- Email: [email protected]
The checklist of nonverbal pain indicators (CNPI)
The Checklist of Nonverbal Pain Indicators (CNPI) yyy Karen S. Feldt, PhD, RN, CS, GNP
y
ABSTRACT:
This article critiques the literature on existing pain assessment instruments for cognitively impaired elders and reports findings of pilot testing of the Checklist of Nonverbal Pain Indicators. This instrument was designed to measure pain behaviors in cognitively impaired elders. Instrument testing was conducted on a population of elderly patients with hip fractures. Interrater reliability showed 93% agreement on the dichotomous checklist items. Behaviors occurred more frequently during movement in this population. Of the six pain-related behaviors in the instrument, facial grimaces/winces occurred in 44% of the patients tested. Observed pain behaviors were positively correlated with self-report of pain. No differences between observed pain behaviors in cognitively intact versus cognitively impaired older adults with hip fractures were noted. Limitations of the instrument and recommendations for tool use are discussed. © 2000 by the American Society of Pain Management Nurses
From the School of Nursing, University of Minnesota, Minneapolis, MN; and Partnering Care, Healthpartners, St. Paul, MN. Address correspondence and reprint requests to Karen S. Feldt, PhD, RN, CS, GNP, School of Nursing, University of Minnesota, 6-101 Weaver Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455. E-mail: [email protected]. © 2000 by the American Society of Pain Management Nurses 1524-9042/00/0101-0002$3.00/0 doi: 10.1053/hm.2000.5831
Assessment of pain in cognitively impaired older adults can be a frustrating and complicated process. Health care professionals are faced with the challenge of finding an assessment instrument that is simple, easily administered, and provides useful information in evaluating pain for cognitively impaired elders. This article critiques the literature on existing pain assessment instruments for cognitively impaired elders and reports findings of pilot testing of the Checklist of Nonverbal Pain Indicators, an instrument designed to measure pain behaviors in cognitively impaired elders.
REVIEW OF LITERATURE A hallmark symptom of Alzheimer’s-type dementia is a loss of short-term memory skills (Alzheimer’s Disease Education and Referral Center, 1998). Persons with cognitive impairment who are presently sitting quietly may not remember wincing with pain during a transfer 5 minutes earlier. Nursing staff may discount complaints because of inconsistency or lack of reliability of patient report (Weiner, Ladd, Pieper, & Keefe, 1995). It is not uncommon for institutionalized cognitively impaired patients to forget a recent hip fracture and attempt to bear weight on a painful leg. Persons with dementia may not initiate conversations about pain or seek relief for pain because they have forgotten where they are, whom they should tell, or what event initially caused the pain. Pain assessment Pain Management Nursing, Vol 1, No 1 (March), 2000: pp 13-21
14
Karen S. Feldt
instruments that require memory of previous pain may not be reliable for this population (Ferrell, Ferrell, & Rivera, 1995; Parmelee, Smith, & Katz, 1993; Weiner et al, 1995). Impaired verbal skills and the ability to abstract concepts further obstruct assessment of pain for this population. Interview schedules or pain scale tools that require the understanding of numerous descriptors of pain or request that the patient select the one word out of five that best describes his pain may be too complex for a person with moderate to severe cognitive impairment (Weiner et al, 1995). Verbal Pain Instruments. Several researchers have reported successful use of simple pain intensity tools in cognitively impaired elders. Raway (1994) reported that 9 of 16 (60%) cognitively impaired patients (mean Mini-Mental State Exam [MMSE] ⫽ 16.6) were able to complete the McGill Present Pain Intensity (McGill PPI) Scale (Melzack, 1975). Similar findings have been reported by others who tested pain intensity tools (Ferrell et al, 1995; Weiner et al, 1995). Patients in Ferrell’s study were moderately cognitively impaired with an average Folstein Mini Mental State (Folstein, Folstein, & McHugh, 1975) score of 12 of 30 possible points, but 83% of the patients tested could complete at least one pain tool. The pain tool with the highest completion rate was the McGill Present Pain Intensity scale (Melzack), with 65% of the impaired patients able to rate pain, similar to Raway’s findings. Researchers concluded that self-ratings of pain intensity for cognitively impaired patients were not only possible, but were reliable and valid. However, Ferrell’s study did not report retest reliability data for each of the scales tested. Other pain intensity instruments have been tested. Weiner’s (1995) study reported that one third of nursing home residents in general (not just cognitively impaired) were unable to use the most commonly used quantitative pain self-report instrument, the verbal 0-10 scale. Rather than using words to describe rankings of pain (as in the McGill PPI) the 0-10 scale requires elders to abstract pain from a verbal description into a number and rank it. This task may be too complex for elders who are losing higher executive functions. Feldt, Ryden, & Miles (1998) reported a 73% completion rate on the Verbal Descriptor Scale (VDS) for cognitively impaired hospitalized older adults. The VDS is a simple verbal description of pain that uses familiar words, “slight pain,” “mild pain,” “moderate pain,” “severe pain,” “extreme pain,” and “pain as bad as it could be” (Herr & Mobily, 1993). The higher rate
of completion for the VDS compared with the McGill scale may be related to the simplicity of language. The McGill scale uses the words “discomforting,” “distressing,” “horrible,” and “excruciating,” not in the common language of older adults with limited education (Melzack, 1975). However, retest reliability for the VDS was poor for the 28 cognitively impaired hospitalized patients who were tested (Spearman r ⫽ .31, P ⫽ .11; Feldt et al, 1998). Cognitively impaired patients easily forget a pain rating from 20 minutes ago and, given the fluctuating nature of pain, may simply identify their existing pain rating. For simple yes/no questions about pain, cognitively impaired patients did as well as intact patients, with an 81% agreement between the initial test and the retest (Kappa ⫽ 0.601, P ⬍ .001; Feldt, 1996; Feldt et al, 1998). Scored Observational Pain Instruments. Although researchers suggest that clinicians attend to behavioral cues indicative of the presence of pain, few scales exist to measure these nonverbal indicators. Some attempts have been made to quantify pain and discomfort in nonverbal patients. A scale for measuring discomfort in noncommunicative patients with advanced Alzheimer’s-type dementia has been developed (Hurley, Volicer, Hanrahan, Houde, & Volicer, 1992). Discomfort, defined by these researchers as a negative emotional and/or physical state subject to variation in magnitude in response to internal or environmental conditions, differs somewhat from the concept of pain (Simons & Malabar, 1995). The Discomfort in Dementia of the Alzheimer’s type (DS-DAT) scale includes nine items, two positive and seven negative: noisy breathing, negative vocalization, content facial expression, sad facial expression, frightened facial expression, frown, relaxed body language, tense body language, and fidgeting (Hurley et al, 1992). Observers score each item on a continuous scale from absent (0) to extreme (100) based on the presence of the defining characteristics. Although initial testing showed good interrater reliability (.86 to .98) and tool reliability (Cronbach’s alpha .86 to .89), the tool was used on mostly men (90%), and a fairly small sample (n ⫽ 82) (Hurley et al, 1992). One of the items, noisy breathing, could be attributed to medical conditions such as an upper respiratory tract infection or chronic obstructive pulmonary disease. Although not tested in elders, it is possible that facial expressions of distress or discomfort may differ by culture or sex (Mostofsky & Lomranz, 1997). Researchers who have used the DS-DAT have identified difficulty with interrater reliability for specific items (relaxed body language, sad facial expression, and frown) and have modified the tool to im-
Checklist of Nonverbal Pain Indicators
prove the reliability (Miller, Neelon, Dalton, Ng’andu, Bailey, Layman, & Hosfeld, 1996). These researchers also identified that the DS-DAT is not user friendly for routine nursing care because of the in-depth training required to obtain accurate, reliable ratings. Two other scales for observer rating of pain behaviors in patients with chronic pain have been tested. The University of Alabama Birmingham Pain Behavior Scale (UAB-PBS) (Richards, Nepomuceno, Riles, & Suer, 1982) is a tool designed for use in a hospital setting and the Pain Behavior Checklist (PBC) (Dirks, Wunder, Kinsman, McElhinny, & Jones, 1993), a similar tool, is designed for use with patients with chronic pain in an outpatient or rehabilitation setting. Neither tool has been tested with cognitively impaired patients. The UAB-PBS 10-item scale includes observations of vocal complaints, grimacing, body language, and stationary restlessness. Similarly, the 16-item PBC includes grimacing, sighing, rigid posturing, bracing, and clutching or rubbing the pain site. The PBC was found to be highly correlated (r ⫽ .68, P ⬍ .001) with present pain ratings and least and worst pain ratings of 395 pain patients (Dirks et al, 1993). The UAB-PBS tool was shown to have high interrater reliability (.94 to .96) and a test-retest reliability coefficient of .89 indicating a high degree of stability for pain scores over 2 days (Richards et al, 1982). Authors of the tool indicate that measures of validity with other observation scales were not conducted because no other well-validated scales for assessing pain behavior existed. However, when the tool was compared with the McGill Pain questionnaire and a 0 to 10 analog scale, the UAB-PBS score did not significantly correlate, indicating that the relationship between observable manifestations of pain and selfreport may not be a close one. Both the UAB-PBS and the PBC tools include items that could lead to inaccurate scores for elders and patients with dementia. For example, the UAB-PBS includes a category that requires the patient to identify how many minutes are spent in bed during daytime hours because of pain, an impossible task for patients with severe dementia who may spend time in bed owing to profound cognitive impairment rather than pain. Because the tools were used for younger chronic pain populations, both instruments assume mobility, rating limping (PBC) or walking (UAB-PBS) with no explanation of how to rate nonambulatory elders. Patients are rated higher (indicating worse pain) on both scales if they use support equipment such as canes or walkers. Older adults who use a device for support or balance (rather than in response to pain) would automatically be rated as having more pain than those who do not use devices. In addition, the PBC includes items
