Because of the increased incidence of chronic illness in the elderly, pain is a constant companion for many. Haritins estimates that 80% of the elderly have at least one chronic ailment, often resulting in complaints of pain.1 Roy and Thomas found that 83% of nursing home residents reported pain.2 In a subsequent study designed to assess the prevalence of pain in a group of noninstitutionalized elderly, a surprising 70% registered complaints of pain.3
Whether nurses work with the elderly in long-term care facilities, acute care settings, extended care, or home or community-based settings, pain management problems are encountered daily. Accurate pain assessment is critical for the identification of appropriate interventions, as well as ultimately evaluating the effectiveness of interventions used. However, in the elderly population, collecting and interpreting pain information is complicated by a myriad of factors that often require adaptations pertinent to this special population. This article will discuss the complexities of gathering and interpreting pain information and provide suggestions for adaptations to facilitate accurate and reliable assessment.
PAIN ASSESSMENT TECHNIQUES IN THE ELDERLY
Assessment of pain in the elderly includes parameters similar to those used with younger individuals. The Table identifies content to be included in a thorough assessment of pain experienced by the eîderly patient. Because pain may severely restrict mobility, activity tolerance, self-care, and independence, associated impairment in functional status must be assessed.
As with patients of any age, current health status, severity of pain, energy level, and ability to concentrate are crucial factors in determining the timing of assessment, the method used, and the amount of data in the Table to be collected. Information on location, intensity, and quality of pain may be all that is needed to select initial interventions. After the pain is decreased, the nurse may gather more detailed information to facilitate future intervention.
When possible, information about the pain should be gathered directly from the patients in their own words. Information can then be validated through both questioning and observation. For example, in addition to asking where it hurts, ask the patient to point to the area and carefully observe nonverbal reactions when the patient is at rest and moving.
It is important to communicate a recognition of the patient's experience of pain and concern for the patient's suffering. A detailed pain assessment in itself communicates concern and interest in what the elderly patient is experiencing. One elderly individual reported to the authors that other people in his residential center respond to his expressions of discomfort with "what do you expect at your age" or treat him as a malingerer. His response was to stop expressing pain complaints and try to silently live with his suffering. After a detailed interview on his pain experiences, the patient responded with lengthy notes of appreciation for the time taken for listening and caring.
Establishing rapport and a nonthreatening environment when interacting with the elderly can facilitate the assessment of pain. A supportive, familiar environment may help obtain a more reliable assessment. When possible, gather pain data in the patient's own room in privacy. In the home setting, an initial assessment alone with the elder, before interacting with significant others, may encourage the true verbalization of sensation and emotion. In some instances, however, the elder may prefer the presence of a significant other during assessment.
When gathering data from the elderly, it is very important to avoid time pressures. Data collection should never be rushed. The clinical reality of time constraints and short staffing can be addressed by simplifying the interview or dividing the assessment into several shorter sessions instead of one long interview. Selecting the most crucial elements to be assessed initially and using a tool that requires less time to complete may be the most realistic alternatives.
COMPLEXITIES OF COLLECTING PAIN ASSESSMENT DATA
Whether using an interview or having the patient complete selected instruments to gather information on pain, a number of factors must be considered and integrated into the assessment approach with the elderly. Impairments in hearing and vision and difficulty with articulation or selecting and comprehending certain words have a significant impact on the choice of approach. Strategies must be undertaken initially to determine the patient's ability to communicate verbally. Having the patient describe the pain or read an assessment tool may provide an overall indicator of sensory ability or impairment. Careful questioning and validation of responses will increase the reliability of information obtained.
A patient's inability to verbally communicate pain does not excuse the nurse from trying to assess it in other ways. When the patient is unable to communicate pain complaints, the nurse must be alert for other means of expression and nonverbal behaviors indicative of discomfort. Moaning, whimpering, withdrawal, restlessness, guarding, and protective posturing are examples of behaviors alerting the nurse of the patient's pain.
