Guideline For The Assessment And Management Of Pain In Dementia

Document Title
RCHT Guideline for the Assessment and
Management of Pain in People with Dementia or
with Sever Cognitive Impairment v.2
Type of document
Brief summary of contents
Executive Director responsible for
Clinical Guideline:
Directorate / Department responsible
(author/owner):
Corporate: Clinical
Provides practical guidance on the identification
and management of end of life care needs for
people who have dementia
Christine Rashleigh, Executive Director of
Nursing, Midwifery and AHPs
Dr Fiona Boyd, Consultant Geriatrician.
Department of Eldercare
Contact details: 01872 252447
Date original version written: July 2009
Date revised: June 2011
This document replaces (exact title of
previous version):
Approval route (names of
committees)/consultation:
Divisional Manager confirming approval
processes
Name and Post Title of additional
signatories
Equality Impact Assessment appended
Approval must not be given if the EIS is
not attached
Signature of Executive Director giving
approval
Publication Location (refer to Policy on
Policies – Approvals and Ratification):
Document Library Folder/Sub Folder
Guidelines for the Assessment Pain in Persons
with Severe Dementia. v1.1
Eldercare Specialty Group, RCHT Dementia
Care Action Group
Frazer Underwood, Associate Director of
Nursing / Consultant Nurse for Older Peoples
Services
Not Applicable
Yes
{Original Copy Signed}
Internet & Intranet Intranet Only
Clinical / Dementia Care
Date of final approval: 28 th July 2011
Date guideline becomes live: 28 th July 2011
Date due for revision: May 2014
Links to key external standards CQC Outcomes: 1,2, 4, 5, 6, 7, 9

Related Documents:
Suggested Keywords:
Training Need Identified
RCHT Dementia Care Policy
RCHT Mental Capacity Act Policy
Dementia; Delirium ; Pain; Eldercare
Yes
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
This version supersedes any previous versions of this document.
All or part of this document can be released under the Freedom of Information Act
2000
This document is to be retained for 10 years from the date of expiry.
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
Page 2 of 11

CLINICAL GUIDELINE FOR THE ASSESSMENT AND
MANAGEMENT OF PAIN IN PEOPLE WITH DEMENTIA OR WITH
SEVER COGNATIVE IMPAIRMENT
1. Aim/Purpose of this Guideline
1.1. This guideline provides practical guidance on the assessment and
management off pain in people who have dementia or with sever cognitive
impairment. It covers all adult patients within RCHT services.
1.2. This guideline applies to all Trust staff directly involved in the care of such
patients. It should be read in conjunction with the RCHT Dementia Care Policy.
2. The Guidance
2.1. What to Consider
2.1.1. Evidence shows that ageing is associated with a high rate of painful
conditions, irrespective of cognitive status. The number of patients with
dementia who will experience pain is therefore likely to increase.
2.1.2. Patients with dementia may interpret and express their pain in ways
that are quite different from those without cognitive impairment, particularly in
the more severe stages of dementia where verbal communication might be
impaired or impossible. Therefore, the complexity and consequent inadequacy
of pain assessment can lead to the under-treatment of pain.
2.1.3. In the early stages of dementia - Self-reporting of discomfort/pain are
reasonably reliable.
o Accuracy depends on:
o Understand the question
o Recall the pain within a given time frame
o Interpreting the experience as painful event
2.1.4. In mid- late stages of dementia - Assessment is more complex as
language and cognition abilities are diminished & there are difficulties in selfreporting
as the person may not have ability to communicate effectively.
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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2.2. Pathway for Assessment of Pain in Older Person with Severe Cognitive
Impairment
Presence of pain behaviour during
movement No
Assess using PAINAD scale
PAINAD score >1
NO
Presence of other behaviour suggestive of
pain
Assess using PAINAD scale
PAINAD score >1
YES
YES
Comprehensive pain assessment
YES
Ensure basic comfort needs are met
(Toileting, thirst, hunger, visual/hearing
YES
Is pain impairing the person’s quality of life
No
YES
Is there evidence of pathology that may be
causative
(E.g.: infection, constipation, and fractures)
Treat causative pathology
Continue to be
vigilant for
behavioural changes
that indicate pain
Consider empirical analgesic trial
Commence care plan.
Consider non-pharmacological and pharmacological management.
Ensure medication is given safely.
Reassess pain at regular intervals (PAINAD)
Consider referral to specialist pain team if complex situation.