15
such as “hunched or unusual shoulder posture” (fairly common in osteoporotic elders); “number of stands/ hr” and “has to walk” as measures of restlessness that would have to be altered for nonambulatory elders; and “difficulty arising” and “difficulty seating” (which can be problematic owing to simple perceptual impairments in cognitively impaired older adults regardless of pain status). Raway (1994) examined nonverbal pain behaviors in hospitalized postoperative cognitively impaired elders. She videotaped 22 patients (11 of whom were cognitively impaired) who had been hospitalized for surgical repair of a hip fracture to observe them for nonverbal pain behaviors. The patients pain-related facial expressions were coded using a facial coding system devised by Ekman & Friesen (1978). This coding procedure had several problems such as poor camera placement to capture patient expression, blockage of the patient’s face during transfers, and poor interrater reliability. She did report frequencies of “brow lowering” or “brow lowering with jaw drop” that were similar to the items of “grimacing” found in the UAB and PBS tools. She also examined 16 20second intervals of videotape for other nonverbal pain behaviors for each of the patients in her study. These observations included six 20-second intervals while the patient was in bed, four 20-second intervals during transfer from bed to chair, and six 20-second intervals while the patient sat in a wheelchair. Of the 10 body behaviors related to pain that Raway (1994) identified, five behaviors occurred in more than half of her patients. These included bracing the leg while standing (95.6%), guarding the torso or whole body (86.4%), repositioning the foot or ankle on the affected side (68%), guarding the leg on the affected side (63.6%), and repositioning the leg on the affected side (50%). Only guarding of the leg on the affected side occurred significantly less frequently in the confused group in her study. She noted three nonlanguage vocalizations that were commonly observed in the patients: sighing and grunting were each observed in 73% of the patients, and groaning/moaning was observed in 46% of the patients. The only nonlanguage behavior found to differ significantly in frequency between the confused and intact patients was grunting. She also reported four pain-related verbalizations. These were almost exclusively observed in the confused group (only one intact patient in her study had a pain-related verbalization) and included words of protest (“no, no, no,” “don’t”) observed in 46% of the patients; exclamations, observed in 36% of the subjects; and profanity in 27% of the patients. Correlations between observed pain behaviors and self-ranked pain intensity were not reported.
16
Karen S. Feldt
Observational Pain Instruments Under Development. Other observational pain instruments for cognitively impaired elders found in the literature appear to be in developmental stages. Psychometric properties and scoring of these instruments were not addressed, however, the tools identify similar behaviors as important indicators of pain for cognitively impaired elders. The Observable Pain Behaviors Tool was tested in a study of 105 older hospitalized patients (Simons & Malabar, 1995). The instrument requires the examiner to enter a number (from a menu of observable pain behaviors) into a pain assessment chart. The menu lists normal as well as pain-related behaviors, and nurses unfamiliar with this method would need to look back to the menu to determine whether previously recorded behaviors indicated pain and warranted pain treatment. The instrument is not scored to identify more intense or worsening pain. With revisions, the tool may provide valuable information for clinicians in practice settings. Baker, Bowring, Brignell, and Kafford (1996) developed a Behavior Checklist that identifies several behaviors indicative of pain in confused elders. This checklist identifies several behaviors that are congruent with those noted by other researchers. These include: moaning, outgoing, quiet, agitated, cheerful, withdrawn, mute, verbally abusive, cries easily, refuses food, aggressive, noisy breathing, friendly, rocking, disjointed verbalization, involved, eats well, describes pain, calling out, and picking. The lack of testing for reliability, validity, or method of scoring limits use of the instrument for research. However, the checklist could provide important clinical information for assessing pain-related behaviors in long-term care facilities. In a recent study of nursing home residents who had daily pain for at least 3 months, patients were asked to identify behaviors that they engage in when they experience pain (Weiner et al, 1999). These selfreported behaviors were compared with behaviors identified by nursing and family caregivers. Of the pain behaviors endorsed by at least half of each of the three groups (residents, nurses, and family caregivers), eight behaviors had a substantial test-retest agreement (kappa ⬎ 0.6). These included: using mechanical help (cane, walker, grabbing onto furniture); moving extremely slowly; taking or asking for medication; lying down; appearing upset or sad; sighing/moaning; having difficulty getting up after lying down or sitting; and asking someone to do something to help the pain. These behaviors identify the effect of pain on function and the limitation or modification of function that is
used by residents to manage pain. Further development of this instrument is being conducted. Nonverbal cognitively impaired residents who may communicate pain through behaviors were not included in the above scales. Although the scales include many useful observational behaviors that may signify pain (vocalizations or crying out, facial expressions of grimacing or wincing, wrinkling of the forehead in response to movement, and increased restlessness, rocking, rubbing, or guarding of a body part), cognitively impaired patients may also show increased irritability or aggressive behaviors, increased resistance to any personal care that requires movement, changes in appetite or sleep patterns, or social withdrawal (Ferrell, Ferrell, & Osterweil, 1990; Parke, 1992; Herr & Mobily, 1991; Marzinski, 1991; Ryden & Feldt, 1992; Sengstaken & King, 1993; Weiner, Peterson, & Keefe, 1999). These behaviors could also be attributed to factors other than pain, which complicates the use of these items in pain assessment tools. In addition, variability of nonverbal pain-related behavior in different patients raises questions about whether reliable assessment of pain is possible for this population (Marzinski, 1991).
CHECKLIST OF NONVERBAL PAIN INDICATORS In response to the difficulties in identifying a reliable and valid instrument for measuring pain in cognitively impaired elders, the Checklist of Nonverbal Pain Behaviors was developed. This instrument was piloted in a study that examined the treatment of pain in cognitively impaired compared with cognitively intact older adults after surgery for hip fracture (Feldt, 1996; Feldt et al, 1998). Tool Development and Initial Testing. The Checklist of Nonverbal Pain Indicators (CNPI) instrument was initially developed because of concerns that some of the cognitively impaired patients would be unable to use the scaled instrument or respond reliably to the yes/no questions about pain after hip fracture surgery. To provide some estimation of pain, it was necessary to develop a tool that would measure pain behaviors. Modifications were made to the UAB-PBS tool to eliminate items that required ambulation, an item that evaluated standing posture, the item that required a ranking of number of hours spent in bed because of pain, and the item on medicationseeking behavior (Richards et al, 1982). In addition, restlessness was redefined as “constant or intermittent shifting of position, rocking, intermittent or constant hand motions, or inability to keep still” to allow for
Checklist of Nonverbal Pain Indicators
nonambulatory elders. An item, “vocal complaints,” was added to the instrument, based on Raway’s (1994) experience with pain-related verbalizations in cognitively impaired patients. This revised tool was called the CNPI. The CNPI has good face validity based on literature regarding pain behaviors in demented elders (Marzinski, 1991; Raway, 1994; Sengstaken et al, 1993). The modified scale includes those behaviors most frequently cited by other researchers: nonverbal vocalizations (defined as sighs, gasps, moans, groans, cries), facial grimacing or wincing (defined as furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expression), bracing (defined as clutching or holding onto furniture or equipment or affected area during movement), rubbing (massaging affected area), restlessness (defined as constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still), and vocal complaints (defined as words expressing discomfort or pain, “ouch,” “that hurts”; cursing during movement; and exclamations of protest “stop,” “that’s enough”). To retain construct validity, items potentially related to disease states or problems other than pain (such as appetite changes), were not added to the instrument, although observation for these issues can be an important part of assessing pain for this population. Two raters (both gerontological nurse practitioners with Master’s degrees) simultaneously observed in 12 of the initial patients enrolled in the study (13.6% of the total sample) to establish interrater reliability. These observations took place in the patient’s hospital room with observations during rest (lying in bed) and during movement (a transfer from bed to chair conducted with the assist of nursing staff). Interrater reliability for the CNPI showed 93% agreement on the dichotomous checklist items. The Kappa statistic was 0.625 to 0.819 (P ⫽ .019 to .0057) for the behaviors observed. However, prevalence attenuation was a problem for the dichotomous (present/absent) items of the tool. Frequencies for many of the behaviors were fairly low. Bracing was not observed at rest on any of the 12 joint observations. Two of the tool behaviors, restlessness and rubbing, were not seen at any of the joint observations either at rest or with movement.
