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Clinimetric properties of the electronic Pain Assessment Tool (ePAT) for aged-care residents with moderate to severe dementia

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Purpose Accurate pain assessment is critical to detect pain and facilitate effective pain management in dementia patients. The electronic Pain Assessment Tool (ePAT) is a point-of-care solution that uses automated facial analysis in conjunction with other clinical indicators to evaluate the presence and intensity of pain in patients with dementia. This study aimed to examine clini-metric properties (clinical utility and predictive validity) of the ePAT in this population group. Methods Data were extracted from a prospective validation (observational) study of the ePAT in dementia patients who were ≥65 years of age, living in a facility for ≥3 months, and had Psychogeriatric Assessment Scales – cognitive scores ≥10. The study was conducted in two residential aged-care facilities in Perth, Western Australia, where residents were sampled using purposive convenience strategy. Predictive validity was measured using accuracy statistics (sensitivity, specificity, positive predictive value, and negative predictive value). Positive and negative clinical utility index (CUI) scores were calculated using Mitchell’s formula. Calculations were based on comparison with the Abbey Pain Scale, which was used as a criterion reference. Results A total of 400 paired pain assessments for 34 residents (mean age 85.5±6.3 years, range 68.0–93.2 years) with moderate–severe dementia (Psychogeriatric Assessment Scales – cognitive score 11–21) were included in the analysis. Of those, 303 episodes were classified as pain by the ePAT based on a cutoff score of 7. Unadjusted prevalence findings were sensitivity 96.1% (95% CI 93.9%–98.3%), specificity 91.4% (95% CI 85.7%–97.1%), accuracy 95.0% (95% CI 92.9%–97.1%), positive predictive value 97.4% (95% CI 95.6%–99.2%), negative predictive value 87.6% (95% CI 81.1%–94.2%), CUI⁺ 0.936 (95% CI 0.911–0.960), CUI⁻ 0.801 (95% CI 0.748–0.854). Conclusion The clinimetric properties demonstrated were excellent, thus supporting the clinical usefulness of the ePAT when identifying pain in patients with moderate–severe dementia.
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... 12 Assessing pain usually begins with a person's verbal or non-verbal self-report using pain assessment tools but this can be challenging in older patients, consequently, technology-driven pain assessments have been developed to improve pain assessment in these patients. [13][14][15] One such application is PainChek Universal (www.painchek.com), which has sound psychometric validity and reliability and enables better assessment of pain at the point of care for patients whose ability to communicate fluctuates. ...
... PainChek uses automated facial recognition and analysis to identify pain-related facial microexpressions, together with a series of user completed checklists of pain behaviours to produce a pain score. [13][14][15] PainChek has been implemented and evaluated in aged care settings; however, no previous studies have evaluated its effectiveness in an AC setting. [13][14][15][16] Multicomponent interventions involving volunteers for hospitalised older adults improve clinical outcomes, with a reduction in fall rates, incidences of delirium, pain and reduced length of stay. ...
... [13][14][15] PainChek has been implemented and evaluated in aged care settings; however, no previous studies have evaluated its effectiveness in an AC setting. [13][14][15][16] Multicomponent interventions involving volunteers for hospitalised older adults improve clinical outcomes, with a reduction in fall rates, incidences of delirium, pain and reduced length of stay. 17 Volunteer programmes such as the Hospital Elder Life Program (HELP), which includes multicomponent physical, nutritional and cognitive strategies, have been implemented successfully around the world and have been shown to improve quality and effectiveness of care of hospitalised older adults; to maintain cognitive and physical functioning of high-risk older adults throughout hospitalisation; maximise independence at discharge; assist with the transition from hospital to home; and prevent unplanned hospital readmissions. ...