Nurses caring for hearing-impaired elderly clients who are experiencing pain must integrate interventions that facilitate communication, including proper positioning, lighting, tone, pacing, and speed. With a severe hearing impairment, it is obviously wise to keep verbal questions and instructions to a minimum and use other modalities of communication (ie, written questions). Even a mild hearing loss can cause problems with concentration and understanding if background noise is interfering.4 Extraneous noises should be reduced whenever possible. It is important that the older person understand exactly what is being asked. Failure to monitor basic understanding of instructions can lead to incorrect assessment or misinterpretation of response.5
Common visual impairments that occur with aging, such as decline of visual acuity, rate of accommodation, color discrimination, and the ability to adjust to glare,6 will require adaptation of assessment tools to ensure reliable responses. Some suggested alterations include the use of large, simple lettering using both upper and lower case letters, adequate spacing between lines, and avoidance of italics. Buff, orange, or yellow-colored nonglare paper provides a contrast to the printing and may be seen more readily by those with a visual impairment. Increased lighting, combined with nonglare bulbs, may also improve visual perception. Line drawings using thick outlines are easier to understand than full-color photographs. Decorative or inappropriate drawings can confuse the focus of interest. Collecting data by interview or reading selected tools to the patient, combined with close observation by the nurse, may be the best strategies for those with visual impairment.
Failing memory and cognitive impairment can also interfere with the ability to obtain an accurate history of the patient's pain and precipitating events. Cognitive functioning can be temporarily or permanently disturbed by a variety of physical illnesses or treatments. In assessing pain in an elderly patient with a cognitive impairment, it is important to be sure that the patient is attentive and understands what is being asked. Keeping the content of assessment simple, providing clear explanations that clarify medical terminology, and using examples and demonstrations of assessment activities are strategies that aid in obtaining complete and reliable data. Although it is beyond the scope of this article to discuss confusion and dementia, consideration of these factors in assessing pain must be noted.
A number of simple screening tools exist that determine the patient's ability to process information effectively. These include the Mini-Mental Status Questionnaire,7 the Short Portable Mental Status Questionnaire,8 and the Cognitive Capacity Screening Examination.9 These tools are useful in identifying impaired mental processes that may interfere with accurate assessment of pain and can be located through the references identified.
When gathering assessment data is impossible because of severe sensory or cognitive impairment, significant others can be a reliable source for obtaining information on behaviors or changes of function, which serve as indicators of pain status. For example, has the family noticed any change in the patient's level of activity or movement? Are there any subtle changes in interactions, sleep patterns, or behavior that the family has observed? In addition to significant others, individuals such as other health-care workers, roommates, and activity therapists may provide valuable information about the patient's behavior associated with, or indicative of, pain.
Obviously, decreased psychomotor function can affect the elder's ability to respond to certain methods of assessment. Declining response time should be a consideration. Quicker and less fatiguing methods may be most appropriate, such as the visual analogue scale or verbal descriptor scale. Decreased finger dexterity and fine motor control may interfere with the elder's ability to mark or write and turn pages of an assessment tool. These factors should be assessed early and adaptations made in materials and design for special disabilities. Tools with several pages, such as the McGiIl Pain Questionnaire,10 may be completed more reliably if the page width is graduated or numbered page tabs are used. When more than one page is involved, it is advisable to print on one side of the paper only to prevent accidental omission.11
CONTENT FORASSESSING PAIN IN THE ELDERLY PATIENT*
The use of multiple drugs to treat chronic illness, a frequent occurrence in the elderly, increases the risk of drug interactions and side effects that can affect the patient's perception of and ability to report pain. Many elderly patients take a combination of prescription and over-the-counter drugs that may contribute to confusion, impaired memory, lethargy, and delirium. A thorough drug history may help identify drug effects that impair the communication of pain. Discussion of these concerns with the primary physician may result in alterations in the elder's pharmacologie management to decrease mental impairments and increase the accuracy of pain assessment.
TOOLS FOR ASSESSING PAIN IN THE ELDERLY
A variety of tools are available for gathering data about specific aspects of the elderly's pain experience.12,13 Selection of an effective tool for assessment should take into consideration the individual characteristics discussed above. Many elderly will not exhibit memory or cognitive impairment and have adapted to perceptual losses with prescription glasses and hearing aids. For those individuals, the assessment process may require few adaptations. However, for those with special needs, the nurse must match or adapt a particular tool to meet the elderly person's capabilities.
Determination of the patient's ability to read and understand the directions for completing an assessment form is prerequisite to selection of an appropriate paper and pencil tool. Because it has been reported that nursing home residents may have significantly lower education levels than noninstitutionalized elderly,11 special consideration of the abilities of this population is important. Assessment tools requiring reading skills and advanced conceptualization may need to be adapted and edited.
Although several pain assessment tools are discussed briefly below, few of the tools traditionally used to assess pain have been validated with the elderly population. Research regarding assessment tools for the elderly is clearly needed.
