1. ASSESSING PAIN IN PATIENTS WITH ADVANCED DEMENTIA
PAINAD
ASSESSING PAIN IN PATIENTS WITH ADVANCED DEMENTIA

2. OBJECTIVES Discuss the definition of pain
Review the various ways pain is assessed at LHS
Review the five components of pain
Explain the use of the PAINAD Scale
Apply the concept of PAINAD to situations.

3. HISTORICAL FACTS
Self report of pain most reliable measure of pain intensity
Many patients unable to rate their pain using the Wong-Baker rating scale
These include: infants, young children, pts with advanced dementia, sedated or intubated patients

4. Pain Assessment Tools at LHS
Wong-Baker Scale (1-10 scale) – used for responsive adult patients
FLACC Scale developed to measure pain in infants and young children
FLACC used at LHS for other types of non-verbal patients
Research indicates FLACC is not useful in assessing pain of the cognitively impaired elderly population

5. PAIN Pain can be defined in two ways. Clinically-based
Scientifically-based

6. PAIN Clinically-based Pain:
Whatever the experiencing person says it is, existing wherever the person says it does
(McCaffery, 1997)
Scientifically-based Pain
“an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (Mersey, 1994)

7. These components are interrelated and connected to the understanding of pain and pain management.

8. Pain as a Multidimensional Phenomenon
As a phenomenon pain is multidimensional and consists of five components:
affective
behavioral
cognitive
sensory
physiological.

9. Factors that are Influenced by the Perception of Pain
Emotional Pain
(Affective)
Social Pain
(Behavioral)
Physical Pain
(Physiological)
Spiritual Pain
(Cognitive)
Social Isolation
Fear Depression Anger Sadness
Financial Worries
Family Distress Inability to Work
Illness(cancer)
Treatment
Unrelated to Cancer
Guilt
Regret
Fear of Dying

10. Literature Review
Literature on use of FLACC scale in the adult is negligible.
FLACC scale developed to measure pain in infants and children who could not report pain.
Ten pain assessment tools evaluated in nonverbal older adults with dementia.
FLACC scale scored the lowest overall.

11. Reliability and Validity of FLACC
FLACC scale appropriate for infants and young children
Validity and Reliability in the adult population has not been established
Conclusion: A more suitable behavioral pain scale needed for the non-verbal adult population with dementia

12. PAINAD
Found to be valuable in assessing pain behaviors in patients with advanced dementia.
Not recommended for assessing pain in the intubated/sedated population.

13. PAINAD Scale consists of five items Each recorded on a scale of 0-2
Patient’s score can range from 0-10
Scale requires little training
Is easy to use
Can be used by nurses

14. Pain Assessment in Advanced Dementia (PAINAD)Scale

15. PAINAD
BREATHING
Normal breathing –effortless, quiet, rhythmic (smooth) respirations.
Occasional Labored Breathing – episodic bursts of harsh, difficult or wearing respirations

16. PAINAD Breathing Cont.
Short Period of Hyperventilation - Intervals of rapid, deep breaths lasting a short period of time
Noisy Labored Breathing –Loud, gurgling, wheezing that appear strenuous or wearing
Long Period Of Hyperventilation – Excessive rate and depth of respirations lasting a considerable time.

17. PAINAD Breathing Cont.
Cheyne-Stokes respirations – rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea (cessation of breathing)

18. PAINAD NEGATIVE VOCALIZATION
None- speech or vocalization that has a neutral or pleasant quality.
Occasional moan or groan – Mournful or murmuring sounds, wails or laments. Groaning is characterized by louder thabn usual inarticulate involuntary sounds, often abruptly beginning and ending

19. PAINAD NEGATIVE VOCALIZATION
Low Level Speech with a Negative or Disapproving Quality – Muttering, mumbling, whining, grumbling, or swearing in a low volume with a complaining sarcastic or caustic tone
Repeated Troubled Calling Out – phases or words being used over and over in a tone that suggests anxiety, uneasiness, or distress

20. PAINAD NEGATIVE VOCALIZATION
Loud Moaning or Groaning – Mournful or murmuring sounds, wails or laments in much louder than usual volume. Louder than usual inarticulate involuntary sounds, of abruptly beginning and ending
Crying – Utterance of emotion accompanied by tears. There may be sobbing or quiet weeping.

