Assessing Post-Hip Surgical Pain in Hospitalized Older Adults with Severe Dementia

Abstract

Patients with severe cognitive impairment experience undertreated pain because health care providers assessments rely on the gold standard of self-report. Observational tools that use behaviors indicative of pain are necessary when self-report is unobtainable. A single-group repeated measures design was used to compare The Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and the Pain Assessment for Advanced Dementia (PAINAD) on older patients with severe cognitive impairment experiencing post-surgical hip fracture pain. Twenty-four patients with hip fracture requiring surgery were assessed three times over 72 hours. Inter-rater reliability was more consistent across time on the PACSLAC than the PAINAD. A novel statistical approach of using reliable change index showed similar patient-level agreement of increase, decrease, and no change in pain scores over time. Consequently, pain scores of both tools did not follow the expected trajectory of decrease pain over time post-surgery. The nurses who participated, preferred the PAINAD because of its familiarity and brevity. While some nurses preferred the PACSLAC for its comprehensive nature to assess pain effectively in patients with severe dementia. More studies using reliable change on other observational pain tools with a larger sample are necessary to find the most sensitive tool for this patient population.