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Introduction Hospitalised older adults are prone to functional deterioration, which is more evident in frail older patients and can be further exacerbated by pain. Two interventions that have the potential to prevent progression of frailty and improve patient outcomes in hospitalised older adults but have yet to be subject to clinical trials are nurse-led volunteer support and technology-driven assessment of pain. Methods and analysis This single-centre, prospective, non-blinded, cluster randomised controlled trial will compare the efficacy of nurse-led volunteer support, technology-driven pain assessment and the combination of the two interventions to usual care for hospitalised older adults. Prior to commencing recruitment, the intervention and control conditions will be randomised across four wards. Recruitment will continue for 12 months. Data will be collected on admission, at discharge and at 30 days post discharge, with additional data collected during hospitalisation comprising records of pain assessment and volunteer support activity. The primary outcome of this study will be the change in frailty between both admission and discharge, and admission and 30 days, and secondary outcomes include length of stay, adverse events, discharge destination, quality of life, depression, cognitive function, functional independence, pain scores, pain management intervention (type and frequency) and unplanned 30-day readmissions. Stakeholder evaluation and an economic analysis of the interventions will also be conducted. Ethics and dissemination Ethical approval has been granted by Human Research Ethics Committees at Ramsay Health Care WA|SA (number: 2057) and Edith Cowan University (number: 2021-02210-SAUNDERS). The findings will be disseminated through conference presentations, peer-reviewed publications and social media. Trial registration number ACTRN12620001173987.
... Additionally, there is a lack of consensus in the literature about which behaviour signs are valid indicators of pain and differentiating this with psychological symptoms such as fear or anxiety [44]. This has been explored in relation to a novel pain assessment tool, the ePAT [17,25]. Hoti et al. (2018) found that facial descriptors are valid indicators of pain for nonverbal individuals living with advanced dementia. ...
... This has been explored in relation to a novel pain assessment tool, the ePAT [17,25]. Hoti et al. (2018) found that facial descriptors are valid indicators of pain for nonverbal individuals living with advanced dementia. Additionally ePAT was found to have strong clinimetric properties. ...
... Social heterogeneity was also evident in the literature. Across the studies, demographic detail provided was basic; frequently limited to age and gender [18,22,27] and two with references to the percentage of Caucasians in the sample [21,25]. Information on factors such as ethnicity, education levels, and socio-economic background of participants or assessors is absent or minimal, which may impact on the expression, interpretation, and assessments of pain [16,17,37,40]. ...
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Pain is prevalent in older people, especially in those with advanced dementia who have communication impairments. Although pain is recognised to be present in this population, it is often under-assessed and ineffectively managed. The assessment of pain in advanced dementia is extremely challenging and complex, particularly in institutional settings such as care homes. This study systematically reviews the literature to examine and characterise the evidence for the use of pain assessment tools in care homes with individuals living with advanced dementia. Relevant publications were sourced from electronic bibliometric medical databases including AMED, CINAHL Plus, Medline, PsycINFO, EMBASE, TRIP Pro, Google Scholar, and HINARI. The database search was supplemented by screening citations and reference lists, in addition to a grey literature searches. The search identified 2221 studies, among which 26 were included in the review. The majority of the studies were observational, which created a rich source of data to create four major themes. The findings were informed and shaped by working with key stakeholders to develop a conceptual model that can contribute to developing evidence-based practice. This highlights the importance of a comprehensive, multi-disciplinary approach to pain assessment in this population, which is beyond the use of tools.
... More details on how the PainChek® tool works has been published elsewhere [19]. PainChek® has previously undergone psychometric [18,20] and clinimetric [21] evaluations in Australia, and has demonstrated significant potential for use in the assessment of pain in people with moderate-to-severe dementia when compared to the APS. In 2018 the Royal College of Physicians, British Pain Society and British Geriatric Society provided guidelines for observational pain assessment in older people with dementia. ...
... It is an observational pain assessment tool which consists of 42 items spread across six domains; namely The Face (n = 9), The Voice (n = 9), The Movement (n = 7), The Behaviour (n = 7), The Activity (n = 4) and The Body (n = 6) [30]. Items included in PainChek® cover all six pain domains recommended by the AGS [21] for accurate and reliable observational pain assessment in people with cognitive impairment (See Table 1). However, the items in The Face domain have been based around the FACS, because as reported by Beach et al. [33], behavioural pain scales that have objective facial measures have better psychometric properties, than those containing vague facial descriptors. ...
... The instrument informs the user about the intensity of present pain, which adds to its clinical utility in that the choice of analgesics is often based on the intensity of the pain detected. The cut-off points for different pain intensities have previously established against the APS [21]. However, to date no studies have been reported that evaluated the impact of PainChek® use on clinical outcomes, although this is planned as part of a major implementation trial in aged care currently underway in Australia. ...
