Book Pain Older People

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CONCISE GUIDANCE TO GOOD PRACTICE

A series of evidence-based guidelines for clinical management

NU M BER 8

The assessment of pain in older people

NATIONAL GUIDELINES

Octob er 2007

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Guideline Developm ent Grou p

These guidel ines were prepared by B Col let t

FRCA, S OMahon y FRCP, P Schofield Ph D ,

SJ Closs Ph D and J Potter FRCP o n b e h a l f o f

the mu l t id isc ip l inary Gu ide l ine Deve lopment

Group convened by t he Br i t i sh Ger ia t r ics

Society and t he Br i t ish Pain Society in

con jun c t ion w i th t he Cl in i cal Standards

Depar tm ent o f the Royal Co l lege o f

Physicians.

Professor S Jos Closs Ph D (Nursing)

Chair of N ur sing Research, Uni versi ty of

Leeds, Leeds

Dr Beverly Collett FRCA (Pa in m ed ic ine)

Consu l tan t in Pa in Management andAnaesthesia, Univers i ty Hospita ls

of Leicester

Mrs Jean Giffin Patient representat ive

Mrs Joanna Gough (Adm in is t ra t ive supp or t )

Br i t ish Geriatr ics Society, London

Dr Danielle Harari (Geriatr ic medic ine)

Con sul tan t Physic ian/Senio r Lecturer,

St Thomas Hospi ta l , London

Mr Lester Jones (Physiotherapy)

Senior Lecturer, Kingston Univers i ty and

Univers i ty o f Londo n

Dr Sinead OMahony FRCP (Geriatr ic

medic ine) Senior Lecturer/ConsultantPhysic ian, L landough NHS Trust, Penarth,

South Glam organ

Dr Jonathan Potter FRCP Clin ical Director,

Cl in ical Effect iveness and Evaluat ion Unit ,

Royal Col lege of Physic ians; Con sul tan t

Acknowledgements

The Gu id e l ine Deve lopm ent Group (GDG) wou ld l i ke to t hank and

acknow ledge the supp or t rece ived f rom Jo Gough fo r h er adm in is t ra t ive

he lp in o rgan ising th e ac t iv i t ies o f th e GDG and in assist ing w i th the

dra f t in g o f the gu id ance.

The GDG are gratefu l to the Br i t ish Pain Society and the Br i t ish

Geriatr ics Society for the provis ion of fac i l i t ies for meet ings, and to

the peer reviewers who took th e t im e to p rov ide va luab le and

considered feedback.

Clinical Standards Depart m ent

The a im o f th e Cl in ica l Standards Depar tm ent o f the Royal Co l lege o f

Physic ians is to im prove pa t ien t care and hea l thcare p rov ision by

se t t ing c l in i ca l standards and m on i t o r ing t he i r u se . We have exper t ise

in t he deve lopm ent o f ev idence-based gu ide l ines and the o rgan isat ion

and repor t ing o f mu l t i cen t re compara t ive per fo rmance da ta . The

depar tm ent h as th ree core s t ra tegic ob jec t ives: to defines tandards

around the c l in ica l work o f ph ysic ians, to measureand eva lua te the

imp lementa t ion o f s tandards and i ts impac t on pa t ien t care and to

effect ively implement th ese standard s.

Our p ro gramm e invo lves co l labora t ion wi t h spec ia l i st socie t ies, pa t ien t

g roups and n a t iona l bod ies inc lud i ng : the Nat iona l Ins t i tu te fo r Hea l th

and Cl in ical Excel len ce (NICE), th e Health care Com m ission and th e

He a l t h Fo u n d a t i o n .

Con cise Guidance to Go od Practice series

The conc ise gu ide l ines in t h is ser ies a re in tend ed to in fo rm those

aspec ts o f p hysic ians c l in ica l p rac t ice wh i ch m ay be ou t side t he i r own

specia l is t area. In many instances, the guidance wi l l a lso be useful for

other c l in ic ians inc luding GPs, and other heal thcare professionals.