METHODS Design. A prospective comparative survey design was used for the study on older adults with hip fractures. Patients who had undergone surgical repair of a hip fracture were interviewed in the hospital on the third
17
postoperative day. The interview included assessment of pain using the Ferrell Pain Experience Interview, a rating of pain severity using the VDS, and an assessment of cognitive status using the Mini-Mental State Exam (MMSE). Data regarding pain treatment and pain report from the hospital interview have been reported elsewhere (Feldt et al, 1998). Setting and patients. The study was approved by human subjects committees at each of three Midwestern urban hospitals. Between the months of February and October, 1995, a convenience sample of 88 hip fracture patients were enrolled in the study and interviewed in the hospital. Patients were all English speaking, predominately women (86%), and aged 65 years or older (range, 65 to 101; m ⫽ 83.2 yrs, SD ⫽ 7.7). Cognitive impairment was defined as a score of 23 points or less on the Folstein MMSE. There were 53 cognitively impaired patients and 35 cognitively intact patients enrolled. The mean MMSE for the group as a whole was 18.1 of 30; impaired patients MMSE mean was 12.2 (SD ⫽ 8.0) and intact patients MMSE mean was 27.2 (SD ⫽ 1.9). At the end of the hospital interview, patients were observed for nonverbal signs of pain behavior at rest using the CNPI. Patients were also observed for nonverbal signs of pain during movement that was operationalized as a simple transfer by the nursing staff (from bed to chair or chair to bed). Of the total hospitalized sample of 88 patients, observations for nonverbal signs of pain at rest using the CNPI were completed on 87 of the patients. One patient in the intact group was not observed because of an interruption by therapy services. An additional eight patients (5 impaired and 3 intact) were not observed for nonverbal signs of pain during movement because they were up in a chair and there were no immediate plans by nursing staff to transfer the patient back to the bed.
RESULTS CNPI observations for the sample as a whole. The research question sought to determine if there were differences in observed pain behaviors for cognitively intact older adults compared with cognitively impaired hospitalized older adults. There were no significant differences between the two groups with regard to individual pain behaviors observed, although patients in the intact group showed fewer nonverbal indications of pain at rest and with movement than did impaired patients (see Table 1). The patients in the intact group were noted to have received significantly higher amounts of pain medication when compared with the impaired group (Feldt et al, 1998).
18
Karen S. Feldt
TABLE 1. Nonverbal Pain Indicators in Hospitalized Patients IMPAIRED
Nonverbal Behavior Vocalizations Grimaces Bracing Rubbing Restlessness Verbal complaint
INTACT
TOTAL
AT REST n ⴝ 49 % (n)
WITH MOVEMENT n ⴝ 44 % (n)
AT REST n ⴝ 34 % (n)
WITH MOVEMENT n ⴝ 31 % (n)
AT REST n ⴝ 83 % (n)
12.2 (6) 30.6 (15) 6.1 (3) 8.2 (4) 20.4 (10) 12.2 (6)
36.4 (16) 47.7 (21) 18.2 (8) — (0) 2.3 (1) 36.4 (16)
5.9 (2) 20.6 (7) 5.9 (2) 8.8 (3) 5.9 (2) 5.9 (2)
19.4 (6) 38.7 (12) 16.1 (5) — (0) — (0) 22.6 (7)
9.6 (8) 26.5 (22) 6.0 (5) 8.4 (7) 14.5 (12) 9.6 (8)
WITH MOVEMENT n ⴝ 75 % (n) 29.3 (22) 44.0 (33) 17.3 (13) — (0) 1.3 (1) 30.7 (23)
Frequency of behavior at rest.
Total CNPI score.
The most commonly observed behavior at rest was facial grimaces, which were observed in 15 (30.6%) of the impaired patients and 7 (20.6%) of the intact patients. For impaired patients, the second most frequent behavior at rest was restlessness, which was observed in 20.4% (n ⫽ 10) of the patients. In general, these postoperative patients at rest were very still and the frequency of pain behaviors on this instrument was very low. The stillness and lack of mobility after surgery was likely a pain behavior in itself, to guard against the pain experienced with movement.
A summed score of the number of nonverbal indicators observed at rest and with movement was calculated for each patient. The impaired and intact groups did not differ with regard to the total number of nonverbal indicators observed at rest, with both groups having a very low frequency of nonverbal indicators at rest (mean ⫽ 0.89, SD ⫽ 1.1 for the impaired group, mean ⫽ 0.53, SD ⫽ 1.1 for the intact group). There were significantly more nonverbal indicators of pain observed with movement for the cognitively impaired group than for the cognitively intact group, although overall frequency of observed behavior was still very low (impaired: mean ⫽ 1.56, SD ⫽ 1.4, intact mean ⫽ 0.94, SD ⫽ 1.1, t ⫽ 2.1, df ⫽ 71, P ⫽ .04). Observations for pain were performed at the time of the interview, which was conducted at approximately day three postoperatively (mean ⫽ 2.9, SD ⫽ .88). Because there was some variation from the time of surgery to the time of the observation, the sample as a whole was divided into two groups, those who were observed within 60 hours (⬍2.5 days) postoperatively, and those who were observed after 60 hours postoperatively. Of the 26 patients (14 impaired and 12 intact) observed within 60 hours postoperatively, the impaired group had significantly more nonverbal indicators of pain observed (impaired: mean ⫽ 1.64, SD ⫽ 1.3, intact: mean ⫽ .66, SD ⫽ .78, t ⫽ 2.2, df ⫽ 24, P ⫽ .03). Observation during rest did not differ significantly for the groups within 60 hours postoperatively. Of the 47 patients (27 cognitively impaired and 20 intact) that were observed after 60 hours postoperatively, the CNPI at rest and with movement did not differ significantly between groups.
Behavior during movement. During movement, the most frequently observed behaviors for cognitively impaired patients in descending order were grimacing (47.7%, n ⫽ 12), verbal complaints (eg, “ouch,” “that hurts,” and words of protest “stop”) (36.4%, n ⫽ 16), nonverbal vocalizations (36.4%, n ⫽ 16), and bracing (18.2%, n ⫽ 8). Although both of the verbal complaints and nonverbal vocalizations were seen more frequently in impaired patients than intact patients, this did not reach statistical significance. During movement, the most frequently observed behaviors for intact patients in descending order were grimacing (38.7%, n ⫽ 12), verbal complaints (22.6%, n ⫽ 7), nonverbal vocalizations (19.4%, n ⫽ 6), and bracing (16.1%, n ⫽ 5). The CNPI indicators were more commonly observed with movement rather than while the patient was resting. In fact, slightly over half of the sample (56%) showed no nonverbal indications of pain at rest. However, nearly two thirds (62%) of the patients showed nonverbal signs of pain when observed during movement.
Checklist of Nonverbal Pain Indicators
Measures of internal consistency. To measure internal consistency, the Kuder-Richardson 20 (KR-20, an alpha measure for dichotomous items) was performed. The KR-20 is the most useful reliability coefficient for dichotomous items because it makes no special assumptions regarding the distribution of items (SPSS Base System Syntax Reference Guide, 1997). The alpha coefficient for the CNPI at rest was .54 (95% confidence interval [CI] ⫽ .38 to .68). The alpha coefficient for the CNPI with movement was .64 (95% CI ⫽ .49 to .75). The low number of items in the scale may partially account for these modest alpha coefficients. As the number of items on a scale increases, the average correlation among the items increase and the alpha takes on a larger value.
COMPARISON WITH OTHER PAIN ASSESSMENT INSTRUMENTS The scores on the CNPI were compared with pain intensity report (VDS) scores: ranked no pain ⫽ 0; slight pain ⫽ 1, and so forth, to pain as bad as it could be ⫽ 6, for those patients who were able to give a severity ranking of their pain. Sixty-four patients who had CNPI observations also had responses to the VDS. The summed score of observed pain at rest and the summed score of observed pain with movement were significantly correlated with the VDS score for the sample as a whole for this acute postoperative population (CNPI at rest with VDS, Spearman correlation rs ⫽ .372, P ⫽ .001; CNPI with movement with VDS, Spearman correlation rs ⫽ .428, P ⬍ .0001). When the observed pain behaviors were correlated for each of the groups separately, the intact group (n ⫽ 32) showed significant correlations with the VDS both at rest and with movement (CNPI at rest with VDS, rs ⫽ .50, P ⫽ .003; CNPI with movement with VDS, rs ⫽ .385, P ⫽ .032), but the impaired group (n ⫽ 32) CNPI score was significantly correlated with the VDS with movement only (CNPI at rest with VDS, rs ⫽ .299, P ⫽ .076; CNPI with movement with VDS, rs ⫽ .4629, P ⫽ .009).
