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Nursing

Pain Assessment in the Cognitively Impaired

Introduction: Many illnesses are accompanied by pain, and the pain can be mild, moderate, or severe.  In fact, pain is an indication that the entire body or some part of the body is not functioning as well as it should in its normal state.  Therefore, it is critical for a patient to communicate to the attending physician or the nurse regarding all aspects of the pain and its source.  However, not all patients are capable of verbalizing or expressing their physiological or psychological sufferings in a written format. These patients may be handicapped by age (infants and toddlers), impaired mental status (dementia, Alzheimer’s Disease, delirium, and head injuries), administration of tranquilizers that render them helpless, or loss of consciousness (state of coma).  As a result, caregivers and nurses must figure out how best they can evaluate the pain and offer adequate treatment for this condition.

Comprehension: Establishing an effective understanding of pain management requires the identification of the source of the pain, its level of severity, and the development of a treatment plan for a patient whenever possible. However, for patients with advanced dementia or other similar conditions, it is difficult to obtain sufficient information regarding the source and degree of pain; therefore, it becomes necessary to identify other means of identifying and assessing pain, particularly during the postoperative phase (Morrison and Siu, 2000). Many healthcare professionals do not recognize the level of pain that exists in many of their patients and this reflects a challenge to identify methods to improve pain recognition and management within this population (Morrison and Siu, 2000). According to the authors, “Patients with dementing illnesses (e.g., Alzheimer’s disease, vascular dementia) may be at even greater risk for undertreatment of pain” (Morrison and Siu, 2000, p. 241). Therefore, it becomes necessary to conduct studies and evaluations of methods to improve symptom recognition and management within this population (Morrison and Siu, 2000).

            The study by Morrison and Siu (2000) evaluates the specific nature of pain management through the development of new principles and protocols that are designed to encourage effective outcomes for pain and the treatment of patients with cognitive deficits. In particular, for patients with hip fractures, there are considerable challenges associated with the creation of an environment that will identify and manage pain effectively throughout the duration of the hospital stay (Morrison and Siu, 2000). Therefore, it is important to identify these risks and how pain management might be improved through the development of new resources and methods to ensure that patient care and treatment is not compromised in the postoperative phase (Morrison and Siu, 2000).

            Comparison: The study utilized a patient population over the age of 70 who had been diagnosed with a hip fracture in a specific window of time, and were identified through the services of a research assistant (Morrison and Siu, 2000). Patients who were selected were evaluated using the Mini-Mental State Exam by telephone and were divided into two groups, cognitively intact and dementia (Morrison and Siu, 2000). Those selected for study participation were also evaluated in the context of their analgesic treatments as noted in their charts, using the World Health Organization’s Analgesic Ladder as a guide (Morrison and Siu, 2000). The study utilized this type of data and information to capture a greater understanding of the population and their degree of pain, as well as their specific needs (Morrison and Siu, 2000).

This study addresses a very specific population where pain assessment is not readily explored because of the difficulties of cognitive impairment (Morrison and Siu, 2000). In comparison to this study, an article by Ferris (2008) explores this topic from the perspective of obtaining adequate information for the case study by asking patients regarding their pain experiences by using simple words that are easy to understand, even for patients who experience cognitive difficulties (Ferris, 2008). This enables the clinician to determine the degree of pain that is experienced more effectively than using complex words and phrases to attempt to obtain this information (Ferris, 2008). In this context, “Elderly patients, like all patients, have a fundamental right to have their pain assessed. A pain assessment tool that has been validated by research is appropriate for this purpose. Commonly used tools include the Numeric Rating Scale and the Visual Analog Scale. These can be used both with patients who are cognitively intact and for some patients who are impaired” (Ferris, 2008).

For persons who have dementia or other cognitive impairments who require pain management methods, it is important to identify the different areas where this practice might be improved through specific strategies. For example, behavioral evaluation and assessment may be indicative of increased pain in patients; therefore, these behaviors should be explored to determine if additional evaluation is required in this manner (Smith, 2007). There are considerable efforts required by clinicians in order to identify these challenges and how they impact patients in order to ensure that the needs of this population are met in an effective and reasonable manner (Smith, 2008).  Patients with cognitive impairments may be able to provide some answers verbally, depending on the severity of these deficits, but those who cannot might benefit from behavioral assessments or other similar practices (Smith, 2008).

            Analysis: This article provides evidence that supports the necessity to improve pain management in the postoperative patient population, particularly for those with dementia or other cognitive deficits, because this population may be difficult to communicate with and to reach a consensus regarding pain and its severity (Morrison and Siu, 2000). The study indicates that over 40 percent of study participants without cognitive deficits experienced severe pain during the postoperative phase; furthermore, this group of patients were prescribed analgesics in triplicate versus those who possessed cognitive impairments (Morrison and Siu, 2000). This is an important reminder of the challenges associated with pain management in the elderly population, and in particular, those who have experienced significant challenges associated with cognitive impairments because they are unable to clearly express the degree of pain that they are experiencing (Morrison and Siu, 2000).