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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2.3. The Assessment Tool - Pain Assessment IN Advanced Dementia (PAINAD)
5 Point Observational Tool
Total scores range from 0 to 10
Divided into five items (score 0-2)
Higher score indicates a likelihood of more severe pain
0="no pain" to 10="severe pain"
For PAINAD and Behaviour Chart - see Appendix 2
2.4. Pain Assessment in Advanced Dementia Scale (PAINAD)
Total scores range from 0-10 (based on item scores 0-2), with a higher score indicating more
severe pain.
Items 0 1 2 Score
Breathing Normal Occasional laboured
breathing. Short period
of hyperventilation.
Negative
vocalization
Facial
expression
None
Smiling or
inexpressive
Occasional moan or
groan. Low-level speech
with a negative or
disapproving quality.
Sad.
Frightened. Frown.
Noisy laboured breathing.
Long period of
hyperventilation.
Cheyne-Stokes respirations.
Repeated troubled calling
out.
Loud moaning or groaning.
Crying.
Facial grimacing.
Body
language
Relaxed
Tense.
Distressed pacing.
Fidgeting.
Rigid. Fists clenched.
Knees pulled up. Pulling or
pushing away. Striking out.
Consolability
No need to
console
Distracted or reassured
by voice or touch.
Unable to console, distract
or reassure.
Total score
Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in
advanced dementia (PAINAD) scale. J Am Med Dir Assoc. 2003; 4: 9-15.
2.5. Common Pain Behaviours in Cognitively Impaired Persons
Facial expressions
• Frown, frightened face, grimacing, closed or tightened eyes,
rapid blinking, any distorted expression
Verbalisations, vocalisations
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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• Sighing, moaning, groaning, grunting, chanting, calling out,
noisy breathing, asking for help, verbally abusive
Body movement
• Rigid, tense body posture, guarding, fidgeting, increased
pacing, rocking, restrictive movement, gait or mobility
changes
Changes in interpersonal interactions
• Aggressive, combative, resisting care, decreased social
interactions, socially inappropriate, disruptive, withdrawn
Changes in activity patterns and routines
• Refusing food, appetite change, increase in rest periods,
sleep, rest pattern change, sudden cessation of common
routines, increased wandering
Mental status changes
• Crying or tears, increased confusion, irritability, distress
2.6. Assessment of Pain in Elderly Persons with Severe Dementia
Assess patient on admission for evidence of pain using the PAINAD
scale.
If the patient appears to have pain or pain is suspected, the patient
should undergo a comprehensive pain assessment.
History (where possible)
o Pain intensity, character, frequency, location, duration, and
precipitating and relieving factors.
o Note impairment of physical, social function (Activities of daily
living, sleep, exercise, mood, appetite) due to pain.
o Medication, including current and previous analgesic use,
complementary therapies, their effectiveness and side effects.
o Patient and carer concerns should be identified.
Physical examination
o Examine site of reported pain.
o Focus examination on musculosceletal system (inflammation,
deformity, posture, leg length discrepancy)
o Focus examination on neurological system (search for weakness,
hyperalgia, allodynia, numbness, paraesthesia or other
neurological impairments).
o Observe physical functioning (Activities of daily living).
Assess Mood (depression, anxiety, ‘pain related’ fears).
Evaluate cognitive functioning for new deterioration.
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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Initial assessment should include evaluation of social support, caregivers,
family relationships, work history and spirituality.
Consider laboratory and diagnostic tests.
For patients with moderate to severe cognitive impairment assess pain
via direct observation (PAINAD) or history from caregivers.
• ASK the person if they are
experiencing pain
• LOOK for behavioural signs of
pain (in everyone)
• INVESTIGATE (physical &
psychological)
• TREAT
• RE-ASSESS
2.7. Non-pharmacological management of pain in elderly persons with
Dementia
Active involvement of patient and carer helps to build self-reliance and
control over pain
Intensive multidisciplinary management that addresses physical and
psychological, social and occupational dimensions that can improve pain
and function.
Anxiety and depression are common in people with chronic pain and
need to be anticipated and treated – consider advice from eldercare and
/or psychiatric liaison services.
Regular physical exercise reduces pain and enhances functional capacity
of older adults with persistent pain
Consider - Transcutaneous electrical nerve stimulation (TENS),
Acupuncture, heat or cold packs; massage.
Although there is no evidence for the effectiveness of alternative
medicine methods (homeopathy, chiropractics, spiritual healing) it is
important not to discourage benign therapies if the patient derives benefit
from it
Pain Team can offer other option
2.8. Pharmacological management of pain in elderly persons with severe
cognitive impairment
The three step analgesic ladder, originally proposed for cancer pain relief by the
WHO is useful and now widely employed for all types of pain:
Mild pain:
Moderate pain:
Severe pain:
Non-opioid medication ± adjuvant
Mild opioids ± adjuvant ± non-opioids
Strong opioids ± adjuvant ± non-opioids
For further information regarding prescribing please liaise with pharmacy and refer to
the current British National Formulary.