DISCUSSION Nurses in both acute and long-term care settings have indicated a need for an instrument that assesses pain in cognitively impaired elders. The CNPI proved to be an initially reliable and simple tool to measure pain behaviors in postoperative elders. The low frequencies of observed behaviors at rest indicate that the tool is less useful during rest and may be more useful for observing activities such as transfers, standing, or ambulation during physical therapy.
19
Although the impaired and intact groups did not differ with regard to the total number of nonverbal indicators observed at rest, there were significantly more nonverbal indicators of pain observed with movement for the cognitively impaired group than for the cognitively intact group. This finding indicates that, while at rest, impaired and intact patients appear fairly comfortable and, unless asked about pain or discomfort while moving, would give the appearance that they are not in need of medication. Nursing staff must be made aware that impaired patients may forget the painful areas while at rest and be less likely to request pain medication. However, movement provides an instant and, perhaps surprising, reminder that they are experiencing pain. Cognitively impaired patients who are undertreated for pain may become reluctant to move, increasing their risk for postoperative pneumonia and skin breakdown and slowing their progress in rehabilitative therapies. During movement, cognitively impaired patients show higher frequencies than intact patients with regard to vocalizations, grimaces, and verbal complaints, although none of these individual behaviors were statistically significantly higher. Only one other study was found that had examined nonverbal pain behaviors in hospitalized postoperative cognitively impaired elders (Raway, 1994). That study reported much higher frequencies of pain behaviors (46% to 87%) than those noted in the present study. This may be related to the fact that patients in that study were observed during transfers and were videotaped, allowing careful review of observation over time, instead of the single observation conducted in this study. Raway noted that confused patients showed guarding of the leg on the affected side significantly less frequently than intact patients, but showed grunting and pain-related verbalizations significantly more frequently. Unlike the present study in which both the impaired and the intact groups were observed to have pain-related verbalizations, Raway reported those verbalizations as almost exclusively observed in the confused group (only one intact patient in her study had a pain-related verbalization). Cognitively impaired patients observed at rest may give misleading cues to staff with regard to pain. Bell (1997) examined charts of 36 elderly postoperative hip fracture patients and found no significant differences in the number of times pain was assessed and documented for cognitively impaired versus cognitively intact patients, but did find that the impaired group had pain described more often in nonverbal terms with a descriptive statement rather than a standardized score, indicating that nursing observations are an important part of assessment of pain for cogni-
20
Karen S. Feldt
tively impaired patients who are less capable of completing a scaled tool. Nurses need to be attentive to pain-related behaviors during transfers and patient care activities because they provide good indicators of the patients’ discomfort. As physical care activities become increasingly delegated to nonlicensed staff, nurses may be less available to assess elderly patients for these more subtle cues of discomfort.
LIMITATIONS AND RECOMMENDATIONS FOR FURTHER RESEARCH The development and pilot testing of this tool was a very small part of a larger study. The small number of interrater observations severely limit broad conclusions about reliability. No retest reliability was con-
REFERENCES Alzheimer’s Disease Education and Referral (ADEAR) Center. (1998). Progress report on Alzheimer’s disease (p. 2). Silver Spring, MD: Author. American Geriatrics Society Panel on Chronic Pain in Older Persons. (1998). The management of chronic pain in older persons. Journal of the American Geriatrics Society, 46, 635-651. Baker, A., Bowring, L., Brignell, A., & Kafford, D. (1996). Chronic pain management in cognitively impaired patients: A preliminary research project. Perspectives, 20, 4-8. Bell, M.L. (1997). Postoperative pain management for the cognitively impaired older adult. Seminars in Perioperative Nursing, 6, 37-41. Dirks, J.F., Wunder, J., Kinsman, R., McElhinny, J., & Jones, N.F. (1993). A pain rating scale and a pain behavior checklist for clinical use: Development, norms, and the consistency score. Psychotherapeutics and Psychosomatics, 59, 41-49. Ekman, P., & Friesen, W.V. (1978). Manual of the Facial Action Coding System, Palo Alto, CA: Consulting Psychologists Press. Feldt, K.S. Treatment of pain in cognitively impaired versus cognitively intact post hip fractured elders. (Doctoral dissertation, University of Minnesota, 1996). Dissertation Abstracts International, 57-09B, 5574. Feldt, K.S., Ryden, M.B., & Miles, S. (1998). Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip fracture. Journal of the American Geriatrics Society, 46, 1079-1085. Ferrell, B.A., Ferrell, B.R., & Osterweil, D. (1990). Pain in the nursing home. Journal of the American Geriatrics Society, 38, 409-414. Ferrell, B.A., Ferrell, B.R., & Rivera, L. (1995). Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management, 10, (8), 591-598. Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). ‘Mini-mental state’. A practical method for grading the cog-
ducted on the instrument because of the acute postoperative fluctuating nature of pain for these patients. The tool needs testing on a larger population and would benefit from testing on populations with chronic as well as acute pain. Consideration should be given to adding items that may improve the internal consistency of the tool. Comparisons with other pain measures should be further pursued, including measures such as the visual analogue scale and the faces scaled recommended by the American Geriatrics Society Chronic Pain Guidelines (American Geriatrics Society Panel on Chronic Pain in Older Persons, 1998). The tool should also be tested for use with cognitively impaired residents in long-term care facilities in conjunction with other observations (sleep and appetite changes, aggressive behavior during care) that may be indicative of pain.
nitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Herr, K.A., & Mobily, P.R. (1991). Complexities of pain assessment in the elderly. Journal of Gerontological Nursing, 17, 12-18. Herr, K.A., & Mobily, P.R. (1993). Comparison of selected pain assessment tools for use with the elderly. Applied Nursing Research, 6, 39-46. Hurley, A.C., Volicer, B.J., Hanrahan, P.A., Houde, S., & Volicer, L. (1992). Assessment of discomfort in advanced Alzheimer’s patients. Research in Nursing & Health, 15 (5), 369-377. Mostofsky, D.I., & Lomranz, J. (1997). The psychology of pain and suffering. In D.I. Mostofsky, & J. Lomranz (Eds.), Handbook of Pain and Aging (p. 8). New York: Plenum Publishers. Marzinski, L.R. (1991). The tragedy of dementia: Clinically assessing pain in the confused nonverbal elderly. Journal of Gerontological Nursing, 17, 25-28. Melzack, R. (1975). The McGill pain questionnaire: Major properties and scoring methods. Pain, 1, 277-299. Miller, J., Neelon, V., Dalton, J., Ng’andu, N., Bailey, D., Jr., Layman, E., Hosfeld, A. (1996). The assessment of discomfort in elderly confused patients: A preliminary study. Journal of Neuroscience Nursing, 28, 175-182. Parke, B. (1992). Pain in the cognitively impaired elderly. Canadian Nurse, 88, 17-20. Parmelee, P.A., Smith, B., & Katz, I.R. (1993). Pain complaints and cognitive status among elderly institution residents. Journal of the American Geriatrics Society, 41, 517-522. Raway, B. (1994). Pain behaviors and confusion in elderly patients with hip fracture. (Doctoral dissertation, Catholic University of America, 1994). Dissertation Abstracts International, 55, 02B. (University Microfilms No. AAI94-18593) Richards, J.S., Nepomuceno, C., Riles, M., & Suer, Z. (1982). Assessing pain behavior: The UAB pain behavior scale. Pain, 14, 393-398.
Checklist of Nonverbal Pain Indicators
Ryden, M., & Feldt, K. (1992). Goal directed care: Caring for aggressive nursing home residents with dementia. Journal of Gerontological Nursing, 18 (11), 35-42. Sengstaken, E.A., & King, S.A. (1993). The problems of pain and its detection among geriatric nursing home residents. Journal of the American Geriatrics Society, 41, 541-544. Simons, W., Malabar, R. (1995). Assessing pain in elderly patients who cannot respond verbally. Journal of Advanced Nursing, 22, 663-669.
