FOUNDATION OF NURSING STUDIES

IDENTIFYING A PAIN ASSESSMENT TOOL FOR PATIENTS WITH COGNITIVE

IMPAIRMENT IN ACUTE CARE

7/4/2011
Royal Bolton Hospitals NHS Foundation Trust
Project Lead: Julie Gregory, Acute Pain Nurse Specialist

Key words: pain assessment, acute care, cognitive impairment and dementia,
participatory action research, practice development

E-mail. Julie.gregory@manchester.ac.uk
CONTENTS

PAGE NO.
SUMMARY 3

Introduction 4

Background 4

Aim and objectives of the project 5

Methods and approaches 5

Action cycle one 5

Audit 6

Literature review 6

Action cycle two 8

Workshops 8

Claims, concerns and issues 8

Action cycle three 9

Trial of assessment tools 9

Evaluation 9

Final evaluation 10

Discussion 10

Conclusion 11

References 13

Appendix 1 members of the steering group 15

Appendix 2 the evaluation tool 16

Appendix 3 Bolton Pain Assessment Scale 17

Identifying a pain assessment tool for patients with cognitive impairment Page 2
Summary:

This project aimed to identify a pain assessment tool sensitive to the cognitively
impaired patient in acute care settings to ensure good pain control and improved
outcomes for this group of patients.

Funding was obtained from the Foundation of Nursing Studies and General Nursing
Council Trust to support the project. A steering group comprising of members of the
pain team, representatives from the complex care and trauma unit and the mental
health liaison team for older people was formed. The purpose of the group was to
provide expert advice, to set mile stones and to meet regularly to ensure project kept
to the set targets.

The method and approaches used were based on participatory action research
methodology. Using a collaborative and participatory approach and incorporating
cycles of assessment, planning, action, evaluation and reflection the clinicians
involved examined and evaluated established behavioural pain assessment tools
within practice.

None of the behavioural pain assessment tools trialled was ideal and therefore the
group have devised their own pain assessment tool which has recently been
introduced into practice and will be evaluated by the clinical team.

Identifying a pain assessment tool for patients with cognitive impairment Page 3
INTRODUCTION

Pain is a common symptom associated with injuries and surgery with up to 79% of
hospitalised patients experiencing pain (Clinical Standards Advisory Group [CSAG]
1999, Strong et al 2002, Donovan et al 1987). Good pain management improves
function, reduces complications and the duration of hospitalisation (Murdock and
Larsen 2004).The recognition, assessment and treatment of pain should be
conducted routinely for all patients. Unfortunately this does not always occur and in
older people, pain is often under reported and frequently under treated (Murdock and
Larsen (2004). There is evidence that there is even less treatment in cognitively
impaired patients who cannot self-report pain (Warden et al 2003, Murdock and
Larsen 2004).

Self report is considered the most reliable way of assessing pain due to its subjective
nature and based on the definition pain is what the experiencing person says it is,
existing whenever he/she says it does McCaffery and Pasero (1999, p17). The
patient needs to describe the sensation, its impact and its meaning for them as an
individual. However there are groups of patient who cannot interpret, describe and
communicate their experience of pain to clinicians. This project examined the pain
assessment tools available for the recognition and assessment of pain for patients
with cognitive impairment.

BACKGROUND
Following a pain management course, nurses and therapists from the complex care
unit reflected on and critically examined their practice and as a result they identified
specific difficulties with pain assessment in patients with cognitive impairment and/or
dementia. The staff realised that this group of patients cannot always express or
describe their pain and they felt that the number of patients admitted to the complex
care wards with cognitive impairment appears to have increased. As a result of the
National Dementia Strategy (2009) there is an increased awareness of the specific
care needs for this group of patients.

