS, Hanson LC, DeVellis RF, et al. Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. J Pain Symptom Manage. 2008;35(4):388—396.
6. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer disease in the US population: Prevalence estimates using the 2000 census. Arch Neurol. 2003;60(8):1119—1122.
7. Alzheimer’s Association. (2015.) Types of dementia. Retrieved Dec. 15, 2015, from www.alz.org/dementia/types-of-dementia.asp.
8. Chertkow H. Diagnosis and treatment of dementia: Introduction. Introducing a series based on the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. CMAJ. 2008;178(3):316—321.
9. Lord B, Woollard M. The reliability of vital signs in estimating pain severity among adult patients treated by paramedics. Emerg Med J. 2011;28(2):147—150.
10. Lichtner V, Dowding D, Esterhuizen P, et al. Pain assessment for people with dementia: A systematic review of systematic reviews of pain assessment tools. BMC Geriatr. 2014;14:138.
11. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9—15.
The PAINAD scale was developed through a government entity; therefore it’s in the public domain and is free to use with appropriate reference to the authors, Warden at al.11 Access it at www.amda.com/publications/caring/may2004/painad.cfm.
