Measure of Pain in Elderly People with Dementia

Ross Finesmith M.D.www.linkedin.com/pub/ross-finesmith-m-d/20/407/894

Abstract

The care of the elderly patient suffering from dementia is complex, particularly when

the nurse employs patient-centred, individualised approaches to care. Pain assessment

in such cognitively impaired individuals is made much more difficult by their

condition. Pain is frequently experienced by elderly patients, with reported prevalence

rates as high as 45–84% among patients in healthcare settings. Cognitive impairment

is also common in the elderly, with studies showing that approximately half of

patients in nursing homes or palliative care settings are affected to some degree

The Doloplus-2 method of clinical evaluation has been used to assess pain in elderly

and those with dementia for 15 years. This paper will examine the published literature

on the Doloplus-2 scale, evaluate the clinical utility and psychometric properties of

this instrument through critical appraisal, and discuss how Doloplus-2 may be used in

pain management for elderly patients with dementia.

Perspective

This article presents a critical review of a behavioural pain assessment scale, the

Doloplus-2. The Doloplus-2 is a rating scale completed by nursing staff to categorize

patient’s behavioral responses to acute pain. This measure could potentially help

clinicians more effectively identify the extent of pain in elderly who are unable to

verbalize their painful symptoms.

Page 1

Key words: Pain scales, Doloplus, Alzheimer’s, Pain assessment. Elderly pain scale

Index

Introduction ………………………………………………………………………4-5

Critical Appraisal …………………..…………………………………………………5

- The Doloplus-2 scale ……………………………..………………………………..6

- Clinical Utility …………………………………………...………………………6-8

- Psychometric Properties …………………………..…………………...…………..8

2

- Validity…………………. …………………………………………………….8-9

- Reliability………..………………………………...…………………………9-10

- Responsiveness………………………………………………...……………10-11

- Other factors to consider …………………………………………………………..11

Conclusion ……………………………………………………………………….12-13

Appendices ……………………………………………………………………….14-16

References………………………………………………………………………...17-20

3

Introduction

Evidence based practice is an essential aspect for all health care professionals because

it is becoming fundamental for practice clinical decision making. Macnee and

McCabe18 stress the importance of the evidence base in delivering care quality

improvement. Although the nature of evidence based practice continues to be debated,

especially from the differing ideological positions of nurses, medical staff and other

professions, the use of evidence to inform and change practice is an important

function of any nurse and requires the ability to apply critical evaluation to key areas

of care as Melnyk and Fineout-Overholt 21 emphasise.

The care of the elderly patient suffering from dementia (any one of the spectrum of

disorders which produce dementia) is complex, particularly when the nurse employs

patient-centred, individualised approaches to care. Elderly patients often present with

complex healthcare needs, yet from some evidence available it is suggested that the

elderly nursing care standards continue to be less than optimal.14 Over 50% of

nursing home residents, and a similar number of elderly patients admitted to acute

care hospitals, have dementia.11 Pain assessment in such cognitively impaired

individuals is made much more difficult by their condition3. Pain can result in

behavioral changes in any person and should always be considered as a potential

cause in patients with dementia, especially in those that are non-verbal. Failure to

recognize pain in older adults can have serious effects on cognitive performance,

quality of life; increase symptoms of depression and functional ability29.

An evaluation of pain measurement would serve many purposes, including identifying

how consistently measurement tools or instruments are used by nursing staff (or other

4

staff), identifying how effective the tools are in actually identifying pain, or how

effective they are in reduced negative outcomes or behaviours in patients such as

those with dementia whose cognitive impairments limit their ability to communicate

pain levels. Davies et al6 identify that altered cognitive patients are unable to inform

others of their pain.

This essay examines one method of clinical evaluation applied to the clinical setting;

the clinical evaluation method chosen is outcome measurement Pain assessment is the

chosen intervention for elderly people who suffer dementia. The outcome measure

tool is the Doloplus-2 (see appendix 1). This paper will examine published literature

on the Doloplus-2 scale, evaluate the clinical utility and psychometric properties of

this instrument through critical appraisal, and discuss how Doloplus-2 may be used in

pain management for elderly patients with dementia (see appendix 2).

