Vol. 10 No. 8 November 1995
foun~at of Pain and Symptom Manal~ement 591
Original Article
Pain in Cognitively Impaired
Nursing Home Patients
Bruce A. Ferrell, MD, Betty R. Ferrell, PhD, FAAN, and Lynne Rivera, RN
Departnwnt of Medicine/Geffatrics (B.A.E), UCLA School of Medicine, and the Geriatric
Research Education and Clinical Center (GRECC), Sepulveda Veterans Administration (VA)
Medical Center, Sepulveda, and Department of Nursing Education and Research (B.R.F.,
L.R.), City of Hope Medical Center, Duarte, California
Abstract
Pain is an understudied problem in frail elderly patients, especially those with cognitive
impairment, delirium, or dementia. The focus of this study was to describe the pain
experienced by patients in skilled nursing homes, which have a high prevalmtce of cognitive
impairment. A random sample of 325 subjects was selectedfrom ten community skilled
nursing homes. Subjects underwent a cross-sectional interview and chart rev~o for the
prevalence of pain complaints, etiology, and pain management strategies. Pain was
assessed using the McGill Pain Questionnaire and four unidimensional scales previously
utilized in younger adults. Thirty-three percent (33 %) of subjects were excluded because
they were either comatose (21%), non-English speaking (3. 7%), temporarily away (sich in
hospital) (4.3 %), or refused to participate (3. 7%). Of 217 subjects in the final analysis,
the mean age was 84.9years, 85% were women, and most were dependent in all activities
of daily living. Subjects demonstrated substantial cognitive impairment Onean Folstein
Mini-Mental State exam score was 12.1 +. 7. 9), typically having deficits in memory,
orientation, and visual spatial skills. Sixty-two percent reported pain complaints, mostly
related to musculoskeletal and neuropathic causes. Pain was not consistently documented
in records, and pain managonent strategies appeared to be limited in scope and only
partially successful in controlling pain. None of the four unidimen~ional pain-intensity
scales studied in this investigation had a higher completion rate than ttw Present Pain.
b~tensity Scale of the McGill Pain Questionnaire (65 % completion rate). Howeveg 83 %
of subjects who had pain could complete at least mw of the scales. We conclude that
cognitive impairment among elderly nursing home residents presents a substantial barrier
to pain assessment and managonent. Nonetheless, most patients with mild to moderate
cognitive impairment can be assessed using at least one of the available bedside assessment
scales. J Pain symptom Manage 1995;10:591-598.
Key Words
Cognitive impairment, pain assessment, pain scales, elderly patients
Introduction
Address reprint requests to: Bruce A. Ferrell, MD,
GRECC (11E), Sepulveda VA Medical Center, 16111
Hummer Street, Sepulveda, CA 91348, USA.
Acceptedfor publication: March 31. 1995.
© U.S. Cancer Pain Relief Committee, 1995
Published by Elsevier, New York, New York
Pain is a serious problem a m o n g frail elderly p e o p l e . 1'~ Impaired mobility, decreased
socialization, depression, sleep disturbances
0885-3924/95/$9.50
SSDI 0885-3924(95)00121-E
592
Ferrell et ai.
and increased health care utilization a n d costs
have each b e e n associated with the p r o b l e m of
pain in elderly patients, s-6 D e c o n d i t i o n i n g ,
gait disturbances, falls, slow rehabilitation,
polypharmacy, cognitive dysfunction, a n d malnutrition are a m o n g the many c o m m o n geriatric conditions that are potentially worsened by
the experience a n d treatment o f pain. l T h e
Agency for Health Care Policy a n d Research
(AHCPR) has r e c o g n i z e d the elderly as a
population with special needs for ~ain assessm e n t a n d m a n a g e m e n t strategies. 7'°
Today there are more than 1.5 million frail
elderly p e r s o n s r e s i d i n g in a p p r o x i m a t e l y
20,000 nursing h o m e s in the U n i t e d States.