The gu ide l ines are designed to a l lo w c l in ic ians to m ake rap id ,

informed decis ions based wherever possib le on synthesis of the best

avai lab le ev idence and exper t consensus ga thered f rom prac t ising

cl in i c ians and serv ice users. A key feature of th e ser ies is to p rovid e

b th d t i f b t t i d h ib l t i l

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Contents

Guideline Development Group ii

Foreword 1

Methodology 2

Background 2

The challenge of impaired cognition and

communication 2

Assessment 3

Types of scales used to assess pain

Implications and implementation 4

SUMMARY OF THE GUIDELINES 5

Appendices

1 Gu i d el i n e d ev el o pm e n t p r o ce ss 7

2 A lgo r i t h m f o r a sse ssm e n t o f p ai n i n o l d e r p eo p l e 8

3 Pain m ap 9

4 Exa m p l es o f p ai n sca le s

A N u m er ic r at i ng scal e 10

B Ve r b al d e scr i p t i ve r at i n g sca l e 10C Ve rb al n u m er i ca l r at i n g sca le 11

D Pai n Th er m om et er 11

E Ab b ey Pa in Scal e 12

References 14

Foreword

Pain is so un iversal that it is essential that it is

recognised by all people working with older people.

It places a blight on daily life, limiting functional

ability and imp airing the qu ality of life. The symptom

manifests itself in m any ways, not on ly as a sensory

experience but also by causing psychological distress.

It may be difficult for some to articulate their pain,for examp le those with d ementia, some forms of

stroke or Parkinsons disease. The non -verbal

m anifestations of p ain m ust be recognised and

interpreted so th at the distress caused to th ese m ost

vulnerab le mem bers of society can be alleviated.

The Nation al Service Framework ( NSF) for Older

People placed great emphasis on t he dignity of older

people. The appropriate management of pain is

essential to en sure the dignity and well-being of older

people. This important need has been reiterated in

my review of progress with t he NSF and p lans for t he

next ph ase in A new am bit ion for old age.*

It is timely therefore that the British Pain Society has

worked with the British Geriatrics Society and the

Royal College of Physicians t o r eview th e cur rent

evidence in the literature and to produ ce sound

guidan ce to help all practitioners in assessing for the

presence of pain.

I fully com men d t he guidance presented here, and

hope that health and social practitioners will takeheed an d u tilise it in their everyday practice.

October 2007 Ian Philp

National Director for Older People,

D t t f H lth

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Methodology

The guidance has been developed in accordance with

the requ iremen ts for concise guidelines as detailed at

www.rcplondon.ac.uk/college/ceeu/conciseGuideline

DevelopmentNotes.pdfDetails are shown in Appendix 1.

Background

mu ltidimensional and m ay be described at several

levels:

sensory dimension: the intensity, location and

character of the pain sensation

affective dim ension: th e emotion al com pon ent o f

pain and how pain is perceived

imp act: the disabling effects of pain on the

persons ability to fun ction an d participate in

society.

The purpose of this guideline is to provide

professionals with a set of practical skills to assess

pain as the first step towards its effective

man agemen t. The guidance does not seek to

differentiate between acute and persistent pain as the

literature relating to pain in older people shows that

such a distinction is impractical.

For m ore detailed guidance and evaluation of th e

supp or ting literatur e, please see the full guideline.4, 5

The challenge of impaired

cognition and communication

Assessing pain becom es even m ore challenging in the

presence of severe cognitive imp airm ent,

comm un ication d ifficulties or language and cultural

barr iers. However, even in the p resence of severe

cognitive and communication impairment, many

individuals m ay have their pain assessed u sing

appropriate observational scales.

Verbal and nu m erical ratin g scales best quan tify the

intensity of pain in older p eople with n o

cognitive/comm un ication imp airment and can also

be used with ap propr iate assistance in many p atients

Pain is under-recognised and under-treated inolder people. It is a subjective, personal

experience, only known to the person who

suffers. The assessment of pain is particularly

challenging in the presence of severe cognitive

impairment, communication difficulties or

language and cultural barriers.

These guidelines set out the key components

of assessing pain in older people, together

with a variety of practical scales that may be

used with different groups, including those

with cognitive or communication impairment.

The purpose is to provide professionals with a

set of practical skills to assess pain as the first

step towards its effective management. The

guidance has implications for all healthcare

and social care staff and can be applied in all

settings, including the older persons own

home, in care homes, and in hospital.