Some of the observations made by members of staff from the complex care wards
and trauma unit included, for example, problems in mobilising the patient as they
may resist, when the physiotherapist attempted to move them. This may indicate
pain, but without an assessment tool or confirmation from the patient it was difficult
to verify this. Members of the team contacted the physiotherapists on the elderly
psychiatric unit and discovered that they did not use an assessment tool for their
client group; they used an instinctive feeling that relies on their knowledge of
patients over a prolonged period of time.

The pain assessment tool currently used within the hospital is a simple verbal
descriptor tool which depends on an individual expressing pain when asked. A brief
examination of assessment tools for cognitively impaired people by members of the
care team did not identify a tool suitable for acute care.

The project involved members of the healthcare teams on the complex care wards
and the trauma unit where they had recognised this problem for many of their
patients.

Identifying a pain assessment tool for patients with cognitive impairment Page 4
AIM:
To identify and implement a pain assessment tool sensitive to the cognitively
impaired patient in acute care settings to ensure good pain control and improved
outcomes for this group of patients.

OBJECTIVES:
To develop individual practitioners skills in collecting and analysing data from
a number of sources, examining evidence and changing practice
To examine current pain assessment practice for this specific group by
observation, interviewing relatives, holding staff focus groups and examining
documented care
To carry out a review of the literature and tools available on pain assessment
in dementia with clinical practitioners and choose tools to trial
To analyse the range of assessment tools to evaluate their effectiveness and
efficacy for all members of the healthcare team and relatives to use in clinical
practice
To disseminate the findings of the teams
To produce our own assessment tool if required

METHODS AND APPROACHES

The method and approaches used were based on participatory action research
methodology. Participatory action research (PAR) removes the distinction between
practitioner and researcher. The researcher or project leader (in this project the
Acute Pain Nurse Specialist) undertakes the role of a process facilitator to help
participants (Fox, Martin and Green 2007). This involves using a cyclical process
and including as many stakeholders as possible in the activities and decisions made
during the project. A participatory approach was chosen to involve those responsible
for pain assessment practice, to broaden the range of evaluation and to include them
in decision making relating to the project.

A multi-professional steering group was formed and included the project lead (the
Acute Pain Nurse Specialist), the Nurse Specialist from the mental health liaison
team for older people, medical staff, nurses and physiotherapists from the complex
care and trauma wards A full list of members of the steering group is available in
Appendix 1. The purpose of the steering group was to provide expert advice, set mile
stones and meet regularly to ensure the project kept to the targets.

ACTION CYCLE 1

Audit of current practice

An audit of current practice was undertaken using a variety of approaches. This
involved observing practice using audit tools produced by the steering group and
was conducted by nurses and therapists on each of the wards. The data obtained
from five wards compared cognitively intact patients with those that appeared to
have some cognitive impairment. A total of forty five patients were observed, see
table 1 for results. The observations suggest that cognitively impaired patients were
less likely to be asked about pain and there were issues about recording a pain
score for both groups of patients.

Identifying a pain assessment tool for patients with cognitive impairment Page 5
Table 1: Results of the observational audit
Number of patients 35 cognitively intact 19 cognitively impaired
Asked about pain 30 ( 86%) 15 (79%)
Pain recorded 23 (66%) 9 (47%)

An attempt to undertake an assessment of the context was made at this time using
Context Assessment Index (McCormack et al 2009) but just a few nurses completed
the assessment. The feedback obtained to explain this poor response from the
nursing staff was that the questionnaire appeared too long and complex and the
physiotherapists who attempted the questions found it difficult because they work on
a number of wards. The context assessment index examines elements of a context
to ensure there is person centred practice and it can help identify areas of strength
and weakness to develop practice towards person centred care (McCormack et al
2009).

Literature
An examination of the literature relating to pain assessment tools and cognitive
impairment and dementia was conducted by a one of the geriatricians, a
physiotherapist and nursing staff, with the help of the hospital librarian. A total of 17
behavioural pain assessment tools were identified. The abstracts for many of the
assessment tools were examined and inclusion/exclusion criteria agreed upon prior
to examining the specific assessment tools.

