Usability Testing of the iPhone App to Improve Pain Assessment for Older Adults with Cognitive Impairment (Prehospital Setting): A Qualitative Study

OBJECTIVES. : Pain assessment in older adults with cognitive impairment is often challenging, and paramedics are not given sufficient tools/training to assess pain. The development of a mobile app may improve pain assessment and management in this vulnerable population. We conducted usability testing of a newly developed iPhone pain assessment application with potential users, in this case as a tool for clinical paramedic practice to improve pain assessment of older adults with cognitive impairment. METHODS. : We conducted usability testing with paramedic students and a Delphi panel of qualified paramedics. Participants studied the app and paper-based algorithm from which the app was developed. The potential use for the app was discussed. Usability testing focus groups were recorded, transcribed verbatim, and analyzed using a thematic approach. Proposed recommendations were disseminated to the Delphi panel that reviewed and confirmed them. RESULTS. : Twenty-four paramedic students from two UK ambulance services participated in the focus groups. Usability of the app and its potential were viewed positively. Four major themes were identified: 1) overall opinion of the app for use in paramedic services; 2) incorporating technological applications into the health care setting; 3) improving knowledge and governance; and 4) alternative uses for the app. Subthemes were identified and are presented. DISCUSSION. : Our results indicate that the pain assessment app constitutes a potentially useful tool in the prehospital setting. By providing access to a tool specifically developed to help identify/assess pain in a user-friendly format, paramedics are likely to have increased knowledge and confidence in assessing pain in patients with dementia

“What? That’s for Old People, that.” Home Adaptations, Ageing and Stigmatisation: A Qualitative Inquiry

Older people, even those living with long-term conditions or poor mobility, can be supported to live well at home, through adapting their home to meet changing need. Installing home adaptations, from grab rails to walk in shower rooms, is cost effective, may prevent falls, reduce social isolation and improve self confidence. Despite austerity cuts to public spending, the UK government increased home adaptations’ funding. However, not much is known about older people’s experiences and understanding of acquiring and living with home adaptations and uptake of home adaptations could be improved. Using wearable camera and face to face interview data, this qualitative study explored a diverse group of older people’s retrospective experiences (n = 30). Focus group discussions were also carried out with a wide range of professionals involved in the provision of home adaptations (n = 39). Findings suggest people may delay having adaptations, because of perceived stigmatising associations with decline and vulnerability. As delaying the installation of home adaptations until crisis point is known to reduce their effectiveness, such associations need to be challenged

Advanced multi-targeted composite biomaterial dressing for pain and infection control in chronic leg ulcers

This study aimed to develop advanced biomaterial polysaccharide based dressings to manage pain associated with infected chronic leg ulcers in older adults. Composite carrageenan (CARR) and hyaluronic acid (HA) dressings loaded with lidocaine (LID) and AgNPs were formulated as freeze-dried wafers and functionally characterized for porous microstructure (morphology), mechanical strength, moisture handling properties, swelling, adhesion and lidocaine release. Antimicrobial activity of AgNPs was evaluated (turbidity assay) against Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus whilst cell viability studies (MTT) was performed on normal adult human primary epidermal keratinocyte cells. The wafers were soft, flexible and elegant in appearance. HA affected the wafer structure by increasing the resistance to compression but still possessed a balance between toughness and flexibility to withstand normal stresses and prevent damage to newly formed skin tissue respectively. Water uptake was influenced by HA, whilst equilibrium water content and LID release were similar for all the formulations, showing controlled release up to 6 h. AgNPs loaded CARR/HA wafers were effective in inhibiting the growth of both Gram positive and Gram negative bacteria. MTT assay showed evidence that the AgNPs/ LID loaded wafers did not interfere with cell viability and growth. CARR/HA wafers seem to be a promising system to simultaneously deliver LID and AgNPs, directly to infected chronic leg ulcers