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Scales shou ld use large clear letters/nu m bers and be

presented u nder good lighting. Once the mostappropriate scale has been chosen to suit the

ind ividual persons strengths, staff shou ld contin ue

to use this for sequential assessment in order to

observe the response to treatment .

People with very severe cognitive/com mun ication

impairm ent m ay not be able to self-report pain even

with fu ll assistance. Clinicians m ay need to rely on

behavioural responses, but these can be hard to

interpret.

Assessment

The key components of an assessment for anyone

suffering from pain are shown in Box 1.

It is particularly important to use observations for

signs of pain in older p eople with cognitive or

communication impairment (Table 1).

For an algorith m for assessm ent, see Append ix 2. For

an example of a pain map, see Appendix 3.

Table 1. Observational changes associated with pain.

Type Description

Autonom ic changes Pa l lo r, sweat ing , tachypnoea, a l te red b rea th ing pa t te rns , tachycard ia , hyper tens ion

Faci al exp ressi on s Gr im a ci ng, w i nci ng, f ro wn in g, r ap id bl in ki ng, b ro w r ai si ng, b ro w l ow er in g, ch eek rai si ng,

eyel id t igh ten ing , nose wr in k l ing , l ip corner pu l l ing , ch in r a ising , l ip pucker ing

Bo dy m o vem en ts Al tered gai t p aci ng ro ck in g h an d w ri ngi ng rep et it ive m o vem en ts i ncreased ton e

Box 1. Key components of an assessment of pain.

Direct enqu iry ab out t he presence of pai n

i nc lud ing the u se o f a l te rna t ive words to descr ibe pa in

Observation for signs of pain

espec ia l l y in o lder peop le w i th cogn i t i ve /

c om m u n i c at i o n i m p a i rm e n t

Descript ion of pain t o i n c l u d e :

sensory d im ens ion t h e n at u re o f t h e p ai n (eg sh ar p, d u l l , b u r n i n g et c)

p ai n l oca t i on an d r ad i at i o n (b y p at i en t s p o i n t i n g t o

the pa in o n th emse lves o r by us ing a pa in m ap)

i n t en si t y, u si n g a st an d ar d i sed p ai n asse ssm en t sca l e

af fec t ive d im ens ion

em o t i o n al r esp o n se t o p ai n (eg fea r, an xi et y,

depress ion)

im pac t : d isab l ing e f fec ts o f pa in a t the leve ls o f

fu n ct i o n al ac t i vi t ies (eg ac t i vi t i es o f d ai l y l i vi n g)

p ar t i ci p at i o n (eg w o rk , so ci al ac t i vi t ies, r el at i o n sh i p s)

Measurement of pain

us ing s tandardised scales in a format that is access ib le

t o t h e i n d i v i d u a l

Cause of pain

examin a t ion an d in vest iga t ion to estab l ish the cause

o f pa in

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Table 2. Types of scale for assessing pain.

Type of pain assessment Practical suggestions Comments and references

for scale selection

Self-report

High va l id i t y and re l iab i l i t y in

o l d e r p e o p le911

Can be used in m i ld /modera te

c o gn i t i v e im p a i r m e n t 9,12

Ver t ica l as opposed t o h or izon ta l

o r i e n t a t i o n m a y h e lp t o a vo id

m is in te rp re ta t ion in t he p resence o f

v isuo-spa t ia l neg lect , eg in pa t ien ts

w i t h st r o k e

High va l id i t y and re l iab i l i t y in

o l d e r p e o p le911

Older peop le w i t h m odera te to severe Pa in Thermom eter6 Easy to use

co gn i t i ve/ co m m u n i cat i o n im p ai rm en t (Ap p en d ix 4 ) Val i d i t y h as n o t b een fu l l y evalu at ed 6

Colou red Visual Anal ogue Scale7 Wel l un ders tood in ear ly and m id-stage

stage Alzhei m ers di sease8

Observati ona l p ain assessm entOl d er p eo p le w i th se ver e co gn i ti ve/ Ab b ey Pai n Sca le Sh o rt an d ea sy t o ap p ly scal e13

c o m m u n i c a t i o n im p a i r m e n t (n o si n g l e (Ap p e n d i x 4 )13,14 Requ i res mo re de ta i led eva lua t ion

recommendat ion cur ren t ly poss ib le )