Table 2: Inclusion and exclusion criteria for the literature review

INCLUSION EXCLUSION
The tool needs to have been validated If the tool has not been validated or
used on real patients
Used on patients
Used in long-term care facilities only
Used in the acute care setting
Appears complex and difficult to use
Be easy to use (subjective)
Requires a lot of instruction/education
Clear appearance

As a result of this activity, the audit of practice and examination of literature, we

confirmed that assessment of pain was a problem on the complex care and trauma
wards and that there were a large number of behavioural assessment tools have
been produced. An assessment tool for cognitively impaired patients was not used
within the six wards involved in the project. This may be because there is no pain
behavioural assessment tool that has strong reliability and validity that can be
recommended for adoption in clinical practice (Herr et al 2006).

The results of the audit and examination of literature were presented and discussed
at a meeting of the steering group. The literature search had identified seven
assessment tools and the steering group examined them and rated the
appropriateness of the tools for use in practice. Three assessment tools obtained a
higher rating and these are highlighted in table 3.

Identifying a pain assessment tool for patients with cognitive impairment Page 6
 Table 3: Summary of literature examined for pain assessment tool
SCALE REFERENCE COMMENTS INITAIL
RATING
ABBEY Pain Abbey et al (2004) the abbey Validated Rated by
Scale scale: a 1 minute numerical Long-term care and relies on group as
indicator for people with end previous knowledge of 5-6 / 10
stage dementia. International patient
Journal of Palliative Nursing, Easy to use
10(1), 6-13.
Checklist of Feldt KS (2000) The Used on hip fracture Rated by
nonverbal pain checklist of nonverbal pain patients(n=88) group as
indicators (CNPI) indicators. Pain management Not pain specific, no grading 7 / 10
observation score Nursing of pain
1 (1) 13-21 Scores on movement and on
rest.
But the scoring system
confusing
PADE Pain Villaneuva MR et al (2003) 2 studies involving 25 and Rated by
assessment for Pain assessment for the then 40 residents over 10 day group as
the dementing dementing elderly reliability period 1/10
elderly and validity of a new Long-term care and extended
measure. Journal of the amount of time required.
American medical directors Lots of questions i.e. 23 and
association January/ over 2 pages long
February 4:1-8
PACSLAC Pain Fuchs-Lacelle S and List of 60 items with yes no Rated by
assessment Hadjistavropolous T (2004) responses. No measure of group as
checklist for development of and degree of pain. 3/10
seniors with preliminary validation of the Long-term care and relies on
limited ability to Pain assessment checklist knowledge of patients
communicate for seniors with limited ability Not validated- relied on care
to communicate. Pain givers providing a list of
Management Nursing 5(1) behaviours relating to pain
37-49
PAINAID Pain Warden V et al (2003) Small sample size all male Rated by
assessment IN development and and white. group as
advanced psychometric evaluation of Tested in nursing homes and 5/10
dementia the Pain assessment in specialist dementia care
advanced dementia. Journal units.
of the American directors Complicated to use and
Association January / misleading but we liked some
February 4: 9-15 aspects of the tool
PATCOA pain Decker SA and Paerry AG Validated using 116 post Rated by
assessment tool (2003) the development and surgical (orthopaedic) group as
in confused older testing of the PATCOA to patients. Statistically 2/10
adults assess pain in confused analyzed results
older adults. Pain 22 behaviours identified by
management nursing 4 (2) tool.
77-86 Looked complicated for use.
MOBID Husebo, B. S., et al (2007). Used in nursing homes and Rated by
Mobilization- Mobilization-observation- validated with just 26 group as
Observation- behaviour-intensity-dementia patients. 2/10
Behaviour- pain scale (MOBID): Suitable for long-term care,
Intensity- Development and validation chronic pain and muscular

Identifying a pain assessment tool for patients with cognitive impairment Page 7
Dementia of a nurse-administered pain
assessment tool for use in
dementia. Journal of Pain
and Symptom Management,
34(1), 67-80.
skeletal pain. Identifies three
pain behaviours and difficult
to elicit an intensity score