The critical appraisal checklist as Jerosch-Herold16 guide is followed in this paper

because it is rigorous and comprehensive. It is hoped that the evidence gathered will

allow informed decision-making on the acceptability of this scale for use by nurses

and other care providers in everyday clinical practice.

Critical appraisal

Pain is frequently experienced by elderly patients, with reported prevalence rates as

high as 45–84% among patients in healthcare settings.12,19 Cognitive impairment is

also common in the elderly, with studies showing that approximately half of patients

in nursing homes or palliative care settings are affected to some degree. 8,20,22 Regular

assessment is vital in order to manage pain effectively. Elderly patients who had mild

cognitive impairment might be able to communicate well enough to understand and

use simple self-report tools for pain assessment such as the (VAS) tool, which is

Visual Analogue Scale, (VRS) Verbal Rating Scale, (NRS) Numeric Rating Scale or

(FPS) Facial Pain Scale. However, patients with moderate or severe impairment are

frequently unable to understand or answer even simple questions.8

These patients present a challenge for nurses and other care providers and evidence

shows that their pain management is frequently suboptimal, often as a result of

inadequate assessment and diagnosis.22,37

5

Behavioural pain assessment instruments must be used with this group for their pain

assessment. It is important to note that the behavioural pain assessment tools do not

measure pain directly, but are based on observations of behaviour related to sleep

patterns, level of appetite, patterns of physical activity and mobility, and expression of

body language .37 Assessment of physiological indicators for example: the heart rate

(Pulse) or blood pressure (BP) may also be included.37 There are many scales of

behavioural pain assessment that have been developed for use including Doloplus-2,

Pain Assessment in Advanced Dementia (PAINAD), Pain Assessment in Dementing

Elderly (PADE), Pain Assessment Checklist for Seniors with Limited Ability to

Communicate (PACSLAC) and Abbey Pain Scale.9,1,34,33,35

Glendinning 10 defines the outcomes as “Outcomes refer to the impact or the end

results of services on the person’s life”. Therefore it is important to evaluate and

appraise the tools used to measure them as Melnyk and Fineout-Overholt21 define the

“outcomes measurement is a generic term used to describe the collection and

reporting of information about an observed effect in relation to some care delivery

process or health promotion action. It requires the careful identification of reliable and

valid outcome indicators, the selection of appropriate measurement methods, and the

assurance of timeliness of data collection and reporting”.

Using these tools is intended to improve the elderly people quality of life and

monitoring the effectiveness of the intervention as well as for the professional

development by discovering who needs training as Corr and Siddons 5 say. Those

tools which form part of models of care planning and management of pain, underline

and reinforce continuous reassessment of pain in the light of changes in the patient’s

condition due to medical procedures, movement, activities of daily living, and the

administration of methods of pain relief. This kind of approach reflects the essence of

nursing care. As such, pain assessment must also be considered an essential

component of the nursing care of these individuals, because with the cognitive

impairments that are caused by dementia, they are some of the most vulnerable

patients that nurses will have in their care.

6

The Doloplus-2 scale

Clinical utility

The clinical utility of an instrument is an important factor in determining if the

instrument will be acceptable in clinical practice.28 To date, there are a lack of

published data on all of the available behavioural pain assessment tools demonstrating

their clinical utility, but the Doloplus-2 scale is the most widely tested scale.37

The Doloplus scale was originally developed as a 15-item scale in 1992 as a tool to

assess pain in elderly patients with cognitive failure, then refined to the present

Doloplus-2 scale in 1999.36 The scale comprises 10 items across 3 domains: somatic

(5 items), psychomotor (2 items) and psychosocial (3 items), and records observations

of various aspects of patient behaviour that may be indicative of pain. Items assess

pain-related behaviours such as facial expressions, disturbed sleep, verbal reaction,

protective body postures and functional impairment in daily activities, as well as

psychosocial reactions and changes in patterns of communication (see appendix 1).

