More reliable tools are needed for the assessment of pain in people with dementia

A study carried out by researchers from the UAB and UNIZAR concludes that carrying out a better evaluation of pain in people with dementia involves having more reliable observation tools, more time dedicated, guides with standardized guidelines and specific training for professionals. .

In cognitive damage, especially in dementia, alterations in cognitive and emotional brain areas, along with difficulties in expressing oneself verbally, make the evaluation and management of pain a challenge for health professionals. The usual tools, based on questionnaires and scales with patient responses, lose their usefulness, and observable aspects of their behavior, such as facial expressions, movements or vocalizations, become key clues. Carrying out a better pain assessment in these patients requires, among other factors, having more reliable, faster and easier-to-use observation tools, specific training and more dedication time.

This is indicated by a study carried out by researchers from the Autonomous University of Barcelona (UAB) and the University of Zaragoza (UNIZAR) published in Frontiers in Neurology, which has analyzed the opinion of more than a hundred health professionals on the evaluation of pain in people with dementia in Spain and how to improve this evaluation. The work is the result of two surveys carried out in 2015 and 2017 among medical, nursing, physiotherapy and psychology staff, from hospitals, nursing homes and day centers in 16 autonomous communities.

«In both surveys we detected concern among professionals about the lack of reliable measurement instruments, the lack of guidelines or recommendations from public administrations and the limited training provided on pain assessment tools based on non-verbal communication in people with dementia. The consequence of all this is worse when the disease progresses, since in most cases there are neuropsychiatric symptoms, and the ability to speak is not only compromised, but may become non-existent," says study coordinator Lydia Giménez. Llort, professor of Psychiatry and researcher at the Institute of Neurosciences (INc-UAB) and the UAB Mental Health CORE.

The study carried out by the Spanish researchers was part of multidisciplinary research funded by the European Union to reach a consensus on the criteria and validate optimized pain assessment tools based on observation, based on existing ones. The German psychologist Stephan Lautenbach and the Dutch geriatrician Wilco Achterberg led the research, carried out between 2011 and 2018, in which 16 countries participated.

"The data obtained in Spain is in line with that of most countries and shows that health professionals in the EU have to face the same challenges," says Patricia Schofield, from Abertay University and Sheffield Hallam University. , who coordinated the field study in the United Kingdom, Holland, Germany, Denmark, Belgium, Switzerland and Austria, whose results have been compared with those of Spain in the study published now. «The recognition of the forms of facial expression of pain, considered one of the key elements of non-verbal communication in observational tools, is the most valued feature by Spanish professionals, while in central Europe until now it has occurred more relevance to body movements," adds the researcher, for whom this difference would be due to a cultural issue.

Improve pain assessment for more precise treatment

Spanish researchers consider it key to improve the evaluation of pain in patients with dementia, who represent between 40 and 80% of people in nursing homes, to achieve more precise treatment.

«In some cases, the presence of pain aggravates the manifestation of behavioral alterations, such as agitation and other disruptive behaviors, which are treated with antipsychotics. If the pain is underdiagnosed, it is more likely that it will be undertreated and that the pharmacological management of the disease will cost more to optimize," adds María Luisa Bernal Ruiz, professor of Pharmacology at the UNIZAR Faculty of Pharmacy and researcher at the Aragón Health Research Institute ( IIS Aragon).

An agreed tool

The results of the studies carried out in different countries made it possible to develop in 2018 an agreed measurement scale with the assessment items that professionals considered most useful, which is already being applied. It is the PAIC 15 scale (from the acronym in English Pain Assessment Impairment Cognition), with a total of 15 behavioral descriptors, distributed in groups of facial expressions, body movements and vocalizations, among which are frown y narrow your eyes, restlessness, alert, to complain o are not allowed.

The portfolio of actions to be implemented also includes the development of standardized guidelines and recommendations, and training actions so that pain in patients with dementia can no longer be under-evaluated and valued.

"Efforts to establish more viable instruments and policies, together with education, that improve the diagnosis and treatment of pain in these patients are key objectives for the countries that have participated in this EU initiative," says Antoni Bulbena, head from the Department of Psychiatry and Legal Medicine at the UAB, who also participated in the study.

Reference: Giménez-Llort, L et al. Pain in Older Adults With Dementia: A Survey in Spain. Front. Neurol. (2020) https://doi.org/10.3389/fneur.2020.592366