Nursing h o m e s represent m o r e than triple the
n u m b e r of acute care hospitals a n d m o r e than
double the n u m b e r of acute hospital beds. '~
T h e National Nursing H o m e Survey of 1985
described this population as 80% female and
m o r e than 40% over 85 years of age. 1° T h e
nursing home population exhibits an
extremely high prevalence of functional disability, which is potentially worsened by the
experience a n d treatment of pain. More than
88% n e e d assistance with bathing, almost 75%
n e e d help with dressing, and m o r e than 60%
n e e d help with transfers. More than 50% of
nursing h o m e residents are incontinent, and
m o r e than 40% n e e d assistance with eating. In
a d d i t i o n to these i m p a i r m e n t s , m o r e t h a n
65% of nursing h o m e residents have cognitive
dysfunction or mental illness. Visual acuity a n d
h e a r i n g i m p a i r m e n t s are c o m m o n . Nursing
h o m e residents often have multiple medical
diagnoses and require numerous medications. ° In a study of pain in a single nursing
h o m e , the average patient h a d m o r e than six
clinical p r o b l e m s a n d was p r e s c r i b e d m o r e
than seven medications. 6
Cognitive i m p a i r m e n t , such as d e m e n t i a
a n d delirium, represents a major barrier to
pain a s s e s s m e n t a n d m a n a g e m e n t in this
p o p u l a t i o n . N u r s i n g h o m e r e s i d e n t s with
d e m e n t i a related to cerebrovascular disease or
d e m e n t i a of the Alzheimer type often have
cognitive deficits in memory, attention, visual
spatial skills, and language (aphasia). It Behavioral problems are n o t u n c o m m o n . Despite
these potential barriers, P a r m e l e e a n d colleagues f o u n d no evidence of " m a s k i n g " of
pain complaints by cognitive i m p a i r m e n t in a
study of 758 residents of a single long-term
Vol. 10 No. 8 November 199.~
care facility in Philadelphia. va Data from this
study s u g g e s t that, " a l t h o u g h cognitively
i m p a i r e d elderly may slightly u n d e r r e p o r t
experienced pain, their self-reports are generally no less valid t h a n those of cognitively
intact individuals." 12
To o u r k n o w l e d g e , previous research o f
pain in long-term care facilities has been limited to single facilities that have i n c l u d e d
mixed populations of residential a n d skilled
levels o f nursing care. T h e p u r p o s e of this
investigation was to explore the p r o b l e m o f
pain in skilled nursing h o m e s using multiple
settings that m i g h t be m o r e generalizable to
c o m m u n i t y n u r s i n g h o m e s . T h e study was
designed to answer two study questions: (a)
What is the prevalence o f pain complaints in
skilled nursing homes? a n d (b) What is the
percentage of nursing h o m e patients with pain
that can be assessed using o n e of several available bedside pain-lntensity scales?
Methods
Design
T h e study design was a randomly selected
cross-section c h a r t review a n d interviewerassisted survey o f r e s i d e n t s o f c o m m u n i t y
skilled nursing homes.
Settings
Ten skilled nursing h o m e s in Los Angeles
were included in the study. Sixty p e r c e n t o f
the facilities were proprietary, and 40% were
n o n p r o f i t with an average o f 100 beds (range,
50-200 beds). T h e facilities had an average o f
15 staff physicians (range, 8-59), a n d 45%
(range, 0%-76%) of residents were receiving
Medicaid (Medical) reimbursed care.
Subject Selection
Subjects were r a n d o m l y selected from the
census at each facility. Thirty-five p e r c e n t of all
residents at each facility were chosen for chart
review a n d interview. This study was cond u c t e d as a quality assurance activity in each o f
the facilities. Thus, participation was n o t contingent on the ability of subjects to participate
in a typical written i n f o r m e d consent procedure. Instead, prior to data collection, each
subject was read a s t a t e m e n t that briefly indicated the nature o f the study, the protocol,
Vol. 10 No. 8 November 1995
Pain in Co~. !tively Impaired Patients
and their rights to refuse participation. Family
or surrogate decision makers for the patients
as well as the primary care physicians were
i n f o r m e d o f the study a n d of the patients'
potential inclusion. If the patient, their family,
surrogate decision maker, or p r i m a r y care
physician indicated an objection or desire not
to participate, the subject was excluded from
any further interview or data collection. The
protocol a n d verbal " c o n s e n t " p r o c e d u r e
w e r e a p p r o v e d by t h e S e p u l v e d a VAMC
H u m a n Subjects Protection C o m m i t t e e and
the internal review boards of each o f the participatifig facilities in view of the overall goals,
minimal invasiveness o f the study, a n d the
desire to maximize subject recruitment.