Items are scored at one of four different levels which correspond to pain intensity

levels rising (where 0 = normal behaviour and 3 = high level of pain-related

behaviour).14,17 A final score ≥ 5 out of thirty (where 30 = maximum score of pain)

confirms that the patient is suffering pain.37 The final score obtained is not a measure

of the pain experienced by the patient at a particular point in time, rather a reflection

of the progression of pain experienced.37

Research has shown that scales, which can be used effectively not including an in-

depth knowledge of the patient, are of greater value than those which require the user

to be familiar with the patient which they are assessing.30 A possible limitation of this

scale is that it appears that the nurse or other care provider needs to know the patient

well in order to attain the most accurate results. A further limitation is that although

instructions for use are provided, certain items may be difficult to understand or

interpret.37 Therefore, additional training may be required to ensure competency in

those nurses wishing to use this scale with their patients, which will incur additional

cost, thus making the scale less cost-effective. There is no available information about

how long the scale takes to complete.

There is limited evidence to date on the portability of the Doloplus-2 scale. The

published literature that is available documents the findings of studies involving pain

7

assessment in elderly patients in hospitals and nursing homes, which was the patient

population for which this instrument was developed.14

Psychometric properties of the Doloplus-2 scale

Three psychometric properties are of particular importance when assessing a given

outcome measure, namely validity, reliability and responsiveness. Holen and

colleagues assessed the validity and reliability of the Doloplus-2 scale in a study in

2007. Their paper clearly defines the purpose of the study – to test the Doloplus-2

scale criterion validity and inter-rater reliability in elderly patients recruited from

nursing homes.14 The study was conducted in a total of 73 patients with a mean age

of 84 years. Within this sample, 50% of patients were reported to have severe

cognitive impairment and 36% were classed as moderately impaired (Mini Mental

State Examination [MMSE] scores of 0–10 and 11–20, respectively). It must be noted

that this is a small sample size and no power calculation was reported in the paper.

The study sample was representative of the patient population in whom the instrument

would be used (i.e. elderly patients with cognitive impairment). The scale description

is briefly included in the methods section of the paper, with full referencing of earlier

studies. User competency is demonstrated by the inclusion of a statement indicating

that the nurses who would be administering the instrument were either trained or

familiar with the patient.14

Although this study was conducted in a small number of patients, it can be considered

suitable for inclusion in this evidence-based investigation of the Doloplus-2 scale.

Validity

Validity relates to two factors: whether an instrument measures what it is intended for,

and how much confidence users can have in the results obtained when using the

instrument.5 Three different types of validity must be considered: face, content and

criterion validity. The Doloplus-2 scale is meaningful to both the patient and the nurse

as a behavioural pain assessment tool, thus demonstrating the face validity of this

instrument. Furthermore, this scale provides a comprehensive assessment of changes

in pain-related behaviour across three different domains, confirming content

validity.37

8

Criterion validity examines the extent to which a particular scale corresponds with

another well-established measure, typically considered the ‘gold standard’. However,

in the case of behavioural pain assessment, no gold standard currently exists and other

pain measures must therefore be used for comparison. In an observational study of a

convenience sample of 73 patients by Holen and colleagues,14 a pain specialist nurse

evaluated patients’ pain levels using a Numerical Rating Scale (a widely used pain

measure with favourable psychometric properties).

Results of univariate regression analyses showed no correlation between results

obtained using the Doloplus-2 scale and the expert’s pain ratings (R2 = 0.02).

Interestingly, when results obtained with Doloplus-2 were compared with pain ratings

on a subset of patients (n = 16) assessed by a geriatric expert nurse, a considerable

higher rating of R2 = 0.54 was obtained. It must therefore be debated whether pain

ratings determined by a pain expert who was unfamiliar with the patients provides an

acceptable means of comparison.