Multidimensional assessment

Ol der p eo pl e w it h m i ni m al co gn it ive Br ief Pai n In ven to r y15,16 15- i tem scale assessin g: sever i ty, im pact

im p ai r m en t o n d ai l y l i vi n g, im p act o n m o o d an d

e n jo y m e n t o f l i f e

Older peop le w i th no s ign i f i can t

c o g n i t i v e / c o m m u n i c a t i o n im p a i r m e n t

and

O ld er p e o p le w i t h m i l d t o m o d e r a t e

c o g n i t i v e / c o m m u n i c a t i o n im p a i r m e n t

Num er ic g raph i c ra t ing sca le

(Append ix 4 )

Verbal rat in g scale or

num er ica l ra t ing scale (010)

(Append ix 4 )

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Recommendation Grade

1 Pain awareness C

Al l hea l thcare p ro fessiona ls shou ld be a le r t to the possib i l i t y o f pa in i n o ld er peop le , and to t he fac t tha t o ld er

peop le a re o f ten reluc tan t to acknow ledge and repor t pa in .

2 Pain enquiry C

Any hea l th assessm ent shou ld inc lud e enqu i ry about pa in , u sing a range o f a l te rna t i ve descr ip to rs

(eg sore, hu r t i ng, achin g).

3 Pain description C

Where pa in is p resen t , a de ta i led c l in ica l assessm ent o f t he m u l t i d im ensiona l aspects o f pa in shou ld be

u n d e r t a k e n i n c l u d i n g :

sensory dim ension: the na tu re , loca t ion and in tens i ty o f pa in affective dimension: t h e e m o t i o n a l c o m p o n e n t a n d r e sp o n s e t o p a in impac t : on fu nc t ion in g a t the level o f ac t iv i t ies and par t i c ipa t ion .

3.1 Pain location C

An a t t e m p t t o l o c at e p a in s h o u ld b e m a d e b y :

ask ing the pa t ien t to po in t to th e a rea on them se lves the use o f pa in m aps to de f ine th e locat ion an d the ex ten t o f pa in .

3.2 Pain intensity C

Pain assessm ent shou ld rou t in e ly inc lud e the use o f a s tandard ised in ten si ty ra t in g sca le, p re fe rab ly a

simple verbal descr iptor scale or a numer ic rat ing scale, i f the person is able to use these.

4 Communication C

Every ef fo r t shou ld be m ade to faci l i ta te comm un ica t ion par t i cu la r ly w i th those peop le w i th sensory

im pair m ents (use of hear i ng aid s, g lasses etc).

Sel f - report assessment scales should be of fered in an accessib le format to sui t the strengths of the indiv idual .

5 Assessment in people with impaired cognition/communication C

Peop le w i th m odera te to severe comm un ica t ion p rob l ems shou ld be o f fe red add i t io na l assistance wi th

se l f - repor t th rou gh th e use o f su i tab ly adapt ed sca les and fac i l i ta t ion by sk i l led p ro fessiona ls .

In peop l e w i th very severe im pa i rm ent , and in s i tua t ion s wh ere p rocedures m igh t cause pa in , an

b t i l t f i b h i i ddi t i l l i d ( T bl 1)

SUM MARY OF TH E GUIDELINES

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The prop er evaluation of pain in older people does

require staff training and the add itional tim erequired to u ndert ake a proper evaluation will

inevitably im pact on staff time in already over-

pressed services. However, if pain is sought ou t,

addressed and relieved, the lot of older people would

be greatly enh anced. Moreover, relief from the

disabling effects of pain may potentially save staff

time in o ther areas such as the p rovision of suppo rt

for basic self-care activities etc.

These basic guidelines should be a routine part of the

training and care provision of all healthcare

professionals.

References

1 National Statistics Online. Self-reported health problems: by

gender and age, 199697: social trends dataset.

www.statistics.gov.uk/StatBase/xsdataset.asp?More=Y&vlnk=

670&All=Y&B2.x=86&B2.y=13 (accessed 22 M ay 2007).

