Evolution of Best Practice Pain Assessment in Aged Care

This article is taken from the webinar “Modern Pain Assessment in Aged Care”. Watch the full recording and download the accompanying whitepaper.

For older adults, pain is a common occurrence. This segment of the population is more likely to experience pain than their younger counterparts, and chronic pain is more prevalent amongst this cohort.

Findings from Painaustralia suggest that as many as 80% of aged care residents are living with chronic pain, often caused by conditions such as common arthritis, bone and joint disorders, cancer, and other long-term illnesses. In addition, more than half have dementia and 67% require high-level care to manage behaviour .

Considering these findings, it’s clear that reliable and targeted pain management is critical to providing a high standard of care and this is underpinned by accurate pain assessment.

In this article, we explore insights from PainChek’s Chief Scientific Officer, Professor Jeff Hughes, on the evolution of best-practice pain assessment in aged care.

The difficulties of pain assessment in aged care

Identifying and managing pain is challenging, but it is particularly complex for older adults in aged care with dementia or cognitive impairment. The act of communicating the presence of pain can be difficult as the individual may have lost the fundamental knowledge of, or the ability to, communicate sensations that may be identified as pain .

Jeff Hughes explains:

“We need to have knowledge about what pain is and have the ability to communicate that to others, and that can be very difficult for someone with dementia. Often what you see instead is a change in behaviour.

“As a consequence to that, we start to treat the behaviour rather than the underlying antecedent. This is the focus of better pain management—understanding what happens in a person so that we can better see and understand the underlying needs. We need to keep in the front of our mind that behavioural change may relate to the presence of pain.”

Complex and/or subtle behavioural changes may include restlessness, changes in body language, speech and sleep patterns, and, appetite and facial expressions, all of which can indicate the presence of pain . As many carers are not trained to recognise these indicators, pain behaviours may be misdiagnosed as behavioural and psychological symptoms of dementia (BPSD).

Consequently, poor identification of pain in people living with dementia can lead to unintentional, inappropriate prescription of psychotropic medications. These can have serious side effects that can negatively impact the individual, and, when misdiagnosed, do not treat the cause of the person’s distress.

On top of that, aged care providers and carers face a number of common barriers to implementing consistent and standardised pain assessment protocols, including:

    • potential for subjectivity
    • time constraints
    • heavy workload
    • lack of resources
    • resistance to change by staff
    • lack of management support
    • communication breakdown across departments or professions

Progress in pain assessment methods

In recent years, there have been a number of developments in pain assessment — particularly for those suffering from chronic conditions or who have lost the ability to reliably verbalise their pain, such as people living with dementia.

Today, there are numerous pain assessment methods in use globally. For those who can self-report, the Numerical Rating Scale (NRS) is regarded as the gold standard of pain assessment – the patient or resident rates the intensity of their pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable.

For those who are unable to self-report pain, other strategies must be used to infer pain and evaluate intervention. As an example, the American Society for Pain Management Nursing (ASPMN) recommends a hierarchy of pain assessment techniques for those with advanced dementia , including:

    • being aware of the potential causes of pain in older persons
    • attempting to self-report
    • observing resident behaviours
    • soliciting proxy reporting of pain and behavioural or activity changes
    • attempting analgesic trial

However, challenges such as subjectivity and lack of specialised training amongst staff can limit the capacity to implement standardised pain assessment protocols, particularly in cases where patients or residents cannot reliably self-report their pain.

Jeff Hughes shares:

“The greatest problem is still the ability to assess pain in people who can’t tell you they’re in pain, and this is a problem in aged care, in hospital settings, in primary care. There have been over 30 tools developed to try and solve this, but out of those 30-plus tools, we have no single gold standard. Hence, part of the reason that we developed PainChek® is to address this issue.”

PainChek®: Enabling best-practice pain assessment for all people

PainChek® is a clinically validated pain assessment app that is transforming the way pain is assessed and managed. The app combines PainChek®’s AI pain assessment tool, which intelligently automates the multidimensional pain assessment process, with the Numerical Rating Scale (NRS). This hybrid functionality allows reliable, consistent pain assessment at the point of care for those who can self-report, those who cannot, and those whose ability fluctuates.

PainChek® extends on the capabilities of the Abbey Pain Scale (APS,) which has been the standard pain assessment tool used for people who cannot verbalise in Australia and overseas since 2004.

Jeff Hughes explains:

“Jennifer Abbey is a great supporter of PainChek®. She came up with the Abbey Pain Scale, which was driven by a need to have a better way to assess pain in with people with dementia. It was distributed to all aged care facilities in Australia as a paper-based tool and it changed the way in which pain was assessed. Jennifer sees PainChek® as a transition from a manual, paper-based, low, subjective process to one that is digitally accurate, quick and seamlessly integrated into aged care systems.”

Key benefits of PainChek® include:

    • Automation: Smart automation increases assessment objectivity and saves staff time by digitalising processes.
    • Accessibility: A fast, objective tool allows carers to accurately and consistently monitor pain without expert support.
    • Improved treatment outcomes: Reliable pain assessment supports improved treatment outcomes for people living with pain.
    • Data integrity and compliance: All pain assessment data is stored securely and centrally in PainChek®’s detailed reporting suite, PainChek® Analytics, minimising paper-handling, duplication, and associated risks.

Director of Quality & Care at Orchard Care Homes, Cheryl Baird, describes how implementing PainChek® has been pivotal in their aged care homes’ pain assessment and management strategy, and led to decreased pharmacological intervention amongst residents.

“The greatest achievement to date is a marked decrease in antipsychotic use in those living with dementia. We rolled out PainChek® across the Orchard portfolio, initially focusing on our dementia communities. However, once we observed such amazing results it was agreed to launch in all of our care homes.”

To find out more about the clinical validity of PainChek® and how it can enable best-practice pain assessment protocols within your facility, book a one-on-one session with a PainChek expert.

[1] Painaustralia. (2019) Aged Care and Pain: if you observe a change, consider pain. Available at:
https://www.painaustralia.org.au/media-document/blog-1/blog-2020/blog-2019/aged-care-and-pain-if-youobserve-a-change-consider-pain [online]. (Accessed 9 June 2022).
[2] CSIKCL. (2016) Assessment and management of pain in dementia. Available at: https://www.youtube.com/watch?v=tLZyXFxGJr0 [online video]. (Accessed 9 June 2022).
[3] Mageit, S. (2020). ‘Persistent chronic pain undetected in half of people living with dementia’, mobihealthnews. Available at: https://www.mobihealthnews.com/news/emea/persistent-chronic-pain-undetected-half-people-living-dementia [online]. (Accessed 9 June 2022).
[4] Herr et al. (2019) ‘Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement’, Pain Management Nursing. Available at: https://pubmed.ncbi.nlm.nih.gov/31610992/ [online]. (Accessed 9 June 2022).

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