Step 2
Step 2: Pain Screening
Learn how to conduct a simple screening that detects chronic pain in nursing home residents. This first step is a powerful motivator for change, for once pain is acknowledged, it is difficult to not do anything about it.
Click on one of the following topics to skip to that section:
Are You Listening?
American novelist Naomi Wolf once wrote: “Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria.” To which we might add, “…or old age and dementia.” Thus amended, this remark may go a long way toward explaining why official estimates of pain prevalence among nursing home residents (7-9%) are so much lower than actual pain prevalence (45-83%) (references 1-4).
The MDS Users Manual for December 2002 has this to say about pain assessment (5): “Ask the resident if he or she has experienced any pain…If the resident has pain, take his or her word for it.” As we will see, it’s that simple.
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It Starts With Screening
Effective pain management starts with an initial screening. The importance of this step goes beyond its first place in a series of tasks that lead to better care and quality of life for residents. It is perhaps more significant as a powerful motivator for change.
Though it is natural to defend against it at first, once you awaken to the pain around you it is difficult to not do anything to alleviate it. This very human inclination to ease pain may explain why nursing homes that report a higher prevalence of pain among residents also do a better job of assessing pain and treating it (4).
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Include Cognitively Impaired Residents
Because “pain is subjective and lacks objective biological markers” (6), self-report of pain by residents “is generally held to be the gold standard of pain assessment” (7). In other words, “pain is whatever the person says it is, existing whenever (the person) says it does” (6).
But what if the person is cognitively impaired, as 50% of nursing home residents are? Will this person’s self-report of pain be meaningful? So much is made of this concern that even most studies that have examined pain prevalence in nursing homes have excluded residents with marked cognitive impairment on the assumption that their responses would be unreliable. Among the minority of studies that included cognitively impaired individuals, some have reported a low prevalence of pain among these residents. These findings provide another reason to exclude cognitively impaired residents from further research.
One disturbing consequence of this oversight is that cognitively impaired residents may be short-changed on pain management. In a recent study, we found that as cognitive impairment increased among residents with pain, the nursing staff were increasingly less likely to document pain presence. This finding suggests that nursing staff tend to disregard reports of pain by residents with more severe cognitive impairment.
As it turns out, cognitively impaired residents are remarkably trustworthy reporters about their own subjective pain experience. This conclusion is based on a recent study we conducted in 33 nursing homes with 893 residents (7). No one was excluded based on cognitive impairment.
What we found contradicts assumptions and findings from previous studies. First, we found a higher prevalence of pain among cognitively impaired residents than previous studies have reported. We also found that the vast majority of residents, including the most cognitively impaired residents, could provide us with meaningful self-reports of pain when asked four simple YES/NO questions (Pain Assessment Form):
We designed this study to determine whether a cognitive performance measure derived from the Minimum Data Set (MDS) could accurately identify residents capable of responding to our pain screening interview. Specifically, we used residents’ MDS recall scores, which are calculated from four items on the MDS. Lower scores indicate greater cognitive impairment.
Our findings? Among the 79.4% of residents (n=709) with recall scores between 1 and 4, 83% to 97% answered all four questions. Yet even among the most cognitively impaired residents—the 21% with recall scores of 0—52% were able to answer the interview questions.
This latter finding is in keeping with Parmelee’s assertion that “self reports [of pain in cognitively impaired elderly] are…no less valid than those of cognitively intact individuals (8),” a conclusion that Manz et. al concurred with as well (9).
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Our Recommendation: Four Questions To Pain Screening
This finding also simplifies the initial pain assessment process. Based on it, our recommendation is:
Pain Screening Instructions
A licensed nurse or certified nurse aide should ask all communicative residents directly about pain using these four YES/NO questions:
Use our pain screening interview form to record results.