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Background The aim of this study was to further validate PainChek®, an electronic pain assessment instrument, with a population living with dementia in a UK care home. Method This study utilised a correlational design to evaluate the psychometric properties of PainChek® when compared to the Abbey Pain Scale (APS). Blinded paired pain assessments were completed at rest and immediately post-movement by a researcher and a nurse. A total of 22 participants with a diagnosis of moderate-to-severe dementia and a painful condition were recruited using opportunity sampling. Results Overall, 302 paired assessments were collected for 22 participants. Out of these 179 were conducted during rest and 123 were immediately post-movement. The results demonstrated a positive significant correlation between overall PainChek® pain scores and overall APS pain scores ( r = 0.818, N = 302, p < .001, one-tailed), satisfactory internal consistency (α = 0.810), moderate single measure intraclass correlation (ICC = 0.680) and substantial inter-rater agreement (κ = 0.719). Conclusions PainChek® has demonstrated to be a valid and reliable instrument to assess the presence and severity of pain in people with moderate-to-severe dementia living in aged care.
... The total of these behaviours informs the pain intensity according to the following categories: no pain (0-6), mild (7-11), moderate (12-15) and severe (≥16). 44 45 Based on a number of clinical studies (total participants n=74, 753 paired pain assessments) the PainChek application has demonstrated sound psychometric validity and reliability and clinical utility in people with moderate-to-severe dementia. [44][45][46][47] The prevalence of pain has not previously been assessed across an entire hospital using a technology driven assessment of pain. ...
... 44 45 Based on a number of clinical studies (total participants n=74, 753 paired pain assessments) the PainChek application has demonstrated sound psychometric validity and reliability and clinical utility in people with moderate-to-severe dementia. [44][45][46][47] The prevalence of pain has not previously been assessed across an entire hospital using a technology driven assessment of pain. The use of such a device would allow data to be collected from all participants including those unable to provide a reliable self-report rating of their pain. ...
... Percentage prevalence of pain across the whole sample and by specialty will be calculated separately for PainChek scores (≤6 no pain, ≥7 pain), 45 numerical ratings of current pain (0 no pain, ≥1 pain) and numerical ratings of worst pain in the last 24 hours (0 no pain, ≥1 pain). Demographic characteristics of the patients reporting pain vs no pain will be described and explored. ...
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Introduction Frailty and pain are associated with adverse patient clinical outcomes and healthcare system costs. Frailty and pain can interact, such that symptoms of frailty can make pain assessment difficult and pain can exacerbate the progression of frailty. The prevalence of frailty and pain and their concurrence in hospital settings are not well understood, and patients with cognitive impairment are often excluded from pain prevalence studies due to difficulties assessing their pain. The aim of this study is to determine the prevalence of frailty and pain in adult inpatients, including those with cognitive impairment, in an acute care private metropolitan hospital in Western Australia. Methods and analysis A prospective, observational, single-day point prevalence, cross-sectional study of frailty and pain intensity of all inpatients (excluding day surgery and critical care units) will be undertaken. Frailty will be assessed using the modified Reported Edmonton Frail Scale. Current pain intensity will be assessed using the PainChek smart-device application enabling pain assessment in people unable to report pain due to cognitive impairment. Participants will also provide a numerical rating of the intensity of current pain and the worst pain experienced in the previous 24 hours. Demographic and clinical information will be collected from patient files. The overall response rate of the survey will be reported, as well as the percentage prevalence of frailty and of pain in the sample (separately for PainChek scores and numerical ratings). Additional statistical modelling will be conducted comparing frailty scores with pain scores, adjusting for covariates including age, gender, ward type and reason for admission. Ethics and dissemination Ethical approval has been granted by Ramsay Health Care Human Research Ethics Committee WA/SA (reference: 2038) and Edith Cowan University Human Research Ethics Committee (reference: 2020–02008-SAUNDERS). Findings will be widely disseminated through conference presentations, peer-reviewed publications and social media. Trial registration number ACTRN12620000904976.
... 4 The electronic Pain Assessment Tool (ePAT, or PainChek) adapts automated facial analysis technology to improve recognition of pain in this population and is validated against the APS. 9 It is important to include insights and observations from family members and familiar carers about behaviour that may be pain related. ...
