Page 75 Complete Your CE Test Online - Click Here A good tool that can be used in the majority of older adults is the numerical rating scale which consists of a scale of zero to ten with zero indicating no pain and ten indicating the worst possible pain. The degree of pain worsens as the numbers increase [9]. This type of scale requires that the patient be able to understand your explanation of the scale, correlate pain to a numeric value, and communicate this correlation to you. It is also a good choice for individuals with vision impairments who may not be able to use a visual scale. A verbal descriptor scale is one that requires the patient to describe pain from “no pain,” to “mild,” “moderate,” “severe,” or “as bad as the pain could be” [9]. This requires that the patient be able to understand the descriptive terms used, be able to correlate the terms with pain, and describe pain using the given terms without the benefit of visual or verbal cues or hints [9]. A pictorial scale such as the Faces Pain Scale requires that the patient select a visual depiction of pain. For example, the patient is asked to look at a number of different faces that range from a face with an expression of calm or contentment to faces that look increasingly uncomfortable. The patient chooses the face with the expression that best “fits” his or her current pain experience [9]. This scale does not require the patient to use specific descriptive terms or to understand specific descriptive terms [9]. However, this tool may be difficult with those adults with visual impairments. Assessment tip: A family member, friend or reliable caretaker should be involved in the pain assessment if patients are unable or reluctant to communicate their pain experience. But what about patients who are unable to understand verbal or visual communications, such as a patient suffering from dementia? Researchers are working to develop valid and reliable pain assessment tools for use with patients suffering from dementia. One such tool is the Pain Assessment in Advanced Dementia (PAINAD) scale, which relies on direct observation of five behavioral indicators of pain [32]. An overview of the five behaviors used to assess pain includes [32]: ● ● Breathing (does not include mechanical ventilation): ranges from a score of zero for normal breathing; a score of one for occasional labored breathing or short periods of hyperventilation; to a maximum score of two for noisy, labored breathing and prolonged periods of hyperventilation. ● ● Negative vocalization: ranges from a score of zero for none; a score of one for occasional moaning or groaning; to a maximum score of two for loud moaning or groaning, crying, or calling out. ● ● Facial expressions: ranges from a score of zero for no expression or an expression of calm or smiling; a score of one for frowning or expressions of sadness; to a maximum score of two for facial grimacing, frowning, scowling, etc. ● ● Body language: ranges from a score of zero for a relaxed body posture; a score of one for tenseness, fidgeting, or, if ambulatory, distressed pacing; to a maximum score of two for rigid body posture, clenched fists, pushing or striking out, and/or pulling knees up towards chest. ● ● Consolability: ranges from a score of zero for needing no consolation; a score of one for the need for reassurance by touch or tone of voice; to a maximum score of two if inconsolable. Scores for each category are totaled with scores ranging from a minimum of zero to a maximum total of ten. The higher the total number, the more severe the pain [32]. Research shows that there are a number of pain-associated behaviors. Six main types of pain behaviors and indicators in older adults with dementia include [9]: ● ● Facial expression such as frowning or looking frightened. ● ● Verbalizations/vocalizations such as moaning or sighing. ● ● Body movements such as tense positions or changes in mobility. ● ● Changes in interpersonal interactions such as withdrawal or combativeness. ● ● Changes in activity patterns or routines such as changes in sleep or increased wandering. ● ● Mental status changes such as crying or increased confusion. Nursing consideration: A comprehensive pain management treatment plan is important for anyone dealing with pain. A number of complementary and alternative therapies are being used with increasing frequency. These include acupuncture, herbal supplements, massage therapy, chiropractic care, yoga, meditation, relaxation therapy, biofeedback, and, where not contraindicated, exercise [9]. Any and all complementary and alternative therapies should be initiated and maintained only under the supervision of the patient’s primary health care provider. Most patients dealing with pain participate in some type of medication regimen. Be aware of and help the patient and their family prepare for and deal with some common side effects of analgesics. Some analgesics, particularly opioid analgesics, slow the intestinal tract and can lead to constipation. Stool softeners, adequate fluid intake, and fruit and vegetable intake should help to alleviate the problem of constipation [9,17]. Nausea and vomiting are also fairly common side effects, and an antiemetic may be prescribed for these types of adverse occurrences. Some analgesics cause drowsiness and sedation, and patients should be cautioned against activities that require alertness. In severe pain, morphine may be administered, and pruritus is often associated with its administration. Antihistamines are effective in combating pruritus, but may also cause sedation as a side effect [9,17]. In summary, a thorough pain assessment must be conducted as part of a thorough older adult assessment. Remember that pain is often undertreated in this population, particularly in those older adults who cannot or will not communicate regarding their pain. Patients with dementia are at significant risk for having their pain undertreated. Involve family, friends and caretakers as part of the pain assessment process and the treatment plan. Assist in educating the patient and family as well as other healthcare providers of the need for adequate assessment and treatment of pain. Use a variety of pain assessment techniques including verbal discussion and the use of valid and reliable pain assessment tools. Remain sensitive to the issue of culture and religion and how they influence the expression of pain and compliance with treatment options. Remain alert to the complications of undertreating pain, including depression and social isolation. Also, be sure to monitor and to teach the patient about the side effects of any medications used to alleviate pain, and how to reduce or eliminate such adverse occurrences. Finally, remember that the patient, and their family and caregivers are often the key to success in managing pain. Assessing mental health Mental health and well-being is as important to older adults as it is to any other population. Unfortunately, some mental health issues, such as depression and anxiety, may be overlooked in older adults. The signs and symptoms of these and other mental health problems may be mistakenly attributed to the aging process or dementia, and as a result, a thorough assessment is not done. In fact, research shows that older adults with evidence of a mental disorder are less likely than younger and middle aged adults to receive mental health services and, when they do receive such services, they are less likely to receive care from a mental health specialist [33]. Nursing consideration: When assessing mental health, be sure to evaluate the patient for mental disturbances related to medication side effects. Sometimes adverse occurrences are related to alterations in mental status. The WHO has compiled data regarding mental health and older adults. Some of the most significant data include the following information [34]: ● ● Over 20% of adults 60 years of age and older suffer from a mental health or neurological disorder (excluding headache disorder), and 6.6% of all disability among people over 60 is due to neurological and mental disorders.