Figure:

A nurse advises a family caregiver on assessing pain. Photo courtesy of the AARP Public Policy Institute.

Pain in older adults is common and affects their quality of life. Pain is more than a physical experience; it contributes to psychological distress, sleep disturbances, loneliness, and poor appetite.1 Family caregivers often engage in managing their care recipient's pain, and 80% find this stressful.2

Accurately assessing pain and sharing pain information with health care providers are essential to establishing patient-centered treatment plans and effective ongoing pain management. To that end, this article discusses how nurses can teach family caregivers to recognize and document pain at home in order to optimize pain treatment and outcomes. We outline key elements of the pain assessment process; strategies, tools, and considerations for assessing pain in older adults, including those with cognitive impairment; and challenges faced by caregivers of people living with pain.

BACKGROUND

The components of a comprehensive pain assessment for older adults are similar to those for younger people but may be complicated by unique circumstances associated with aging, including sensory and cognitive impairment, lifelong patterns of pain coping (ranging from heightened attention to pain to suppression or denial of pain), and fear of consequences of reporting pain or loss of independence. Pain assessment requires self-report, when possible, and ongoing observation. Both are subjective and may be filtered through individual and cultural influences. Family caregivers play an important role in helping older adults reflect on their pain, observing behaviors that may suggest pain and discomfort, and recording these findings to share with health care providers when needed.

Steps in comprehensive pain assessment include: 1) determining the presence, source, characteristics, and impact of pain; 2) identifying exacerbating and relieving factors associated with pain; 3) recognizing the presence of coexisting illness or health conditions that might affect pain; 4) reviewing attitudes, beliefs, and expectations regarding pain; and 5) gathering information that may affect the treatment plan, including details about sociocultural factors, the person's quality of life, and their functional goals. The following sections highlight key aspects of pain assessment in older adults.

KEY ELEMENTS OF THE PAIN ASSESSMENT PROCESS

Self-report. With older adults who are cognitively intact and can communicate, the best approach to assessing pain is to directly ask about it. Nurses can coach caregivers to conduct a “one-minute pain assessment,” asking three questions3:

“Do you have any aches or pains today?” “Can you tell me about your pain, aches, soreness, or discomfort?” “Would you say your pain is mild, moderate, or severe?”

Physical assessment. Conducting a physical assessment and determining the impact of pain on the person's functioning can help identify the potential cause of the pain. Caregivers may engage in varying degrees of physical assessment, from observing how the person performs typical daily activities to physical examination. Physical assessment may include inspection for skin discoloration (redness, paleness, bruising, mottling) or obvious deformity. Observation of pain behaviors (facial expressions, vocalizations, body movements like limping or bracing) can also indicate the presence of pain.

Gathering and sharing information with providers. Details about medical history, including surgeries, accidents or injuries, psychological conditions, and past and present medication use, are important in guiding treatment decisions; caregivers should keep a written record on hand and communicate these details to providers. Additionally, it is valuable for caregivers and providers to discuss psychosocial factors pertaining to the older adult, such as their level of social support; participation in recreational activities; and financial resources; as well as attitudes, beliefs, and cultural factors that influence how the older adult perceives and expresses pain.

Substance use. It is also important to assess and share with providers the care recipient's use of substances, such as tobacco, cannabis, alcohol, or illicit drugs, as well as herbal supplements. Ongoing assessment of the amount and frequency consumed, the effects on pain and function, and any side effects (both positive and negative) is needed, and this information is critical in developing successful patient-centered care plans.

Recent literature has highlighted the benefits of cannabis in the treatment of various types of pain.4, 5 Because cannabis use in older adults is increasingly common, obtaining information on whether and how the person uses it, and how it affects them, is essential.

Smoking cessation has been associated with improved pain outcomes in geriatric populations, although the initial phase of cessation may be associated with increased pain, which can precipitate relapse.6

PAIN ASSESSMENT IN OLDER ADULTS WITH COGNITIVE IMPAIRMENT

People with Alzheimer disease and related dementias have a decreased ability to self-report pain due to progressive cognitive decline.7 Pathological brain changes affect language, memory, and the cognitive processing needed to communicate pain.8 Despite their diminished ability to self-report pain, there is no evidence that people with dementia experience less pain.9 In people with Alzheimer dementia or vascular dementia, the two most common types of dementia, pain intensity is similar to that experienced by cognitively intact older adults but the emotional response to pain is more pronounced.9 Further, there is evidence that people with dementia display more pronounced facial indicators of pain than those without dementia.10 This is an important point for caregivers, as the evidence indicates a need for focused attention on pain assessment in this population.