Article
Chronic non-cancer pain is a common problem among older people and has a significant impact on their quality of life. Medical comorbidities and polypharmacy are often additional challenges in managing these patients Appropriate assessment of chronic non-cancer pain is important for the development of a patient-centred, goal-directed management plan. When assessing patients with cognitive impairment, modified communication strategies and validated pain assessment tools can be useful The quantity and quality of the evidence supporting individual drugs in the management of chronic non-cancer pain varies and studies focused on frail older people are limited. Caution is generally advised when introducing drugs and escalating the doses Drugs that are not effective should be stopped. A shared decision-making approach is advised for deprescribing analgesics used for chronic non-cancer pain.
... They were obtained by cross tabulating the raw PainChek R scores against the APS categories, and optimum cutoff scores were obtained in a manner similar to a discriminant analysis (12). The PainChek R pain scale has demonstrated strong psychometric (validity, reliability, internal consistency) and clinimetric (sensitivity, specificity, accuracy) properties in PLWD (12,21,22). ...
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Pain is common in people living with dementia (PLWD), including those with limited verbal skills. Facial expressions are key behavioral indicators of the pain experience in this group. However, there is a lack of real-world studies to report the prevalence and associations of pain-relevant facial micro-expressions in PLWD. In this observational retrospective study, pain related facial features were studied in a sample of 3,144 PLWD [mean age 83.3 years (SD = 9.0); 59.0% female] using the Face domain of PainChek®, a point-of-care medical device application. Pain assessments were completed by 389 users from two national dementia-specific care programs and 34 Australian aged care homes. Our analysis focused on the frequency, distribution, and associations of facial action units [AU(s)] with respect to various pain intensity groups. A total of 22,194 pain assessments were completed. Of the AUs present, AU7 (eyelid tightening) was the most frequent facial expression (48.6%) detected, followed by AU43 (closing eyes; 42.9%) and AU6 (cheek raising; 42.1%) during severe pain. AU20 (horizontal mouth stretch) was the most predictive facial action of higher pain scores. Eye-related AUs (AU6, AU7, AU43) and brow-related AUs (AU4) were more common than mouth-related AUs (e.g., AU20, AU25) during higher pain intensities. No significant effect was found for age or gender. These findings offer further understanding of facial expressions during clinical pain in PLWD and confirm the usefulness of artificial intelligence (AI)-enabled real-time analysis of the face as part of the assessment of pain in aged care clinical practice.
... PainChek has shown good concurrent validity and internal consistency for assessing pain in people with dementia Hoti et al., 2018), preconditions for its broad clinical application to test the efficacy of interventions to manage pain in people with dementia living in RACFs (e.g. training, costs, implementation barriers, the acceptance of using the technology) need further research. ...
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Aim This study aims to test the feasibility of the PainChek app to assess pain for people with dementia living in residential aged care facilities (RACFs). It will also identify the optimal dosage and efficacy of a social robot (personal assistant robot [PARO]) intervention on chronic pain for people with dementia. Design This is a feasibility randomized controlled trial with three groups. Methods Forty-five residents living with dementia and chronic pain will be recruited from one RACF. The intervention consists of an individual 15-min non-facilitated session with a PARO robot twice a day (Group 1), a PARO robot once a day (Group 2), or a Plush-Toy (non-robotic PARO) once a day (Group 3) from Monday to Friday for 4 weeks. Participants will be followed at 4 and 8 weeks after baseline assessments. The primary outcome will be the feasibility of using the PainChek app to measure changes in pain levels before and after each session. Secondary outcomes include staff-rated pain levels, neuropsychiatric symptoms, quality of life and changes in psychotropic and analgesic medication use. Participants, staff and family perceptions of using PARO and the PainChek app will be collected after the 4-week intervention. Discussion This study will test the use of the PainChek app and PARO to improve pain management for people with dementia. Results from this study will help determine its usefulness, feasibility and acceptability for pain management in people with dementia living in RACFs. Impact As pain is a significant problem for people with dementia, this project will generate evidence on the use of the PainChek to measure the efficacy of a social robot intervention that has the potential to improve the quality of pain care in people with dementia. Trial Registration Australian and New Zealand Clinical Trials Registry number (ACTRN12621000837820) date registered 30/06/2021.
... Also, there's potential to explore digital or gamelike apps to make pediatric self-measurements more engaging for children. Apps like electronic Pain Assessment Tool (ePAT) or PainChek® used in older adult patients, use AI technology for facial analysis to evaluate the presence and intensity of pain [41,42]. Such digital apps and game-like formats for PRO assessments will help children be more interested in providing measurements and improve the evaluation of symptoms that children struggle to verbalize or articulate. ...
