Identifying pain

Screening questions

Ask the patient if they are experiencing any pain using questions like the following.

• Do you have pain/are you aching or hurting anywhere right now?
• Where do you have pain/are you aching or hurting?
• How long have you been in pain/aching/hurting?
• Does pain/aching ever keep you from sleeping at night?
• Does your pain/aching ever keep you from participating in activities/doing things you enjoy?
• Do you have pain/are you aching or hurting every day?

If the older person has no pain on admission, record ‘0’ as the pain score and advise them to let staff know if pain develops.

If the older person does report pain during the initial screening interview, then further assessment of pain intensity, location, quality and symptoms is needed to guide diagnosis and treatment.

Assessing for pain

There are two main methods for identifying pain in older people: self-report and observational.

Self-report

Self-report is the most reliable source of information on pain. Use it with all older people, including those with a cognitive or communication impairment.^1,2 Self-report of pain may be obtained by:

• asking an older person questions about their pain – consider using terms such as ‘hurting’, ‘aching’ and ‘soreness’ and document these terms if the older person uses them¹
• using a pain intensity scale
• using a multidimensional self-report tool.

All self-reports should be taken seriously, including those from older people with a cognitive impairment.⁴ Self-reported pain from people with a severe cognitive impairment or non-communicative patients should be cross-validated with an observational pain assessment and, where appropriate, discussed with the patient’s family or carer. However, take care when using family or carer reports of pain in an older person, as pain intensity may be over- or under-estimated.²

Self-report pain assessment tools

Multidimensional tools are used for an initial comprehensive pain assessment. They evaluate the sensory component of pain (what the person is feeling), the emotional response to pain (impact on the person’s function and relationships, and the meaning of the pain) and quality of life (activities, mood, sleep). The following tools may be used.

• Short-form McGill questionnaire
• Brief pain inventory – short form
• Brief pain inventory – long form
• Pain disability index.

Unidimensional pain assessment tools are used for ongoing evaluation of pain intensity and response to treatment. They evaluate only the sensory component of pain. Examples include:

• Numeric Rating Scale (NRS)
• Verbal Descriptor Scale (VDS)
• Pain thermometer
• Visual Analogue Scale (VAS)
• A pictorial pain scale (FACES pain scale).

Some patients prefer to use numbers to describe their pain, while others prefer words. If you are not successful in using one type of self-report tool with an older person, try a different tool.

Observational

In older people who have severe cognitive impairments or communication difficulties, their behaviour may be the only external indicator of pain.²

Pain behaviours are individual, so identifying pain requires clinical judgement and familiarity with the older person. Involving family and carers can help with identifying and confirming observational pain.²

The following observation scales are recommended for older people with severe cognitive or communication difficulties.⁵

• Pain assessment checklist for seniors with limited ability to communicate (PACSLAC)
• Pain Assessment in Advanced Dementia (PAINAD)
• Abbey Pain Scale

Pain should be assessed at rest and during activity, such as movement or transfer.

Behavioural and autonomic signs of pain

Facial expressions

• frowning, sad or frightened face
• grimacing, wincing, eye tightening or closing
• distorted facial expressions - brow raising/lowering, cheek raising, nose wrinkling, lip corner pulling
• rapid blinking.

Vocalisation

• sighing, groaning, moaning
• grunting, screaming, calling out
• aggressive or offensive speech
• noisy breathing
• asking for assistance.

Body movement

• tense posture, guarding, rigid
• fidgeting
• pacing, rocking or repetitive movements
• reduced or restricted movement
• altered gait.

Social interaction

• aggressive or disruptive behaviour
• socially inappropriate behaviour
• decreased social interactions
• withdrawn.

Activities

• appetite change, refusing food
• increase in rest periods
• sleep or rest pattern changes.

Mental status

• cognitive decline
• increased confusion
• crying
• irritability or distress.

Autonomic signs

• pallor
• sweating
• rapid breathing (tachypnoea)
• altered breathing
• rapid heart rate (tachycardia)
• hypertension.

Autonomic signs of pain are only observable during a severe acute pain episode.² They may reflect active nociception and may assist with identifying pain in older people who are intubated or unconscious following surgery but need to be used carefully, because the absence of autonomic signs does not indicate the absence of pain.