ACTION CYCLE 2

Workshops
Two workshops were held, participants included Registered Nurses,
Physiotherapists, Health Care Assistants (HCAs) and Student Nurses. Information
about cognitive impairment, delirium and dementia, pain assessment and the
management of pain for older people was presented. The workshop groups then
carried out a claims, concerns and issues exercise in relation to assessing pain in
patients with cognitive impairment. This exercise is based on fourth generation
evaluation to enable a focus on different stakeholders and leads to mutual
understanding between stakeholders (Guba and Lincoln 1989). See table 4.

Table 4: Summary of claims, concerns and Issues

Claims
That we do recognise pain in
patients with cognitive
impairment
Recognise that dementia
patients do feel pain
Talking and discussing pain
assessment for dementia
patients
Pain is recognised in
dementia patients by visual
rather than by asking them
Recording if in any pain
Discuss how we can improve
the management of pain for
individuals with cognitive
impairment with their
families/carers
Concerns
That pain in dementia
patients is ignored or not
recognised
Pre-judgement by health
professionals that people
with dementia do not
experience pain and so do
not address this
That we cannot get doctors
to recognise this and to
prescribe regular analgesia
Doctors not willing to
prescribe opiates for elderly
confused patients
Issues
Why do patients with
cognitive impairment not get
appropriate assessment in
regards to pain
How to get doctors to
recognise patients are in
pain
How to make sure the pain
does not get ignored
How to improve pain
management in the elderly
Recognising pain in people
with dementia and cognitive
impairment
Tools for dementia patients
to assess pain needed

This exercise was very useful and resulted in the identification of the workshop
participants desire to recognise and assess pain. It also recognised the need for an
assessment tool to provide consistent assessments in patients with cognitive
impairment and dementia. This assessment would identify pain and assist in
overcoming the problem of prescribing analgesia.

The seven behavioural pain assessment tools were also examined by workshop
participants to identify a suitable tool to use in practice. They identified three as
suitable for trial within the clinical area which were the same scales that were
identified by the steering group.

Identifying a pain assessment tool for patients with cognitive impairment Page 8
The assessment tools chosen for the trial were: The Abbey Scale, Pain Assessment
in Advanced Dementia (PAINAD) and Checklist for Non Verbal Indicators (CNVI).
Figure 1 presents the main features of the assessment tools.

Figure 1: main features of the pain assessment tools

Scale Abbey CNVI PAINAD

Vocalisation
Facial grimace
Body language
Behavioural changes Restless/rubbing
Physiological changes X X
Physical changes Breathing X (Consolability)

ACTION CYCLE 3

Six wards were involved in the project, four from the complex care, medical division
and two trauma, surgical wards, therefore two wards trialled one of the three
assessment tools.

A practitioner or champion from each ward who had attended the workshop and
demonstrated an interest volunteered to explain how to use the behavioural pain
assessment tool to staff and to promote its use within their ward.

Evaluation
A sheet to evaluate each assessment tool was produced and approved by the
steering group (Appendix 2). Six weeks after introducing the behavioural pain
assessment tools the staff on each ward were invited to evaluate their assessment
tool. This included ease of use, time taken to complete and any action taken as a
result of their assessment. They were asked to rate the assessment tool out of a
possible score of ten and to add any comments they wished.

Staff (HCAs, Assistant Practitioners, Registered Nurses, Student Nurses and

Physiotherapists) from four of the six wards completed and returned the evaluations.
All three scales were evaluated as understandable, easy to use and took between
one and five minutes to administer.

The overall mean rating for each scale

The evaluation asked practitioners to score the assessment tools out of 10 and the
average score obtained and comments are presented in table 5.