2 Helme RD, Gibson SJ. The epidemiology of pain in elderly

people. Clin Geriatr Med2001;17:41731.

3 Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing

home.J Am Ger iat r S oc 1990;38;40914.

4 British Geriatrics Society, 2007. www.bgs.org.uk/Publications/

Clinical%20Guidelines/clinical_guidelines_index.htm

5 Bri tish Pain Society, 2007. www.britishpainsociety.org

6 AGS Panel on Persistent Pain in Older Persons. The

man agement of persistent pain in older person s.J Am

Geriatr Soc 2002;50:S20524.

7 Scherder EJA, Bouma A. Visual analogue scales for pain

assessmen t in Alzheimers disease. Gerontology

2000;46:4753.

8 Hadjistavropoulos T, Herr K, Turk D et al. An

interdisciplinary expert consensus statemen t on assessmentof pain in older person s. Clin J Pain 2007;23:S143.

9 Chibnall JT, Tait RC. Pain assessment in cognitively impaired

and u nim paired older adults: a com parison of four scales.

Pain 2001;92:17386.

10 Herr KA, Spratt K, Mobily PR, Richardson G. Pain intensity

assessm ent in older adu lts. Clin J Pain 2004;20:20719.

11 Kaasalainen S, Crook J. An exploration of seniors ability to

report pain. Clin Nurs Res 2004;13:199215.

12 Stolee P, Hillier L, Esbaugh J et al. Instruments for the

assessm ent of p ain in older person s with cognitiveimpairment. J Am Ger iat r S oc 2005;53:31926.

13 Abbey J, Piller N, De Bellis A et al. The Abbey pain scale:

a 1-minu te num erical indicator for people with end-stage

dementia.In t J Pallia t N urs 2004;10:613.

14 Abbey J, De Bellis A, Piller N et al. Abbey pain scale. In: The

Royal Austr alian Co llege of Gen eral Pr actition ers Silver

Book Nation al Taskforce.M edical ca re of older p erson s in

residential aged care facilities.

www.racgp.org.au/silverbookonline/4-6.asp

15 Keller S, Bann CM, Dodd SL et al. Validity of th e brief paininventor y for use in docum enting the outcom es of patients

with noncancer pain. Clin J Pain 2004;20:30918.

16 Pain Research Group, University of Wisconsin-Madison.

Brief pain inventory. In: The Royal Australian College of

Gener al Practition ers Silver Book Nation al Taskforce.

M edi cal care of older p erson s in resid en tial aged care faci lit ies.

/ il b k li /4 7

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Appendix 1. Guideline development process

The fu l l gu ide l ines4, 5 have been d eveloped in accordance wi th the p r i nc ip les la id dow n b y the Appra isa l o f Gu ide l in es fo r

Research and Eva lua t ion co l labora t ion . 17

Scope and purpose

Overa l l ob jec t ive o f To p rov ide sim p le and p ragmat ic adv ice fo r c l in ic ians w i th regard to screen in g and

t h e gu id el in es assessm en t o f p ai n in o l d er ad u l t s

Th e p a t i e n t g r o u p c o ve r ed A l l o l d e r p e o p le co m in g i n t o c o n t a c t w i t h h e a l t h ca r e p r o f essi o n a l s

Target aud ience Al l hea l thcare p ro fessiona ls , inc lud i ng those in p r im ary care, hosp i ta ls and care hom e se t t ingsCl in i ca l ar ea s co ver ed Th e assessm e n t of p ai n

Stakeholder involvement

The Gu ide l in e A m u l t id iscip l in ary Gu id e l ine Deve lopm ent Group (GDG) was convened by the Br i t i sh

D e ve l op m e n t Gr o u p Ge r ia t ri cs So ci e ty an d t h e Br i t i sh P ai n So ci e ty i n co n j u n ct i o n w i t h t h e Cl i n i ca l St a n d ar d s

Depar tm ent o f th e Roya l Co l lege o f Physic ians, w i t h represen ta t ives f rom:

n u r si n g

p ai n m e di ci ne

p at ien t gr ou p ge ri at r ic m e d i ci n e

p h ysi o th e ra py.

