THE VALUE OF CNAs IN RECOGNIZING PAIN IN COGNITIVELY IMPAIRED NURSING HOME RESIDENTS

April 8, 2009

The Empire Quality Partnership TeleconferenceAchieving Goals V - Assessment and Management of Residents' Pain

EDWARD CISEK, PhD SUSAN ROSENDAHL-MASELLA, PhD

2

Presentation Overview

Pain and Dementia Facts Our Project Preliminary Findings (Phase 1)

Focus Groups Observational Pain Assessment Tools

3

The Facts

SOURCE: URGENT ALERT: 2009 ALZHEIMER’S FACTS AND FIGURES

http://www.alz.org/national/documents/report_alzfactsfigures2009.pdf

A NEW CASE EVERY 70 SECONDS SIXTH LEADING CAUSE OF DEATH 148 BILLION DOLLARS IN ANNUAL COSTS 9.9 MILLION UNPAID CAREGIVERS 5.3 MILLION PEOPLE HAVE ALZHEIMER’S BY MID-CENTURY SOMEONE WILL DEVELOP

ALZHEIMER’S EVERY 33 SECONDS BY 2010, THERE WILL BE NEARLY A HALF MILLION

NEW CASES OF ALZHEIMER’S EACH YEAR BY 2050, THERE WILL BE NEARLY A MILLION NEW

CASES EACH YEAR

4

The Facts (cont.)

25 to 33% of nursing home residents are known to have moderate pain on a daily basis

• Leong & Nuo (2007); Sawyer et al. (2006); Smalbrugge et al. (2007); Teno et al. (2001)

49 to 83% of nursing home residents have substantial pain that is underdetected and/or undertreated

• Buchanan et al. (2002); Miller et al. (2003); Proctor & Hirdes (2001); Teno et al. (2002)

5

More Facts . . .

As mental impairment increases, reporting of pain decreases

• Parmelee et al. (1993)• Weiner, Peterson, Logue, & Keefe (1998)

There were no differences in the number or type of pain-causing conditions between those who were cognitively intact and those who were cognitively impaired yet pain complaints and reported pain intensity decreased with increasing cognitive impairment

• Parmelee (1996)(N = 871 nursing home residents);

Hadjistavropoulos et al. (2007)

6

More Facts . . . (cont.)

Undertreatment of Pain Cognitively Impaired Nursing Home Residents (N=38)

• All 38 residents exhibited aggressive behaviors• 60% had at least one diagnosis known to cause pain• NO PAIN MEDICATIONS given in previous month

• Feldt et al. (1998) Hospitalized Advanced Dementia Patients with Hip Fractures

(N=59 cognitively intact/N=38 cognitively impaired patients)

• Given less morphine than cognitively intact patients (1/3 the morphine equivalent)

• Over ¾ were without standing orders for analgesia• Morrison & Siu (2000)

7

New York State Department of Health Dementia Grants Program

Schervier is Recipient of 3-year Research

and Training Grant

Assessment, Detection and Treatment of Pain in Nursing Home Residents with Advanced Dementia: Development of an Evidence-Based Best Practice

8

New York State Department of Health Dementia Grants Program (cont.)

Consortium SCHERVIER NURSING CARE CENTER—LEAD FACILITY

• Paulette Sansone, PhD, LMSW • Edward Cisek, PhD and Susan Rosendahl-Masella, PhD• Susan Caccappolo, MSSW, LCSW• Joseph Scarpa, MD and Louis Harris, DPT

RAVAZZIN CENTER FOR SOCIAL WORK RESEARCH ON AGING • Michael Phillips, DSW

CABRINI CENTER FOR NURSING AND REHABILITATION• Jeffrey Nichols, MD and Mary Devlin

ST. CABRINI NURSING HOME• Jeffrey Nichols, MD and Barbara Gaughan

9

New York State Department of Health Dementia Grants Program (cont.)

Overview of Project Primary Goals

• Identification of appropriate tools to assess pain in residents with advanced dementia

• Improvement of nursing home staff’s knowledge and attitudes regarding pain

• Implementation of organizational changes to the nursing home to aid in more accurate assessment and treatment of pain

10

New York State Department of Health Dementia Grants Program (cont.)

Project Phases Phase 1

Conduct further tests of the psychometric properties of existing tools designed for the assessment of pain in residents with dementia

• PAINAD (Warden, Hurley, & Volicer, 2003)

• CNPI (Feldt, 2000)

• Doloplus-2 Scale (Wary & Doloplus, 1999)

11

New York State Department of Health Dementia Grants Program (cont.)

Phase 2

• Provide information to residents’ families regarding behavioral indicators of pain

• Develop and implement brief education program for nursing home physicians, nurses and CNAs

• Design and introduce a structured assessment and tracking process for the reporting and treatment of residents’ pain

12

New York State Department of Health Dementia Grants Program (cont.)

Phase 3

• Develop a comprehensive education and training manual for all nursing homes in NYS regarding pain in residents with advanced dementia

• Produce a step-by-step guide for implementing the best practice for identifying and tracking pain

TRAINING

MANUAL

Step-by

13

Assessment of Pain

THE GOLD STANDARD

Resident Self-Report• “Pain is whatever the patient says it is, ….”