Development of advanced analgesic dressings for chronic wound healing

Background: Pain is a ubiquitous problem in patients with chronic leg wounds. Recent studies have reported that 17 - 65% of patients experience severe or continuous pain that, associated with other characteristics of chronic ulcers such as odour, have debilitating effects on the patients including both their mental and psychological wellbeing. The aim of this work is to develop advanced wound dressings for local delivery of an analgesic drug that can help to manage pain associated with chronic leg ulcers in older adults. The addition of hyaluronic acid (HA) in the composition added beneficial and well recognized HA properties in the wound healing process. Methods: Advanced dressings loaded with an analgesic drug (lidocaine) were formulated as lyophilised xerogels (wafers) by freeze-drying. Different HA ratios by weight were used to improve the wafer characteristics. The dressings were tested for functional characteristics including mechanical strength, porous microstructure, stability, polymorphic/amorphous transitions, hydration, swelling and in vitro mucoadhesion. An HPLC method was developed to assess lidocaine release from wafers. Results: On the basis of feasibility study of the use of analgesic dressings in older adults with leg ulcers, an advanced dressing loaded with lidocaine was formulated. Wafers, due to their porous nature, have proved to be suitable for medium to high exuding wounds (common in leg ulcers), whilst still maintaining their physical integrity. Both blank and drug-loaded wafers were soft, flexible, elegant in appearance and non-brittle in nature. The addition of HA had an influence on wafer structure changing their properties, but mechanical characterisation demonstrated that the wafers were strong enough to withstand normal stresses but also flexible to prevent damage to newly formed skin tissue. The lidocaine release from the optimised dressing showed continuous release for over 12 h. Conclusions: Wafer seems to be a very promising system for delivery of analgesic drug to the wound. Further studies are in progress to evaluate in vitro activity of the dressings and role of HA in the wound healing process

The epidemiology of regional and widespread musculoskeletal pain in rural versus urban settings in those ≥55 years

Objectives: To examine whether the prevalence of regional and chronic widespread pain (CWP) varies with rurality and to determine the characteristics of persons in rural locations in whom pain is found to be in excess. Methods: Participants, aged ≥55 years, from participating general practices in seven different geographical locations in Scotland were sent a postal questionnaire. The 1-month prevalence of 10 regional pain conditions plus CWP was identified using body manikins. Differences in the prevalence of pain with differing rurality were examined using Chi2 test for trend. Thereafter, among the rural population, the relationships between pain and putative risk factors were examined using Poisson regression. Thus, results are described as risk ratios. Results: There was some evidence to suggest that the prevalence of CWP increased with increasing rurality, although the magnitude of this was slight. No large or significant differences were observed with any regional pain conditions. Factors associated with the reporting of CWP included poor general health, feeling downhearted most of the time and selected measures of social contact. Factors independently associated with CWP included female gender (risk ratio: 1.24; 95% confidence interval (CI): 0.997–1.55), poor self-rated health (risk ratio: 3.50; 95% CI: 1.92–6.39) and low mood (risk ratio: 1.54; 95% CI: 1.07–2.20). Also, having fewer than 10 people to turn to in a crisis was associated with a decrease in the risk of CWP – risk ratio: 0.68 (95% CI: 0.50–0.93) and 0.78 (95% CI: 0.60–1.02) for those with 5–10 and <5 people, respectively. Conclusions: This study provides no evidence that the prevalence of regional musculoskeletal pain is increased in rural settings, although there is some evidence of a modest increase in CWP. Risk factors for CWP are similar to those seen in the urban setting, including markers of general health, mental health and also aspects of social contact. It may be, however, that social networks are more difficult to maintain in rural settings, and clinicians should be aware of the negative effect of perceived social isolation on pain in rural areas

Pain in older adults with dementia

Background: We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings. Methods: A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom. Results: Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70–80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management. Conclusion: Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult

Epidemiology of back pain in older adults: prevalence and risk factors for back pain onset.