Fu n d in g Br i t i sh Pain So ciet y

Br i t i sh Ger iatr ics Society

Co n fl i ct s o f in t erest No n e d eclared

Rigour of development

Evidence gather ing Search strategy: Re levan t fu l l len g th a r t i c les were iden t i f ied us ing e lect ron i c searches in M ed l ine ,PubMed, OVID Medline, CINAHL, EMBASE, AMED, SciSearch & Cochrane. Evidence-based reviews

were i den t i f i ed f r om OVID, Cochran e, ACP Jou rnal Clu b, DARE and CCTR. Psychological and socia l

science l i t eratu re was sought th rou gh PsychINFO and ASSIA. Conf erence pap ers were searched via

IASP, the Br i t ish Pain Society and the European Pain Society. Relevant publ icat ions were included.

Inclusion criteria: Papers descr ib in g or ig inal stud ies, evidence-based guid el ines or system at ic reviews

Stud ies inc lud i ng o lder peop le (65 and over ) w i t h o r w i t hou t cogn i t i ve impa i rm ent

Pa in was de f ined as bo th acu te and pers isten t , accord in g to th e In te rna t ion a l Assoc ia t ion fo r t he

Stud y of Pain (IASP) def in i t ions, but the fo cus was on persistent pain (www.iasp-pain.org/ terms-p.html ).Studies including pain assessment

Papers pub l ished a f te r 1990

Exclu sion criteria :Paed ia t r ic l i te ra tu re

Search terms:Com bin a t ion o f search te rm s used in c luded:

pa in o r d iscomfor t o r ag i ta t ion and assessm ent o r sca les o r measurement o r behav iou ra l

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8

The

asses

sm

entof

pain

in

older

people

Observe for potential indicators of pain: f a ci a l e xp r essi o n s v er b a l i sa t i o n s/ v o ca l i sa t i o n s b od y m ovem e nt s a l t e re d i n t e r p e r so n a l i n t e r a ct i o n s c h a n ge s i n a c t i vi t y p a t t er n s o r r o u t i n e s m e n t a l st a tu s c h an g es p h y si o l o g i ca l c h a n ge s.

N o i m m e d i a t e t r e at m e n t n e e d e d .

Co n t i n u e t o m o n i t o r .

Ask wh ether the p erson h as pa in a t r es t o r on m ovemen t . Use a l te rna t ivedescr iptors such as sore, hur t ing or aching.

Observe fo r po ten t ia l i nd ica to rs o f pa in .

Is pain reported/apparent?

Assess pain int ens i ty u s ing a sim ple scale such as averba l r a t ing scale o r n um er ic ra t ing sca le .

Ask the person to show wh ere the i r pa in is(p o i n t i n g o r p a i n m a p ).

Is pain present?

Ta k e a d et a i l ed p a i n h i st o r y . Ex am i n e t h e p at i en t . Tr ea t c au se . Tr e at sy m p t o m s i f c au s e i s n o t i d e n t i f i a b l e . Co n si d e r r ef er r al .

T rea t mo rb id i t y .

Do potential painindicators persist?

N o i m m e d i a t e a ct i o nneeded.

Co n t i n u e t o m o n i t o r .

N o i m m e d i a t e a ct i o n n e e d e d .

Co n t i n u e t o m o n i t o r a n dt rea t as requ i red .

N o i m m e d i at e

ac t ion needed.

Cont in ue tom o n i t o r .

Re l u c t an t t o c o m p l a i n o fp a i n . Evidence of morbidity that may

be causing pain?

Can t he p erson com m un icate successfu l ly?*

Appendix 2. Algorithm for the assessment of pain in older people

*If there is doubt ab out ability to com mu nicate, assess and facilitate as indicated in Recom m endation s 4 and 5 o f the Guidelines.

Yes

Yes

Yes

Yes

N o

Yes

N o

N o

Yes

N o

N o

No

N o

Cons ider empir ical analges ict r ia l o r o ther pa in - re l iev ingi n t e r v e n t i o n .

Mon i to r r esponse care fu l l y .

A t t em p t t o i n t e r p r et m e a n i n g o f b e h a vi o u rw i th he lp o f ca reg ivers fami l ia r w i th theperson . Provide in d iv idu a l ised care .