Table 5: Initial evaluation of three pain assessment tools

Assessment Tool PAINAD Abbey CNVI
Mean Score
(up to 10) 6.3 6.5 7
Comments Easy to follow and Gives prompts, Useful if analgesia
completed fast, it is effective and insufficient
Good to use helps justify
especially in those analgesia
who cannot
communicate

Identifying a pain assessment tool for patients with cognitive impairment Page 9
Other comments included:

Difficult to assess if patient has pain or dementia

Pain assessment in dementia is hard because they are shouting; it doesnt mean
they are in pain.
Find it hard to read body language
I would like more education
Assessment tool is not to be relied on, only as a guidance tool

The evaluations were discussed by the steering group. The assessment tools had
been positively accepted but the overall rating was similar for all three. It was
generally felt something was better than nothing! There was a need to evaluate the
tools further to establish if any one tool was appropriate.

A second trial was suggested and involved asking the wards to use a different
assessment tool to enable a comparison between the behavioural tools. The ward
staff agreed and the champions on each ward ensured that a different tool was
trialled on the wards.

Evaluation
The same evaluation sheet was used and completed six weeks after trialling the
tools for a second time.

The Abbey and PAINAD were again rated as understandable and easy to use by
100% of respondents. The CNVI was found to be understandable by 100%, but just
44% found it easy to use during the second evaluation, compared to 100% initially.
The time taken to carry out the assessments was between one and ten minutes for
all three tools.

Table 4: Final evaluation of three pain assessment tools

Assessment Tool PAINAD Abbey CNVI
Score
(up to 10) 7.75 7.4 4.2
Comments A very good pain like the It is not clear what the
assessment tool, documentation numerical scores
easy to use. Remove effective and justifies should actionP.would
the Cheyne stoke analgesia need several sheets
per day if patient on
regular observations.
no clear guidance as
when to action giving
pain relief
Nowhere to document
findings

Many practitioners asked for Cheyne stokes to be removed from the PAINAD
because Cheyne Stokes is a term used when an individuals breathing is very slow
and irregular with temporary cessation and is not associated with pain.

Identifying a pain assessment tool for patients with cognitive impairment Page 10
During the trial period relatives of patients with dementia / cognitive impairment
identified pain that had not been found using the assessment tool being trialled. The
individual patient did not appear to be in obvious pain and the assessment tools
failed to identify pain behaviour for a small number of patients. This indicated that
pain behaviour can be very individual and the literature describes this issue of
attempting to categorise behaviours that may indicate pain. For example Fuchs-
Lacelle and Hadjistavropolous (2004) identified 60 items and Decker and Paerry
(2003) 22 items. The assessment tool therefore helps to indicate pain, but is not to be
relied on entirely.

DISCUSSION

The project leader was the Acute Pain Nurse Specialist who could have examined
the literature and decided on a pain assessment tool from this literature and then told
practitioners to use it. This would be a conventional way of introducing a change to
practice using a linear or technical practice development approach. The outcomes of
the project are decided in advance by the facilitator and the staff are the instrument
through which practice is to be improved (Manley and McCormack 2004). The focus
is usually to apply new knowledge, or skills, behaviour and attitudes to improve
performance or productivity. There is an assumption that the change will be
unproblematic, linear and rational (Parkin 2009).This approach has been found to
result in limited changes in practice.

This project used an emancipatory practice development approach where

collaboration and participation with as many stakeholders as possible was
encouraged and the practitioners themselves shared the responsibility of introducing
the pain assessment tools (Manley and McCormack 2004). They examined the
literature and decided themselves which pain assessment tools to trial. This was
more successful than traditional models of change because the responsibility for the
change lies with the workplace team rather than policy makers who tend to be far
removed from the situation (Hall 2006). In this project the group itself defined the
issues, instigated, implemented and assessed actions for change in a collaborative
manner (Parkin 2009). Practitioners and managers usually wish to improve their own
service and they tend to feel more confident to say something about their own
situation and own the changes. Using a collaborative approach to the change was
viewed as less specialised or threatening for the clinicians involved (Fox, Green and
Martin 2009).