A prospective observational study by Pautex and colleagues25 in 2007 conducted in

180 hospitalised patients (mean age = 83.7 years; mean MMSE = 18.0) also

investigated the criterion validity of the Doloplus-2 scale. It improved on the previous

study with a larger sample size and by comparing observed pain to patient-reported

pain. The self-report VAS was employed as the gold standard in this study.27,15

Findings showed moderate correlation of Doloplus-2 with the VAS (Spearman

coefficient=0.46).25 Results of a small-scale study (n = 16 participants) conducted

using a French language version of the scale reported a correlation between Doloplus-

2 and both the VAS and L’Echelle Comportementa le Pour Personne Agées (ECPA)

(r = 0.67 using Pearson correlation coefficients).37

Torvik et al32 designed a study to assess the reliability (internal consistency) of

Doloplus-2 and compare registered nurses’ estimations of pain to the findings on the

Doloplus-2 assessment. A total of 77 non-verbal patients with a mean age of 86 were

included from 7 nursing homes in Norway. The patient’s primary registered nurse

administered the Doloplus-2 following an instructional session.

Concordance (90%) was found between proxy rating and Doloplus-2 scores with

respect to estimating ‘pain’ with the two different assessment methods, suggesting

9

that the two measures are addressing the same pain construct. The Cronbach’s alpha

score for the total questionnaire was 0.71

In this study, 52% of the patients were rated by nurses to be experiencing pain,

compared with 68% when using Doloplus-2 (p = 0.01). In one-third of the patients the

nurses could not determine whether the patients were in pain while the Doloplus-2

score represented pain. These findings support the use of Doloplus-2 as a supplement

to proxy rating.

Reliability

Reliability relates to the consistency and stability of a particular outcome measure.

There are two types of reliability, which must be considered in any evaluation: test-

retest reliability (i.e. a measure of how consistent the instrument is in producing the

same results at repeated intervals with the same user) and inter-rater reliability (i.e.

how consistent the instrument when used by different people). A systematic review

carried out in 2006 by Holen and colleagues about behavioural pain assessment tools

that reports adequate test – retest and inter - rater reliability of the Doloplus-2 scale.

The study shows, an inter-rater reliability of 0.77 (CI, 0.47–0.92) was obtained using

intra-class correlation coefficients. 14

An observational study conducted in a non-probability sample of 128 residents in

three nursing homes investigated pain during influenza and care situations using a

Dutch translation of the Doloplus-2 scale.38 Test-retest reliability of this scale was

measured using Cronbach’s alpha (where values ≥7.0 are considered high).26 An alpha

coefficient of 0.74 was obtained for the total scale and a range of 0.58–0.80 was

obtained for individual subscales. These findings therefore demonstrate good test-

retest reliability of Doloplus-2 in this population.

In the development and reliability assessment of the Doloplus-2 Japanese version,

non-verbal patients with AD were assessed for pain following surgery for a hip

fracture. In this study, 31 nurses monitored 6 patients during post-surgical

rehabilitation sessions. The intraclass correlation coefficient for inter-rater reliability

for the Version 2 administrators was 0.90 (P < 0.001), with a 95% confidence interval

10

of 0.88–0.92; the degree of agreement by items (0.67–0.90) was excellent.2 Nurses'

reported that while utilizing the Doloplus-2 there were no difficulties scoring

Japanese expressions and facial expressions. Analysis of individual patient case

studies indicated that pain scores were high only when the patients clearly were

experiencing pain, such as full weight bearing on the surgical hip. These results were

used to finalize the Japanese Doloplus-2. This was a small sample size and a similar

designed larger cohort still must be studied to confirm these findings.

The reliability, validity and clinical feasibility of Chinese version of the Doloplus-2

scale were supported in a study of institutional older people with moderate and severe

dementia. In this study the internal consistency for the total scale, was alpha 0.74 and

the subscales range was 0.67 – 0.87. The intra-class correlation coefficient of the scale

was 0.81 and of the subscales ranged from 0.60 to 0.81. 4 The mean score of clinical

feasibility assessed by 14 RNs was 4.14 (S.D. 0.77; range 3 – 5), supporting the clinical

usefulness of Chinese-Doloplus-2 scale. The mean scores of the total C-Doloplus-2

demonstrated that older people with moderate and severe dementia had low levels of

behavioral expressions of pain.