In patients unable to provide self-report, nurses should take a hierarchical approach to pain assessment that includes the following steps: 1) be aware of potential causes of pain, 2) attempt to obtain a self-report of pain, 3) observe behaviors, 4) seek input from family and caregivers on their observations of the person's pain, and 5) attempt an analgesic trial.8 Self-report may be possible in people with mild to moderate dementia using simple numeric or verbal descriptor scales.10, 11 For those with moderate to severe dementia, observation of behavioral or nonverbal indicators of pain is recommended, including facial expressions (grimacing), body movements (guarding, bracing, or rubbing), and vocalizations (groaning, verbal expressions).10 Changes in behavior may also indicate pain in people with dementia.12 Nurses and other health care providers can educate caregivers on how to use this stepwise approach to guide pain assessment at home, including nonverbal indicators to look out for.

USING PAIN ASSESSMENT TOOLS

Use of a standardized pain assessment tool enables caregivers and health care providers to track the older adult's pain experience over time. Nurses can help caregivers select an appropriate pain assessment tool and encourage them to use it consistently. Among people who can provide self-report, commonly used tools to measure pain intensity include verbal descriptor scales or numerical rating scales.13 Other tools, such as the PEG (pain, enjoyment, general activity) scale, assess the impact of pain on emotional and physical function.14 For older adults who cannot self-report, observational tools are recommended. The Pain Assessment in Advanced Dementia scale is easy to use and can be completed in less than five minutes.15 Caregivers should be encouraged to use this tool to assess pain at different times of the day, such as when the older adult is at rest, during activities or movement, and before and after pain interventions.

CONSIDERATIONS IN ASSESSING PAIN IN OLDER ADULTS

Nurses and other clinicians should educate family caregivers on the importance of consistently monitoring and documenting the older adult's pain. Caregivers can use a pain diary to record pain information and share it with providers (see https://geriatricpain.org/sites/geriatricpain.org/files/2022-08/Older%20Adults_Pain%20Diary.pdf for a template). The information collected in a pain diary can help to identify changes and patterns in pain over time, which is crucial for recognizing exacerbations and evaluating treatment effectiveness.

How often pain should be assessed depends on the type and severity of the pain. For people with persistent musculoskeletal pain, recording pain daily or several times per week may be sufficient. For people with severe or fluctuating pain, more frequent pain assessment and recording is warranted to detect patterns, triggers, and treatment effectiveness. If multiple caregivers care for the older adult, they should all use the same assessment tool, assessment timing, and pain diary.

Some caregivers and older adults may prefer to use mobile apps to assess and record pain.16, 17 The Keele Pain Recorder is an evidence-based, validated pain monitoring app available for download.18 The app helps patients track pain intensity, its impact on daily life, and medication effectiveness, and the recorded data can be easily shared with health care providers.

CARING FOR A PERSON WITH PAIN

Being a caregiver of someone experiencing pain can be challenging. In married couples, adults with chronic pain and their spouses have high rates of depression and marital discord.19 The impact on family caregivers of an older adult's pain can be influenced by the type and closeness of the relationship, accuracy of pain perceptions, coping styles, and communication patterns.20 Having accurate perceptions of the care recipient's pain is associated with more positive family outcomes.20

Assessing caregivers' self-efficacy—their confidence or certainty that they can perform a task21—may identify the need for further education. Nurses can assess pain-related self-efficacy by asking the caregiver questions like, “How certain are you that you can help the patient control her or his pain?” Questions can also focus on specific aspects of pain management, such as communicating about pain or assessing pain. Coaching older adults and caregivers to enhance their self-efficacy to manage pain has been shown to increase caregiver satisfaction and improve patients' pain severity.22 In addition, higher levels of self-efficacy for pain communication were associated with better outcomes in people with pain and their partners.23

It is important to acknowledge and remind caregivers of the effect the care recipient's pain can have on the caregiver's well-being. Seeing someone in pain can trigger fear about disease progression or worry about how long the pain will last or how severe it will become. Nurses can encourage caregivers to seek resources as needed, whether in the form of knowledge, assistance, or respite. It may be helpful for caregivers to discuss their feelings at a support group or with friends or family members. Caregivers should be encouraged to engage in self-care to support their emotional and physical health.

RESOURCES FOR CLINICIANS AND CAREGIVERS

Table 1 summarizes the key steps of the pain assessment process. Additionally, nurses can refer caregivers to the tear sheet, Information for Family Caregivers, which offers tips on assessing the care recipient's pain, gathering pain information, and communicating effectively with the health care provider. It also includes links to pain assessment tools, a pain diary template, and other pain-related resources.

Table 1. - Key Elements of Pain Assessment for Caregivers Take Pain Complaint History

Onset and timing: sudden or developed over time? Constant or intermittent?

Intensity: mild, moderate, severe?

Frequency: how long does pain last? Does it occur at a particular time of day?

Location(s): in one part of the body or several?

Impact on function: does pain limit activity?

Conduct Physical Assessment

Observe general behaviors and activities.

Inspect painful area: redness, paleness, bruising, or mottled skin? Obvious change or joint deformity?

Gently touch painful area to see if it is tender and if movement is affected.

Identify if sensation is decreased or increased in the painful area.

Observe pain behaviors: facial expressions, vocalizations, body movements.

Conduct Psychosocial Assessment

Additional social support: other family members, neighbors, health aides?

Participation in recreational activities?