Participation was sustained by members of the ward teams who introduced and
explained the assessment tool to their colleagues. Because they were members of
the individual wards involved, they understood its context and at the same time it
increased their responsibility and ownership of the use of the assessment tool
(Manley 2004). It also demonstrated that the proposed assessment tools did not
require specialised training by the nurse specialist.

As a result of working through the action cycles members of the steering group and
practitioners from the wards developed a variety of skills including: literature
searching, analysis of the information obtained from the audit, the literature review
and the production of an evaluation sheet. Involvement of the clinical teams led to an
understanding of pain assessment and its difficulty, as indicated by some of the

Identifying a pain assessment tool for patients with cognitive impairment Page 11
comments made during the workshops and the evaluation of the tools. The
practitioners involved had also increased their knowledge and critical skills as a
result of examination and comparison of the various tools.

The CNVI assessment tool was originally devised for use in acute care whereas the
majority of tools were introduced for long-term care. Simply examining the literature
would have identified this tool (CNVI) as suitable for use in acute care. By
conducting the trials in clinical practice the project demonstrates how this tool was
not as easy to use as the other assessment tools. As a result of conducting trials
within practice and comparing the assessment tools the rating for the CNVI was
lower than the initial evaluation.

The PAINAD and the Abbey scales were rated equally. The Abbey Pain scale
provides a scoring system that is compatible with the pain score used within the
hospital. It was found to be subjective; there is little guidance to define the difference
between mild, moderate or severe changes in behaviour. Without previous
experience of caring for the individual this may cause different ratings. The PAINAD
does provide clearer guidance about rating but suggests that severe pain is indicated
by Cheyne Stokes respiration, which none of the steering group or clinicians agreed
with.

There were some patients where the scales failed to identify pain, but their relatives
did describe pain problems to nursing staff. The family or usual carer have not been
included in previous pain assessment scales and it was felt by everyone involved in
the project that this was an important factor.

As a result of the project a combination of the Abbey scale and the PAINAD was
produced and included a rating by a member of their family or usual care giver. A
chart to document the scoring system has also been produced. The Bolton Pain
Assessment Tool is now under trial on all six wards (Appendix 3).

CONCLUSION

There are a large number of behavioural pain assessment tools available, but they
are not used in everyday practice. Using a participatory approach and involving
clinical staff led to three pain tools actually being used in practice. The clinicians
evaluated and became critical of the scales and provided suggestions for
improvement.
From the literature, the CNVI assessment tool appeared to be suitable for acute care
(devised in acute trauma specialities) but in practice and when compared to other
tools it was not useful. None of the established tools were ideal and at times failed to
identify pain. The need to produce an assessment tool specifically for acute care was
identified. Ideally the pain assessment should involve relatives and/or established
carers.
We have produced an assessment tool which combines two established scales.
Behavioural pain assessment should always be used with other information and
ideally with someone who knows the individual well.

Identifying a pain assessment tool for patients with cognitive impairment Page 12
ACKNOWLEDGEMENTS
As the project lead I would like to express my gratitude to Theresa Shaw and the
Foundation of Nursing Studies for their support during the project. The clinicians
involved in this project have demonstrated a real desire to improve their practice,
have been enthusiastic and collaboratively contributed towards it. I would like to say
a massive THANK YOU to all the members of the steering group, especially Dr Emily
Feilding for her support and critical appraisal and the ward Champions who have
encouraged their colleagues to use the various assessment tools and then evaluate
them.

Identifying a pain assessment tool for patients with cognitive impairment Page 13
REFERENCES
Abbey, J.A., Piller, N., DeBellis, A, Esterman, A., Parker, D., Giles, L. & Lowcay, B.
(2004). The Abbey Pain Scale. A 1-minute numerical indicator for people with
late-stage dementia. International Journal of Palliative Nursing, 10(1), 6-13.

Clinical Standards Advisory Group (CSAG) (1999) Services for patients with pain.
London Clinical Standards Advisory Group.

