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Self- and proxy report for the assessment of pain in patients with and without cognitive impairment

Experiences gained in a geriatric hospital

Selbst- oder Fremdeinschätzung im Schmerzassessment bei Menschen mit und ohne kognitive Einschränkung

Erfahrungen aus einer geriatrischen Akutklinik

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Abstract

Background

Pain assessment is a complex procedure in patients with different degrees of cognitive impairment. The challenge is to determine whether self-reporting tools are adequate and to identify the cases in which proxy ratings are necessary.

Patients and methods

As part of an open, prospective observational study, 178 patients underwent a comprehensive pain assessment consisting of the Numeric Rating Scale (NRS), the Verbal Rating Scale with four and five items (VRS4 and VRS5) and the Pain Assessment in Advanced Dementia Scale (PAINAD).

Results

Even without prior knowledge of a patient’s cognitive impairment, this toolkit can be used to reliably identify cases where self-rating is appropriate and where proxy rating becomes necessary. Inter-rater reliability: “good” agreement [Cohen’s κ = 74.2% (p < 0.001) (95%CI, 54.6–93.8%)], test–retest reliability: “moderate” agreement [κ = 55.3% (p < 0.001) (95%CI, 28.5–82.1%)]. Furthermore, movement resulted in a higher correlation between the selected assessments. Self-report assessments are appropriate up to a mini-mental state examination (MMSE) value greater than ten. In comparison to NRS, VRS4 and VRS5 remain more stable as the degree of cognitive impairment increases.

Conclusions

In the majority of the cases, our approach enables reliable appropriate pain assessment without the strict prerequisite of an upstream cognitive assessment.

Zusammenfassung

Hintergrund

Schmerzassessment bei Patienten mit unterschiedlichen Schweregraden einer kognitiven Einschränkung ist ein komplexer Vorgang. Die Herausforderung ist zu erkennen, ob eine Selbsteinschätzung möglich oder ab wann eine Fremdeinschätzung notwendig wird.

Methoden

Im Rahmen einer offenen, prospektiven Beobachtungsstudie erhielten 178 Patienten ein umfassendes Schmerzassessment, bestehend aus Numerischer Rating Skala (NRS), Verbaler Rating Skala (VRS4 und 5) und BESD Skala (Beurteilung des Schmerzes bei Demenz).

Ergebnisse

Das verwendete Toolkit ist geeignet, ohne Kenntnis der kognitiven Einschränkung der Patienten, zuverlässig zu identifizieren, wo eine Selbsteinschätzung angemessen oder eine Fremdeinschätzung notwendig wird. Inter-Rater Reliabilität: „gute“ Übereinstimmung (Cohens κ = 74,2 % (p < 0,001) (95 %CI, 54,6–93,8 %)), Re-Test Reliabilität: „moderate“ Übereinstimmung (κ = 55,3 % (p < 0,001) (95 %CI, 28,5–82,1 %)). Bewegung führt zu höheren Korrelationen zwischen den gewählten Assessments. Selbsteinschätzung ist bis zu einem Wert von MMSE > 10 angemessen. VRS4 und VRS5 sind im Unterschied zur NRS über zunehmende kognitive Einschränkungen länger stabil.

Schlussfolgerung

Unser Verfahren führt in der Mehrzahl der Fälle zuverlässig zu einem angemessenen Schmerzassessment, wobei ein vorangeschaltetes kognitives Assessment nicht absolut notwendig erscheint.

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Conflict of interest

On behalf of all authors, the corresponding author states the following: The first author is partially funded by a Forschungskolleg Geriatrie grant from the Robert Bosch Foundation, Stuttgart, Germany and Mundipharma GmbH, Limburg, Germany. In addition, he received remuneration in the course of giving individual lectures at Mundipharma GmbH, Grünental GmbH and Pfizer GmbH over the last 5 years. Neither The Robert Bosch Foundation nor Mundipharma, Grünental or Pfizer had any influence on the content of this article.

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Authors and Affiliations

  1. Agaplesion Bethesda Clinic, Competence Center of Geriatrics and Aging Research, Stipendiat Forschungskolleg Geriatrie, Robert Bosch Stiftung, University of Ulm, Akademisches Krankenhaus Universität Ulm, Zollernring 26–28, 89073, Ulm, Germany

    A. Lukas, T. Niederecker, I. Günther & T. Nikolaus

  2. Geriatric Center Ulm, Zollernring 26–28, 89073, Ulm, Germany

    A. Lukas, T. Niederecker, I. Günther & T. Nikolaus

  3. Institute of Epidemiology and Medical Biometry, University Ulm, Schwabstr. 13, 89075, Ulm, Germany

    B. Mayer

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  1. A. Lukas
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Correspondence to A. Lukas.

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Lukas, A., Niederecker, T., Günther, I. et al. Self- and proxy report for the assessment of pain in patients with and without cognitive impairment. Z Gerontol Geriat 46, 214–221 (2013). https://doi.org/10.1007/s00391-013-0475-y

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