One of the leading barriers to pain management in older patients is how to assess pain effectively. It's important to know the best methods to assess pain in older clients to improve their quality of life. Pain in patients older than 65 years of age is significantly under-treated and misunderstood.
As part of the aging process, older adults often suffer from sensory and cognitive problems, making it even more difficult to assess pain. Many old aged patients have chronic conditions such as arthritis or diabetic neuropathic, in which pain is a daily occurrence and affects the quality of life. Dementia patients may not be able to express themselves due to their declined ability to communicate the pain symptoms. According to Patricia Bruckenthal, PhD, cognitively impaired patients received one-third fewer analgesics that those patients with intact cognition (Bruckenthal, 2009).
In order to provide older patients with quality care, proper pain assessment tools must be used. To remediate these issues many researches have been done to find the best methods to better assess pain in the elderly population. Some pain assessment scales that are used now by health professionals are also being studied by researchers to find if they are effective. In this literature review we will discuss The Visual Analog Scale, The Numeric Rating Scale, Faces, PAINAD, The Pain Thermometer, and The Verbal Description Scale.
Visual Analogue Scale
Using the Visual Analogue Scale (VAS), the intensity of pain is rated on a 10 cm line marked from no pain at one end, to as bad as it could possibly be at the other end. The scale is sensitive to small changes in pain intensity but may not be suitable for use in visually impaired patients (Marianne et al., 2010). The scale can be more effective when combined with behavioral and physical indicators like notable distress, or elevated blood pressure.
The Numeric Rating Scale
The Numeric Rating Scale (NRS) is a tool to rate the intensity of pain on a scale from 0-10. NRS is less sensitive than the visual analogue scale. A common administration error is to describe "10" as "the worst pain you ever had." For some people, the worst pain they ever had may have been something minor like a toothache (King, 2009). Another difficulty is that many geriatric patients have impairments in communication because of health problems, such as strokes and dementia. The Verbal Numeric Rating Scale may have a limited role for these patients. NRS can be more effective when combined with repeated assessments to determine the efficacy of pain interventions.
Faces Pain Scale
Faces Pain Scale was developed by Donna Wong, a pediatric nurse consultant, and Connie Morain Baker, a child life specialist, to assess pediatric pain, the scale proved effective in other situations. Many geriatric patients can't understand or relate to the popular zero-to-10 numerical pain rating scale, like adults who are cognitively impaired or don't speak English. In these cases The Faces Pain Scale is more effective. The scale usually has six faces ranging in expression from smiling to crying, and they carry numbers from 0 to 5 which would be assigned to a pain level (Kim, Buschmann, 2006). Faces Pain Scale, like other scales used to assess pain, is more effective when combined with behavioral and physical indicators.
The Pain Thermometer is based on Patricia Bruckenthal, PhD research, using a pain thermometer as an assessment tool can prove beneficial in detecting pain in geriatric patients. The pain thermometer is graded from 0-10 including 6 faces. Patients that are critically ill and are unable to express their level can simply point to a face which resembles how they are feeling at that time. Results indicated that patients were able to positively rate their level of pain. Pain thermometer is proven effective by a research conducted by Keela Herr, PhD. The results of this study were compared between younger and older patients and between patients with normal and impaired cognitive function. The study proved the validity and reliability of the pain scale thermometer. The results indicated that of the selected pain intensity scales evaluated, the IPT (Iowa Pain Thermometer) rises to the top as a good choice for older (and younger) adults, including those with mild to moderate cognitive impairment (Herr PhD, 2007). The failure rate of IPT was very low and provides increased options proving to be a better choice of older adults (Herr PhD, 2007). The tool proved to be useful in assessing pain not just in critically ill patients but also in geriatric patients.
