Pain assessment - cognitive impairment

Scottish Palliative Care Guidelines
Healthcare Improvement Scotland

Introduction

Aims

To obtain a clear description of the patient’s pain and if possible to identify the cause or causes of the pain in order to develop a pain management plan in conjunction with the patient and family.

Pain is often poorly assessed and inadequately managed in people with dementia, learning disabilities or a stroke– seek specialist advice.

 

Actions

If the pain is severe and overwhelming immediate treatment may be required before further assessment. Adjust the dose according to current analgesic use and seek specialist advice.

 

Assessment

Assess whether the patient has capacity to be involved in decisions around assessment and treatment of pain. If the patient lacks capacity, the power of attorney must be involved where possible. Treatment under the Adults with Incapacity Act is likely to be required.

Involve the patient as much as possible in the assessment of their pain. Use a team approach:

  • Is there a carer, friend or staff member who knows the patient and can help with the assessment?
  • How is the patient usually when comfortable?
  • How does the patient usually express themselves when in pain?
  • Assess the impact of the pain on the patient and family.
  • Determine if the patient has had a previous problem, for example arthritis.
  • Ascertain previous drug and non-drug history, including effectiveness and side effects. 

Enhance verbal and nonverbal communication

  • Allow plenty of time.
  • Use sensory aids where needed – hearing aids, glasses, signing, visual tools.
  • Minimise distractions – noise, bright lights, activity.
  • Use the person’s preferred name at the start of each question to hold their attention and focus.
  • Use simple language and short sentences.
  • Repeat questions and check understanding.
  • Consider using pictures – body maps, photographs, illustrated books.

Consider behavioural assessment

  • Autonomic changes.
  • Facial expressions.
  • Body movements.
  • Verbalisations or vocalisations.
  • Interpersonal interactions.
  • Activity patterns.

Is pain the main cause of the patient’s distress? Exclude other problems

  • Fear, anxiety, disorientation or isolation.
  • Other physical symptoms for example constipation, urinary tract infection.
  • Delirium or chronic confusion.
  • Stress-related behaviours.

Record your assessment

  • Consider using a behavioural assessment tool, for example DisDAT, Abbey, Doloplus.

 

Management

  • Make a diagnosis and explain this to the patient and family.
  • Different pains may require different interventions. The management of distress-related behaviour is important – refer to Pain management guideline.
  • Decide if the Adults with Incapacity Act is needed to cover treatment.
  • Discuss management with the patient and carers. A trial of analgesics, non-pharmacological treatments or both may be appropriate. If opioids are required, discuss any concerns about their use.
  • Agree goals for pain relief and a monitoring plan.
  • If pain has not settled within 24 hours seek specialist advice.
  • Agree arrangements for regular review.

 

Practice points

  • Consider having a pain chart at the patient’s home.
  • Provide written explanations about opioids.

Resources