21
SPSS Base System Syntax Reference Guide (Release 8.0). (1997). Chicago, IL: SPSS, Inc. Weiner, D.K., Ladd, K.E., Pieper, C.F., & Keefe, F.J. (1995). Pain in the nursing home: Resident versus staff perceptions. Journal of the American Geriatrics Society, 43, SA2. Weiner, D.K., Peterson, B., & Keefe, E.J. (1999). Chronic pain-associated behaviors in the nursing home: Resident versus caregiver perceptions. Pain, 80, 577588.
y
ABSTRACT:
This article critiques the literature on existing pain assessment instruments for cognitively impaired elders and reports findings of pilot testing of the Checklist of Nonverbal Pain Indicators. This instrument was designed to measure pain behaviors in cognitively impaired elders. Instrument testing was conducted on a population of elderly patients with hip fractures. Interrater reliability showed 93% agreement on the dichotomous checklist items. Behaviors occurred more frequently during movement in this population. Of the six pain-related behaviors in the instrument, facial grimaces/winces occurred in 44% of the patients tested. Observed pain behaviors were positively correlated with self-report of pain. No differences between observed pain behaviors in cognitively intact versus cognitively impaired older adults with hip fractures were noted. Limitations of the instrument and recommendations for tool use are discussed. © 2000 by the American Society of Pain Management Nurses
From the School of Nursing, University of Minnesota, Minneapolis, MN; and Partnering Care, Healthpartners, St. Paul, MN. Address correspondence and reprint requests to Karen S. Feldt, PhD, RN, CS, GNP, School of Nursing, University of Minnesota, 6-101 Weaver Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455. E-mail: [email protected]. © 2000 by the American Society of Pain Management Nurses 1524-9042/00/0101-0002$3.00/0 doi: 10.1053/hm.2000.5831
Assessment of pain in cognitively impaired older adults can be a frustrating and complicated process. Health care professionals are faced with the challenge of finding an assessment instrument that is simple, easily administered, and provides useful information in evaluating pain for cognitively impaired elders. This article critiques the literature on existing pain assessment instruments for cognitively impaired elders and reports findings of pilot testing of the Checklist of Nonverbal Pain Indicators, an instrument designed to measure pain behaviors in cognitively impaired elders.
REVIEW OF LITERATURE A hallmark symptom of Alzheimer’s-type dementia is a loss of short-term memory skills (Alzheimer’s Disease Education and Referral Center, 1998). Persons with cognitive impairment who are presently sitting quietly may not remember wincing with pain during a transfer 5 minutes earlier. Nursing staff may discount complaints because of inconsistency or lack of reliability of patient report (Weiner, Ladd, Pieper, & Keefe, 1995). It is not uncommon for institutionalized cognitively impaired patients to forget a recent hip fracture and attempt to bear weight on a painful leg. Persons with dementia may not initiate conversations about pain or seek relief for pain because they have forgotten where they are, whom they should tell, or what event initially caused the pain. Pain assessment Pain Management Nursing, Vol 1, No 1 (March), 2000: pp 13-21
14
Karen S. Feldt
instruments that require memory of previous pain may not be reliable for this population (Ferrell, Ferrell, & Rivera, 1995; Parmelee, Smith, & Katz, 1993; Weiner et al, 1995). Impaired verbal skills and the ability to abstract concepts further obstruct assessment of pain for this population. Interview schedules or pain scale tools that require the understanding of numerous descriptors of pain or request that the patient select the one word out of five that best describes his pain may be too complex for a person with moderate to severe cognitive impairment (Weiner et al, 1995). Verbal Pain Instruments. Several researchers have reported successful use of simple pain intensity tools in cognitively impaired elders. Raway (1994) reported that 9 of 16 (60%) cognitively impaired patients (mean Mini-Mental State Exam [MMSE] ⫽ 16.6) were able to complete the McGill Present Pain Intensity (McGill PPI) Scale (Melzack, 1975). Similar findings have been reported by others who tested pain intensity tools (Ferrell et al, 1995; Weiner et al, 1995). Patients in Ferrell’s study were moderately cognitively impaired with an average Folstein Mini Mental State (Folstein, Folstein, & McHugh, 1975) score of 12 of 30 possible points, but 83% of the patients tested could complete at least one pain tool. The pain tool with the highest completion rate was the McGill Present Pain Intensity scale (Melzack), with 65% of the impaired patients able to rate pain, similar to Raway’s findings. Researchers concluded that self-ratings of pain intensity for cognitively impaired patients were not only possible, but were reliable and valid. However, Ferrell’s study did not report retest reliability data for each of the scales tested. Other pain intensity instruments have been tested. Weiner’s (1995) study reported that one third of nursing home residents in general (not just cognitively impaired) were unable to use the most commonly used quantitative pain self-report instrument, the verbal 0-10 scale. Rather than using words to describe rankings of pain (as in the McGill PPI) the 0-10 scale requires elders to abstract pain from a verbal description into a number and rank it. This task may be too complex for elders who are losing higher executive functions. Feldt, Ryden, & Miles (1998) reported a 73% completion rate on the Verbal Descriptor Scale (VDS) for cognitively impaired hospitalized older adults. The VDS is a simple verbal description of pain that uses familiar words, “slight pain,” “mild pain,” “moderate pain,” “severe pain,” “extreme pain,” and “pain as bad as it could be” (Herr & Mobily, 1993). The higher rate
of completion for the VDS compared with the McGill scale may be related to the simplicity of language. The McGill scale uses the words “discomforting,” “distressing,” “horrible,” and “excruciating,” not in the common language of older adults with limited education (Melzack, 1975). However, retest reliability for the VDS was poor for the 28 cognitively impaired hospitalized patients who were tested (Spearman r ⫽ .31, P ⫽ .11; Feldt et al, 1998). Cognitively impaired patients easily forget a pain rating from 20 minutes ago and, given the fluctuating nature of pain, may simply identify their existing pain rating. For simple yes/no questions about pain, cognitively impaired patients did as well as intact patients, with an 81% agreement between the initial test and the retest (Kappa ⫽ 0.601, P ⬍ .001; Feldt, 1996; Feldt et al, 1998). Scored Observational Pain Instruments. Although researchers suggest that clinicians attend to behavioral cues indicative of the presence of pain, few scales exist to measure these nonverbal indicators. Some attempts have been made to quantify pain and discomfort in nonverbal patients. A scale for measuring discomfort in noncommunicative patients with advanced Alzheimer’s-type dementia has been developed (Hurley, Volicer, Hanrahan, Houde, & Volicer, 1992). Discomfort, defined by these researchers as a negative emotional and/or physical state subject to variation in magnitude in response to internal or environmental conditions, differs somewhat from the concept of pain (Simons & Malabar, 1995). The Discomfort in Dementia of the Alzheimer’s type (DS-DAT) scale includes nine items, two positive and seven negative: noisy breathing, negative vocalization, content facial expression, sad facial expression, frightened facial expression, frown, relaxed body language, tense body language, and fidgeting (Hurley et al, 1992). Observers score each item on a continuous scale from absent (0) to extreme (100) based on the presence of the defining characteristics. Although initial testing showed good interrater reliability (.86 to .98) and tool reliability (Cronbach’s alpha .86 to .89), the tool was used on mostly men (90%), and a fairly small sample (n ⫽ 82) (Hurley et al, 1992). One of the items, noisy breathing, could be attributed to medical conditions such as an upper respiratory tract infection or chronic obstructive pulmonary disease. Although not tested in elders, it is possible that facial expressions of distress or discomfort may differ by culture or sex (Mostofsky & Lomranz, 1997). Researchers who have used the DS-DAT have identified difficulty with interrater reliability for specific items (relaxed body language, sad facial expression, and frown) and have modified the tool to im-
Checklist of Nonverbal Pain Indicators
prove the reliability (Miller, Neelon, Dalton, Ng’andu, Bailey, Layman, & Hosfeld, 1996). These researchers also identified that the DS-DAT is not user friendly for routine nursing care because of the in-depth training required to obtain accurate, reliable ratings. Two other scales for observer rating of pain behaviors in patients with chronic pain have been tested. The University of Alabama Birmingham Pain Behavior Scale (UAB-PBS) (Richards, Nepomuceno, Riles, & Suer, 1982) is a tool designed for use in a hospital setting and the Pain Behavior Checklist (PBC) (Dirks, Wunder, Kinsman, McElhinny, & Jones, 1993), a similar tool, is designed for use with patients with chronic pain in an outpatient or rehabilitation setting. Neither tool has been tested with cognitively impaired patients. The UAB-PBS 10-item scale includes observations of vocal complaints, grimacing, body language, and stationary restlessness. Similarly, the 16-item PBC includes grimacing, sighing, rigid posturing, bracing, and clutching or rubbing the pain site. The PBC was found to be highly correlated (r ⫽ .68, P ⬍ .001) with present pain ratings and least and worst pain ratings of 395 pain patients (Dirks et al, 1993). The UAB-PBS tool was shown to have high interrater reliability (.94 to .96) and a test-retest reliability coefficient of .89 indicating a high degree of stability for pain scores over 2 days (Richards et al, 1982). Authors of the tool indicate that measures of validity with other observation scales were not conducted because no other well-validated scales for assessing pain behavior existed. However, when the tool was compared with the McGill Pain questionnaire and a 0 to 10 analog scale, the UAB-PBS score did not significantly correlate, indicating that the relationship between observable manifestations of pain and selfreport may not be a close one. Both the UAB-PBS and the PBC tools include items that could lead to inaccurate scores for elders and patients with dementia. For example, the UAB-PBS includes a category that requires the patient to identify how many minutes are spent in bed during daytime hours because of pain, an impossible task for patients with severe dementia who may spend time in bed owing to profound cognitive impairment rather than pain. Because the tools were used for younger chronic pain populations, both instruments assume mobility, rating limping (PBC) or walking (UAB-PBS) with no explanation of how to rate nonambulatory elders. Patients are rated higher (indicating worse pain) on both scales if they use support equipment such as canes or walkers. Older adults who use a device for support or balance (rather than in response to pain) would automatically be rated as having more pain than those who do not use devices. In addition, the PBC includes items