At a minimum, this screening for chronic pain should be conducted:
One Exception
One exception to our otherwise global recommendation applies to residents who are uncommunicative, or cannot communicate at all. Often, these residents are stroke victims or are in the final stage of Alzheimer’s disease. With these residents, it’s best to use an observational tool such as the Pain Assessment in Advanced Dementia, also known as PAINAD, which is a simple, valid, and reliable five-item instrument for measuring pain in uncommunicative patients (12).
DO NOT, however, use the PAINAD to assess pain in patients who can communicate. This is a common but inappropriate use of the tool.
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Advantages Of Our Pain Screening Tool
With its yes/no format, our interview tool is particularly appropriate for use with mild to moderately cognitively impaired residents, many of whom would be unable to respond to the commonly used 10-point pain rating scale (where 0 represents “no pain at all” and 10 signifies “the worst pain I have ever experienced”) or even a visual scale with different facial expressions (10, 11). Licensed nurses, who are now required to assess pain as a “5th vital sign”, often use such a 10-point scale for pain assessment, which may explain why so many residents are inappropriately excluded from pain assessment due to cognitive impairment. In our study, 83% of all of the participating residents completed the interview’s four yes/no questions. Thus, we encourage nurses to use these screening questions, instead of the more complicated and commonly used 10-point scale, for pain assessment.
Equally important, this screening interview can be conducted by both licensed nurses and certified nurse aides. It is a screening, not a clinical assessment, which would exclude nurse aides from completing it. It is intended to simply detect the presence of probable chronic pain. Further assessment by a licensed nurse is needed to evaluate pain intensity, location, quality, and associated symptoms.
Based on both research and clinical experience, we recommend that licensed nurses administer these screening questions during medication passes. Minimally, licensed nurses should ask the question, “Do you have pain anywhere right now?” during every medication pass as this provides an excellent opportunity to assess pain as a 5th vital sign and the potential need for “prescribed as needed” (PRN) pain medication. If the resident responds, “yes”, to this question, the medication nurse can ask the follow-up question, “Would you like to take some (medicine) for your pain?”. We have demonstrated that asking these two simple questions during morning, afternoon and evening medication passes results in a significant increase in pain detection and PRN pain medication delivery. Moreover, cognitively impaired residents notice the difference in licensed nurse behavior as evidenced by their own self-report that nurses began asking them about pain “more often”.
In addition to licensed nurse assessment during medication passes, we also suggest that direct care staff (nurse aides) inquire about pain during morning and evening Activities of Daily Living (ADL) care and/or walking and toileting assistance by asking the resident directly, “Do you have pain anywhere right now?” and being observant of the resident’s expression of pain (e.g., facial grimacing, moaning or groaning) during daily care activities. We have found that residents are more likely to experience and express pain during physical movement (transfer out of bed, toileting, walking, dressing) versus when sitting still or lying in bed. Because joint pain is common among nursing home residents, it makes sense that residents are more likely to experience pain during ADL care delivery, and nurse aides need to be aware of this so that they can communicate the resident’s pain to the licensed nursing staff for further assessment.
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Follow-Up Needed
If a resident reports pain during the initial screening interview or during medication pass(es) or ADL care delivery, then further evaluation of pain intensity, location, quality and associated symptoms is needed to guide diagnosis and treatment decisions. Our pain interview includes items about presence, frequency, and effect of pain on residents’ daily lives, but does not have enough specific items upon which to base diagnosis and treatment.
Elsewhere in this module—Next Steps, Links, FAQs, Related Studies —we provide guidance and referrals to other resources to help you accomplish the pain management steps that follow screening.
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Your Assignment
• Use our pain screening tool to interview a random sample of 5-10 residents. Be sure to interview some residents with mild to moderate cognitive impairment. Tell us how the interviews went; please contact us. How many residents answered all four questions? How many residents reported chronic pain? Did you find the interview tool helpful? Would you recommend its use? We hope to report your feedback for the benefit of others in future updates to this site.
Back to Top or proceed to Next Steps
Click on one of the following topics to skip to that section:
- Are You Listening?
