Within the dementia care environment, it is my experience that it is often unclear to nursing staff as to appropriate assessment and management of pain for clients in the palliative stage of their illness. Although nurses have their experience to guide their practice, as the health professional most involved with the client at the end of life, there is a need for review of current assessment tools and management strategies to ensure the care given is evidence based and best practice.
The aim of this review is to examine what is the most appropriate method of pain assessment and management when working with clients with cognitive impairment.
Searches were made of several databases
For articles published between 1990 and 2006 using the keywords, pain assessment, pain management, elderly, dementia and palliative care.
Most evidence in relation to this area of practice is anecdotal demonstrating a need for further research. Evidence presented in this review shows encouraging results in regard to the development of assessment tools and that there are clear standards of process for management of pain at the end of life. The results also show that nurses are concerned and are making attempts to be proactive in this area of care despite many barriers.
Good pain control requires both sensitivity to the clients needs on every level and the competence to meet them. Assessment and management of pain for individuals with a dementia is still very hit and miss, with evidence of both very good and very poor practice being demonstrated. Nurse education is still an unmet need within this area of practice. And that overall clients are experiencing unnecessary pain on a regular basis which could have been prevented.
Pain can be a common experience for many older adults and has negative effects on their health, functioning and general well being Pain presents an enormous challenge for most nurses within their daily working lives. This is due to the individual nature of pain; a client’s experience of pain is affected by their life experience compounded with the procedure or illness. Macaffrey identified the individual nature of pain when he said, “Pain is what the experiencing person says it is and exists whenever he says it does”(1979, Cited in Epps 2001). Pain can be present in the older adult for many reasons. Chronic pain conditions may include arthritis, gout and peripheral vascular disease, acute conditions such as cancer; cardio vascular disease and surgery are also prevalent causes of pain. An elderly client may present with more than one type of pain in different locations with varying causes making the nurses job all the more challenging.
The word dementia comes from Latin and translates as “out of ones mind”(Epps 2001). Although this gives a broad definition of the symptoms, dementia is actually a disease caused by permanent brain changes and loss of neurons. These changes affect the client in several ways. The impairment of cortical functions affects “memory, orientation, comprehension, calculation, learning capacity, language and judgement”(WHO 1993). Various dementias exist the most common being Alzheimer’s, which accounts for 65% of UK diagnosis’s (Stevens et al 2001). There are other dementias such as vascular, lewy body and picks. All of the dementias impair basic functioning and the ability to communicate also the client’s ability to interpret the feelings of pain and recall them to communicate to the nurse. This impairment potentially results with individuals unable to express pain and report it appropriately. This in turn may result in inadequate assessment and management as has been shown in studies (Bernabei Et al; 1998. Horgas & Tsai; 1998). One study reported that 60% of nursing home residents with a physical diagnosis known to cause pain had not received any pain...
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