15
such as “hunched or unusual shoulder posture” (fairly common in osteoporotic elders); “number of stands/ hr” and “has to walk” as measures of restlessness that would have to be altered for nonambulatory elders; and “difficulty arising” and “difficulty seating” (which can be problematic owing to simple perceptual impairments in cognitively impaired older adults regardless of pain status). Raway (1994) examined nonverbal pain behaviors in hospitalized postoperative cognitively impaired elders. She videotaped 22 patients (11 of whom were cognitively impaired) who had been hospitalized for surgical repair of a hip fracture to observe them for nonverbal pain behaviors. The patients pain-related facial expressions were coded using a facial coding system devised by Ekman & Friesen (1978). This coding procedure had several problems such as poor camera placement to capture patient expression, blockage of the patient’s face during transfers, and poor interrater reliability. She did report frequencies of “brow lowering” or “brow lowering with jaw drop” that were similar to the items of “grimacing” found in the UAB and PBS tools. She also examined 16 20second intervals of videotape for other nonverbal pain behaviors for each of the patients in her study. These observations included six 20-second intervals while the patient was in bed, four 20-second intervals during transfer from bed to chair, and six 20-second intervals while the patient sat in a wheelchair. Of the 10 body behaviors related to pain that Raway (1994) identified, five behaviors occurred in more than half of her patients. These included bracing the leg while standing (95.6%), guarding the torso or whole body (86.4%), repositioning the foot or ankle on the affected side (68%), guarding the leg on the affected side (63.6%), and repositioning the leg on the affected side (50%). Only guarding of the leg on the affected side occurred significantly less frequently in the confused group in her study. She noted three nonlanguage vocalizations that were commonly observed in the patients: sighing and grunting were each observed in 73% of the patients, and groaning/moaning was observed in 46% of the patients. The only nonlanguage behavior found to differ significantly in frequency between the confused and intact patients was grunting. She also reported four pain-related verbalizations. These were almost exclusively observed in the confused group (only one intact patient in her study had a pain-related verbalization) and included words of protest (“no, no, no,” “don’t”) observed in 46% of the patients; exclamations, observed in 36% of the subjects; and profanity in 27% of the patients. Correlations between observed pain behaviors and self-ranked pain intensity were not reported.
16
Karen S. Feldt
Observational Pain Instruments Under Development. Other observational pain instruments for cognitively impaired elders found in the literature appear to be in developmental stages. Psychometric properties and scoring of these instruments were not addressed, however, the tools identify similar behaviors as important indicators of pain for cognitively impaired elders. The Observable Pain Behaviors Tool was tested in a study of 105 older hospitalized patients (Simons & Malabar, 1995). The instrument requires the examiner to enter a number (from a menu of observable pain behaviors) into a pain assessment chart. The menu lists normal as well as pain-related behaviors, and nurses unfamiliar with this method would need to look back to the menu to determine whether previously recorded behaviors indicated pain and warranted pain treatment. The instrument is not scored to identify more intense or worsening pain. With revisions, the tool may provide valuable information for clinicians in practice settings. Baker, Bowring, Brignell, and Kafford (1996) developed a Behavior Checklist that identifies several behaviors indicative of pain in confused elders. This checklist identifies several behaviors that are congruent with those noted by other researchers. These include: moaning, outgoing, quiet, agitated, cheerful, withdrawn, mute, verbally abusive, cries easily, refuses food, aggressive, noisy breathing, friendly, rocking, disjointed verbalization, involved, eats well, describes pain, calling out, and picking. The lack of testing for reliability, validity, or method of scoring limits use of the instrument for research. However, the checklist could provide important clinical information for assessing pain-related behaviors in long-term care facilities. In a recent study of nursing home residents who had daily pain for at least 3 months, patients were asked to identify behaviors that they engage in when they experience pain (Weiner et al, 1999). These selfreported behaviors were compared with behaviors identified by nursing and family caregivers. Of the pain behaviors endorsed by at least half of each of the three groups (residents, nurses, and family caregivers), eight behaviors had a substantial test-retest agreement (kappa ⬎ 0.6). These included: using mechanical help (cane, walker, grabbing onto furniture); moving extremely slowly; taking or asking for medication; lying down; appearing upset or sad; sighing/moaning; having difficulty getting up after lying down or sitting; and asking someone to do something to help the pain. These behaviors identify the effect of pain on function and the limitation or modification of function that is
used by residents to manage pain. Further development of this instrument is being conducted. Nonverbal cognitively impaired residents who may communicate pain through behaviors were not included in the above scales. Although the scales include many useful observational behaviors that may signify pain (vocalizations or crying out, facial expressions of grimacing or wincing, wrinkling of the forehead in response to movement, and increased restlessness, rocking, rubbing, or guarding of a body part), cognitively impaired patients may also show increased irritability or aggressive behaviors, increased resistance to any personal care that requires movement, changes in appetite or sleep patterns, or social withdrawal (Ferrell, Ferrell, & Osterweil, 1990; Parke, 1992; Herr & Mobily, 1991; Marzinski, 1991; Ryden & Feldt, 1992; Sengstaken & King, 1993; Weiner, Peterson, & Keefe, 1999). These behaviors could also be attributed to factors other than pain, which complicates the use of these items in pain assessment tools. In addition, variability of nonverbal pain-related behavior in different patients raises questions about whether reliable assessment of pain is possible for this population (Marzinski, 1991).
CHECKLIST OF NONVERBAL PAIN INDICATORS In response to the difficulties in identifying a reliable and valid instrument for measuring pain in cognitively impaired elders, the Checklist of Nonverbal Pain Behaviors was developed. This instrument was piloted in a study that examined the treatment of pain in cognitively impaired compared with cognitively intact older adults after surgery for hip fracture (Feldt, 1996; Feldt et al, 1998). Tool Development and Initial Testing. The Checklist of Nonverbal Pain Indicators (CNPI) instrument was initially developed because of concerns that some of the cognitively impaired patients would be unable to use the scaled instrument or respond reliably to the yes/no questions about pain after hip fracture surgery. To provide some estimation of pain, it was necessary to develop a tool that would measure pain behaviors. Modifications were made to the UAB-PBS tool to eliminate items that required ambulation, an item that evaluated standing posture, the item that required a ranking of number of hours spent in bed because of pain, and the item on medicationseeking behavior (Richards et al, 1982). In addition, restlessness was redefined as “constant or intermittent shifting of position, rocking, intermittent or constant hand motions, or inability to keep still” to allow for
Checklist of Nonverbal Pain Indicators
nonambulatory elders. An item, “vocal complaints,” was added to the instrument, based on Raway’s (1994) experience with pain-related verbalizations in cognitively impaired patients. This revised tool was called the CNPI. The CNPI has good face validity based on literature regarding pain behaviors in demented elders (Marzinski, 1991; Raway, 1994; Sengstaken et al, 1993). The modified scale includes those behaviors most frequently cited by other researchers: nonverbal vocalizations (defined as sighs, gasps, moans, groans, cries), facial grimacing or wincing (defined as furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop, distorted expression), bracing (defined as clutching or holding onto furniture or equipment or affected area during movement), rubbing (massaging affected area), restlessness (defined as constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still), and vocal complaints (defined as words expressing discomfort or pain, “ouch,” “that hurts”; cursing during movement; and exclamations of protest “stop,” “that’s enough”). To retain construct validity, items potentially related to disease states or problems other than pain (such as appetite changes), were not added to the instrument, although observation for these issues can be an important part of assessing pain for this population. Two raters (both gerontological nurse practitioners with Master’s degrees) simultaneously observed in 12 of the initial patients enrolled in the study (13.6% of the total sample) to establish interrater reliability. These observations took place in the patient’s hospital room with observations during rest (lying in bed) and during movement (a transfer from bed to chair conducted with the assist of nursing staff). Interrater reliability for the CNPI showed 93% agreement on the dichotomous checklist items. The Kappa statistic was 0.625 to 0.819 (P ⫽ .019 to .0057) for the behaviors observed. However, prevalence attenuation was a problem for the dichotomous (present/absent) items of the tool. Frequencies for many of the behaviors were fairly low. Bracing was not observed at rest on any of the 12 joint observations. Two of the tool behaviors, restlessness and rubbing, were not seen at any of the joint observations either at rest or with movement.