Verbal and visual pain scales, commonly used to gather information on pain intensity, are quick to administer and interpret. The verbal descriptor scale (VDS) consists of a set of numbers with words representing different levels of pain; patients select the word or number mat best represents the intensity of their pain.14 The visual analogue scale (VAS) is a more sophisticated, yet still quick and simple, pain assessment tool. It consists of a 10-cm line, the left labeled "no pain" and the right labeled "most severe pain"; patients mark the point that best represents the intensity of their pain. 15 The VAS may be too abstract for the elderly in acute pain, with lower educational levels, impaired cognition, or impaired motor coordination. In these instances, the tools may need to be adapted for accurate assessment.
WHERE IS YOUR BACK PAIN?
For patients with difficulty thinking abstractly, vertical presentations of scales may be easier to respond to than those displayed horizontally.11 A pain thermometer is a vertical measurement tool that is effective among the elderly. Rather than placing a mark on a horizontal axis to indicate pain severity, it may be easier to conceptualize pain increasing just as temperature rises. Careful instructions are needed, particularly with the VAS, to ensure proper understanding and use of the scales. Giving clear examples of what the numbers or marks mean in the directions (eg, "circling the O means you have no pain at all," or "placing a line near the right of the VAS means your pain is very bad, but not the worst you have experienced") and highlighting specific aspects of the directions (such as "circle" or "place a mark up and down on the line") assist the elderly in completing these scales. Large, dark type and numbers, contrasting paper color, and adequate spacing between measurements are also helpful. These scales are often administered verbally for a rapid assessment and for those with visual impairments. For example, the patient is asked to rate the severity or intensity of current pain on a scale of O to 10, with O being no pain at all and 10 being the worst pain possible.
McGill Pain Questionnaire
One of the best known and complete assessment tools for thoroughly assessing a pain problem is the McGUl Pain Questionnaire (MPQ), which assesses location of pain, pattern of pain over time, sensory, affective, evaluative and miscellaneous components of pain, and intensity.10 However, the MPQ is complex and time-consuming, and some of the possible descriptors may be difficult for the elderly person to understand. The large list of choices may also be overwhelming for some.
Because of the length of the questionnaire, it may not be feasible to expect an elderly patient to maintain concentration long enough to complete the MPQ in one sitting. However, the one page short-form MPQ may be a more suitable alternative for elderly patients and includes a 15-word descriptor list and a VDS and VAS for assessing pain intensity.16 Reading competency must be validated before using a tool such as the MPQ. An alternative might be using a shortened version of the MPQ in an interview format where the nurse can explain directions and read choices to the patient.
A chart consisting of drawings of the body or body parts on which the patient marks the location of pain, as well as its sensory aspects, can be very effective (Figure). The MPQ contains a body chart on which patients draw dots, dashes, or lines to indicate the location and type of pain experienced. For those who have difficulty describing pain characteristics verbally, a drawing may facilitate accurate identification of the location and quality of the pain. Because the elderly often have more than one source of pain, the body drawing can be an especially effective tool.
Nonverbal Assessment Tools
Several tools have been developed and successfully used with children who are unable to communicate discomfort verbally. Adaptation of these instruments might provide alternatives for assessing pain in the elderly with impaired communication skills. The Children's Hospital of Eastern Ontario Pain Scale is an assessment tool developed for children that describes and scores behaviors such as crying, facial expression, verbal complaints, motion, and touch, which indicate discomfort.17
Color tools have been used successfully with children of limited vocabulary to describe and locate pain, and may serve as effective tools for the impaired elderly.18 The patient selects colors that represent different levels of pain severity and then, using a fullbody diagram, colors the body parts that hurt with the color that best represents the current pain.
An eight-point facial expression scale, depicting varying levels of discomfort, has been shown to correlate well with visual analogue and numerical rating scales.19 The individual selects the facial expression that best represents the current state of discomfort. This might also be useful for elders with language or mental capacity difficulties.
A diary may be useful to identify certain activities or social Stressors that may be linked to pain.20 The patient or significant other records various information related to pain including painrelated positions or behaviors, associated activities, intensity level, use of relief measures, time spent in relief activities, and use of analgesics.21,22 The diary may help identify patterns or factors that exacerbate or mediate the pain experience and may, therefore, be useful in planning interventions. Consistency between verbal and recorded reports of pain and activities can provide insightful data. It should be noted, however, that some elderly may have trouble completing a diary because of the fine motor skills and cognitive processes needed.