In an eloquently designed study, Pickering et al 24 examined the reliability of the

Doloplus-2 scale across 5 different languages. The languages were English, Italian,

Portuguese, Spanish and Dutch.

Nine teams (one for Dutch and two for each of the other languages) were been

developed on the basis of experience and competence in geriatrics and in pain

evaluation of elderly patients with communication disorders. Each team tested the

scale in their native language with at least 40 elderly persons.

There were 40 patients per team and each patient was assessed by two trained

physicians independently. Physician 1 evaluated the patient and physician 2 rated the

patient again 4   hours later without any treatment in between. Each physician assessed

the patients by observing for a few minutes prior to scoring the Doloplus-2 ® scale.

The raters were blind to previous ratings.

11

The aim of the present study was to validate the translation of the Doloplus-2 scale in

five languages, with regard to test – retest and inter-rater reliability. Pearson and intra-

class correlation coefficients reveled good to excellent results for the four languages,

English, Italian, Portuguese and Spanish. The Pearson correlation coefficient ranges

from 0.95 to 0.99 for test – retest reliability and from 0.92 to 0.97 for inter-rater

reliability; the intra-class correlation coefficient ranges from 0.83 to 0.98 for test –

retest reliability and from 0.84 to 0.97 for inter-rater reliability. Dutch correlations are

fair to moderate, inter-rater reliability is 0.75 and test – retest reliability is 0.57

(Pearson) or 0.62 (intra-class).

These results establish that reliability tests and correlations are good to excellent for

the English, Italian, Portuguese and Spanish versions, while the reliability correlations

are fair to moderate and more heterogeneous for the Dutch scale.

Responsiveness

This relates to how sensitive a particular instrument is at detecting meaningful and

clinically important changes over time. The first clinical trial using the Doloplus-2

scale has recently been published. A randomised, crossover, open label study was

carried out in 34 inpatients (aged 53–96 years) at hospitals in France to investigate the

use of nitrous oxide-oxygen mixture for pain relief while taking care of bedsores and

painful ulcers.23 Patients were randomised to receive: morphine only, nitrous-oxide-

oxygen mixture only, or a mixture of morphine plus nitrous oxide-oxygen mixture.

Results showed statistically significant differences between the morphine only and

nitrous oxide-oxygen mixture only treatment groups using the Doloplus-2 scale

(p<0.01). Similar findings were also obtained using the ECPA and VAS scales. This

study serves to demonstrate the responsiveness of the Doloplus-2 scale. However,

further studies are needed to confirm these findings. It should also be noted that the

Doloplus-2 is not designed to detect subtle changes in pain-related behaviour and

focuses mainly on indicators such as facial expressions.37

A number of other early validation studies have also been carried out on the Doloplus-

2 scale and the findings of these are discussed in the systematic review of behavioural

pain assessment tools carried out by Zwakhalen and colleagues in 2006.37 These

12

studies were conducted on patients in geriatric centres and palliative care settings and

investigated validity, test-retest reliability and inter-rater reliability.37 However, in

these studies, only a small proportion (1–5%) of the overall study sample was unable

to communicate verbally. Results confirmed the criterion validity of the scale,

demonstrating significant correlations between Doloplus-2 and the VAS (p<0.001).

Furthermore, Doloplus-2 showed good responsiveness. A test-retest reliability of 0.82

(using Cronbach’s alpha) was reported and correlation testing as a measure of inter-

rater reliability found no significant differences between different users. While these

results are undoubtedly encouraging, it must be remembered that the patient

population in these studies were largely able to communicate verbally which may

have had some bearing on the results obtained.

The Doloplus-2 is available in a number of languages including English, French,

Norwegian and Dutch but further investigation of the psychometric properties of each

of these different language versions is still needed.