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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3. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Tool
Frequency
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared
National and regional standards for pain care in dementia are
established (reflected in this guideline), these will be monitored
The Trust Clinical Lead for Dementia Care takes responsibility for
monitoring (auditing) the Trust’s clinical performance in meeting the
Nationally set standards of care and service delivery for dementia
care.
The Trust is committed to participating in the National Dementia
Care Audit, conducted by the Department of Health and facilitated
by the Royal College of Psychiatry. This template is Nationally
negotiated and published.
The Trust’s clinical care performance is benchmarked with National
results. These are published and reported, currently on an annual
basis.
The Trust’s performance report, local response and improvement
plan are presented through the RCHT Dementia Care Action Group
to the RCHT Divisional Quality Group and RCHT Governance
Committee. Who acts on behalf on the Trust Board to scrutinise
and monitor improvement delivery.
Independent scrutiny of delivery is given from commissioners and
regional peer review processes.
The RCHT Dementia Care Action Group leads on service
improvement for dementia care in the organisation. It is tasked to
deliver the improvement plan developed from audit. This has a
delivery timetable monitored by numerous groups and agencies.
Improvement and change in service delivery is documented in the
notes and minutes of the Action Group, its sub groups and in the
evidence folders linked to the hospital standards.
4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 1.
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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Appendix 1.Initial Equality Impact Assessment Screening Form
Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed:
RCHT Guideline for the Assessment and Management of Pain in People with
Dementia or Sever Cognitive Impairment
Directorate and service area:
Nursing, Midwifery and AHP
Name of individual completing
assessment:
Dr Fiona Boyd
Is this a new or existing Procedure
Existing
Telephone:
01872 252447
1. Procedure Aim* Provides practical guidance on the assessment and
management of pain in people with dementia or sever
cognitive impairment
2. Procedure Objectives* Improve and standardise care
3. Procedure – intended
Outcomes*
Improved patient and carer experience of pain
management
4. How will you measure
the outcome
5. Who is intended to
benefit from the
Procedure
6a. Is consultation
required with the
workforce, equality
groups etc. around this
procedure
Annual Audit
Patient, carers and staff
No
b. If yes, have these
groups been consulted
c. Please list any groups
who have been consulted
about this procedure.
*Please see Glossary
7. The Impact
Please complete the following table using ticks. You should refer to the EIA guidance
notes for areas of possible impact and also the Glossary if needed.
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.
Equality
Group
Age
Positive
Impact
Negative
Impact
No
Impact
Reasons for decision
Disability
Faith and
Belief
Gender
Race
Sexual
Orientation
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
A negative impact and
No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that
the policy promotes equality,
equal opportunities or improved
relations - could it be adapted
so that it does How
Full statement of commitment to policy of
equal opportunities is included in the
guideline
Please sign and date this form.
Keep one copy and send a copy to the Human Resources Team,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department,
Lamorna House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
They will arrange for a summary of the results to be published on the Trust’s web site.
Signed ________________________________________
Date _________________________________________
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
Page 10 of 11

Appendix 2 – PAINAD Chart (Behaviour and Pain Assessment Chart)
Behavioural Assessment 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07
Settle d
Anxiety *
Restless *
Aggression *
Violence *
Non-concordant *
Wandering
Fal ls
Sedated/drowsy
Hallucinations *
Sleeping
Other (please specify)
Pain Assessment 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 01 02 03 04 05 06 07
Breathing
Negative
vocalisation
Facial expression
Body Language
Consolability
Total
Patients Perception
Assessors Initials
0 1 2
Breathing Normal Occasionally laboured/short bursts of hyperventilation Laboured breathing/ extended hyperventilation
Negative vocalisation None Occasional moans/ low level negative speech Repeated calling out loud groaning/crying
Facial expression Smiling/ no expression Sad/frightened/frowning Grimacing
Body language Relaxed Tense/fidgeting/pacing Rigid, pulling or pushing away/ aggression
Consolability Not needed Reassured by voice or touch Unable to console
Patients perception: POM-Pain on Movement 0 – No Pain 1 – Mild/uncomfortable 2 – Moderate/distressing
3 – severe 4 – Very severe/excrutiating 5 – worst pain imaginable
* Please describe behaviours/hallucinations overleaf…
RCHT Guideline for the Assessment and Management of Pain in People with Dementia or with Sever Cognitive Impairment
Version No: 2.0
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