COMPLEXITIES OF INTERPRETING PAIN ASSESSMENT DATA
Once data have been obtained, a number of factors can lead to misinterpretation of the real meaning of the complaints of pain. The failure to report pain or the absence of pain-related behaviors is often misleading; neither ensures that the patient is pain-free. Elderly patients may not report pain for a variety of reasons including:
* A belief that pain is something they must live with. The elderly are often confronted with health-care providers and significant others who imply that pain is a natural result of aging and something that must be endured. Complaints are often ignored or result in anger or frustration from significant others, so the individual may stop talking about the discomfort. Pain is not an inevitable part of aging. When an older person presents with a complaint of pain, assessment, diagnosis, and treatment must proceed similar to that in any age group.1
* Some elderly patients may deny the presence of pain because of fear of the consequences. Many elderly cling to their independence and may be reluctant to admit to distress for fear of losing their autonomy.23 Admitting to pain may lead to diagnostic procedures, hospitalizations, institutionalization, and additional expense.24
* Some patients may believe pain to be a forecast of serious illness or impending death. Failing to acknowledge the presence of pain may allow the elderly to avoid confrontation with these possibilities. The meaning of pain should be explored with elderly clients.
* Use of terminology may vary greatly among the elderly. They may deny pain, but respond affirmatively to terms such as discomfort, ache, soreness, or hurt. Awareness and use of varied descriptive terms are necessary to thoroughly assess the presence of pain.
* Some believe that it is not acceptable to show pain. Consequently, the patient may use a variety of mechanisms to distract attention from the pain, rather than acknowledge it.24 The expression and interpretation of pain can vary dramatically among ethnic groups. These behaviors depend, among other things, on whether the person's culture accepts or condemns demonstrative emotional responses to injury and pain. Rosow's classic study illustrates that the elderly do not obtain, as a result of aging, a set of beliefs that differ from those of the young.25 In other words, cultural values regarding the expression of pain are established early in life and continue to affect behaviors as one ages. If the elderly do not report discomfort during painful situations, it may mean that their culture values stoicism. For example, Old Americans and Irishmen are often unemotional or minimize expressions of pain, whereas those of Jewish or Italian descent tend to be more vocal with expressive pain behaviors.26
There are also gender differences in pain expression that are learned early in life. In many cultures, women are more free to openly express pain than men. In an investigation of Black, Mexican-American, and Caucasian patients with chronic spinal pain, women of all three ethnic groups emphasized their pain more than men.27 Although empirical studies that explore the impact of culture, specifically as it relates to the elderly's expression of pain, have not been reported, cultural values may be held stronger in the elderly because of the increased emphasis on family values of older generations. Nurses must be aware of common cultural patterns of pain expression, as well as their own cultural perspectives, ?? avoid misinterpretation of assessment information.
* Instances of atypical presentations of clinical pain have been documented in the elderly. For example, up to half of all myocardial infarctions in the elderly may occur without pain.20 Peptic ulcer disease, appendicitis, and pneumonia may cause only mild discomfort.28.29 These conditions may elicit behavioral changes only, such as confusion or restlessness, and interfere with accurate assessment of pain and its etiology. Abdominal emergencies, such as perforation of a peptic ulcer, may present as chest pain in the aged. Changing patterns of pain also occur with age. Headaches, for example, appear less commonly in the elderly.28 When they do occur, as in the onset of migraines, serious disorders such as stroke, temporal arteritis, or carotid artery disease may be implicated. Although patterns and presentation of pain may change in the elderly, research indicates that perception, or sensitivity, does not necessarily decrease with age.1
It is not uncommon to encounter complaints of pain that arise from hidden motives. Fordyce notes that a very common problem is the rationalization of other functional impairments as pain.30 For example, many elderly do not wish to reveal disabilities such as memory loss from a minor stroke or sensory loss from cataracts to avoid embarrassment or possible confrontation. Instead, pain complaints and associated impairment may be used to conceal these problems. Chronic illness often leads to increased attention to physical sensations by the elderly. It is also generally accepted that the elderly are more prone to hypochondriasis. Pain complaints may be used to solicit interactions and attention or to manipulate significant others.
Although a number of factors other than pain may be motivating complaints, it is essential to evaluate these thoroughly. It is important to convey that pain-related behaviors are acceptable and determine the underlying cause before directing intervention. Pain complaints are often ignored, but careful assessment might uncover situations in which the nurse could effectively intervene.
Boredom and loneliness can have a significant effect on the elderly person's perception and report of pain. Those who have few distractions or social activities may perceive more pain than those who keep busy.30 The social network and scope of social activities is an important assessment parameter in this population.