D a t a Collection I n s t r u m e n t s
Demographic data was extracted from the
medical record review, including variables of
age, gender, medical diagnoses, prescribed
medications, and whether consultants or o t h e r
n o n d r u g pain m a n a g e m e n t strategies had
been employed or ordered. A structured interview was then c o n d u c t e d using several establ i s h e d i n s t r u m e n t s to e v a l u a t e c o g n i t i v e
impairment, functional status, and pain.
Cognitive impairment was evaluated by the
Folstein M i n i - M e n t a l State E x a m . in This
30-item instrument has been shown to have
broad validity and reliability for the diagnosis
a n d a s s e s s m e n t o f geriatric d e l i r i u m a n d
dementia. Functional status was characterized
by the Katz activities of daily living scale. 14 This
six.point instrument is used widely in nursing
homes in the assessment of individuals' ability
to independently preform activities including
bathing, toileting, transfer, continence, eating,
and dressing.
Pain was evaluated using a 33-item questionnaire adapted from the investigators previous
research in nursing h o m e populations. ~ This
instrument included questions regarding the
frequency, location, and character o f pain as
well as the existence of multiple pain sources
obtained by patient self-report a n d review of
existing medical records. Pilot studies of the
a d a p t e d i n s t r u m e n t a m o n g 20 frail elderly
subjects with chronic pain at a veterans nursing h o m e demonstrated internal consistency
o f 0.85 (Chronbach's alpha) a n d test-retest
reliability (comparison of two assessments 24
593
hours apart) of 87% (mean individual item
weighted agreement; range, 60%-100%).
T h e evaluation o f pain was also assessed
using the McGill Pain Questionnaire) 6 This
78-word descriptor scale has been used in a
large n u m b e r of populations and settings, x°
Subjects with m o r e than one pain problem
were ask to concentrate on the most severe
problem. T h e McGill Pain Questionnaire was
administered by recording each of the 20 subsections of words in o n e inch letters on 8.5 by
11 inch cards. Cards were shown to and simultaneously read to subjects as they were asked
to indicate words that described their pain.
T h e McGill Pain Questionnaire was scored by
the sum of the rank values of words chosen in
e a c h of 20 categories (Pain Rating I n d e x
Total), as well as the four subscales (Pain Rating Index Sensory, Pain Rating Index Affecrive, Pain Rating Index Evaluative, and Pain
Rating Index Miscellaneous subscales). 16 Also
the Present Pain Intensity (PPI) scale was
recorded. This six-point combination wordn u m b e r scale is an additional subscale of the
McGill Pain Questionnaire used as an indicator of pain intensity at the moment.
In addition to the PPI scale, patients who
indicated the presence of pain problems during the interview and pain questionnaire were
p r e s e n t e d f o u r o t h e r u n i d i m e n s i o n a l pain
intensity scales shown in Figure 1. T h e s e
included a verbally administered 0-10 scale; 17
a 100-ram horizontal visual analogue scale; Is a
subscale o f the Memorial Pain Card (modified
Tursky Scale)l°; a n d the Rand COOP Chart
for pain. x° These scales were presented in a
s t r u c t u r e d systematic r a n d o m o r d e r and,
except for the verbal scale, were also presented on 8.5 by 11 inch cards. The verbal
0-10 scale was administered by verbally reading the scale to the subject and waiting for a
verbal reply.
Subjects were given at least 30 sec for a
reply, and the scale was repeated at least three
times before subjects were considered unable
to respond. T h e horizontal visual analogue
scale consisted o f a 100-ram horizontal line
with word anchors of " n o pain" and "worst
possible pain." Subjects indicated their level
o f pain by placing a mark on the line indicating the intensity o f pain at the moment. Subjects unable to hold a pencil and make a mark
on the line were considered unable to corn-
594
Ferrell et al.
