Paramedic assessment of pain in the cognitively impaired adult patient

Although pain is a commonly encountered complaint in prehospital and emergency medicine settings, evidence of inadequate analgesia has been widely documented. Poor pain management practice has been described in the emergency department (ED)[1], and variations in pain management practice in this setting have been associated with ethnicity[2], gender[3], and extremes of age[4].

Reasons for inadequacies in pain management practice are likely to be multifactorial. Failure to assess for the presence and severity of pain may be one factor, as efforts to make pain measurement mandatory in the ED have been shown to improve the frequency of analgesic administration[5]. The importance of early and systematic assessment of pain is exemplified by recommendations to include pain as the "5^th vital sign"[6], reinforcing the need to seek and record evidence of pain in every patient encounter. However, even when pain assessment is encouraged or required, patients may be unable to communicate their experience to carers, or be reluctant to report pain due to concerns about treatment side effects or the possibility that they will be viewed as a complaining or difficult patient, a belief that has been documented in settings that include oncology [7] and aged care[8, 9].

Paramedics have an important role in the assessment and management of pain, and are often a first point of contact for people experiencing pain in the community. Effective management of pain in this context is made possible by evidence-based clinical practice guidelines that enable paramedics to relieve pain by pharmacological and non-pharmacological means. However, effective management of pain depends on the paramedic's ability to gather relevant clinical information to reveal the presence, nature and severity of the patient's pain. As pain is a personal experience with external manifestations that are associated with significant interpersonal variations of expression[10] that limit generalisations regarding standards of pain behaviour, wherever possible the patient's self report of pain should be sought to guide the clinician's assessment and management of this complaint[11].

Pain severity is one component of a complex and highly personal experience that involves sensory-discriminative, motivational-affective and cognitive-evaluative dimensions[12]. Assessment of pain severity is specifically sought to guide paramedics' pain management decisions, which may include strategies designed to mitigate the cause of the pain and to provide relief from pain that includes efforts to manage the environmental, social and psychological mediators of the perception and expression of pain[10]. In addition, the assessment and evaluation of the patient's pain experience will influence pharmacological interventions aimed at providing relief from pain.

Tools used to elicit a patient report of severity include the Verbal Descriptor Scale (VDS), which requires the patient to rate their pain using adjectives such as "none," "slight," "moderate," "severe," or "agonizing," and the Verbal Numeric Rating Scale (VNRS), where the patient assigns a number from 0-10 to quantify their pain, with 0 representing no pain and 10 representing the worst pain imaginable. Both types of scale are recommended for use by paramedics[13]. The Visual Analogue Scale (VAS) has also been used to measure pain severity in adults in the prehospital setting[14, 15].(In Australia the Victorian Ambulance Service recommends the use of the VNRS for the assessment of pain in adults[16], and in the United Kingdom, the clinical practice guidelines developed by the Joint Royal Colleges Ambulance Liaison Committee also recommends the use of the VNRS for scoring pain severity in adult patients[17].

While these scales have been shown to be valid methods of documenting pain severity and changes in severity, their effectiveness depends on the patient's ability to understand instructions in their use in order to quantify their pain. In addition, self-report of pain severity requires the use of higher cognitive functions and the ability to use abstract reasoning to associate numbers or a list of adjectives with the severity of pain that an individual may be experiencing. While many patients can use these scales to indicate the severity of their pain, in others the ability to communicate their pain experience may be impaired by language difficulties, developmental barriers (developmental disability and pre-verbal children), physiological barriers (for example coma), or cognitive barriers that include diseases such as dementia. These problems can pose special challenges for health professionals seeking to establish the nature and severity of the patient's distress, and this has the potential to result in suboptimal care.

Evidence to support this assertion may be found in a recent study involving a large number of nursing home residents (n = 551), which revealed that the incidence of nursing staff records of pain in residents declined as cognitive disability increased[18]. While 34% of patients with no cognitive disability reported pain during the study period, pain prevalence rates of 31%, 24%, and 10% were associated with residents with mild, moderate, and severe cognitive impairment. Furthermore, as cognitive disability increased the administration of analgesics decreased, despite there being no statistical difference in the prevalence of painful pathologies between cognitively impaired and cognitively normal residents. This suggests that the higher the level of cognitive impairment the more difficult it is to record or report pain.