• McCaffery (1968)

Although cognitively impaired residents may be able to answer yes or no questions about whether they have pain, they may have difficulty identifying the location of their pain or describing temporal variations in their pain

• Stolee et al. (2005)

Complex pain measures that require abstract thinking or discrimination may be too difficult for cognitively impaired residents to use reliably

• Parmelee (1994)

14

Pain in cognitively impaired nursing home residents is difficult to detect particularly when

communication is limited

+Underreporting and

inadequate assessment of pain________________________________

NEED TO IMPROVE METHODS OF DETECTING AND MANAGING PAIN

15

Residents with Cognitive Impairment: Guiding Principles for the Assessment of Pain

Self-Report Attempt to obtain with residents having

mild to moderate cognitive impairment

As dementia progresses, the ability to self-report decreases and eventually self-report is NO LONGER POSSIBLE

• 2006 American Society of Pain Management Nursing

http://www.medscape.com/viewarticle/533939;

2002 American Geriatrics Society

16

Residents with Cognitive Impairment: Guiding Principles for the Assessment of Pain (cont.)

Searches for Potential Causes of Pain/ Discomfort Consider chronic pain conditions

• E.g., arthritis, low back pain, neuropathies Musculoskeletal and neurologic disorders

are most common

Observation of Resident Behaviors

17

Focus Groups

Four Focus Groups (2 CNA, 2 Nurse) Questions

How do you know when a person with advanced dementia is experiencing pain?

What do you do when you recognize a resident is in pain?

Do you think some kind of form would help you to better communicate a resident’s pain to a nurse/doctor?

18

CNA Focus Groups

How do you know when a person with advanced dementia is experiencing pain? Grimacing Facial Expressions Moaning/Crying Less Movement Shifting Positions Holding Body Part Less Talkative/Withdrawn Agitation/Behavior Problems Change in ADL Ability Change of Appetite Attempts to Verify Behavior is Pain-Related

19

CNA Focus Groups (cont.)

CNAs reported behavioral pain indicators consistent with American Geriatrics Society Guidelines Facial Expressions Verbalizations, Vocalizations Body Movements Changes in Interpersonal Interactions Changes in Activity Patterns or Routines Mental Status Change

http://www.americangeriatrics.org/products/positionpapers/JGS5071.pdf

20

CNA Focus Groups (cont.)

What do you do when you recognize a resident is in pain?Verbal report to nurseFollow-up with nurse

Nurses report that they rely on CNAs to report pain

21

CNA Focus Groups (cont.)

Do you think some kind of form would help you to better communicate a resident’s pain to a nurse/doctor?Written form would reinforce and

provide back-up to their verbal reportsForm can be used to track pain over

time

22

Psychometric Properties of Pain Assessment Tools: Reliability

Sample 55 long term care residents with severe to

very severe dementia

Results Intra-rater reliability (24-48 hrs.) ranged

from .56 to .67 across three pain measures Internal consistency ranged from .61 to .87

23

Psychometric Properties of Pain Assessment Tools: Validity

Sample 46 cognitively intact short-term

rehabilitation patients

Results Correlations between CNA

ratings of patient’s pain and patient’s self-report of pain were .31, .50 & .58, all of which are statistically significant

IOWA PAIN THERMOMETERHerr and Mobily (1993)

Used with permission of Keela Herr, PhD, RN, FAAN, AGSF, College of Nursing, The University of Iowa

No pain

Slight pain

Mild pain

Severe pain

Moderate pain

Extreme pain

Pain as bad as it could be

24

Conclusions

Nurses rely on CNAs as source of pain information CNAs can identify most behavioral signs of pain CNAs recognize their role in communicating pain to

nurses CNA report of residents’ pain to nurses is primarily

verbal Written documentation can reinforce verbal reports When given tools to measure pain, CNAs appear to

be reliable reporters CNAs are a gold mine of information

25

Questions

How often should pain be measured?How should pain assessment and

reporting be integrated into nursing home practice?

How will CNAs react to the added responsibility of pain assessment?

26

Contact Information

Susan Rosendahl-Masella:

Susan_Rosendahl-Masella@bshsi.org

(718) 548-1700 ext. 337Edward Cisek:

Ed_Cisek@bshsi.org

(718) 548-1700 ext. 336

27

Pain Assessment Tools for Residents with Dementia

Attempt Self Report (Faces Pain Scale, Numeric Rating and Verbal Descriptor Scales)

Abbey Pain Scale ADD Protocol (Assessment of Discomfort in Dementia) CNPI (Checklist of Nonverbal Pain Indicators) Doloplus-2 Scale DS-DAT (Discomfort Scale – Dementia of the Alzheimer’s Type) FLACC (Faces, Leg, Activity, Cry, Consolability) NOPPAIN (The Non-Communicative Patient’s Pain Assessment

Instrument) PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability

to Communicate) PADE (Pain Assessment for the Dementing Elderly) PAINAD (Pain Assessment for Advanced Dementia) RaPID (Rating Pain in Dementia)

• Palliative Care Dementia Consortium (2008) http://www.scherviercares.org/resources.html

28

References and Online Resources

29

Source: http://consultgerirn.org/uploads/File/trythis/assessingPain.pdf

30

Acknowledgments

Bon Secours New York Health System James T. Higgins, CEO Schervier Center for Research in Geriatric Care

Paulette SansoneSusan CaccappoloYvette Rondeau

Mike Phillips, Ravazzin Center Karen Wilson, VP of Nursing, Nurses, CNAs and all the

staff at Schervier Nursing Care Center Beth Dichter and the NYSDOH Empire Quality Partnership