MoGIII Pain Questionnaire
Preoent Pain Intensity Subscale
(PPI)
01 2 3 -
No Pain
Mild
Discornfortlng
Distressing
4- Horrible
8 - Excruciating
100mm
VoL 10 No. 8 November 1995
Visual Analog
Scale
M a k e a m a r k on t h e llne
for t h e s e v e r i t y of y o u r pain.
I
I
No Pain
Worst Possible
P~in
Rand Coop Chart
Memorial Pain Card Subecale
(Modified Turskey Scale)
Iio Pain
|
I
Moderato 4
~.~ '
Very Mild Pain
Strontl 5
Mild Pain
Just Notlcable 1
~
'
Moderate Pain ~
'
Mild •
No Pain °
Excruciating 7
Severe o
Weak =
Severe Pain
(~
k2
Verbal Scale
On a scale of zero to ten, zero m e a n i n g no pain and ten m e a n i n g the worst pain
y o u can Imagine, h o w m u c h pain are you having n o w ?
Fig. 1. Figure illustrating five unidimensional pain scales.
plete the scale. Responses were scored by the
interviewer by measuring the distance (in millimeters) from the zero a n c h o r ( " n o pain") to
the patient's indicated response.
T h e r e m a i n i n g two instruments, the modified Tursky subscale o f the Memorial Pain
Assessment Card, a n d the Rand Coop Chart
were a d m i n i s t e r e d by showing and r e a d i n g
each card to the subjects a n d waiting for a verbal reply o r p o i n t i n g to t h e a p p r o p r i a t e
r e s p o n s e . Care was taken to give subjects
a m p l e t i m e to c o m p l e t e e a c h task, a n d
p r o m p t i n g was limited to repeating the questions a n d directions. All data were collected by
a single trained study nurse and care was taken
to s t a n d a r d i z e subjects' r e p o r t e d p a i n by
avoiding interviews within an h o u r of pain
medication, physical therapy or other physical
activities. Care was taken to ensure that sub-
jects were sitting upright, usually at a table or
writing surface, facing the interviewer, a n d
using appropriate a m b i e n t light and hearing
assistance devices if necessary.
Results
A sample o f 325 subjects was obtained from
a total of 915 potential subjects. Fourteen subjects (4.3%) were n o t available for interview
(on leave from the nursing h o m e ) , and 12
subjects (3.7%) refused to participate. Following chart review a n d brief interview, 70 subjects (21.5%) were essentially m u t e a n d unresponsive, a n d no m e a n i n g f u l i n f o r m a t i o n
could be obtained from the patient interview.
Twelve subjects (3.7%) were n o n - E n g l i s h
s p e a k i n g a n d were s u b s e q u e n t l y e x c l u d e d .
Thus, 217 subjects were included in the final
analysis.
VoL 10 No. 8 November 1995
Pain in Co~titivel~vbn~aired Patients
Table 1
Age in years (mean; range)
Gender (% females)
Ethnic status
Caucasian
Black
Hispanic
Asian (and Pacific islands)
Number of medical problems
(mean; range)
Number of prescribed
medications (mean; range)
l~atz activities of daily living
Need help with feeding
Incontinent
Need help wkh transfers
Need help w~,th toileting
Need help with dressing
Need help with baflfing
Folstein Miui-Mental State
Exam Score (mean; range)
Value
84.9 (49-103)
84.8%
90%
2%
6%
2%
7.9 (1-19)
8.7 (0-25)
28%
22%
81%
82%
96%
98%
12.1 (0-30)
Demographic a n d Medical Characteristics
Demographic characteristics of the sample
are shown in Table 1. T h e m e a n age was 84.9
years, a n d a b o u t 85% were women. Subjects
h a d an 'average of almost eight active medical
diagno'~es a n d were prescribed an average of
almost nine medications. In general, there was
a very high prevalence of cognitive impairment. Most patients had p o o r recall m e m o r y
a n d were disoriented to date, time, a n d place.