Department of Health (2009) Living well with dementia: A national Strategy. London.
Department of Health.

Donovan M Dillon P and Mc Guire L (1987) Incidence and characteristics of pain in a

sample of medical-surgical patients Pain. 30 69-78.

Feldt, K. S. (2000) The Checklist of Nonverbal Pain Indicators (CNPI). Pain

Management Nursing, 1(1)

Fox M, Martin P, and Green G (2007) Doing Practitioner Research London Sage

Fuchs-Lacelle S, Hadjistavropoulos T (2004), Development and preliminary

validation of the pain assessment checklist for seniors with limited ability to
communicate (PACSLAC) Pain Management Nursing. Vol.5: pp3749.

Guba EG and Lincoln YS (1989) Fourth generation evaluation. Newbury Park. Sage
publication

Hall (2006) Hall JE (2006) Professionalizing action research a meaningful strategy

for modernizing services? Journal of Nursing Management. 14, 195-200. In Parkin P
(2009).Managing Change in Healthcare Using Action Research. London. Sage
Publications.

Herr K, Coyne PJ, Key T, et al (2006) Pain assessment in the nonverbal patient: a
position statement with clinical practice recommendations. Pain Management
Nursing 7 (2) 44-52

Kaasalainen S and Crook J (2004) An exploration of seniors ability to report pain.

Clinical Nursing Research. 13, 2 , 199-215.

Manley K (2004) Transformational culture. A culture of Effectiveness. Chp 4 in

McCormack B, Manley K and Garbett R (editors) (2004) Practice Development in

Nursing. Oxford Blackwell Publishing.

Manley K. and Mc Cormack B.(2004) Practice Development Purpose ,Methodology,

Facilitation and Evaluation. Chapter 3 in Mc Cormack B, Manley K and Garbett R
(Eds) (2004) Practice Development in Nursing. Oxford Blackwell Publishing.
McCaffery M and Pasero C (1999) PAIN: clinical manual. (Second edition) St Louis,
Mosby.

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McCormack, B., McCarthy, G., Wright, et al (2009) Development and testing of the
Context Assessment Index (CAI) Worldviews on Evidence Based Nursing. Vol. 6.
No. 1. pp27-25

Murdock J and Larsen D (2004) Assessing pain in cognitively impaired older adults.
Nursing Standard 18 (38) 33-39

Parkin P (2009).Managing Change in Healthcare Using Action Research. London.

Sage Publications. Strong J, Unruh A M, Wright A, Baxter DG (2002) Pain. A text
book for Therapists. Edinburgh, Churchill Livingstone.

Villanueva, M. R., Smith, T. L., Erickson, J. S., Lee, A. C., & Singer, C. M. (2003).
Pain assessment for the Dementing Elderly (PADE): Reliability and validity of a new
measure. Journal of the American Medical Directors Association, 4(1), 1-8

Warden, V., Hurley, A.C., Volicer, L. (2003). Development and psychometric

evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal
of the American Medical Directors, Jan/Feb, 9-15.

Zwakhalen SMG, Dongen KAJ, Hamers JPH, ABU-Saad HH (2004) Pain

assessment in intellectually disabled people: non-verbal indicators. Journal of
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Identifying a pain assessment tool for patients with cognitive impairment Page 15
 APPENDIX 1
MEMBERS OF THE STEERING GROUP

