By Roberta Heale, Associate Editor EBN @robertaheale @EBNursingBMJ
I read an alarming study last week. 
The paper cited several aims, with an overarching goal to determine the quality of end-of-life care in nursing homes. A survey was given pre and post the delivery of educational seminars to 320 care staff from 22 residential care homes in Hong Kong.
When asked…‘‘What is the proportion of patients likely to suffer from pain in end-stage dementia?’’
only 23% answered correctly, with 60% underestimating the proportion. Seventy-seven percent of participants thought the effects of analgesics will decrease with repeated use. Over 60% of participants believed narcotic analgesics will induce gastrointestinal bleeding or ulcers, and that end-stage dementia patients have reduced pain sensations.”(1)(pg. 1270).
Even post education, the majority continued to respond that people with dementia have reduced pain sensations. Clearly appropriate assessment of pain for people with dementia suffers when carers beliefs are incorrect.
Not only are the beliefs of carers an issue, but reduced cognition of residents with advanced dementia leads to failure to recognize pain both by carers as well as family, with resulting reductions in treatment.(2) Often, pain is expressed through behaviour changes, by such things as fidgeting, grimacing or even physical aggression. Treatment is typically targeted to the behaviour change, rather than the underlying cause, which may be pain related.
It’s important to have an evidence-based approach to the assessment of residents with advanced dementia to ensure that their pain is recognized and appropriately treated. One tool is the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). https://geriatricpain.org/sites/geriatricpain.org/files/wysiwyg_uploads/pacslac_checklist_with_sm_logo_0.pdf
The tool is meant tobe used by a professional nurse to assess the patient on admission to establish a baseline and determine behaviours that may be related to pain. Then there should be a quarterly review or a weekly for those residents with known pain issues and an assessment with any changes in behaviour that might be related to pain. Finally, evaluation post treatment is required. https://geriatricpain.org/sites/geriatricpain.org/files/wysiwyg_uploads/pacslac_instructions_with_sm_logo.pdf
This type of systematic approach to assessment for pain through behaviour changes will go a long way to recognizing and appropriately treating residents with advanced dementia. Given that long-term care facilities often hire unregulated care providers for most of the day-to-day care, nurses will need to work closely with all staff to ensure appropriate pain treatment. Attention to pain issues with older adults who aren’t able to speak for themselves is important in all settings. Nurses have the potential to play a pivotal role in the issue of pain assessment for this population.
References
- Lee et al. – 2013 – Improving the quality of end-of-life care in long-term care institutions. Journal of Palliative Medicine. 2013.16(10):1268-1274.
- Lawrence V, Samsi K, Murray J, Harari D, Banerjee S. Dying well with dementia: Qualitative examination of end-of-life care. Br J Psychiatry. 2011 Nov;199(5):417–22.