T h e average Folstein Mini-Mental State Exam
score was 12 -----7.9 (range, 0-30; n o r m a l being
greater than 24 o u t of 30). Subjects were very
low in physical functioning and d e p e n d e n t in
m o s t o f t h e six activities o f daily living
described by the Katz scale, including bathing,
dressing, toileting, transfer, continence, a n d
feeding.
Frequency o f P a i n
O n e h u n d r e d a n d thirty.-four (134) subjects
(62%) r e p o r t e d pain complaints d u r i n g the
interview a n d pain questionnaire. Eighty-three
subjects (38%) d e n i e 4 any painful problems
or could n o t give meaningful responses to the
questionnaire. Table 2 lists the locations a n d
frequency of pain complaints obtained from
interview a n d pain questionnaire. Forty percent of subjects described m o r e than o n e location for pain (average 3.0), with a range of
1-14 separate locations. It was n o t e d that 37%
of subjects who c o m p l a i n e d of pain h a d no
595
Table 2
Paln Ll~cations (N = 134)
Demographic Data (N = 217)
Ch,-,xacteristic
,
Location
Back
Knee
Foot/ankle
Shoulder
Neck
Wrist
Headache
Hip
Abdomen
Chest wall
Elbow
Heart/angina
Rectai/pelvlc
Face/jaw
Other
Frequency N (%)
90(67.1%)
78(58.2%)
70(52.2%)
64 (47.8%)
61 (45.5%)
60(44.8%)
58 (43.8%)
56 (41.8%)
55(41.0%)
48(35.8%)
g9(29.1%)
34(25.4%)
34(25.4%)
34(25.4%)
57(42.5%)
Most StlbjecL,i described inore thalt one Iocaliolt
(mean, 3,0; rallgt:, 1-14).
Note:
d o c u m e n t e d etiology for their pain description in the medical records. Of those with
s o m e d o c u m e n t a t i o n , arthritis was the most
c o m m o n etiology identified for the prlmary
c o m p l a i n t (70%) followed by old fractures
(13%), neuropathies (10%), and malignancies
(4%) (see Table 3). Pain was most often docum e n t e d in nursing notes (including the nursing care plan) (49%), physician's notes (44%)
a n d consultant's notes (8%). Notes regarding
pain were usually n o n s t r u c t u r e d , a n d n o n e of
the patients were being systematically evaluated for o n g o i n g pain on a routine basis.
P a i n Treatments
A c e t a m i n o p h e n was o r d e r e d for 81% o f
subjects who c o m p l a i n e d of pain, although the
exact indication for the order could n o t always
be d e t e r m i n e d from the chart. For example,
s o m e subjects may have had a c e t a m i n o p h e n
available for fever rather than specifically for
pain. Only 18 subjects (13%) were actively taking nonsteroidal antiinflammatory drugs a n d
8 subjects (6%) were receiving aspirin specifiTable 3
Etiology o f Primary Pain Complaint
Identified in Medical Records (N = 84)
Etiology
Arthritis
Old fractures (including
prosthetic related)
Neuropathy
Malignancy
Muscle spasm
All other
Frequency
59(70%)
11 (13%)
8(10%)
3(4%)
1 (1%)
2(2%)
Nole: Fifty subjects (37%) with pain had no clio|ogy
identified in the medical record.
596
Ferrell et al.
'col. 10 No. 8 November 1995
Table 4
Pain Intensity as Measured By Various Pain Scales (N = 134)
Scale
C o m p l e t i o n rate
Median (range)
87(65%)
79(59%)
2.0(0-5)
4.0(0-7)
77(57%)
64(47%)
5.0(0--4)
5.5(0-10)
Present Pain Intensity (McGill PPI)
Memorial Pain Assessment Card
Subscale
Rand Coop Chart
Verbal 0-10 scale
100-ram visual analogue scale
59(44%)
48 (1-99)
Note: Only 35 sttbjccts (82%) could complete all live scales; however, 115 subjects (83%) could complete at le~t one of the scales.
cally o r d e r e d for pain. Forty-five subjects
(34%) had orders for opioid analgesic medications including propoxyphene (16%), codeine
(13%), h y d r o c o d o n e (5%), and m o r p h i n e
(1%).