The results may also illustrate a lack of willingness to seek evidence of pain in individuals where communication difficulties complicate the assessment process. A similar result has been observed in an earlier study that found a decrease in the prescription and administration of analgesics in cognitively impaired nursing home residents despite similar proportions of painful pathologies in the impaired and non-impaired cohorts[19].

Dementia is a major cause of cognitive impairment in adults. Many developed countries are experiencing a rapidly aging population, and as dementia is an age-related disease, the prevalence of dementia in many countries is predicted to increase. For those living in Australia who are aged more than 65, the likelihood of having dementia doubles every five years, so that by age 85 it is estimated that 24% of people are affected[20]. The prevalence in this country is estimated to increase from approximately 175,000 in 2003 to approximately 465,000 by 2030[21]. Although this disease may impair an individual's ability to report pain, the ability to feel pain may remain unimpaired[22, 23].

The increasing prevalence of this disease means that more people may be at risk of living with pain that cannot be adequately reported to others, making the need to establish a valid and reliable means of identifying pain in this population a priority, as failure to identify pain and subsequently implement strategies to relieve a patient's pain may be considered a form of medical error and a denial of a basic human right[24, 25].... As tools currently used by paramedics to assess pain may be unreliable in the presence of cognitive impairment this paper aims to identify tools that may assist paramedics to assess these challenging cohorts of patients in order to ensure that their pain is recognised, thereby enabling interventions aimed at relieving their pain. The primary objective of this review was to systematically locate evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults and to identify those that have been recommended for use by paramedics. A secondary objective was to make recommendations regarding the paramedic assessment of pain in cognitively impaired individuals if no existing recommendations could be found. The focus will be the assessment of pain in people with cognitive impairment due to dementia, as this represents the major cause of cognitive impairment in older adults.

In order to locate evidence relating to the research questions the following databases were searched over the period January 1985 through June 2008: Medline, Cumulative Index to Nursing & Allied Health (CINAHL), Biological Abstracts, and Psycinfo. The search included key words and/or medical subject headings (pain measurement OR pain assessment) AND (dementia OR cognition disorders/cognitive impairment OR nonverbal communication).

An extended search was subsequently conducted of the electronic database of the National Guideline Clearinghouse to identify guidelines on pain assessment in older adults, particularly those recommended for the assessment of the nonverbal older adult or those with dementia. In addition, position statements and clinical practice guidelines were sought through searches of relevant Internet sources such as the International Association for the Study of Pain, the Australian Pain Society, and the National Health and Medical Research Council.

Due to the large number of research reports that were located using the initial search strategy it was decided to restrict the search to reports that met the following criteria:

The search strategy returned 575 results:

1 pain measurement.mp. or Pain Measurement/(48729)

2 pain assessment.mp. (11225)

3 Dementia/or dementia.mp. (111623)

4 Cognition Disorders/or cognitive disorders.mp. (46458)

5 cognitive impairment.mp. (34158)

6 nonverbal communication.mp. or Nonverbal Communication/(5621)

7 1 or 2 (53402)

8 limit 7 to (english language and humans and yr="1985 - 2008")(43422)

9 3 or 4 or 5 or 6 (165940)

10 limit 9 to (english language and humans and yr="1985 - 2008") (129860)

11 8 and 10 (857)

12 remove duplicates from 11 (575)

When the search result was limited using keywords "paramedic" OR "emergency medical technician" OR "ambulance/s" OR "prehospital" OR "emergency medical services", there were no (0) results.

The full-text versions of studies that matched the initial inclusion criteria were reviewed. This strategy identified two reports that met the selection criteria:

The reviews of pain assessment tools for the cognitively impaired that were included in the cited systematic reviews show that the majority were developed to assess chronic pain in aged care, hospital or hospice settings. An analysis of the characteristics of these pain assessment tools identified attributes that may limit their use in paramedic practice. These include assessment that is possibly too comprehensive and time consuming for paramedics to perform. For example, several tools included in the systematic reviews are recommended for use in aged care institutions and involve complex scoring that requires repeated observation of patient behaviours over time by trained observers. Some, such as the NOPAIN tool[31], are designed to be used while observing the patient undertaking daily tasks such a dressing and bathing, which restricts its use by paramedics.

The DOLOPLUS-2[29] scale requires observation of patient behaviour over time in several different situations including social interactions and sleep. Its use is limited in the acute setting as the patient's normal behaviour must be well known to the carers who complete the assessment. A recent review of this tool has questioned its validity and has identified the considerable administrative demands required to assess pain behaviours[32].