METHODS Design. A prospective comparative survey design was used for the study on older adults with hip fractures. Patients who had undergone surgical repair of a hip fracture were interviewed in the hospital on the third
17
postoperative day. The interview included assessment of pain using the Ferrell Pain Experience Interview, a rating of pain severity using the VDS, and an assessment of cognitive status using the Mini-Mental State Exam (MMSE). Data regarding pain treatment and pain report from the hospital interview have been reported elsewhere (Feldt et al, 1998). Setting and patients. The study was approved by human subjects committees at each of three Midwestern urban hospitals. Between the months of February and October, 1995, a convenience sample of 88 hip fracture patients were enrolled in the study and interviewed in the hospital. Patients were all English speaking, predominately women (86%), and aged 65 years or older (range, 65 to 101; m ⫽ 83.2 yrs, SD ⫽ 7.7). Cognitive impairment was defined as a score of 23 points or less on the Folstein MMSE. There were 53 cognitively impaired patients and 35 cognitively intact patients enrolled. The mean MMSE for the group as a whole was 18.1 of 30; impaired patients MMSE mean was 12.2 (SD ⫽ 8.0) and intact patients MMSE mean was 27.2 (SD ⫽ 1.9). At the end of the hospital interview, patients were observed for nonverbal signs of pain behavior at rest using the CNPI. Patients were also observed for nonverbal signs of pain during movement that was operationalized as a simple transfer by the nursing staff (from bed to chair or chair to bed). Of the total hospitalized sample of 88 patients, observations for nonverbal signs of pain at rest using the CNPI were completed on 87 of the patients. One patient in the intact group was not observed because of an interruption by therapy services. An additional eight patients (5 impaired and 3 intact) were not observed for nonverbal signs of pain during movement because they were up in a chair and there were no immediate plans by nursing staff to transfer the patient back to the bed.
RESULTS CNPI observations for the sample as a whole. The research question sought to determine if there were differences in observed pain behaviors for cognitively intact older adults compared with cognitively impaired hospitalized older adults. There were no significant differences between the two groups with regard to individual pain behaviors observed, although patients in the intact group showed fewer nonverbal indications of pain at rest and with movement than did impaired patients (see Table 1). The patients in the intact group were noted to have received significantly higher amounts of pain medication when compared with the impaired group (Feldt et al, 1998).
18
Karen S. Feldt
TABLE 1. Nonverbal Pain Indicators in Hospitalized Patients IMPAIRED
Nonverbal Behavior Vocalizations Grimaces Bracing Rubbing Restlessness Verbal complaint
INTACT
TOTAL
AT REST n ⴝ 49 % (n)
WITH MOVEMENT n ⴝ 44 % (n)
AT REST n ⴝ 34 % (n)
WITH MOVEMENT n ⴝ 31 % (n)
AT REST n ⴝ 83 % (n)
12.2 (6) 30.6 (15) 6.1 (3) 8.2 (4) 20.4 (10) 12.2 (6)
36.4 (16) 47.7 (21) 18.2 (8) — (0) 2.3 (1) 36.4 (16)
5.9 (2) 20.6 (7) 5.9 (2) 8.8 (3) 5.9 (2) 5.9 (2)
19.4 (6) 38.7 (12) 16.1 (5) — (0) — (0) 22.6 (7)
9.6 (8) 26.5 (22) 6.0 (5) 8.4 (7) 14.5 (12) 9.6 (8)
WITH MOVEMENT n ⴝ 75 % (n) 29.3 (22) 44.0 (33) 17.3 (13) — (0) 1.3 (1) 30.7 (23)
Frequency of behavior at rest.
Total CNPI score.
The most commonly observed behavior at rest was facial grimaces, which were observed in 15 (30.6%) of the impaired patients and 7 (20.6%) of the intact patients. For impaired patients, the second most frequent behavior at rest was restlessness, which was observed in 20.4% (n ⫽ 10) of the patients. In general, these postoperative patients at rest were very still and the frequency of pain behaviors on this instrument was very low. The stillness and lack of mobility after surgery was likely a pain behavior in itself, to guard against the pain experienced with movement.
A summed score of the number of nonverbal indicators observed at rest and with movement was calculated for each patient. The impaired and intact groups did not differ with regard to the total number of nonverbal indicators observed at rest, with both groups having a very low frequency of nonverbal indicators at rest (mean ⫽ 0.89, SD ⫽ 1.1 for the impaired group, mean ⫽ 0.53, SD ⫽ 1.1 for the intact group). There were significantly more nonverbal indicators of pain observed with movement for the cognitively impaired group than for the cognitively intact group, although overall frequency of observed behavior was still very low (impaired: mean ⫽ 1.56, SD ⫽ 1.4, intact mean ⫽ 0.94, SD ⫽ 1.1, t ⫽ 2.1, df ⫽ 71, P ⫽ .04). Observations for pain were performed at the time of the interview, which was conducted at approximately day three postoperatively (mean ⫽ 2.9, SD ⫽ .88). Because there was some variation from the time of surgery to the time of the observation, the sample as a whole was divided into two groups, those who were observed within 60 hours (⬍2.5 days) postoperatively, and those who were observed after 60 hours postoperatively. Of the 26 patients (14 impaired and 12 intact) observed within 60 hours postoperatively, the impaired group had significantly more nonverbal indicators of pain observed (impaired: mean ⫽ 1.64, SD ⫽ 1.3, intact: mean ⫽ .66, SD ⫽ .78, t ⫽ 2.2, df ⫽ 24, P ⫽ .03). Observation during rest did not differ significantly for the groups within 60 hours postoperatively. Of the 47 patients (27 cognitively impaired and 20 intact) that were observed after 60 hours postoperatively, the CNPI at rest and with movement did not differ significantly between groups.
Behavior during movement. During movement, the most frequently observed behaviors for cognitively impaired patients in descending order were grimacing (47.7%, n ⫽ 12), verbal complaints (eg, “ouch,” “that hurts,” and words of protest “stop”) (36.4%, n ⫽ 16), nonverbal vocalizations (36.4%, n ⫽ 16), and bracing (18.2%, n ⫽ 8). Although both of the verbal complaints and nonverbal vocalizations were seen more frequently in impaired patients than intact patients, this did not reach statistical significance. During movement, the most frequently observed behaviors for intact patients in descending order were grimacing (38.7%, n ⫽ 12), verbal complaints (22.6%, n ⫽ 7), nonverbal vocalizations (19.4%, n ⫽ 6), and bracing (16.1%, n ⫽ 5). The CNPI indicators were more commonly observed with movement rather than while the patient was resting. In fact, slightly over half of the sample (56%) showed no nonverbal indications of pain at rest. However, nearly two thirds (62%) of the patients showed nonverbal signs of pain when observed during movement.
Checklist of Nonverbal Pain Indicators
Measures of internal consistency. To measure internal consistency, the Kuder-Richardson 20 (KR-20, an alpha measure for dichotomous items) was performed. The KR-20 is the most useful reliability coefficient for dichotomous items because it makes no special assumptions regarding the distribution of items (SPSS Base System Syntax Reference Guide, 1997). The alpha coefficient for the CNPI at rest was .54 (95% confidence interval [CI] ⫽ .38 to .68). The alpha coefficient for the CNPI with movement was .64 (95% CI ⫽ .49 to .75). The low number of items in the scale may partially account for these modest alpha coefficients. As the number of items on a scale increases, the average correlation among the items increase and the alpha takes on a larger value.
COMPARISON WITH OTHER PAIN ASSESSMENT INSTRUMENTS The scores on the CNPI were compared with pain intensity report (VDS) scores: ranked no pain ⫽ 0; slight pain ⫽ 1, and so forth, to pain as bad as it could be ⫽ 6, for those patients who were able to give a severity ranking of their pain. Sixty-four patients who had CNPI observations also had responses to the VDS. The summed score of observed pain at rest and the summed score of observed pain with movement were significantly correlated with the VDS score for the sample as a whole for this acute postoperative population (CNPI at rest with VDS, Spearman correlation rs ⫽ .372, P ⫽ .001; CNPI with movement with VDS, Spearman correlation rs ⫽ .428, P ⬍ .0001). When the observed pain behaviors were correlated for each of the groups separately, the intact group (n ⫽ 32) showed significant correlations with the VDS both at rest and with movement (CNPI at rest with VDS, rs ⫽ .50, P ⫽ .003; CNPI with movement with VDS, rs ⫽ .385, P ⫽ .032), but the impaired group (n ⫽ 32) CNPI score was significantly correlated with the VDS with movement only (CNPI at rest with VDS, rs ⫽ .299, P ⫽ .076; CNPI with movement with VDS, rs ⫽ .4629, P ⫽ .009).