            Evaluation: In this study, the determination of specific factors associated with the care and treatment of elderly patients within pain the postoperative setting is of critical importance in shaping the lives of these patients and their specific needs (Morrison and Siu, 2000). In this context, it is important to recognize that many patients with cognitive deficits or dementia are unable to clearly express themselves and their needs, including their degree of pain (Morrison and Siu, 2000). As a result, they may suffer from severe pain and are not treated accordingly in the hospital setting (Morrison and Siu, 2000). This is a challenging set of circumstances to consider and requires a greater understanding of the challenges and limitations of pain management for elderly persons (Morrison and Siu, 2000).

This article describes the importance of evaluating cognitive deficits and the determination of pain in this population through improvements in the assessment process in order to expand treatment options for the cognitively impaired (Morrison and Siu, 2000). For this population group, it is evident that there must be additional factors in place that are important in demonstrating the value of clinical interventions that will produce greater outcomes for this population group through the development of specific strategies to accommodate cognitively impaired patients who require surgery (Morrison and Siu, 2000). These efforts are important because they convey the challenges associated with pain management for this population group and its impact on patient wellbeing (Morrison and Siu, 2000). For many clinicians, there may be an existing fear regarding the impact of analgesics on the cognitive state and the possible risk of delirium; therefore, these ideas must be explored more effectively in order to accomplish the desired objectives in a reasonable manner (Morrison and Siu, 2000).

The efforts that are made by clinicians to further investigate pain management in the elderly must also address the mixed perceptions of analgesics and how they impact body systems (Morrison and Siu, 2000). Many patients with or without cognitive deficits may be hesitant to take analgesics out of fear or for other reasons; therefore, these circumstances must also be evaluated for their significance to this population group (Morrison and Siu, 2000). It is expected that additional interventions must be addressed that will accomplish the objectives of achieving greater pain management through new types of assessments and other indicators that will address pain more effectively (Morrison and Siu, 2000).

Which topic did you choose?  “Pain assessment in the cognitively impaired.”  It is the duty of a nurse to ensure that every patient obtains optimal pain relief and is not at risk of harm during the hospital stay.  The cognitively impaired are highly vulnerable and require greater assistance than those who are able to communicate effectively.  Furthermore, the evidence from the described research study prompted me to deeply consider the matter in question.  The study notes that after surgery, “only 24% of these non-communicative patients received an order for standing analgesia.  The remaining 76% received analgesia only if they exhibited a visible behavior that could be interpreted as resulting from pain during a routine nurse or physician assessment” (Morrison & Siu, 2000, p.245).  In this example, these elderly patients were suffering from dementia.  Therefore, pain management and alleviation is the first step toward achieving improvement in the patient’s condition.

 

Which three databases will you use?

1.  Google Scholar

2.  Google Search

3.  Center of Disease Control

 

Search each database, using key words, for relevant research on this subject. What key words did you use in the Search Strategy fields? Include all attempts and limitations used to refine your search.

1.  Non-communicative patients, non-communicative patients with pain, pain management in non-communicative patients, and pain management in the cognitively impaired

2.  Pain assessment, cognitive impairment, elderly people with cognitive impairment, and non-communicative older adults

3.  Cognitively-impaired patients, pain assessment and pain management, gauging pain in nonverbal patients who cannot communicate, cognitively impaired older adults, and pain management in the cognitively impaired.

 

Report the number of citations identified from each database in the number of articles found field.

1.  6

2.  7

3.  0

 

Conclusion:  A search of databases such as Google Scholar, Google Search, and Center of Disease Control revealed that this is not a very common topic for research.  There are many ordinary articles on the subject of pain assessment in the cognitively impaired, but peer-reviewed articles or journal articles are less common. With this evaluation method, it is important to recognize the value of creating new types of assessment tools to increase the scope and breadth of research in this area and to capture a greater understanding of the different elements that are critical to the success of pain management and treatment for this population group to ensure that their needs are met as effectively as possible. Patients in this group must be treated to ensure that pain management is under control and that treatment options are utilized on a regular basis.

 

References

Ferris, M. (2008). Pain in the cognitively impaired elderly: guidance for clinicians. Topics in                 Advanced Practice Nursing, retrieved from

http://www.medscape.com/viewarticle/573642

Morrison, S. & Siu, A. L. (2000). A Comparison of Pain and Its Treatment in Advanced

Dementia and Cognitively Intact Patients with Hip Fracture.  Journal of Pain and Symptom Management, 19(4). New York. 240-248. Retrieved from

http://www/cera/usyd.edu.au/10_4_Hip_Pain.pdf

Smith, SDM. (2007). Assessing pain in people with dementia 1: the challenges. Nursing             Times.net, 103(29), 28, retrieved from

http://www.nursingtimes.net/home/clinical-zones/mental-health/assessing-pain-in-people-with-dementia-1-the-challenges/197743.article