Assessment of pain using PACSLAC[28] involves observation of 60 items that include behaviour during movement, eating and sleeping as well as mood and changes in social interactions. This tool also requires observation of the patient over time to enable observation of often subtle changes in behaviour. As such this tool is likely to be impractical for paramedic use.

One behaviourally-based pain assessment tool that is currently used by paramedics in the Australian state of Victoria is the Face, Legs, Activity, Cry and Consolability (FLACC) tool, which is used to assess pain in nonverbal children[33]. Although there is some evidence of the use of this tool for assessment of pain in cognitively impaired older adults[26], this tool may not be appropriate for the assessment of pain in this population. The FLACC scale was developed to guide the assessment of pain in infants and pre-verbal children, and the pain-related behaviours that form the basis of this tool were identified from studies of children undergoing painful procedures such as circumcision. Some behaviour addressed by this scale such as leg kicking and a quivering chin does not appear to be relevant when assessing adults. The review of adult pain assessment tools undertaken by Herr and colleagues found that the FLACC has low levels of validity and reliability and as such was not recommended for use in this population[26].

Any tool used by paramedics must be reliable, valid and practical, with the latter influenced by operational requirements to minimise time spent on scene. As such, tools that assess multiple dimensions of pain that require observation of behaviour over time during different activities may have less utility than a tool that identifies the presence of pain and attempts to evaluate the severity in a way that parallels tools that are already familiar to paramedics for use in patients without cognitive impairment. In a report published by the Australian Pain Society[34] that describes the use of best available evidence and the results of a clinical trial of pain assessment tools to inform pain management practice in aged care facilities, the Abbey pain scale (Figure 1) was recommended as the most appropriate means of assessing pain in residents with severe cognitive impairment. This one-dimensional scale is designed to rate pain severity. Although this tool attempts to address acute, chronic and acute-on-chronic pain using six behaviour categories that include physiological and physical changes, vocalisation, facial expressions, and changes in body language and behaviour, some cues may be non-specific. This is particularly apparent in the facial cue category, where cues such as frowning may not have a strong correlation with pain[35]. The tool takes between two to six minutes to complete[36], and as such this tool may be practical for use in the paramedic practice setting.

Following a recent review of available evidence the Abbey Pain Scale was recommended by the Royal College of Physicians in the UK for assessment of pain in patients with severe cognitive impairment[37]. The authors of this report recognised that limited clinical data was available to support this decision, but made this recommendation on the basis on ease of use while adding the caveat that no single method of pain assessment could be recommended for this cohort.

At this time no pain assessment tools for use in the setting of cognitive impairment have been validated for use by paramedics. Until studies of the paramedic use of tools such as the Abbey Pain Scale are undertaken, general recommendations can be made to aid the assessment of pain in patients with cognitive impairment. The following clinical practice recommendations are adapted from the American Society of Pain Management Nursing Position Statement on Pain Assessment in the Nonverbal Individual[38]. Given the evidence that establishes a link between cognitive impairment and reduced pain management interventions, paramedics need to be proactive in seeking evidence of pain in this vulnerable population. Strategies that may be employed to improve the identification of pain in cognitively impaired adults include assessment of injuries associated with pain, interpretation of behaviour, surrogate estimation of pain by carers or close family members, use of a pain assessment tool, and observation of clinical response to analgesics or other non-pharmacological interventions designed to relieve pain. However, no single assessment strategy is sufficient by itself[38].

Paramedics have the tools to relieve pain in the form of effective pharmacological - opioid and non-opioid - and non-pharmacological adjuncts. However, equitable and effective management of pain relies on the self-report of this symptom. In patients whose self-report is limited by cognitive disability paramedics may need to use other methods of seeking evidence of pain. A patient who cannot clearly articulate their pain experience is just as deserved of relief from pain as those who are not burdened with disability. While some pain assessment tools have been recommended for use in patients with cognitive impairment there is currently lack of consensus on the most appropriate tool to use. As such, research is recommended that aims to test the utility, validity and reliability of the Abbey Pain Scale in identifying pain in this at-risk population in the prehospital setting. Further research should also evaluate the effectiveness of paramedic pain management practice in older adults to ensure that the care of all patients is unaffected by age or disability.