Current Pain Assessment Tools for Geriatric Patients Missing from Practices

Although many reliable and valid pain assessment tools for cognitively intact and impaired geriatric patients are currently available, clinical evidence emphasized by Keela Herr, PhD, RN, FAAN, AGSF, co-director of the John A. Hartford Center for Geriatric Nursing Excellence at the University of Iowa College of Nursing, suggests those scales are not consistently administered throughout practice settings.

At a plenary session of the American Pain Society’s 32nd Annual Scientific Meeting, held May 8-13, 2013, in New Orleans, LA, Herr said one study found 95 percent of geriatric hospital patients experiencing pain received no objective pain assessment based on a valid tool during initial assessment from a doctor. In the hospice setting, initial assessment was sound, but reassessment — which Herr said is crucial to monitoring a treatment’s effectiveness — was extremely low.

Additionally, a study by Elizabeth Manias of the University of Melbourne School of Health Sciences found that a group of nurses were applying the same strategies they used throughout their careers to all geriatric pain patients, rather than individualizing care with available tailored pain scales, while another study by Andrea Gilmore, RN, of the University of Wisconsin-Madison School of Nursing, conducted qualitative interviews of 13 nurses across four nursing homes and discovered that they lacked clear procedures for assessing pain.

But Herr said issues surrounding pain assessment in older adults also stem from the sheer number of tools available and the variability among them, as she noted “there are now over 35 non-verbal pain tools available across the world — ranging from five behavioral categories to 60 individual behaviors and from presence of pain to pain intensity — and there’s no single best tool for practices to use.”

Instead of building better assessment tools, Herr recommended refining and redeveloping existing ones to make them not only capture pain intensity, but also gauge patients’ function, tolerability, and satisfaction with treatment, which she said would improve pain recognition and treatment decision-making in older adults with severe cognitive impairment who can’t verbally communicate with their providers and often suffer from undertreated pain as a result.

“The pain intensity number scales do not provide information about pain tolerability, interference with daily activity, or need for treatment, and they don’t address the uniqueness in each person’s pain experience,” Herr said. “There’s also backlash from patients about ‘giving a number, a number, a number’ that doesn’t fully capture their experience with pain, so what we need is a more patient-centered approach.”

While two patient-centered approaches to initial pain assessment will soon be tested by the U.S. Department of Veterans Affairs and the University of Utah, Herr said knowledge about managing pain in the geriatric population is just as vital to advancing treatment and outcomes as tool transformations.

“There are many barriers to translating best practice recommendations, but I really believe what’s essential is education. Education and training to manage pain in the elderly right now is insufficient, and clinician training programs must address this serious deficiency,” Herr said. “Establishing core pain competencies as essential content in pre-licensure programs would be an important next step.”

Herr said UC Davis Health System is already taking that step with grant support from the Mayday Fund, as a team of faculty will design and implement a curriculum that aims to increase health care professionals’ knowledge and response to pain.