Some elderly patients who complain of chronic pain have long-standing personality disorders.31 However, it is recommended that pain be viewed as evidence of a personality disorder only if the disorder has been well-established throughout life and other causes of pain are ruled out.
Depression and chronic pain may coexist and interact in a way that interferes with accurate assessment Chronic pain may understandably contribute to depression, or a depressed person may present with pain-related behaviors. Because of the high prevalence of depression among elderly individuals, it is important to carefully evaluate complaints of chronic pain.30·32 When the pain problem seems puzzling in pattern, onset, or distribution, it is possible that the main problem is, indeed, depression. Differentiating between pain and depression is difficult. Complaints of sleep-disturbance with early morning wakening, psychomotor retardation or agitation, and anorexia or weight loss may be indicators that depression rather than pain is the underlying problem.1 A thorough assessment to identify the extent to which depression is present should be completed. An overview of depression assessment by Dreyfus serves as a valuable resource.33 Because of the interaction between pain and depression, nurses must direct interventions appropriately to promote comfort.
Interpreting data on the pain experienced by the elderly can be seriously biased by the attitudes and beliefs held by the nurse.12 The nurse's attitudes and beliefs about the aging process can result in inappropriate responses to pain complaints. For example, if the nurse believes that the elderly complain excessively for attention, pain complaints may be ignored. As in any assessment situation, the nurse must be aware of personal biases that might interfere with the pain relief interventions that the elderly deserve.
The elderly comprise the fastest growing segment of our population and are one of the largest patient populations for which the nursing profession provides skilled care. Accompanying the aging process is an increased incidence of illness and degenerative processes that contribute to a high prevalence of pain complaints. It is imperative that health professionals, particularly nurses, be aware of changes associated with aging that require alterations in assessing and interpreting the pain experiences of the elderly.
Many elderly, as well as many health professionals, believe pain is simply a part of aging and must be accepted. This often leaves the elderly patient feeling alone, frustrated, and hopeless. Establishing a trusting, caring relationship that acknowledges the suffering experienced is an important first step toward the goal of pain management for the elderly. Spending time exploring the problem with sincere concern and interest in the elderly's pain can have a significant impact on the nurses' ability to accurately assess pain and evaluate the effectiveness of pain management strategies.
Although the content is similar to that used when assessing those who are not elderly, strategies for obtaining an accurate and reliable pain assessment in the elderly require special consideration of sources of information, the manner and timing of the assessment, and the choice of tools. It is crucial that nurses consider the many potential factors impinging on accurate assessment, including severity of pain, health status, ability to concentrate, and energy level, when dealing with the elderly client in pain.
A number of specific problems associated with aging have been identified, such as sensory, cognitive, and psychomotor impairment, which affect the elder's ability to communicate pain and require adaptation in the gathering of assessment data. Nurses should consider alternative assessment strategies for gathering data from the elderly when it becomes evident that the patient is experiencing a deficit in ability to communicate pain, or the nurse's observation of the patient conflicts with reported discomfort.
Some form of pain evaluation must be used to obtain initial baseline data, as well as periodic evaluation during the intervention period, to determine effectiveness of pain management strategies. A variety of tools are available that can be adapted for gathering information on the elderly's pain. However, lack of consideration of the variables identified above may result in an inaccurate or invalid assessment. The selection of appropriate pain assessment tools must incorporate the individual characteristics of the geriatric patient.
Interpreting pain report and painrelated behaviors in the elderly is complicated by myths and misunderstandings commonly held by the elderly as well as many health professionals. Fac- 4 tors interfering with accurate interpretation of pain or lack of pain behaviors, such as fear of dying, viewing pain as a natural part of aging, and atypical presentations of pain, have been discussed and must be considered when evaluating the elderly's pain experience. Psychosocial factors, such as boredom, loneliness, and depression, may result from retirement, death of significant others, and immobility, and each can contribute to difficulties interpreting the presence and meaning of pain in the elderly.
The physical and emotional discomforts of aging are not inevitable, nor should they be an accepted part of growing old. The pain of this rapidly expanding subpopulation of society cannot be ignored. Of utmost importance is increased efforts to understand the pain problems of the elderly. Thoughtful, concerned assessment and interpretation is the necessary first step toward alleviation of discomfort and promotion of a more positive quality of life in the aged.
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CONTENT FORASSESSING PAIN IN THE ELDERLY PATIENT*