- It Starts With Screening
- Include Cognitively Impaired Residents
- Our Recommendation: Four Questions To Pain Screening
- One Exception
- Advantages Of Our Pain Screening Tool
- Follow Up Needed
- Your Assignment
Are You Listening?
American novelist Naomi Wolf once wrote: “Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria.” To which we might add, “…or old age and dementia.” Thus amended, this remark may go a long way toward explaining why official estimates of pain prevalence among nursing home residents (7-9%) are so much lower than actual pain prevalence (45-83%) (references 1-4).
The MDS Users Manual for December 2002 has this to say about pain assessment (5): “Ask the resident if he or she has experienced any pain…If the resident has pain, take his or her word for it.” As we will see, it’s that simple.
Back to Top
It Starts With Screening
Effective pain management starts with an initial screening. The importance of this step goes beyond its first place in a series of tasks that lead to better care and quality of life for residents. It is perhaps more significant as a powerful motivator for change.
Though it is natural to defend against it at first, once you awaken to the pain around you it is difficult to not do anything to alleviate it. This very human inclination to ease pain may explain why nursing homes that report a higher prevalence of pain among residents also do a better job of assessing pain and treating it (4).
Back to Top
Include Cognitively Impaired Residents
Because “pain is subjective and lacks objective biological markers” (6), self-report of pain by residents “is generally held to be the gold standard of pain assessment” (7). In other words, “pain is whatever the person says it is, existing whenever (the person) says it does” (6).
But what if the person is cognitively impaired, as 50% of nursing home residents are? Will this person’s self-report of pain be meaningful? So much is made of this concern that even most studies that have examined pain prevalence in nursing homes have excluded residents with marked cognitive impairment on the assumption that their responses would be unreliable. Among the minority of studies that included cognitively impaired individuals, some have reported a low prevalence of pain among these residents. These findings provide another reason to exclude cognitively impaired residents from further research.
One disturbing consequence of this oversight is that cognitively impaired residents may be short-changed on pain management. In a recent study, we found that as cognitive impairment increased among residents with pain, the nursing staff were increasingly less likely to document pain presence. This finding suggests that nursing staff tend to disregard reports of pain by residents with more severe cognitive impairment.
As it turns out, cognitively impaired residents are remarkably trustworthy reporters about their own subjective pain experience. This conclusion is based on a recent study we conducted in 33 nursing homes with 893 residents (7). No one was excluded based on cognitive impairment.
What we found contradicts assumptions and findings from previous studies. First, we found a higher prevalence of pain among cognitively impaired residents than previous studies have reported. We also found that the vast majority of residents, including the most cognitively impaired residents, could provide us with meaningful self-reports of pain when asked four simple YES/NO questions (Pain Assessment Form):
We designed this study to determine whether a cognitive performance measure derived from the Minimum Data Set (MDS) could accurately identify residents capable of responding to our pain screening interview. Specifically, we used residents’ MDS recall scores, which are calculated from four items on the MDS. Lower scores indicate greater cognitive impairment.
Our findings? Among the 79.4% of residents (n=709) with recall scores between 1 and 4, 83% to 97% answered all four questions. Yet even among the most cognitively impaired residents—the 21% with recall scores of 0—52% were able to answer the interview questions.
This latter finding is in keeping with Parmelee’s assertion that “self reports [of pain in cognitively impaired elderly] are…no less valid than those of cognitively intact individuals (8),” a conclusion that Manz et. al concurred with as well (9).
Back to Top
Our Recommendation: Four Questions To Pain Screening
This finding also simplifies the initial pain assessment process. Based on it, our recommendation is:
Pain Screening Instructions
A licensed nurse or certified nurse aide should ask all communicative residents directly about pain using these four YES/NO questions:
- Do you have pain anywhere right now?
- Does pain ever keep you from sleeping at night?
- Does your pain ever keep you from participating in activities/doing things you enjoy?
- Do you have pain every day?
Use our pain screening interview form to record results.
At a minimum, this screening for chronic pain should be conducted:
- upon admission,
- at each quarterly review, and
- when routinely assessing for pain as a 5th vital sign.