Ensure bas ic com for t n eeds are m et .

Prov ide reassurance i f behav iour suggestsfear.

Cons ider prov id ing analges ics pr ior tom o v e m e n t .

Do potential pain indicators persist?

Yes

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Appendix 3. Pain m ap

Where is your pain? Please mark where you feel pain on the drawings below.

Right Left Left Right

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Most severe

pain imaginable

No pain at all

Say to the patient:

This is a scale to m easure p ain.

0 ind ica tes no pa in a t a l l .

The num bers on th e sca le ind ica te inc reasing leve ls o f pa in ,

up to 10 w h ich is the mo st severe pa in im ag inab le . Which po in t on th e sca le show s how m uch pa in you h ave today?

To the administrator:

In your op in ion was the person ab le to u nders tand th is sca le?

Yes N o

Co m m e n t :

10

9

8

7

6

5

4

3

2

1

0

Reproduced with permission from Professor Lynne Turner-Stokes, Concise Guidance Series Editor, Royal Col lege of Physicians, London.

Append ix 4. Examples of pain scales

4A Numeric rating scale

The Numeric Graphic Rating Scale (NGRS)

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On a scale of 0 to 10, please tell me how severe your pain is today.

4C Verbal numerical rating scale

4D Pain Thermometer

Pain as bad as it could be

Extreme pain

Severe pain

Moderate pain

Mild pain

Slight pain

No pain

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4E Abbey Pain Scale

Use of the Abbey Pain Scale

The Abbey Pain Scale is best u sed as par t o f an overa l l pa in m anagem ent p lan . Som e pa in m anagem ent s t ra tegies can

be foun d in the w ebsi te c i ted in Ref 19 .

Object ive

The Pain Scale is an instrument designed to assist in the assessment of pain in residents who are unable to c lear lyar t i cu la te the i r needs.

Ongoin g assessm ent

The Scale does not d i f ferent iate between distress and pain, so measur ing the ef fect iveness of pain-re l iev ing

intervent ions is essent ia l .

Recent work by the Austra l ian Pain Society 20 recom m ends tha t th e Abbey Pain Scale be u sed as a m ovement -based

assessm ent . The s ta f f record ing th e sca le shou ld there fo re observe th e residen t wh i le th ey a re be ing m oved, eg dur in gpressure area care, whi l e sho weri ng etc.

Com ple te the sca le im m edia te ly fo l lowin g the p rocedure and record the resu l ts in th e residen t s no tes . Inc lude th e

t im e o f com ple t ion o f th e sca le, the score , sta f f m em ber s signa ture and ac t ion ( i f any) taken in response to resu l ts o f

the assessm ent , eg pa in m ed ica t ion o r o ther therap ies.

A second eva lua t ion shou ld be condu c ted one hou r a f te r any in te rven t ion taken in respon se to th e f i rs t assessm ent , to

de te rm ine th e e f fect iveness o f any pa in - rel iev ing in t e rven t ion .

I f , at th is assessm ent, th e score on th e pain scale is th e sam e, or wor se, consider fu r th er int ervent ion and act as

appropr ia te . Com ple te the pa in sca le hou r ly , un t i l th e residen t app ears comfor tab le , then four -hour ly fo r 24 h ours ,

t rea t ing pa in i f i t recurs . Record a l l the p a in - re l iev ing in te rven t ion s under taken. I f p a in /d ist ress persists , un der take a

com prehens ive assessm ent o f a l l facets o f residen t s care and m on i t o r c losely over a 24-hou r p er iod , in c lud ing any

fu r t h e r i n t e r v e n t i o n s u n d e r ta k e n . I f t h e re i s n o im p ro v em e n t d u r i n g t h a t t im e , n o t i f y t h e me d i c al p ra c t i t i o n e r o f t h e

pa in scores and th e ac t ion /s taken.

Jenn y Abbey

Apr i l , 2007

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Ad d scores fo r Q1 t o Q6 an d reco rd h ere Tot al p ain sco re

The Abbey Pain Scale

Fo r m e asu re m e n t o f p a i n i n p e o p l e w i t h d e m e n t i a w h o c a n n o t v e rb a l i se

How to u se scale: Whi le ob serv in g the resident, score qu est io ns 1 to 6.