Thirty-three subjects (25%) with pain had
received physical therapy consultation in the
preceding 6 months. Only five subjects (4%)
were currently using a heating pad, and only
one subject had received a local nerve block.
Eight subjects (6%) stated that they had been
to a pain m a n a g e m e n t clinic at one time.
Pain Assessment
Although it is beyond the scope of this
paper to present a complete psychometric
analysis o.f the McGill Pain Q u e s t i o n n a i r e
using the methods of administration described
above, most patients (80%) identified several
words that described their pain (median, 8.5
words; range, 1-20). All 78 words included in
the scale were used and the most frequently
chosen words were "tiring" (N = 36), "nagging" (N= 32), "hurting" (N-- 29), "exhausting" (N = 29), and "annoying" (N = 27). The
least frequently use words included "scalding"
(N= 1), "vicious" (N-- 2), "drilling" (N= 2),
"beating" (N = 2), "pricking" (N = 3), and
"squeezing" (N = 4). An analysis of the Pain
Rating Index Total and subscales revealed a
m e d i a n Total score o f 17 (range, 0 - 7 5 ) ;
median Sensory subscale score of 10.0 (range,
1-40); median Miscellaneous subscale score o f
3.0 (range, 0-17); median Affective subscale
score of 2.0 (range, 0-13); and median Evaluative subscale score of 1.0 (range, 1-5). There
were no statistically significant correlations
between severity of cognitive impairment as
measured by the Folstein Mini-Mental State
score and the n u m b e r of words chosen or the
Pain Rating Index Total score.
O f five unidimensional scales presented,
most subjects (83%) could complete at least
o n e o f the scales (Table 4). T h e highest
completion rate was observed for the Present
Pain Intensity Scale of the McGill Pain Questionnaire (65% completion rate) followed by a
59% completion rate for the Memorial Pain
Card Subscale and 57% for the COOP Chart.
Subjects seemed to have more difficulty with
the verbal scale and a high proportion o f
patients were unable to complete the visual
analogue scale, either due to inability to follow
commands or hold a pencil. Only about onethird of subjects (32%) were able to complete
all of the scales. More importantly, 17% were
unable to complete any of the pain rating
scales p r e s e n t e d despite having a n s w e r e d
appropriately to yes or no questions about the
presence o f pain during the interview and
pain questionnaire.
For subjects who were able to complete at
least two of the scales, interclass correlation
Table 5
Relationships Between Pain Reports as Measured By Various Pain Rating Scales
McGill PPI
Memorial Subscale
Verbal scale
Visual analogue scale
Rand Coop Chart
McGiU PRIT
0.67(N=-71)
0.54 (N=-6O)
0.55(N=55)
0.72(N-=71)
0.55(N=84)
Memorial subscale
0.50 (N=54)
0.63(N=55)
0.79(/~--73)
0.38 (N-=-77)
Verbal scale
0.53(N=45)
0.48(N-=-53)
0.54(N=-64)
PPi, Present Pain Intensity; I'RIT,.
Note: Numbers represent Speat'man rho coemcients; P < 0.001 for all values.
Visual
analogue scale
0.60(N=-55)
0.55(N=58)
Rand C o o p Chart
0.43(N=-76)
"Col. 10 No. 8 November I995
Pain in Cognitively Impaired Patients
coefficients are shown in Table 5. This analysis
indicated moderately strong correlations
b e t w e e n the various scales in this p a t i e n t
population (r= 0.38-0.79; P < 0.0001).
D/scuss/on
Findings from this study confirm that pain is
c o m m o n in elderly people requiring skilled
nursing h o m e care. Of patients who were able
to make their needs known, over 60% had
complaints of pain. Most of these complaints
were from musculoskeletal causes, although a
substantial portion arose from neuropathies
and a smaller proportion from o t h e r nonmalignant sources. Nursing h o m e patients in this
study were profoundly disabled a n d most were
unable to p e r f o r m any basic activities of daily
living, w h e t h e r or n o t they h a d substantial
pain problems.