NAME PROFESSIONAL GROUP AREA OF PRACTICE

JULIE GREGORY ACUTE PAIN NURSE PAIN MANAGEMENT
GWEN AINSWORTH TEAM LEADER COMPLEX CARE
(PHYSIOTHERAPY)
WENDY COLE SENIOR COMPLEX CARE
PHYSIOTHERAPIST
DR EMILY FEILDING CONSULTANT COMPLEX CARE
GERIATRICAN
ANITA HOLME WARD SISTER COMPLEX CARE
CHRIS VERNON WARD MANAGER COMPLEX CARE
USHER PATEL STAFF NURSE COMPLEX CARE
ANDREW FEARN STAFF NURSE COMPLEX CARE
SAMANTHA SPENCER STAFF NURSE COMPLEX CARE
GALE PARTINGTON WARD MANAGER COMPLEX CARE
FELICIA ONWUDIKIE MATRON COMPLEX CARE
DAWN MAGEE STAFF NURSE COMPLEX CARE
GILL ZAJEC ROLES CLINICAL NURSE MENTAL HEALTH AND
SPECIALIST/ MENTAL ELDERLY
HELATH LIASON
GEMMA TIMPSON TRAUMA CO- ORTHOPEADICS AND
ORDIBNATOR NURSE TRAUMA
JULIE PILKINGTON MATRON ORTHOPEADICS AND
TRAUMA
SHARON ROBINSON STAFF NURSE ORTHOPEADICS AND
TRAUMA
JOANNE BONNEY STAFF NURSE ORTHOPEADICS AND
TRAUMA
JANICE TAYLOR WARD MANAGER ORTHOPEADICS AND
TRAUMA
ELIZABETH PATEL CNS COPS TEAM ORTHOPEADICS AND
TRAUMA

Identifying a pain assessment tool for patients with cognitive impairment Page 16
 APPENDIX 2
EVALUATION OF PAIN ASSESSMENT TOOL
FOR COGNITIVELY IMPAIRED / DEMENTIA PATIENTS

Ward

You are?

Reg Assistant Physiotherapist Occupational HCA doctor Other,

Nurse Practitioner therapist please
state

1. Did you understand how to use the assessment tool? YES/ NO

2. Was it easy to complete?

3. How long did it take to assess the pain/Complete the tool? ------------

4. Did the use of this assessment tool prompt you to act? YES /NO

If yes, what action did you take?

5. Do you feel there is anything that needs to be added to the pain assessment tool?

Is there anything that is not required?

6. Overall how would you rate this pain assessment tool? (Indicate on the scale 1=
Not useful and 10 = very useful)
1 2 3 4 5 6 7 8 9 10

Can you please explain your rating?

Any other comments:

Thank you

Identifying a pain assessment tool for patients with cognitive impairment Page 17
 BOLTON PAIN ASSESSMENT SCALE
NAME OF PATIENTPPPPPPPPPPPPPPPPPPPPPPPP.
NAME AND DESIGNATION OF PERSON COMPLETING SCORE:PPPPPPPPPPPPPPPPPP
DATE AND TIMEPPPPPPPPPPPPPPPPPP
SCORE ABSENT 0 MILD 1 MODERATE 2 SEVERE 3 SCORE
Occasional moan or Low level speech with a Repeatedly crying out, loud
VOCALISATION none groan negative or disapproving moaning or crying
quality

FACIAL EXPRESSION Smiling or Looking tense, Sad Grimacing and looks

e.g. relaxed Frowning, frightened

CHANGE IN BODY None Tense, fidgeting Guarding part of the Withdrawn, rigid, fists
LANGUAGE body, clenched. Knees pulled up
Refusing to eat, Pulling or pushing away,
BEHAVIOURAL CHANGE None Increased confusion alterations in usual striking out
pattern
Occasional laboured Hyperventilation, Change in pulse BP,
PHYSIOLOGICAL CHANGE Normal breath, increased increased heart rate and respiratory rate and
heart rate BP perspiring, flushed or pallor

PHYSICAL CHANGES None Skin tears Pressure sores, arthritis Post surgery, trauma,
Comments by family or usual care
givers
Pain on movement/ physiotherapy

0-2 = no pain (0) 3-7 = mild pain (1) 9-13 = moderate pain 14+ severe pain (3)
(2)
Royal Bolton Hospital NHS Foundation Trust 2011. All rights reserved. Not to be reproduced in whole or in part without the
permission of the copyright owner.
Identifying a pain assessment tool for patients with cognitive impairment Page 2