One Exception
One exception to our otherwise global recommendation applies to residents who are uncommunicative, or cannot communicate at all. Often, these residents are stroke victims or are in the final stage of Alzheimer’s disease. With these residents, it’s best to use an observational tool such as the Pain Assessment in Advanced Dementia, also known as PAINAD, which is a simple, valid, and reliable five-item instrument for measuring pain in uncommunicative patients (12).
DO NOT, however, use the PAINAD to assess pain in patients who can communicate. This is a common but inappropriate use of the tool.
Back to Top
Advantages Of Our Pain Screening Tool
With its yes/no format, our interview tool is particularly appropriate for use with mild to moderately cognitively impaired residents, many of whom would be unable to respond to the commonly used 10-point pain rating scale (where 0 represents “no pain at all” and 10 signifies “the worst pain I have ever experienced”) or even a visual scale with different facial expressions (10, 11). Licensed nurses, who are now required to assess pain as a “5th vital sign”, often use such a 10-point scale for pain assessment, which may explain why so many residents are inappropriately excluded from pain assessment due to cognitive impairment. In our study, 83% of all of the participating residents completed the interview’s four yes/no questions. Thus, we encourage nurses to use these screening questions, instead of the more complicated and commonly used 10-point scale, for pain assessment.
Equally important, this screening interview can be conducted by both licensed nurses and certified nurse aides. It is a screening, not a clinical assessment, which would exclude nurse aides from completing it. It is intended to simply detect the presence of probable chronic pain. Further assessment by a licensed nurse is needed to evaluate pain intensity, location, quality, and associated symptoms.
Based on both research and clinical experience, we recommend that licensed nurses administer these screening questions during medication passes. Minimally, licensed nurses should ask the question, “Do you have pain anywhere right now?” during every medication pass as this provides an excellent opportunity to assess pain as a 5th vital sign and the potential need for “prescribed as needed” (PRN) pain medication. If the resident responds, “yes”, to this question, the medication nurse can ask the follow-up question, “Would you like to take some (medicine) for your pain?”. We have demonstrated that asking these two simple questions during morning, afternoon and evening medication passes results in a significant increase in pain detection and PRN pain medication delivery. Moreover, cognitively impaired residents notice the difference in licensed nurse behavior as evidenced by their own self-report that nurses began asking them about pain “more often”.
In addition to licensed nurse assessment during medication passes, we also suggest that direct care staff (nurse aides) inquire about pain during morning and evening Activities of Daily Living (ADL) care and/or walking and toileting assistance by asking the resident directly, “Do you have pain anywhere right now?” and being observant of the resident’s expression of pain (e.g., facial grimacing, moaning or groaning) during daily care activities. We have found that residents are more likely to experience and express pain during physical movement (transfer out of bed, toileting, walking, dressing) versus when sitting still or lying in bed. Because joint pain is common among nursing home residents, it makes sense that residents are more likely to experience pain during ADL care delivery, and nurse aides need to be aware of this so that they can communicate the resident’s pain to the licensed nursing staff for further assessment.
Back to Top
Follow-Up Needed
If a resident reports pain during the initial screening interview or during medication pass(es) or ADL care delivery, then further evaluation of pain intensity, location, quality and associated symptoms is needed to guide diagnosis and treatment decisions. Our pain interview includes items about presence, frequency, and effect of pain on residents’ daily lives, but does not have enough specific items upon which to base diagnosis and treatment.
Elsewhere in this module—Next Steps, Links, FAQs, Related Studies —we provide guidance and referrals to other resources to help you accomplish the pain management steps that follow screening.
Back to Top
Your Assignment
• Use our pain screening tool to interview a random sample of 5-10 residents. Be sure to interview some residents with mild to moderate cognitive impairment. Tell us how the interviews went; please contact us. How many residents answered all four questions? How many residents reported chronic pain? Did you find the interview tool helpful? Would you recommend its use? We hope to report your feedback for the benefit of others in future updates to this site.
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