Results indicate that pain m a n a g e m e n t in
skilled nursing homes is limited in scope and
only partially successful. Despite the overall
n u m b e r of medications patients were receiving, analgesic drugs appeared to be used sparingly. Fear of adverse reactions a n d polypharmac), may be c o m m o n decision-making issues
for physicians and nurses in this setting. On
the o t h e r h a n d , use of n o n p h a r m a c o l o g i c
s t r a t e g i e s also a p p e a r e d to be l i m i t e d .
Although 25% had received physical therapy
consultation d u r i n g the preceding 6 months,
few patients had received any o t h e r pain mana g e m e n t strategy. Many patients could not
cooperate in physical therapy, m a i n t e n a n c e
exercises, or other self-care strategies (such as
using h e a t i n g pads) b e c a u s e o f cognitive
i m p a i r m e n t or other functional limitations.
Indeed, these barriers may present formidable
challenges to effective pain m a n a g e m e n t in
this setting.
Cognitive impairment
(dementia or
delirium) is a substantial barrier to pain assessm e n t and m a n a g e m e n t in this population.
Twenty-one percent of patients in these skilled
nursing facilities were unable to make their
needs known. Of the subjects who did complain of pain, 17% could not complete any of
the quantitative assessment scales presented.
These patients were n o t comatose or incapable of feeling pain. They were able to make
most of their needs known in a qualitative but
n o t always quantitative way. N o n e of the unide-
597
mensional pain intensity scales included in
this study was ideal for all cognitively impaired
patients with pain. However, pain assessment
was usually successful using at least one of the
available instruments that was suited to the
individual patient a n d administered in a mann e r sensitive to the disabilities elderly patients
often have. These observations indicate that
self-ratings o f pain in this u n d e r s t u d i e d population are n o t only possible but are also reliable and valid as shown by Parmelee and colleagues. 12
This cross-sectional study focused on pain
complaints at the m o m e n t , and most patients
were able to describe pain they were presently
experiencing. The extent to which cognitively
impaired patients are able to report pain "in
the last m o n t h , " or "in the last week" remains
to be studied, but it would seem highly limited
from o u r observations.
The findings from this study are descriptive in
nature and limited in sampling from ten skilled
facilities in file Los Angeles community. These
potential limitations, as well as the use of a single
data collector, may threaten the reliability, validity, and genel~izability of the results.
Nonetheless, our observations have important
implications for improving quality of care in this
setting. Pain assessment and management strategies for elderly patients with cognitive impairm e n t will likely require constant and frequent
assessment o f pain at the mome~-~t, so that management strategies can be maximized. Existing
pain assessment scales may require altered presentation and administration techniques to compensate for c o m m o n disabilities.
Experience from this study indicates that
elderly patients with mild to moderate cognitive i m p a i r m e n t often require time to assimilate questions a b o u t pain a n d to r e s p o n d
appropriately. Cognitively impaired patients
and patients with severe pain often have limited attention spans and are easily distracted.
Therefore it may be helpful to prepare these
patients by limiting distractions in the room
and by providing g o o d a m b i e n t lighting and
amplified h e a r i n g devices w h e n necessary.
Likewise, visual cues for most patients should
be presented in large print.
It is clear that innovative strategies are
n e e d e d to solve m a n y of these distressing
problems. As this is the fastest growing segm e n t of the population in many countries,
598
Ferrell a al.
m u c h additional research is n e e d e d for effective solutions.
Acknowledgment
This project was supported in part by the
Sepulveda VA Medical Center Geriatric Research
E d u c a t i o n a n d Clinical C e n t e r (GRECC),
Sepulveda, CA; City of Hope Medical Center
Department of Nursing Education and
Research, Duarte, CA; and a grant from the Purdue Frederick Company, Norwalk, CT.
The authors would like to thank the staff
and residents of the following nursing homes
for their cooperation and participation in this
project: Alderwood Manor, San Gabriel, CA;
Atherton Baptist Homes, Alhambra, CA; Berryman H,-:alth East, Whittier, CA; Clara Baldwin Stocked; West Covina, CA; Colonial Manor,
West Covina, CA; Community Convalescent,
Glendora, CA; Congress Convalescent, Pasadena, CA; El Monte Convalescent Hospital, El
Monte, CA; and Mount San Antonio Gardens,
Pomona, CA.
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