Pain Assessment in the Cognitively Impaired

Author(s): L. Scott Wilner, MD and Robert Arnold, MD

The inability of cognitively impaired patients to communicate information about pain places them at high risk for inadequate pain control. Two common risk groups in palliative care include: 1) Patients with underlying brain pathology — e.g. dementia, Parkinson’s disease, stroke, developmental abnormalities; and 2) Patients receiving sedating medication — e.g. ICU patients receiving sedative/hypnotics to control anxiety/agitation from mechanical ventilation.

Recommended strategies to assess pain in these patients include the following:

Ask the patient—many patients who appear cognitively impaired may still be able to provide useful information concerning pain;
Interview the caregivers and family—patterns of particular behaviors may have developed that indicate pain (e.g. placing a hand on the forehead for headache);
Review the medical record for known pain-inducing pathology (e.g. diabetic with painful neuropathy that was manifest when the patient was cognitively intact);
Complete a physical examination and directed laboratory studies to assess for common pain-inducing problems (e.g. fracture, UTI)

In addition to these measures, clinicians should use a validated pain rating system for the cognitively impaired. Such rating systems focus the following observational items:

facial expression
body posture
vocalizations
appetite
interactivity

Representative examples of pain rating scales for the cognitively impaired, along with background information concerning validation studies and clinical experience can be found here. Doloplus-2 scale www.doloplus.com (1997)

References: 1) Closs SJ, Barr B, Briggs M, et al. A Comparison of Five Pain Assessment Scales for Nursing Home Residents with Varying Degrees of Cognitive Impairment. J Pain and Symptom Manage. March, 2004; 27(3); 196-205. 2) Feldt K. The Checklist of Nonverbal Pain Indicators (CNPI). Pain Manage Nursing. March, 2000; 1(1): 13-21. 3) Frampton M. Experience assessment and management of pain in people with dementia. Age and Ageing. 2003; 32(3): 248-251.

HospiceCare of Boulder and Broomfield Counties offer Palliative Medicine Consults. For more information contact us at 303-449-770.