There are not that many studies done on pain in the geriatrics population, especially in dementia patients. That is why researchers such as Jordan, Alice, Hughes, Julian, Pakresi, Mani, Hepburn, Sarah, & O'Brien, John T (2011) developed a behavior pain assessment scale called The Pain Assessment in Advanced Dementia (PAINAD) to recognize and evaluate pain in this vulnerable population. Elderly dementia clients who have pain are often under-recognized and under-treated comparing to those patients that do not have cognitive impairment. A literature review study was conducted to see if the PAINAD scale is an effective tool to assess pain in geriatric population. The participants were nursing home residents who have advanced dementia. Participant's behavior that indicated the presence of pain are determine by a review of medical, psychiatric and nursing notes; report from observations on three occasions; a discussion after the observations between the doctor and the nurse; and physical examination if necessary (Jordan et al., 2011). PAINAD tool is shown to be an effective tool for detecting pain in people with advanced dementia who cannot communicate. Beside this, the study has also found that PAINAD can be used to assess whether pain management strategies have been successful.
Verbal Descriptor Scale
The Verbal Descriptor Scale uses words instead of numbers. The nurse could say, "Would you please describe your pain for me, from 'no pain' to 'mild,' 'moderate,' 'severe,' or 'pain as bad as it could be'?". Interpreting the results of the verbal descriptor scale should focus on the words used to describe the pain. The nurse should record the words used by the patient and compare them with words the patient used previously. This can be complicated if patients choose to use different descriptors than those specified by the scale. A study measuring "experimentally induced thermal stimuli" conducted by Herr and colleagues found the verbal descriptor scale to have the "strongest psychometric support," followed by the FPS-R and the NRS or its equivalent. The participants in the study said they most preferred a version of the NRS with 21gradations (from 0 to 20), then the verbal descriptor scale, the 11-point NRS (from 0 to 10), and the FPS-R (Ware LJ, et, p. 121, 2006)
As the geriatric population grows, pain continues to be a dominant clinical challenge to all medical facilities. All medical professionals need to assess pain levels correctly using the proper tools. Immediate treatment and management should be provided to all patients including those who are cognitively impaired. The pain assessment scales explained above have been proved effective to assess pain in the geriatric population. Using the correct pain scale at the correct time can make a great difference in the patients' lives.
- Bruckenthal, P. PhD. (2009). The American Academy of Pain Medicine. Special Issues in the Management of Chronic Pain in Older Adults, 10, 1-13
- Jordan, A., Hughes, J., Pakresi, M., Hepburn, S., & O'Brien, J. T. (2011). The utility of PAINAD in assessing pain in a UK population with severe dementia. International Journal Of Geriatric Psychiatry, 26(2). Retrieved on Oct 6, 2012.
- Kim, E. , & Buschmann, M. (2006). Reliability and validity of the faces pain scale with older adults. International Journal of Nursing Studies, 43(4), 447-456.
- King, S. A. (2009, July). The challenge of geriatric pain. Psychiatric Times, 26(7), 13.
- Marianne Jensen Hjermstad, PhD, Peter M. Fayers, PhD, Dagny F. Haugen, MD, PhD, Augusto Caraceni, MD, Geoffrey W. Hanks, DSc (Med), MB et al. (2010). Studies Comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for Assessment of Pain Intensity in Adults. Journal of Pain and Symptom Management,Volume 41, Issue 6, Pages 1073-1093.
- Herr, K. PhD. (2007). Pain Medicine. Evaluation of the Iowa Pain Thermometer and Other Selected Pain Intensity Scales in Younger and Older Adult Cohorts Using Controlled Clinical Pain: A Preliminary Study, 8, 585-600.
- Ware LJ, et al. Evaluation of the Revised Faces Pain Scale,Verbal Descriptor Scale, Numeric Rating Scale, and Iowa Pain Thermometer in older minority adults. Pain Management Nurse 2006;7(3):117-25.
- Wong-Baker Faces Foundation. (2012). Faces History. Retrieved November 3, 2012, from http://www.wongbakerfaces.org/resources/faces-history
Nashwa Moustafa, Manveen Kaur, Mindy Lou, Oryalis Sarmiento, Voleak Thorng and Esther Ramirez are nursing students at California State University San Bernardino.