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Objective To provide an assessment of the quality of the most frequently used self-reported, generic patient-reported outcome measures (PROMs) that measure health-related quality of life (HRQoL) in children against the good research practices recommended by ISPOR task force for the pediatric population. Method Literature search was conducted on OvidSP database to identify the generic pediatric PROMs used in published clinical studies. The quality of PROMs used in more than ten clinical studies were descriptively evaluated against the ISPOR task force’s good research practices. Results Six PROMs were evaluated, namely Pediatric Quality-of-Life inventory 4.0 (PedsQL), Child Health Questionnaire (CHQ), KIDSCREEN, KINDL, DISABKIDS and Child Health and Illness Profile (CHIP). All PROMs, except KIDSCREEN, had versions for different age ranges. Domains of physical, social, emotional health and school activities were common across all the instruments, while domains of family activities, parent relations, independence, and self-esteem were not present in all. Children’s input was sought during the development process of PROMs. Likert scales were used in all the instruments, supplemented with faces (smileys) in instruments for children under 8 years. KIDSCREEN and DISABKIDS were developed in a European collaboration project considering the cross-cultural impact during development. Conclusion The comparison of the instruments highlights differences in the versions for different pediatric age groups. None of the PROMs fulfill all the good research practices recommended by the ISPOR task force. Further research is needed to define which age-appropriate domains are important for older children and adolescents.
... Further, the authors rightly point out the importance of using novel and automated methods in capturing facial expressions of pain in an attempt to improve pain assessment in this population [8,10]. These methods have proven to be effective in recognizing pain with strong psycho- metric and clinimetric properties in people living with dementia [8,[11][12][13]. ...
... 82 Yet, this was possibly minimized in our study by the familiarity of consultants with residents' behaviors and the use of a robust, systemized, and structured pain assessment, which was validated in RACHs. 35,36,71,83 This assessment puts less emphasis on changes in physiological indicators (e.g., temperature) because these can be influenced by confounders (e.g., medications) and may be blunt and less useful in mild-moderate or chronic pain, particularly in those with AD. 36,84e87 Clinical Implications ...
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Context: Pain is linked to behaviours and psychological symptoms of dementia (BPSD); however, it often remains under-recognised in this population. Objectives: We aimed to investigate the prevalence and intensity of pain in people living in aged care homes with BPSD and by dementia subtypes, and the association between pain intensity and specific BPSD. Methods: A 1-year retrospective cross-sectional analysis was conducted on BPSD and the presence of pain in referrals to a national BPSD support service using the Neuropsychiatric Inventory (NPI) and PainChek®, respectively. Referrals were categorised into two groups: Pain group and No Pain group. Results: Of the 479 referrals (81.9 ± 8.3 years old) included in the analysis, two-thirds (65.6%) had pain identified with almost half (48.4%) of these categorised as experiencing moderate-severe pain. Pain was highly prevalent (range: 54.6-78.6%) in all subtypes of dementia, particularly in mixed dementia and DLB. Compared to the No Pain group, the Pain group had 25.3% more neuropsychiatric behaviours, 33.6% higher total severity of these behaviours, and 31.4% higher total distress caused to caregivers. For all results, effect sizes were small to medium (η²p = 0.04-0.06). Despite a high prevalence of aggressive or agitated behaviours across the entire group, the Pain group was 3.8 times more likely to experience these behaviours compared to referrals not in pain. Conclusion: There is a strong need to consider the possibility of pain as a contributor to behavioural changes in aged care residents living with dementia.
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Background/aims: Pain is common in aged care residents with dementia; yet it often goes undetected. A novel tool, the electronic Pain Assessment Tool (ePAT), was developed to address this challenging problem. We investigated the psychometric properties of the ePAT. Methods: In a 10-week prospective observational study, the ePAT was evaluated by comparison against the Abbey Pain Scale (APS). Pain assessments were blindly co-performed by the ePAT rater against the nursing staff of two residential aged care facilities. The residents were assessed twice by each rater: at rest and following movement. Results: The study involved 34 residents aged 85.5 ± 6.3 years, predominantly with severe dementia (Psychogeriatric Assessment Scale - Cognitive Impairment score = 19.7 ± 2.5). Four hundred paired assessments (n = 204 during rest; n = 196 following movement) were performed. Concurrent validity (r = 0.911) and all reliability measures (κw = 0.857; intraclass correlation coefficient = 0.904; α = 0.950) were excellent, while discriminant validity and predictive validity were good. Conclusion: The ePAT is a suitable tool for the assessment of pain in this vulnerable population.