DISCUSSION Nurses in both acute and long-term care settings have indicated a need for an instrument that assesses pain in cognitively impaired elders. The CNPI proved to be an initially reliable and simple tool to measure pain behaviors in postoperative elders. The low frequencies of observed behaviors at rest indicate that the tool is less useful during rest and may be more useful for observing activities such as transfers, standing, or ambulation during physical therapy.
19
Although the impaired and intact groups did not differ with regard to the total number of nonverbal indicators observed at rest, there were significantly more nonverbal indicators of pain observed with movement for the cognitively impaired group than for the cognitively intact group. This finding indicates that, while at rest, impaired and intact patients appear fairly comfortable and, unless asked about pain or discomfort while moving, would give the appearance that they are not in need of medication. Nursing staff must be made aware that impaired patients may forget the painful areas while at rest and be less likely to request pain medication. However, movement provides an instant and, perhaps surprising, reminder that they are experiencing pain. Cognitively impaired patients who are undertreated for pain may become reluctant to move, increasing their risk for postoperative pneumonia and skin breakdown and slowing their progress in rehabilitative therapies. During movement, cognitively impaired patients show higher frequencies than intact patients with regard to vocalizations, grimaces, and verbal complaints, although none of these individual behaviors were statistically significantly higher. Only one other study was found that had examined nonverbal pain behaviors in hospitalized postoperative cognitively impaired elders (Raway, 1994). That study reported much higher frequencies of pain behaviors (46% to 87%) than those noted in the present study. This may be related to the fact that patients in that study were observed during transfers and were videotaped, allowing careful review of observation over time, instead of the single observation conducted in this study. Raway noted that confused patients showed guarding of the leg on the affected side significantly less frequently than intact patients, but showed grunting and pain-related verbalizations significantly more frequently. Unlike the present study in which both the impaired and the intact groups were observed to have pain-related verbalizations, Raway reported those verbalizations as almost exclusively observed in the confused group (only one intact patient in her study had a pain-related verbalization). Cognitively impaired patients observed at rest may give misleading cues to staff with regard to pain. Bell (1997) examined charts of 36 elderly postoperative hip fracture patients and found no significant differences in the number of times pain was assessed and documented for cognitively impaired versus cognitively intact patients, but did find that the impaired group had pain described more often in nonverbal terms with a descriptive statement rather than a standardized score, indicating that nursing observations are an important part of assessment of pain for cogni-
20
Karen S. Feldt
tively impaired patients who are less capable of completing a scaled tool. Nurses need to be attentive to pain-related behaviors during transfers and patient care activities because they provide good indicators of the patients’ discomfort. As physical care activities become increasingly delegated to nonlicensed staff, nurses may be less available to assess elderly patients for these more subtle cues of discomfort.
LIMITATIONS AND RECOMMENDATIONS FOR FURTHER RESEARCH The development and pilot testing of this tool was a very small part of a larger study. The small number of interrater observations severely limit broad conclusions about reliability. No retest reliability was con-
REFERENCES Alzheimer’s Disease Education and Referral (ADEAR) Center. (1998). Progress report on Alzheimer’s disease (p. 2). Silver Spring, MD: Author. American Geriatrics Society Panel on Chronic Pain in Older Persons. (1998). The management of chronic pain in older persons. Journal of the American Geriatrics Society, 46, 635-651. Baker, A., Bowring, L., Brignell, A., & Kafford, D. (1996). Chronic pain management in cognitively impaired patients: A preliminary research project. Perspectives, 20, 4-8. Bell, M.L. (1997). Postoperative pain management for the cognitively impaired older adult. Seminars in Perioperative Nursing, 6, 37-41. Dirks, J.F., Wunder, J., Kinsman, R., McElhinny, J., & Jones, N.F. (1993). A pain rating scale and a pain behavior checklist for clinical use: Development, norms, and the consistency score. Psychotherapeutics and Psychosomatics, 59, 41-49. Ekman, P., & Friesen, W.V. (1978). Manual of the Facial Action Coding System, Palo Alto, CA: Consulting Psychologists Press. Feldt, K.S. Treatment of pain in cognitively impaired versus cognitively intact post hip fractured elders. (Doctoral dissertation, University of Minnesota, 1996). Dissertation Abstracts International, 57-09B, 5574. Feldt, K.S., Ryden, M.B., & Miles, S. (1998). Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip fracture. Journal of the American Geriatrics Society, 46, 1079-1085. Ferrell, B.A., Ferrell, B.R., & Osterweil, D. (1990). Pain in the nursing home. Journal of the American Geriatrics Society, 38, 409-414. Ferrell, B.A., Ferrell, B.R., & Rivera, L. (1995). Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management, 10, (8), 591-598. Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). ‘Mini-mental state’. A practical method for grading the cog-
ducted on the instrument because of the acute postoperative fluctuating nature of pain for these patients. The tool needs testing on a larger population and would benefit from testing on populations with chronic as well as acute pain. Consideration should be given to adding items that may improve the internal consistency of the tool. Comparisons with other pain measures should be further pursued, including measures such as the visual analogue scale and the faces scaled recommended by the American Geriatrics Society Chronic Pain Guidelines (American Geriatrics Society Panel on Chronic Pain in Older Persons, 1998). The tool should also be tested for use with cognitively impaired residents in long-term care facilities in conjunction with other observations (sleep and appetite changes, aggressive behavior during care) that may be indicative of pain.
nitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Herr, K.A., & Mobily, P.R. (1991). Complexities of pain assessment in the elderly. Journal of Gerontological Nursing, 17, 12-18. Herr, K.A., & Mobily, P.R. (1993). Comparison of selected pain assessment tools for use with the elderly. Applied Nursing Research, 6, 39-46. Hurley, A.C., Volicer, B.J., Hanrahan, P.A., Houde, S., & Volicer, L. (1992). Assessment of discomfort in advanced Alzheimer’s patients. Research in Nursing & Health, 15 (5), 369-377. Mostofsky, D.I., & Lomranz, J. (1997). The psychology of pain and suffering. In D.I. Mostofsky, & J. Lomranz (Eds.), Handbook of Pain and Aging (p. 8). New York: Plenum Publishers. Marzinski, L.R. (1991). The tragedy of dementia: Clinically assessing pain in the confused nonverbal elderly. Journal of Gerontological Nursing, 17, 25-28. Melzack, R. (1975). The McGill pain questionnaire: Major properties and scoring methods. Pain, 1, 277-299. Miller, J., Neelon, V., Dalton, J., Ng’andu, N., Bailey, D., Jr., Layman, E., Hosfeld, A. (1996). The assessment of discomfort in elderly confused patients: A preliminary study. Journal of Neuroscience Nursing, 28, 175-182. Parke, B. (1992). Pain in the cognitively impaired elderly. Canadian Nurse, 88, 17-20. Parmelee, P.A., Smith, B., & Katz, I.R. (1993). Pain complaints and cognitive status among elderly institution residents. Journal of the American Geriatrics Society, 41, 517-522. Raway, B. (1994). Pain behaviors and confusion in elderly patients with hip fracture. (Doctoral dissertation, Catholic University of America, 1994). Dissertation Abstracts International, 55, 02B. (University Microfilms No. AAI94-18593) Richards, J.S., Nepomuceno, C., Riles, M., & Suer, Z. (1982). Assessing pain behavior: The UAB pain behavior scale. Pain, 14, 393-398.
Checklist of Nonverbal Pain Indicators
Ryden, M., & Feldt, K. (1992). Goal directed care: Caring for aggressive nursing home residents with dementia. Journal of Gerontological Nursing, 18 (11), 35-42. Sengstaken, E.A., & King, S.A. (1993). The problems of pain and its detection among geriatric nursing home residents. Journal of the American Geriatrics Society, 41, 541-544. Simons, W., Malabar, R. (1995). Assessing pain in elderly patients who cannot respond verbally. Journal of Advanced Nursing, 22, 663-669.
21
SPSS Base System Syntax Reference Guide (Release 8.0). (1997). Chicago, IL: SPSS, Inc. Weiner, D.K., Ladd, K.E., Pieper, C.F., & Keefe, F.J. (1995). Pain in the nursing home: Resident versus staff perceptions. Journal of the American Geriatrics Society, 43, SA2. Weiner, D.K., Peterson, B., & Keefe, E.J. (1999). Chronic pain-associated behaviors in the nursing home: Resident versus caregiver perceptions. Pain, 80, 577588.