Barriers to identifying pain

Several factors may interfere with an older person disclosing pain, including:

• communication issues – the older person and health professionals use different words to describe pain
• fears, beliefs and misconceptions about pain – the older person may be concerned that pain means their condition is worse, that they may have to rely on medication or that complaining about pain will distract health professionals from taking care of more important health issues
• literacy skills, numeracy skills, language and cultural needs
• cognitive impairments – be aware that behavioural and psychological symptoms of dementia (BPSD) could indicate a person is experiencing pain
• communication or sensory impairments
• some behaviours or autonomic responses may have other underlying causes.

Comprehensive pain assessment

When an older person is identified as being at risk of pain or experiencing pain, a comprehensive geriatric-focused pain assessment should be conducted. The assessment should include the following elements.^1,5,6

General medical history

Include prior and coexisting medical conditions, pain and treatment outcomes.

Pain history

• Commencement and trajectory
• Intensity – at rest and on movement, duration, current, during last week, highest level
• Aggravating and relieving factors
• Location – point to pain site on body or body map
• Radiation or referred sites of pain
• Quality – descriptors such as dull, throbbing, aching (associated with nociceptive pain) or burning tingling, pins and needles, numbness or itching (associated with neuropathic pain)
• Acute or chronic, including acute exacerbations of chronic pain

Physical examination

• Reported and referred pain and common pain sites
• Musculoskeletal and neurological systems – stiffness, muscle strength, range of motion, gait and balance problems
• Signs of arthritis – swelling, inflammation, stiffness
• Sensitisation of pain responses – pin prick or brush tests to assess for heightened or abnormal sensitivity to pain such as hyperalgesia (an increased response to a painful stimulus) or allodynia (pain from a stimulus which wouldn’t usually cause pain)⁷.

Functional assessment

• Physical function
• Assistance needed to perform activities of daily living
• Changes in mobility and activity levels (such as not wanting to get out of bed)
• Sleep – difficulty falling asleep or waking due to pain
• Changes in appetite
• Pain intensity
• Range of movement

Psychosocial function

• Mood – anxiety and depression may worsen with pain and make it harder for the older person to find ways to cope. Older people with chronic pain are four times more likely to develop depression than people with no pain
• Social relationships, coping skills and social supports, pain-related fears, feelings of loneliness
• Social engagement-experiencing chronic pain increases the risk of becoming socially isolated, as a person can lose the confidence and/or ability to participate in activities⁸

Cognitive function

• Mental status including acute or sub-acute confusion or delirium associated with pain
• Pain beliefs and fears
• Behavioural and psychological symptoms of dementia (BPSD) – unrelieved pain has been identified as a possible cause of BPSD

Previous pain treatments

• Effectiveness and side effects of all past and present pharmacological and non-pharmacological pain management strategies
• Older person’s satisfaction with past and present pain management strategies
• Older person’s expectation of and goals for pain management

¹ The American Geriatric Society, The management of persistent pain in older persons: American Geriatric Society panel on persistent pain in older persons. Journal of American Geriatric Society, 2002. 50: pp. S205-S224.

² British Pain Society and British Geriatrics Society, Guidance on: The assessment of pain in older people., 2007, British Pain Society and British Geriatrics Society.

³ Royal College of Physicians, British Geriatrics Society, and British Pain Society, The assessment of pain in older people: national guidelines. Concise guide to good practice series, No 8., L. Turner-Stokes and B. Higgins, Editors. 2007, Royal College of Physicians: London.

⁴ Herr, K., Pain assessment in the older adult with verbal communication skills, in Pain in Older Persons, S. Gibson and D. Weiner, Editors. 2005, IASP Press: Seattle. pp. 111-133.

⁵ Zwakhalen, S.M., et al., Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatrics, 2006. 6.

⁶ The Australian Pain Society, Pain in residential aged care facilities: Management strategies, 2005, The Australian Pain Society: Sydney.

⁷ International Association for the Study of Pain. IASP Taxonomy 2012. 2012 [cited 2015 April 15]; Available from: https://www.iasp-pain.org/resources/terminology/.

⁸ Commissioner for Senior Victorians. Ageing is everyone’s business: a report on isolation and loneliness among senior Victorians, 2016, State of Victoria: Melbourne.