Financial resources: medical or other insurance for medication, additional care, special equipment if needed?

Attitudes and beliefs about pain and its treatment?

Cultural considerations that might affect pain experience or treatment?

History of trauma or abuse that may affect pain experience?

Document Medical and Surgical History and Medication Use

Keep a written record of

all medical conditions including date of diagnosis.

any surgical procedures and dates they were performed.

any accidents or injuries.

any psychological diagnoses including depression and anxiety.

all current medications (including over the counter) with dosages, side effects, and treatment response.

past medications used for pain with dosages, side effects, and treatment response.

Have this list available when communicating with health care providers.

Assess All Nonprescribed Substances

Cigarettes: when started, how many per day, for how many years?

Cannabis: what type, how often, for how many years?

Illicit substances: heroin, cocaine, others? How often, for how many years?

Alcohol: what type, how often, how much in each serving, for how many years?

Herbal or other over-the-counter products?

For any nonprescribed substances: effect on pain and function, side effects (both positive and negative)?

Box 1:

Information for Family Caregivers

Box 1:

Information for Family Caregivers

Resources for Nurses

Note: Family caregivers can access these videos, as well as additional information and resources, on AARP's Home Alone Alliance web page: www.aarp.org/nolongeralone.

REFERENCES 1. Horgas AL. Pain assessment in older adults. Nurs Clin North Am 2017;52(3):375–85. 2. Reinhard SC, et al. Home alone revisited: family caregivers providing complex care. Washington, DC: AARP Public Policy Institute; 2019 Apr. Special report by the founders of the Home Alone Alliance; https://www.aarp.org/content/dam/aarp/ppi/2019/04/home-alone-revisited-family-caregivers-providing-complex-care.pdf. 3. GeriatricPain.org. Fast facts: one minute pain assessment. Iowa City, IA: Csomay Center, University of Iowa College of Nursing; 2022 Jan. https://geriatricpain.org/one-minute-pain-assessment-fc. 4. Abuhasira R, et al. Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly. Eur J Intern Med 2018;49:44–50. 5. Poli P, et al. Medical cannabis in patients with chronic pain: effect on pain relief, pain disability, and psychological aspects. A prospective non-randomized single arm clinical trial. Clin Ter 2018;169(3):e102–e107. 6. LaRowe LR, Ditre JW. Pain, nicotine, and tobacco smoking: current state of the science. Pain 2020;161(8):1688–93. 7. Husebo BS, et al. Identifying and managing pain in people with Alzheimer's disease and other types of dementia: a systematic review. CNS Drugs 2016;30(6):481–97. 8. Herr K, et al. Pain assessment in the patient unable to self-report: clinical practice recommendations in support of the ASPMN 2019 position statement. Pain Manag Nurs 2019;20(5):404–17. 9. Achterberg W, et al. Pain in dementia. Pain Rep 2020;5(1):e803. 10. Achterberg WP, et al. Are chronic pain patients with dementia being undermedicated. J Pain Res 2021;14:431–9. 11. Schofield P. The assessment of pain in older people: UK national guidelines. Age Ageing 2018;47(suppl_1):i1–i22. 12. Resnick B, et al. Pain assessment, management, and impact among older adults in assisted living. Pain Manag Nurs 2019;20(3):192–7. 13. GeriatricPain.org. Fast facts: selected pain assessment tools. Iowa City, IA: Csomay Center, University of Iowa College of Nursing; 2022 Jan. https://geriatricpain.org/selected-pain-assessment-tools-fc. 14. Krebs EE, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med 2009;24(6):733–8. 15. Warden V, et al. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 2003;4(1):9–15. 16. Col N, et al. Improving patient-provider communication about chronic pain: development and feasibility testing of a shared decision-making tool. BMC Med Inform Decis Mak 2020;20(1):267. 17. Rao N, et al. A novel method for digital pain assessment using abstract animations: human-centered design approach. JMIR Hum Factors 2022;9(1):e27689. 18. Bedson J, et al. Development and validation of a pain monitoring app for patients with musculoskeletal conditions (the Keele pain recorder feasibility study). BMC Med Inform Decis Mak 2019;19(1):24. 19. Post KM, et al. A dyadic investigation of depressed affect and interspousal behavior in couples with chronic back pain. Ann Behav Med 2021 Nov 27. Online ahead of print. 20. Riffin C, et al. Impact of pain on family members and caregivers of geriatric patients. Clin Geriatr Med 2016;32(4):663–75. 21. Bandura A. Self-efficacy: the exercise of control. New York, NY: W. H. Freeman/Times Books/Henry Holt and Co.; 1997. 22. Porter LS, et al. Caregiver-guided pain coping skills training for patients with advanced cancer: results from a randomized clinical trial. Palliat Med 2021;35(5):952–61. 23. Porter LS, et al. Pain communication in the context of osteoarthritis: patient and partner self-efficacy for pain communication and holding back from discussion of pain and arthritis-related concerns. Clin J Pain 2008;24(8):662–8.