Paramedic assessment of pain in the cognitively impaired adult patient

<p>Abstract</p> <p>Background</p> <p>Paramedics are often a first point of contact for people experiencing pain in the community. Wherever possible the patient's self report of pain should be sought to guide the assessment and management of this complaint. Communication difficulty or disability such as cognitive impairment associated with dementia may limit the patient's ability to report their pain experience, and this has the potential to affect the quality of care. The primary objective of this study was to systematically locate evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults and to identify those that have been recommended for use by paramedics.</p> <p>Methods</p> <p>A systematic search of health databases for evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults was undertaken using specific search criteria. An extended search included position statements and clinical practice guidelines developed by health agencies to identify evidence-based recommendations regarding pain assessment in older adults.</p> <p>Results</p> <p>Two systematic reviews met study inclusion criteria. Weaknesses in tools evaluated by these studies limited their application in assessing pain in the population of interest. Only one tool was designed to assess pain in acute care settings. No tools were located that are designed for paramedic use.</p> <p>Conclusion</p> <p>The reviews of pain assessment tools found that the majority were developed to assess chronic pain in aged care, hospital or hospice settings. An analysis of the characteristics of these pain assessment tools identified attributes that may limit their use in paramedic practice. One tool - the Abbey Pain Scale - may have application in paramedic assessment of pain, but clinical evaluation is required to validate this tool in the paramedic practice setting. Further research is recommended to evaluate the Abbey Pain Scale and to evaluate the effectiveness of paramedic pain management practice in older adults to ensure that the care of all patients is unaffected by age or disability.</p

Prescribing databases can be used to monitor trends in opioid analgesic prescribing in Australia

Objective: There has been increased use of prescription opioid analgesics in Australia in the past 20 years with increasing evidence of related problems. A number of data sources collect information about the dispensed prescribing for opioid medications, but little is known about the extent to which these data sources agree on levels of opioid prescribing. Methods: In Queensland, all opioid prescriptions (S8 prescriptions) dispensed by community pharmacies must be submitted to the Drugs of Dependence Unit (DDU). This potentially comprises a gold standard' against which other data sources may be judged. There are two national data sources: the Pharmaceutical Benefits Schedule (PBS) for all medications subsidised by government; and an annual national survey of representative pharmacies, which assesses non-subsidised opioid prescribing. We examined the agreement between these data sources. Results: The three data sources provided consistent estimates of use over time. The correlations between different data sources were high for most opioid analgesics. There was a substantial (60%) increase in the dispensed use of opioid analgesics and a 180% increase in the dispensed use of oxycodone over the period 20022009. Tramadol was the most used opioid-like medication. Conclusions: Since 2002 different data sources reveal similar trends, namely a substantial increase in the prescribing of opioid medications. With few exceptions, the conclusions derived from using any of these data sources were similar. Implications: Improved access to PBS data for relevant stakeholders could provide an efficient and cost-effective way to monitor use of prescription opioid analgesics

The assessment of pain in older people: UK National Guidelines

We are facing a huge increase in the older population over the next 30 years. This brings an anticipated increase in the prevalence of chronic pain and with this comes the challenge of assessment of pain in many varied settings. Our first iteration of this document was published in 2007. But there has been a proliferation of literature and research since then, so we have developed a new set of guidelines. Different patterns and sites of pain were seen in men and women. Age differences suggest that pain prevalence increased with age up to 85 years and then decreased. The available studies on barriers and attitudes to pain management point towards an adherence to bio-medically orientated beliefs about pain, concern amongst clinicians in relation to activity recommendations, and a negative orientation in general towards patients with chronic painful conditions. A multidisciplinary approach to the assessment and treatment of pain is essential, but the assessment is a complex process which is hampered by many communication issues, including cognitive ability and socio-cultural factors. Such issues are part of the UK ageing population. Structured pain education should be implemented that provides all health professionals (whether professionally or non-professionally trained) with standardised education and training in the assessment and management of pain according to level of experience. Although subjective, patient self-report is the most valid and reliable indicator of pain and it may be necessary to ask questions about pain in different ways in order to elicit a response. A number of valid and reliable self-report measures are available and can be used even when moderate dementia exists. The Numerical Rating Scale or verbal descriptors can be used with people who have mild to moderate cognitive impairment. For people with severe cognitive impairment Pain in Advanced Dementia (PAINAD) and Doloplus-2 are recommended. PAINAD and Doloplus-2 scales continue to show positive results in terms of reliability and validity. There has been no recent evaluation of the Abbey pain scale although it is widely used throughout the UK. There is a need for more research into pain assessment using the collaborative role of the multidisciplinary team in all care settings. Self-report questionnaires of function are limited in their ability to capture the fluctuations in capacity and ability. The concentration on items of relevance to the population of interest means that issues of personal relevance can be obscured. Strong associations were seen between pain and depressed mood with each being a risk factor for the other. Additionally, loneliness and social isolation were associated with an increased risk of pain. Clinicians should be cognisant that social isolation and or depressive signs and symptoms may be indicators of pre-existing pain or a predictor of future pain onset. There are a number of evidence based guidelines on pain assessment in older people with or without cognitive impairment from around the world, including Australia and Europe

Effectiveness of manual therapies: the UK evidence report

<p>Abstract</p> <p>Background</p> <p>The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.</p> <p>Methods</p> <p>The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.</p> <p>Results</p> <p>By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.</p> <p>Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.</p> <p>Conclusions</p> <p>Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.</p> <p>Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.</p

Descriptive, exploratory study of the role of nursing assistants in Australian residential aged care facilities: the example of pain management

Aim: This study explored the experiences of nursing assistants (NAs) who work with older people in residential aged care facilities (RACFs), to ascertain their role in Australian RACFs. Experiences with pain management were used as an example to explore their work role. Methods: A descriptive, exploratory qualitative approach was used to examine NAs' experiences. Participants included six NAs from three RACFs in regional Western Australia. In-depth interviews focused on the NAs' experiences of providing care to older people in RACFs and in particular their experiences providing pain management for residents. Results: The role of NAs often extends beyond their scope of practice. NAs describe making clinical decisions, initiating clinical care and advocating for residents. Conclusions: NAs represent a majority of the staff in Australian RACFs and they have a significant role in clinical care. There is a need to ensure that NAs are adequately prepared and supported in their role