Other factors to consider

In any evaluation of a particular outcome measure, it is important to consider whether

the instrument is user-centred. Assessment of pain in elderly patients with moderate

or severe cognitive impairment is challenging because of their lack of understanding

and verbal communication. By necessity, the Doloplus-2 scale is completed entirely

by the user with little or no input from the patient. As previously discussed, if the

nurse is unfamiliar with the patient or inexperienced in using this tool, it may not be

possible to make an accurate assessment. Behavioural pain assessment instruments

such as Doloplus-2 cannot therefore be considered as user-centred as self-reported

pain assessment measured such as the VAS which patients complete themselves.

Torvik et al32 compared reported pain scale ratings between a cohort verbal and non-

verbal elderly patients. The study was a cross-sectional, interviewer-assisted and

proxy-rated survey using the Doloplus-2. The patients were divided into two groups

depending on their cognitive functioning. Patients who were able to verbally respond

appropriately during the Mini-Mental Status Examination (MMSE) were classified as

self-reporting and those unable to respond verbally were entered into or the proxy-

13

rated group. Of the 214 patients in the study, 128 were classified, and able to, self-

report symptoms and 86 were unable to self-report and therefore assessed with the

Doloplus-2. In the self-report group, 80% were rated mildly or moderately impaired

on the MMSE.

The group assessed with the Doloplus-2, none of the selected variables were

significantly related to pain. The variables included Barthel index, pain-related

diagnosis, receiving pain medication, age and gender. There was no difference

between the groups with or without pain and therefore raises questions about the

whether the Doloplus-2 scale was used in the correct way or if it is sensitive enough

to discriminate between pain and other observed behaviors. The limitation o=f the

study was the criteria for stratification of the patients. The verbally responsive group

was assessed with the MMSE and by default those that could not appropriately

respond where classified in the other group. The degree of their dementia is not clear.

Additional research comparing cognitively equal verbal and non-verbal groups are

needed to study the raised questions.

Conclusions

Assessing pain for elderly patients with cognitive impairment presents a considerable

challenge for nurses and other care providers. Accordingly, reports suggest that pain

is frequently unrecognised and under treated among in this patient group.13 To date,

there is a lack of published literature on all of the behavioural pain assessment tools

which are available. This paper examined the available evidence of the clinical utility

and psychometric properties of the Doloplus-2 scale.

Available studies are limited in number and offer inconclusive evidence about the

validity, reliability, and responsiveness of the Doloplus-2 scale to measure pain in

older adults. Without a valid, reliable, and responsiveness tool, measuring

improvements in care quality is impossible.

While the problem of unrecognised pain in cognitively impaired individuals is a

serious one, the evidence does not support implementing the Doloplus-2 behavioural

pain assessment tool in the clinical setting. Evidence suggests that the Doloplus-2

14

scale requires knowledge of the patient in order to assess the patient accurately. The

information gathered by the scale may not always be easily interpreted by the nurse or

other care provider without the need for training to ensure competency, thus

increasing the costs associated with using this scale. While the face and content

validity of the Doloplus-2 scale are confirmed, there is insufficient evidence to

confirm the criterion validity of the Doloplus-2 scale in this patient population. It

must be noted that as there is no gold standard behavioural pain assessment tool,

either self-report instruments or expert pain ratings are currently used for comparison

which may not be ideal for comparison and thus limit the accuracy of the information

obtained on the criterion validity of Doloplus-2. Test-retest reliability of Doloplus-2

was shown to be high in one study but again; further investigation of this property is

required to confirm these findings. Only one randomised clinical trial has so far been

published which employs the Doloplus-2 scale and although findings demonstrated

the sensitivity of this scale, it should be noted the sample size in this study was small.

Behavioural pain assessment tools cannot be considered as user-centred as self-

reported pain measures but offer the only way of assessing pain in patients with

limited ability to communicate.

To conclude, following this review of the published literature on the Doloplus-2 scale,

currently the evidence to recommend the implementation of the Doloplus-2 in

everyday clinical practice are insufficient, particularly for inexperienced users or

those who are unfamiliar with the patients which they are assessing.

Appendices

Appendix 1

15

16

17

Disclosures

The author has received no funding and this article was written independently. No

funding sources were provided. This is a declaration statement stating there are no

conflicts of interest with the author and any material in this paper.

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