There has been much interest in the assessment of pain in recent years, but pain scales and guidelines are only one part of the whole management process
Pat Schofield DipN PGDipEd RGN PhD
Professor of Nursing, University of Greenwich, UK
The population is aging fast, and it has been suggested that the number of older people will be at an all-time high by the year 2050, rising from 7.4% to 16.4%. Furthermore, it is anticipated that the number of people aged over 80 years will more than triple.(1)
Similarly, in the UK as with other countries in the Western world, the figures are on the increase. Over the past 25 years there has been a rise in the over-65 years age group from 15-17%, a total of 1.7 million people. In the UK in 1985, there were approximately 690,000 people over the age of 85 years and by 2010, those figures had doubled to almost 1.4 million. By 2035, we anticipate that 5% of the total population will be the ‘oldest old’.(2)
Evidence suggests that pain is a common problem for older people, with chronic persistent pain affecting at least 50% of community dwelling older adults,(3,4) although earlier work suggests that this number is even higher.(5) When we consider the oldest and most vulnerable, such as those living in care homes, it is believed that the number increases to 80%.
It has been demonstrated that the use of pain scales can be influenced by age. For example, a review carried out on behalf of the British Pain Society and British Geriatric Society (BPS/BGS) in 2007 revealed that adults over the age of 65 years were generally unable to assess their pain in the same way as their younger counterparts, reinforcing that the most appropriate pain scales for use in this age group were the numerical rating scale (0–10) or verbal descriptor scales.(6) When communication problems exist, it is not appropriate for the professional to assume that pain does not exist. There are a number of pain scales that have been developed specifically for measuring pain in older adults with communication problems. In total, 11 behavioural pain assessment scales have been identified from a systematic literature review.
Such scales included PAINAD, PACSLAC, ABBEY and DOLOPLUS.(7) All of these scales appeared to consistently identify particular behaviours as being consistent with pain, such as facial expression, body language and verbal sounds. The problem at that time was that there many scales had been developed in practice butthere had been no evaluation to ensure reliability and validity across settings and client groups. A further review in 20088 identified three key scales (DOLOPLUS, PAINAD and Abbey) that demonstrated stronger evidence than others.
All three were deemed appropriate for the assessment of chronic pain, often in long-term care settings. In fact, work by Jordan and colleagues(9) demonstrated the appropriateness of PAINAD as a scale for the assessment of pain in adults with dementia in long-term care settings and there has been further work on this scale by Zwakalen and colleagues,(10) which is proving positive in terms of its use. Finally, the DOLOPLUS scale has been recently adapted by Rat et al11 for induced pain and we have subsequently seen the introduction of the ALGOPLUS scale, a sister scale to the original scale.
It is clear that there has been much interest in the assessment of pain in recent years, with a proliferation of scales and recommendations. However, pain scales and guidelines are only one part of the whole pain management process. Even in general adult care, where pain scales do exist, there is limited evidence of their use. Similarly, even though many behavioural pain scales have been developed, development seems to outweigh validation of existing scales.
The problem is not the lack of pain assessment scales, but the lack of use of such scales in practice. While healthcare workers are enthusiastic and supportive of pain assessment, they are often overloaded with documentation and paperwork that prevents best pain assessment practice. One way forward has been the introduction of technology to capture the minds of younger care staff; an iPhone App, for example, has been developed by the University of Greenwich and is currently being evaluated in an acute setting for staff working with adults with dementia.
In terms of pain management, there is still a great need to evaluate approaches among the older population itself. There is a fear among healthcare professionals to prescribe many drugs and this is understandable because the trials have generally involved younger adults. Approaches such as cognitive behavioural therapy have not been fully evaluated in this population, so there is still room for more research. The BPS/BGS guidelines for the management of pain in older adults will be available very soon and will point the way for both clinical practice and future research.
In summary, we have an ageing ‘time bomb’ and within that, we have a potential pool of people with poorly assessed and poorly managed pain. While there are some innovative ways of assessing pain that is just the first step and more work needs to be carried out. In the first instance, we as health care professionals need to acknowledge that pain among the older population does indeed exist.
- Evidence suggests that pain is a common problem for older people.
- When communication problems exist, it is not appropriate for the healthcare professional to assume that pain does not exist.
- There are a number of pain scales that have been developed specifically for measuring pain in older adults with communication problems.
- It is clear that there has been much interest in the assessment of pain in recent years, with a proliferation of scales and recommendations.
- While there are some innovative ways of assessing pain, that is just the first step and more work needs to be carried out.
- In terms of pain management, there is still a great need to evaulate approaches among the older population itself.
- US Census Bureau 2002. http://www.census.gov/econ/census02/ (accessed 16 September 2013).
- National Statistics. www.statistics.gov.uk/cci/nugget.asp?id=949 (accessed 16 September 2013).
- Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995;10.591–8.
- Helme RD, Gibson SJ. The epidemiology of pain in elderly people. Clin Geriatr Med 2001;17:417–31.
- Brody EM, Kleban MH. Day-to-day mental and physical health symptoms of older people: a report on health logs. Gerontology 1983;23:75–85.
- The British Geriatric Society / British Pain Society. Guidelines for the assessment of pain in older adults. www.bgs.org.uk/index.php?option=com_content&view=article&id=313:painassessment&catid=42:catclinguidelines&Itemid=107 (accessed 16 September 2013).
- Schofield PA et al. Chronic pain in later life: a review of current issues and challenges. Ageing Health 2011;7:551–6.
- Schofield P. Assessment and management of pain in older adults with dementia: a review of current practice and future directions. Curr Opin Support Palliat Care 2008;2(2):128–32.
- Jordan A et al. Pain and distress inadvanced dementia: Choosing the right tools for the job. Palliat Med 2012;26(7):873–8.
- Zwakhalen SM, van der Steen JT, Najim MD. Which score most likely represents pain on the observational PAINAD pain scale for patients with dementia? J Am Med Dir Assoc 2012;13(4):384–9.
- Rat P et al. The Algoplus scale for the assessment of induced pain behaviour. Soins 2010;749:50–1.