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Thomas Hadjistavropoulos
http://dx.doi.org/10.1037/14459-016
APA Handbook of Clinical Geropsychology: Vol. 2. Assessment, Treatment, and Issues of Later Life,
P. A. Lichtenberg and B. T. Mast (Editors-in-Chief)
Copyright 2015 by the American Psychological Association. All rights reserved.
413
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Exhibit 16.1
Central Pain Assessment Domains
Assessment
A detailed international interdisciplinary statement
on pain assessment in older people (Hadjistavropoulos et al., 2007) outlines the benefits of intedisciplinarity and discusses the importance of considering
the effects of biological factors, disease, disuse,
and environmental factors affecting functional outcomes. A physical evaluation by a qualified health
professional (e.g., a physician) is of utmost importance. Under ideal circumstances, a functional
evaluation also will be conducted (usually by a
physiotherapist), as will an assessment of emotional
functioning (e.g., by a psychologist). Moreover, a
comprehensive pain assessment will include a
detailed history, which can be the most important
initial source of information about the pain and its
causes. The history will establish a time frame for
the pain, antecedents and consequences, reactions
of others, comorbidities, treatments, expectations
about outcomes, lifestyle factors, social history,
coping efforts, psychological concerns, substance
use, and other related areas (see Exhibit 16.1). Interviews with family members are helpful (e.g., family
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EXHIBIT 16.2
Guidelines for Assessing Pain With Seniors Who Have
Cognitive Impairments
General guidelines
1. Determine whether Mini-Mental Status Examination scores are available or can be obtained. This would facilitate
determination of patient ability to provide valid self-report.
2. Always attempt self-report regardless of level of cognitive functioning.
3. Baseline scores should be collected for each individual (ideally on a regular basis, which would allow for the examination of
unusual changes from the persons typical pattern of scores).
4. Patient history and physical examination results should be taken into consideration.
5. If assessments are to be repeated over time, assessment conditions should be kept constant (e.g., use the same assessment
tool, use the same assessor where possible and conduct pain assessment during similar situations).
6. Pain assessment results should be used to evaluate the efficacy of pain management interventions.
7. Knowledgeable informants (e.g., caregivers) should be asked about typical pain behaviors of the individual.
8. Other aspects of the pain experience should also be evaluated including environmental factors, psychological functioning and
social environment.
Recommendations specific to self-report measures
1. Use of synonyms when asking about the pain experience (e.g., hurt, aching) will facilitate the self-report of some patients
who have limitations in ability to communicate verbally.
2. Self-report scales should be modified to account for any sensory deficits that occur with aging (e.g., poor vision, hearing
difficulties).
3. Use self-report tools that have been found to be most valid among seniors (e.g., the Numeric Rating Scales, Verbal Rating
Scales).
4. Use of horizontal visual analogue scales should be avoided as some investigators have found unusually high numbers of
unscorable responses among seniors.
Recommendations specific to observational measures
1. Examples of observational tools that have been shown to be reliable and valid for use in this population include the Pain
Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Doloplus-2. Nonetheless, clinicians
should always exercise caution when using these measures because they are relatively new and research is continuing.
2. When assessing pain in acute-care settings tools that primarily focus on evaluation of change over time should be avoided.
3. Observational assessments during movement-based tasks would be more likely to lead to the identification of underlying pain
problems than assessments during rest.
4. Some pain assessment tools, such as the PACSLAC, do not have specific cutoff scores because of recognition of tremendous
individual differences among people with severe dementia. Instead, it is recommended that pain be assessed on a regular
basis (establishing baseline scores for each patient) with the clinician observing score changes over time.
5. Examination of pain assessment scores before and after the administration of analgesics is likely to facilitate pain
assessment.
6. Some of the symptoms of delirium (which is seen frequently in long-term care) overlap with certain behavioral
manifestations of uncontrolled pain (e.g., behavioral disturbance). Clinicians assessing patients with delirium should be
aware of this. On the positive side, delirium tends to be a transient state, and pain assessment, which can be repeated or
conducted when the patient is not delirious, is more likely to lead to valid results. Note also that pain can cause delirium, and
clinicians should be astute to avoid missing pain problems among patients with delirium.
7. Observational pain assessment tools are screening instruments only and cannot be taken to represent definitive indicators
of pain. Sometimes, they may suggest the presence of pain when pain is not present, and other times they may fail to
identify pain.
Outcomes of interest
In addition to improved scores on various assessment tools, evidence of more effective pain management can be observed in
such areas as greater participation in activities, improved sleep, reduced behavioral disturbance, improved ability to ambulate,
and improved social interactions.
Note. Many of these recommendations are from Hadjistavropoulos et al. (2007) and Herr et al. (2006). Copyright
by Thomas Hadjistavropoulos. Reprinted with permission.
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FIGURE 16.1. Use of a pain diary for the Pain Assessment Checklist for Seniors With Limited Ability to
Communicate (PACSLAC). The vertical axis represents scores on the PACLAC (range 060). See Misson et al., 2011.
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In long-term care facilities, both resource limitations and inadequate staff pain education prevent
implementation of potentially beneficial protocols
for pain patients. Education gaps can be addressed
with effective pain education (e.g., Ghandehari et al.,
2013), but central management support often is
needed for the permanent implementation of effective protocols (Gagnon et al., 2013). Geropsychologists can play a key role in pain education, given the
psychological sequelae of pain as well as the psychological components of the experience itself. Proficient in behavioral assessment, psychologists can
provide appropriate pain assessment education.
With respect to intervention, much more needs to
be done to reach older people who live in remote
areas or who have limited mobility. Psychological
interventions as well as assessment can be administered effectively via the Internet but not enough evaluations of Internet-administered pain management
interventions have been conducted with older people.
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