Presently, between 2 and 5 million Americans suffer from dementia. By the year 2000, this number is expected to increase by 60%.' Dementia, caused by a variety of acute and chronic conditions, has been defined as the decrease of mental functions in an otherwise awake and alert individual. Despite ongoing research, the cure for dementias such as Alzheimer's disease is not likely in the next several years.2
Many chronic dementias are progressive, leading to a confused, nonverbal state in which all activities of daily living must be performed by a caregiver. The patient is unable to communicate in any but the most rudimentary manner. Although the very real possibility exists that some of these confused, nonverbal elderly will be in pain, it is likely they will be unable to communicate their distress.
Pain assessment is a complex process based on the identification of pain behaviors, which includes verbal and nonverbal cues.2 If these behaviors are not clearly communicated or understood, pain will be poorly assessed and, as a result, undertreated.3 There is evidence that nurses do not routinely ask patients whether they are in pain or use any type of pain rating scale.4 Furthermore, it has been noted that nurses chart less than 50% of what patients described.5 This may indicate problems with both assessment skills and charting of pain behaviors. There is ample documentation concerning the lack of pain assessment skills in health professionals,6·8 although no one would argue the difficulty in identifying the personal, subjective experience we know as pain.
Not only is there a tendency for health professionals to underestimate pain on a consistent basis,9 but also, pain is frequently poorly managed.10 The frustration that comes from the inability to alleviate pain makes the health-care team withdraw from the patient and be less aggressive in finding a solution to the problem. Clearly, better pain assessment techniques are needed with frequent questioning about the presence and severity of pain.10
Another problem is the stereotyping of patients with chronic pain, especially those with no visible pathology.11 In the absence of altered physiology, nurses tend to consider chronic pain as psychological in origin.3 Despite this, nurses are unwilling to administer analgesics that have a psychological effect. In two unrelated studies, 50% of nurses questioned said that if they assessed euphoria in a patient receiving narcotics for chronic pain, they would decrease the amount of pain medicine administered.11,12 Euphoria is a well-documented, expected, and temporary sideeffect of appropriately prescribed analgesics.11 Pain with no clear pathological cause is often undermedicated.
The problem of inadequate pain assessment is put into perspective by Ferrell and Schneider, who note that pain is a universally frightening, allconsuming experience.13 Pain can immobilize patients, interfering with every aspect of their daily activities and relationships. Despite the magnitude of the pain experience, 60% of hospital patients and 83% of home care patients were medicated less often than ordered.12 Even when health professionals recognize pain, they may incorrectly estimate its severity and duration because cultural differences are found in the assessment of pain. Attitudes about pain and suffering appear to be socially learned responses.2
Most pain assessment instruments rely on verbal reports of pain, although documented methods of assessment exist using nonverbal behavior.14·15 These methods are valid only in certain circumstances and were developed using a younger population. The nonverbal behaviors observed include gait, facial expressions, and posture changes. Other pain behaviors that are used for assessment include diaphoresis and pupillary changes. These behaviors are usually associated with acute pain and may be absent in clients with chronic pain.13'16'17 Pain may appear as confusion in an otherwise alert elder.18 The person in pain may be unable to concentrate on anything but the painful feeling and may exhibit behavior similar to that seen in sensory overload.19
PAIN IN THE ELDERLY
Confused, disoriented, or nonverbal elderly often have the diagnosis of chronic brain syndrome (CBS). Diseases in this category include AIzheimer's disease, multi-infarct dementia, normal pressure hydrocephalus, alcoholic encephalopathy, Pick's disease, and Creutzfeldt-Jakob's disease. More than 3 million Americans are affected by CBS, and 65% of these have Alzheimer's disease. All types of CBS result in decreased memory and cognition and, in the later stages, communication defects and mutism. CBS is associated with a poor prognosis.20
Alzheimer's disease, the leading type of CBS, is the fourth leading cause of death in the elderly. Whereas there is a 5% chance of developing Alzheimer's disease at age 65, the risk rises to 10% by age 75 and to 33% by age 90. Furthermore, the life expectancy of an Alzheimer's victim is up to 60% shorter than that of a nonaffected eJder.21
There is a high prevalence of chronic conditions in the elderly, many of which are painful. Thus, pain is a frequent nursing diagnosis.9 In fact, chronic pain is the third largest health problem in the United States today.17 Pain accompanying chronic conditions is associated with sleep disturbances, nutritional alterations, and impaired mobility. The loss of mobility may cause social isolation and depression, further worsening pain.22 This leads to a marked deterioration in quality of life and an increase in pain behaviors.9'23
DIAGNOSES OF PAINFUL CONDITIONS AND NUMBER OF PATIENTS HAVING EACH CONDITION
Pain behaviors may be unwittingly reinforced by caregivers, who reward complaints with medication.24 A cyclic effect is seen as pain causes isolation, which causes increased pain behaviors and deterioration in quality of life. This leads to further isolation and more pain behaviors.
Stereotyping of the elderly frequently occurs.25 Pain may be dismissed as expected and therefore poorly managed. Those who cannot express themselves bear an even greater burden because they may not only be under-treated but also totally ignored.26 If pain, as defined by McCaffery, is "whatever the patient says it is and occurs whenever the patient says it does,"27 it follows that if patients cannot express themselves, they are not in pain. This definition of pain is unacceptable for use with the confused or nonverbal elderly; behavior becomes the only method of assessing pain in this population.
