Observational Tools May Lack Sensitivity for Evaluating Pain Intensity in Advanced Dementia

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The PAINAD-G examines 5 pain-related categories: breathing, negative vocalization, facial expression, body language, and consolability.
The PAINAD-G examines 5 pain-related categories: breathing, negative vocalization, facial expression, body language, and consolability.

The Pain Assessment in Advanced Dementia German version (PAINAD-G) does not show significant differences in pain reduction in patients with advanced dementia treated with oxycodone vs placebo, according to results published in Pain. These results indicate that this tool may not be sensitive enough to detect changes in pain intensity in this patient population.

The study included 45 participants with advanced dementia expected to be in pain who were randomly assigned to receive oxycodone 10 mg or placebo. The researchers sought to evaluate the validity of PAINAD-G and that of 3 other pain assessment tools, the Observation Instrument for Assessing Pain in the Elderly with Dementia, the Checklist of Nonverbal Pain Indicators (CNPI), and Algoplus. Assessments were made at baseline and 3 and 6 hours after the first intervention. 

The PAINAD-G examines 5 pain-related categories: breathing, negative vocalization, facial expression, body language, and consolability. The Observation Instrument for Assessing Pain in the Elderly with Dementia includes 4 behavioral items and 4 movement items. The CNPI consists of 6 items: vocal complaints (verbal and nonverbal), facial grimaces, bracing, restlessness, and rubbing. The Algoplus is a newer French observational tool for acute pain.

The CNPI total score during movement indicated a marginally significant difference between the 2 study groups (P =.05). All of the other assessment tools, including PAINAD-G, indicated comparable levels of pain in participants treated with oxycodone vs placebo (for PAINAD-G: pain at rest, P =.85; pain during movement, P =.65).   

Moderate to high correlations were established among the 4 tools, providing additional proof of the underlying validation concept.

The researchers hypothesized that difficulties regarding sensitivity to change/responsiveness, consistence of the fundamental construct, influence of the early onset study, and efficacy of the analgesic in advanced dementia could possibly contribute to these results.

“Clinicians have to be aware that a score in these instruments does not necessarily mean that a patient [has] pain,” the researchers wrote.

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Reference

Lukas A, Hagg-Grun U, Mayer B, Fischer T, Schuler M. Pain assessment in advanced dementia. Validity of the German Painad – a prospective double-blind randomised placebo-controlled trial. [published online October 26, 2018]. Pain. doi:10.1097/j.pain.0000000000001430

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