21. PAINAD FACIAL EXPRESSION
Smiling or Inexpressive – Upturned corners of the mouth, brightening of the eyes and a look of pleasure or contentment. Inexpressive refers to a neutral, at ease, relaxed or blank look
SAD – Unhappy, Lonesome, sorrowful, or dejected look. There maybe tears in the eyes.

22. PAINAD FACIAL EXPRESSION
Frightened- a look of fear, alarm, heightened anxiety. Eyes appear wide open
Frown – Downward turn of the corners of the mouth. Increased facial wrinkling in the forehead and around the mouth
Facial Grimacing- distorted, distressed look. More wrinkled brow and around the mouth. Eyes may be squeezed shut.

23. PAINAD BODY LANGUAGE
Relaxed – calm, restful, mellow appearance. Taking it easy.
Tense – Strained, apprehensive or worried appearance. Jaw maybe clenched
Distressed Pacing- activity that seems unsettled, fearful, worried or disturbed

24. PAINAD BODY LANGUAGE
Fidgeting – restless movement, squirming or wiggling, repetitive touch, tugging or rubbing body parts
Rigid – stiffening of the body. Arms and legs are tight and inflexible. Trunk straight and unyielding.

25. PAINAD BODY LANGUAGE
Fists clenched – tightly close hand. Maybe opened and closed repeatedly or held tightly shut.
Knees Pulled Up – Flexing legs and drawing knees up toward chest
Pulling or pushing away- Restiveness upon approach; yanking or wrenching him /herself free or shoving you away

26. PAINAD BODY LANGUAGE
Striking Out – Hitting, kicking, grabbing, punching, biting or other form of personal assault.

27. PAINAD CONSOLABILITY
No Need To Console – a sense of well being, appears content
Distracted or Reassured by Voice or Touch – Disruption in the behavior when the person is spoken to or touched. Behavior stops during the period of interaction; no indication of distress
Unable to Console, Distract or Reassure-No amount of comforting, verbal or physical will stop a behavior

28. CONCLUSION
Wong Baker Pain Scale will continue to be used for patients who can respond to the 0-10 scale
FLACC pain scale will continue to be used for children and infants
PAINAD scale will be used to assess non-verbal dementia patients
PAINAD scale has not been proven useful in comatose patients

29. CONCLUSION
PAINAD should not be used by the PCAs/Student Techs/ED Techs
Patients who are unresponsive must be assessed for pain by the RN or LPN
PAINAD will be an available choice in Soarian

30. COMPUTER BASED LEARNING TEST FOR PAINAD SCALE
1. The PAINAD scale is appropriate for use with which of the following patients?
A 24 year old alert and oriented patient admitted for post-operative appendectomy
An 86 year old female with late stage dementia who only moans when you ask her to rate her pain level
A 72 year old male with early dementia who is answers appropriately to questions but is occasionally confused to time.
A 60 year old female intubated for pulmonary edema.
Ans: (B) Patients with advanced dementia cannot report pain because of verbal and cognitive deficits. The PAINAD scale was specifically developed for this type of patient.)
True or False – The PAINAD scale uses a 0-10 rating.
Ans: (True – The PAINAD scale rates each of the 5 behaviors {breathing, negative vocalization, facial expression, body language and consolability} on a 0-2 rating for a total possible pain rating of 0-10)

31. TEST Cont.
3. True or False – The PAINAD scale is replacing the FLACC scale to assess pain in nonverbal dementia patients.
Ans: (True – The PAINAD scale was developed specifically for assessing pain in patients with advanced dementia, whereas the FLACC scale was designed for assessing pain in infants and children.)

32. TEST
Mr. Brown is a 70 year old patient admitted with cellulitis. He is in advanced stage of dementia, nonverbal with contracted arms and legs. When turning him, Mr. Brown moans loudly and pushes away striking at the nurses. He has short periods of hyperventilation during care. He appears frightened but stops moaning when distracted by the nurses voice of reassurance. What is this patient’s pain level?
0/10
5/10
7/10
10/10
Ans: C Assessing each of the 5 behaviors: Breathing – score of 1, Negative Vocalization- score of 2, Facial expression- score of 1, Body Language- score of 2, Consolability- score of 1---for a total pain score of 7/10)