AJN, American Journal of Nursing:
In the NEWS
Relatives and staff often poorly estimate pain, especially in the cognitively impaired.
It's estimated that 40% to 80% of nursing home residents experience some kind of pain from an injury or chronic condition. Unfortunately, evaluating pain levels in residents is a difficult task, particularly in those with cognitive impairments.
Figure. A pain scale...Image Tools
A recent study sought to find out whether relatives and caregivers (proxies) understood residents' pain well enough to assist in pain assessment and to discover what factors affected their judgments of pain. The findings showed, however, that their reports didn't consistently match the pain ratings of nursing home residents themselves.
The study was conducted over a four-year period in six nursing homes in the Netherlands with 174 total residents. The patients were divided into two groups: those who were cognitively intact and those who were cognitively impaired or nonverbal. The patients were asked to rate their pain both at rest (to judge chronic pain) and over the preceding week on a 0-to-10 numeric pain-rating scale.
Cognitively intact residents rated their own pain, as did 43% of those with cognitive impairment who could complete the test. A total of 171 caregivers and 122 relatives who frequently visited the residents took part in the study. The relatives' and caregivers' assessments were compared with one another and with the patients' own reports of pain. Proxies were also asked to rate the certainty of their assessments.
Overall, "[a]greement levels between residents and relatives were higher than those between residents and caregivers." And 100% of the residents said they had had pain in the previous week, whereas 89% and 67% of caregivers and relatives, respectively, had the same assessment. Residents gave their pain at rest a significantly higher score (4) than either group of proxies did (0), although relatives were less sure of their assessments of pain at rest than caregivers. Caregivers were more likely to rate a resident's pain as high if the patient was taking analgesics. The cognitive abilities of the patients also affected the results, with less agreement evident between proxies and the more cognitively impaired patients.
The authors point out that previous studies have shown that caregivers often underestimate pain and relatives tend to overestimate it, even when they say they're certain they're correct.
"The low agreement between pain scores of caregivers and self-reported pain scores of residents was surprising," said Monique van Dijk, a study coauthor, in an e-mail. One possible reason is that "residents might feel more confident to discuss pain problems with relatives than with caregivers," she said. "Caregivers seem to primarily rely on verbal complaints of residents and may assume that residents who don't complain and don't take pain medication are pain free."
According to van Dijk, difficulty communicating with residents with cognitive impairments could account for relatives' reports of greater pain in residents without cognitive impairments.
The authors suggest that pain management in nursing homes could be improved through caregiver education, including the implementation of pain assessment education in combination with treatment. They recommend basic training for nurses and nursing assistants on pain, pain behavior, and pharmacologic and nonpharmacologic pain treatment, such as "massage, applying warmth, mobility[, and] distractions with music or story telling." They also suggest that "treatment effects could be determined more easily using a pain observation scale."
van Herk R, et al. J Clin Nurs 2009;18(17):2478–85.
© 2009 Lippincott Williams & Wilkins, Inc.