Most studies concerning pain assessment and management do not focus on the elderly, nor do they include confused elderly. However, more than 50% of all cancers occur in those 65 years of age or older,28 and elders take more drugs, including analgesics, per capita than any other segment of the population.29 Chronic pain, both malignant and non -malignant, is a significant problem in the elderly.
For the purposes of this survey, an Alzheimer's unit was selected from a large midwestern nursing home. The staffing ratio was 1 to 7.5. For 60 patients, there was 1 RN, 2 LPNs, and 5 nursing assistants. A chart review was conducted to check for diagnosis of potentially painful conditions and to correlate the diagnosis with analgesics received. Of the 60 charts reviewed, all had a diagnosis of CBS. Twenty-six patients (43%) had potentially painful conditions ranging from metastatic colon cancer to degenerative joint disease (Table 1). Seven patients (11.6%) had pain of malignant origin, whereas 19 patients (31.6%) had non-malignant pain. Only three patients were receiving routinely scheduled analgesics, and none of these patients suffered from malignant pain. Interestingly, these three patients had only mild confusion and exhibited many pain behaviors.
A pain assessment was performed on each of these 26 patients by an experienced geriatric/oncology certified practitioner. Pain behaviors were difficult to elucidate. Most patients had no pain behaviors, and seemed not to be in pain despite their diagnosis of painful conditions. Only three patients exhibited pain behaviors. The staff was also surveyed. Nurses and assistants were dismayed at the idea of "their" patients in pain. Remarks heard frequently were, "Our patients are not in pain," or "Pain isn't a problem here." Staff were unable to verbalize how they assessed pain in the patients, but as one assistant said, "It's like when someone you love is in pain; you just know."
With repeated questioning, the staff could accurately describe most of the residents' pain behaviors. A patient who normally moaned and rocked became quiet and withdrawn when in pain. Another contracted, nonverbal individual exhibited rapid blinking during episodes of pain. Patients who had extremely disjointed verbalizations could, when in pain, describe the location of the pain very accurately (Table 2). There was marked differences in the level of assessment and the education and experience of the staff. Although nursing assistants could describe pain behaviors, their skills were poor and they were unable to attribute specific pain behaviors to a particular patient. The majority of the staff consisted of licensed practical nurses. Those LPNs with experience were able to discuss a particular patient's pain behavior in detail.
A very experienced LPN with good assessment skills said: "Do you see R over there? See how she moans and rocks? Well, she's not in pain, that's just her normal behavior. When she hurts, she gets very quiet, and doesn't eat. Then I know something's wrong with her." Another experienced LPN used fecial expression as an indicator, focusing most on glazed or squinted eyes. She also considered agitation, appetite, and guarding when assessing for pain.
Discussions between nurses also yielded information about assessment skills. If a patient was acting unusual, two or three nurses examined patteras of behavior and tried to fit the current behavior into the usual pattern. If it did not fit, the nurses assumed the patient was becoming ill, and searched for signs to support this.
The pain assessment skills of the staff and the low level of pain in this population are related. What appeared to be intuition was actually a complex recognition of verbal and nonverbal cues and the arrangement of these cues into a meaningful pattern. These patients are "owned" by this staff. The staff has identified each patient's normal behaviors and any deviation from normal is quickly assessed and acted upon. Therefore, patients who might have pain are ambulated, medicated, or turned, alleviating potential problems.
It is of interest that the patients exhibiting pain behaviors are only mildly confused. In fact, some confused patients do not exhibit pain behaviors even when undergoing painful procedures. A patient with Alzheimer's disease who had undergone abdominalperineal resection for cancer was found running down the hallway less than 6 hours after surgery. She had gotten out of bed by climbing over the side rails. This patient exhibited none of the usual pain behaviors associated with postoperative patients.
The relation of memory and pain is an area needing more study. If confused patients cannot remember what pain feels like, or what behavior causes pain, they cannot anticipate pain. If patients do not identify the sensation they are feeling as "pain," they do not exhibit pain behaviors. Does mis mean the patient is not having pain? The answer to this question has many implications for nursing care of confused or nonverbal elders.
Not only do we lack an operational definition of pain in the nonverbal elderly, but there is also a marked lack of assessment tools useful in this population. Because the only method of assessing pain in the confused or nonverbal patient is behavioral, research must be conducted to begin to identify pain behaviors in this population. Presently, most documented pain behaviors deal with acute pain in patients 65 years old or younger.30·31 Among those studies that deal with chronic pain, the population upon whom the research was conducted includes only alert elders.
DIFFERENCES BETWEEN NORMAL BEHAVIORSAND PAIN BEHAVIORS IN CONFUSED PATIENTS*
An extensive literature search resulted in few articles dealing with pain assessment in the confused, nonverbal elder.18·26 No reliable pain management studies have been conducted in this population. Given this present and ever-growing problem, extensive research is needed to determine pain assessment and management techniques that are appropriate and useful for this population.
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DIAGNOSES OF PAINFUL CONDITIONS AND NUMBER OF PATIENTS HAVING EACH CONDITION
DIFFERENCES BETWEEN NORMAL BEHAVIORSAND PAIN BEHAVIORS IN CONFUSED PATIENTS*