OBJECTIVES: To determine the prevalence of disabling and non-disabling back pain across age in older adults, and identify risk factors for back pain onset in this age group. METHODS: Participants aged ≥ 75 years answered interviewer-administered questions on back pain as part of a prospective cohort study [Cambridge City over-75s Cohort Study (CC75C)]. Descriptive analyses of data from two surveys, 1988-89 and 1992-93, estimated prevalence and new onset of back pain. Relative risks (RRs) and 95% CIs were estimated using Poisson regression, adjusted for age and gender. RESULTS: Prevalence of disabling and non-disabling back pain was 6 and 23%, respectively. While prevalence of non-disabling back pain did not vary significantly across age (χ²trend : 0.90; P = 0.34), the prevalence of disabling back pain increased with age (χ²trend : 4.02; P = 0.04). New-onset disabling and non-disabling back pain at follow-up was 15 and 5%, respectively. Risk factors found to predict back pain onset at follow-up were: poor self-rated health (RR 3.8; 95% CI 1.8, 8.0); depressive symptoms (RR 2.2; 95% CI 1.3, 3.7); use of health or social services (RR 1.7; 95% CI 1.1, 2.7); and previous back pain (RR 2.1; 95% CI 1.2-3.5). From these, poor self-rated health, previous back pain and depressive symptoms were found to be independent predictors of pain onset. Markers of social networks were not associated with the reporting of back pain onset. Conclusion. The risk of disabling back pain rises in older age. Older adults with poor self-rated health, depressive symptoms, increased use of health and social services and a previous episode of back pain are at greater risk of reporting future back pain onset

Mentorship within the paramedic profession: a practice educator’s perspective

Background – The rapid ascension of paramedic science within higher education is creating a significant culture change within the profession. Clinicians are now accountable for both their patients as well as the learning of their students. Mentoring practices in the paramedic profession have been adopted from the findings of professions allied to healthcare, including medicine, nursing and midwifery, where mentorship is well established. The insufficiencies of this model need to be tested to account for the idiosyncrasies of the paramedic role. Methods – A convenience sample of paramedic educators were identified across two ambulance services. Focus groups were conducted to obtain rich data about participants’ opinions on current mentoring practices within the paramedic profession and recommendations for how this can be improved. Results – Results demonstrated the importance of learning through observation, teaching skills and personal qualities in relation to the paramedic educator role, as previously identified in the literature produced by professions allied to healthcare. Paramedic educators also identified current challenges to practice that included organisational issues such as ‘support’, ‘recognition’ and the ‘mental wellbeing’ of students. Conclusions – This is the first primary research to explore mentoring from the paramedic educator perspective. In order to undertake their role more effectively paramedic educators are looking for a greater investment into the culture of mentoring by ambulance services and universities to address the identified organisational issues

Pain Management and assessment

Older adults are especially vulnerable to pain. They report more pain complaints in general and exhibit an increased incidence of chronic pain conditions. To compound the problem, standard drug treatments are frequently problematic due to side effects and pain is often under-assessed leading to under-treatment. It is therefore important to explore alternatives to drug treatment as well as methods for accurately assessing pain. This chapter reviews non-pharmacological interventions for pain and developments in assessment methods, and reviews current evidence to help evaluate their potential for pain management and assessment in older adults

Attitudinal & Knowledge Barriers towards Effective Pain Assessment & Management in Dementia: A Narrative Synthesis

Under-assessment and inadequate treatment of pain is a common problem for older adults, particularly those with dementia. This may be in part attributed to knowledge deficits and negative attitudes among healthcare staff and informal caregivers towards pain, its assessment and its management in dementia. Knowledge and attitudes have a significant predictive relationship with behavior, potentially impacting pain assessment and management practices. Despite this there remains a paucity of research in the area and a lack of clarity about existing knowledge levels and attitudes among dementia caregivers. Therefore, the aims of this review were to: identify what knowledge deficits and attitudinal barriers exist amongst dementia caregivers; and identify the scales available to measure these. A search was carried out in the following electronic databases: Academic Search Premier; CINAHL; Education Research Complete; Humanities International Journals; Psychology and Behavioral Sciences Collection; PsychINFO; PsychArticles; Teacher Reference Center; and MEDLINE. A total of 13 articles met the inclusion criteria. A number of knowledge deficits and negative attitudes were identified, particularly in the use self-reports and pain assessment tools in dementia, and the safety of opioids. Understanding and positive attitudes were demonstrated in some areas, such as non-narcotic pain medications and identifying behavioral pain indicators. Of the 4 scales identified, positive results were found for internal consistency and content validity, however further refinement and testing is necessary. It was concluded attitudinal and knowledge barriers exist which should be addressed given their influence over practice behavior, however, there is a willingness and knowledge base from which progress can build