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Pain is common among people with moderate to severe dementia, but inability of patients to self-report means it often goes undetected and untreated. We developed the electronic Pain Assessment Tool (ePAT) to address this issue. A point-of-care App, it utilizes facial recognition technology to detect facial micro-expressions indicative of pain. ePAT also records the presence of pain-related behaviors under five additional domains (Voice, Movement, Behavior, Activity, and Body). In this observational study, we assessed the psychometric properties of ePAT compared to the Abbey Pain Scale (APS). Forty aged care residents (70% females) over the age of 60 years, with moderate to severe dementia and a history of pain-related condition(s) were recruited into the study. Three hundred and fifty-three paired pain assessments (either at rest or post-movement) were recorded and analyzed. The ePAT demonstrated excellent concurrent validity (r = 0.882, 95% CI: 0.857-0.903) and good discriminant validity. Inter-rater reliability score was good overall (weighted κ= 0.74, 95% CI: 0.68-0.80) while internal consistency was excellent. ePAT has psychometric properties which make it suitable for use in non-communicative patients with dementia. ePAT also has the advantage of automated facial expression assessment which provides objective and reproducible evidence of the presence of pain.
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Background The management of pain in long-term care residents with dementia is complex. A prospective exploratory study was conducted to describe the course of pain and pain management strategies following a guideline-based pain assessment procedure in long-term care (LTC) residents with pain and dementia. Measures Pain observations with the MOBID-2 Pain Scale, review of the medical records and pharmacy files and physical examination of LTC residents with pain and dementia. Intervention Communication of the assessment results to the attending physician including guideline-based treatment recommendations. Outcomes After three months complete follow-up data was obtained for 64 residents. Pain intensity was significantly reduced (p <0.001). The proportion of residents with persistent pain was 58% and the total number of analgesic prescriptions did not change significantly. Conclusions There is room for improvement regarding pain management in LTC residents with pain and dementia, and performance feedback seems a promising strategy to explore further.
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Background: Assessment and management of pain in patients with dementia is known to be challenging, due to patients' cognitive and/or communication difficulties. In the UK, pain in hospital is managed through regular assessments, with the use of pain intensity scores as triggers for action. The aim of this study was to understand current pain assessment practices, in order to later inform the development of a decision support tool designed to improve the management of pain for people with dementia in hospital. Methods: An exploratory study was conducted in four hospitals in the UK (11 wards), with observations of patients with dementia (n = 31), interviews of staff (n = 52) and patients' family members (n = 4) and documentary analysis. A thematic analysis was carried out, structured along dimensions of decision making. This paper focuses on the emergent themes related to the use of assessment tools and pain intensity scores. Results: A variety of tools were used to record pain intensity, usually with numerical scales. None of the tools in actual use had been specifically designed for patients with cognitive impairment. With patients with more severe dementia, the patient's body language and other cues were studied to infer pain intensity and then a score entered on behalf of the patient. Information regarding the temporality of pain and changes in pain experience (rather than a score at a single point in time) seemed to be most useful to the assessment of pain. Conclusions: Given the inherent uncertainty of the meaning of pain scores for patients with dementia, numerical scales were used with caution. Numerical scores triggered action but their meaning was relative - to the patient, to the clinician, to the time of recording and to the purpose of documenting. There are implications for use of data and computerized decision support systems design. Decision support interventions should include personalized alerting cut-off scores for individual patients, display pain scores over time and integrate professional narratives, mitigating uncertainties around single pain scores for patients with dementia.