Nam e of residen t: ............................................................................................................................................................

Nam e and designat io n of per son com pl eti ng th e scale: .................................................................................................

Date: ............................................................................. Tim e: ........................................................................................

Latest p ain reli ef given w as ........................................................................................................................... at .......hrs.

Q1. Vo cal isat io n

eg wh imper ing , g roan ing , c ry ing

Absen t 0 M i ld 1 M oderate 2 Severe 3

Q2 . Fa ci al ex pr essi o n

eg look ing tense , f rown in g , gr im acing , look in g f r igh tened

Absen t 0 M i ld 1 M oderate 2 Severe 3

Q3 . Ch a n ge i n bo d y l an gu a ge

eg f idget ing , rock ing , guard in g par t o f body , wi t hdr awn

Absen t 0 M i ld 1 M oderate 2 Severe 3

Q4 . B eh avi ou r al ch an ge

eg inc reased con fus ion , re fus ing to ea t , a l te ra t ion in usua l pa t te rns

Absen t 0 M i ld 1 M oderate 2 Severe 3

Q5 . Ph ysi o lo gi ca l ch a n ge

eg tempera tu re , pu lse o r b lood pressure ou t side norm al l im i ts , persp i r in g ,

f lush ing o r pa l lo r

Absen t 0 M i ld 1 M oderate 2 Severe 3

Q6 . Ph ysi ca l ch an ges

eg skin tears, pressure areas, arth r i t is , contr actures, previo us in ju r ies

Absen t 0 M i ld 1 M oderate 2 Severe 3

Q1

Q2

Q3

Q4

Q5

Q6

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CAN BE PHOTOCOPIED FOR STAFF USE

Observe for potential indicators of pain: fac ial expressions ve rbal i sa t i ons/vocal i sa t i ons b o dy m o vem e n t s a l te red i n te rpersona l i n te ract i ons changes in ac t i v i ty pa t te rns o r rou t i nes m e n ta l st a tu s c h an g es physio log i ca l changes.

No imm ed ia te t rea tment needed .

Con t inue to m on i to r .

Ask wh ether th e person h as pain at rest or on m ovemen t. Use a l ternat ivedescr iptor s such as sore, hu rt in g or achin g.

Observe fo r po ten t i a l i nd i ca to rs o f pa in .

Is pain reported/apparent?

Assess pain int ensity u sing a sim ple scale such as a

verbal rat in g scale or num eric rat ing scale.

Ask th e person to show w here thei r p ain is (poin t ingor pa in m ap).

Is pain present?

Take a de ta i l ed pa in h i s to ry. Ex am i n e t h e p at i e n t . Treat cause . Treat sympt oms i f cause i s no t i den t i f i ab le . Cons ider re fer ra l .

No im m ed ia te act i onneeded.

Con t inue to m on i to r .

No im m ed ia te ac t i on needed .

Con t inue to m on i to r andtreat as requi red.

N o i m m e d i ateact ion needed.

Continue tom o n i t o r .

Re luc tan t to com p la ino f p ai n .

Evidence of morbidity that maybe causing pain?

Can th e p erson com m un icate successfu l ly?*

Algorithm for the assessm ent of pain in older people

* I f there is doubt abou t abi l i ty to comm unicate, assess and fac i l i ta te as indicated in Recom m endat ions 4 and 5 of the Guidel ines (over leaf) .

Yes

Yes

Yes

Yes

No

No

NoNo

No

No

No

Yes

Yes

Treat morbid i ty.

Do potential painindicator s persist?

Consider emp ir ica l an algesict r i a l o r o the r pa in - re l i evingin te rven t ion .

Mon i tor respon se carefu l l y.

A t t em p t t o i n te r p r et m e an i n g o f b e h av i ou rw i th he lp o f caregive rs fami l i a r w i th th eperson. Provide indi v idual ised care.

Ensure basic comfo rt n eeds are m et.

Provide reassuran ce i f behaviour suggestsfear.

Consider p rovid in g analgesics pr ior t om o v e m e n t .

Do potential pain indicators persist?

Yes

Copyright 2007 Royal College of Physicians