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There is evidence of under-detection and poor management of pain in patients with dementia, in both long-term and acute care. Accurate assessment of pain in people with dementia is challenging and pain assessment tools have received considerable attention over the years, with an increasing number of tools made available. Systematic reviews on the evidence of their validity and utility mostly compare different sets of tools. This review of systematic reviews analyses and summarises evidence concerning the psychometric properties and clinical utility of pain assessment tools in adults with dementia or cognitive impairment. We searched for systematic reviews of pain assessment tools providing evidence of reliability, validity and clinical utility. Two reviewers independently assessed each review and extracted data from them, with a third reviewer mediating when consensus was not reached. Analysis of the data was carried out collaboratively. The reviews were synthesised using a narrative synthesis approach. We retrieved 441 potentially eligible reviews, 23 met the criteria for inclusion and 8 provided data for extraction. Each review evaluated between 8 and 13 tools, in aggregate providing evidence on a total of 28 tools. The quality of the reviews varied and the reporting often lacked sufficient methodological detail for quality assessment. The 28 tools appear to have been studied in a variety of settings and with varied types of patients. The reviews identified several methodological limitations across the original studies. The lack of a ‘gold standard’ significantly hinders the evaluation of tools’ validity. Most importantly, the samples were small providing limited evidence for use of any of the tools across settings or populations. There are a considerable number of pain assessment tools available for use with the elderly cognitive impaired population. However there is limited evidence about their reliability, validity and clinical utility. On the basis of this review no one tool can be recommended given the existing evidence.
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Aim: To validate a Danish version of the observational Abbey Pain Scale (APS) in a geriatric ward. Material and methods: The study population consisted of 50 old patients (70+ years), consecutively admitted to the geriatric wards of Aarhus University Hospital, Denmark, and fulfilling one of the following inclusion criteria: Mini Mental State Examination (MMSE) < 5, delirium, non-communicative aphasia, or unconsciousness. APS has six subscales and ranges from 0 (no pain) to 18 (worst pain). Criterion validity was assessed by using Verbal Rating Scale (VRS) as the gold standard. Cohen's kappa (k) was the measure of agreement. Inter-rater reliability was measured by two independent ratings of the same patient at the same time and assessed by Intraclass Correlation Coefficient (ICC). Internal consistency between the subscales was analysed by Cronbach's Alpha. Responsiveness was tested if the first APS score was positive for pain. 'Before' and 'after' sum scores were compared by paired t-test. Results: We found poor agreement between APS and VRS (k=0.42). The inter-rater reliability was good (ICC=0.84). Cronbach's Alpha was 0.52 (fair agreement). In 66% of the patients, pain was observed and re-tested when an expected effect of analgesics had occurred. Of these, 88% reached a reduction on the APS sum-score (p<0.001). Conclusion: Our assessment of the Danish version of APS shows that this pain assessment scale should be considered as qualified and usable in severely demented and non-communicative older patients admitted to a geriatric ward.
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Background The Patient Health Questionnaire (PHQ) is the most commonly used measure to screen for depression in primary care but there is still lack of clarity about its accuracy and optimal scoring method. Aims To determine via meta-analysis the diagnostic accuracy of the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 questions to detect major depressive disorder (MDD) among adults. Method We systematically searched major electronic databases from inception until June 2015. Articles were included that reported the accuracy of PHQ-9 or PHQ-2 questions for diagnosing MDD in primary care defined according to standard classification systems. We carried out a meta-analysis, meta-regression, moderator and sensitivity analysis. Results Overall, 26 publications reporting on 40 individual studies were included representing 26 902 people (median 502, s.d.=693.7) including 14 760 unique adults of whom 14.3% had MDD. The methodological quality of the included articles was acceptable. The meta-analytic area under the receiver operating characteristic curve of the PHQ-9-linear and the PHQ-2 was significantly higher than the PHQ-9-algorithm, a difference that was maintained in head-to-head meta-analysis of studies. Our best estimates of sensitivity and specificity were 81.3% (95% CI 71.6–89.3) and 85.3% (95% CI 81.0–89.1), 56.8% (95% CI 41.2–71.8) and 93.3% (95% CI 87.5–97.3) and 89.3% (95% CI 81.5–95.1) and 75.9% (95% CI 70.1–81.3) for the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 respectively. For case finding (ruling in a diagnosis), none of the methods were suitable but for screening (ruling out non-cases), all methods were encouraging with good clinical utility, although the cut-off threshold must be carefully chosen. Conclusions The PHQ can be used as an initial first step assessment in primary care and the PHQ-2 is adequate for this purpose with good acceptability. However, neither the PHQ-2 nor the PHQ-9 can be used to confirm a clinical diagnosis (case finding).