ARTICLE 4 REVIEW

MARASIGAN, IZA THERESE C.

“Nursing Staff Knowledge and Belief about Pain in
Elderly Nursing Home Residents with Dementia”

What is discussed in this study is far from the setting here in our country. Most Filipinos have extended families wherein a family stays with their immediate relatives particularly, the grandparents. This is due to the close family ties we Filipinos have. We also have high respect for elders and are famous for our “po”and ”opo”, words that we add to our sentences to show respect. Because of our deep love and gratitude to our elders, there are few nursing homes established in our country. We are willing to take care of our elders in return of the love and care they have shown us.

It has been known that children and elders are the ones who need most attention and care. In this case, geriatric patients are given focus. The older adult’s biopsychosocial wellbeing may be affected because of the aging process they are undergoing. Aging decreases the internal body’s regulation and may increase the pain perception among them.

This is a study of nurses’ perception of pain among geriatric patients who have dementia in nursing homes in Netherlands. Dementia is a condition in which the cognitive functions are slowly fading. Short-term memory loss, the first sign of dementia, most often occurs with the older adults. Patients who have dementia have more difficulty expressing their emotions regarding pain, decision-making, etc. These said patients are the chosen variable in finding out how the geriatric nurses are taken care of.

There is a high prevalence rate of pain among the older adults who reside in nursing homes. Along with aging, negative results arise. Some of these negative results are depression, social isolation, anxiety, disturbed sleep pattern, and imbalanced nutrition. Among the negative results, persistent pain is the least recognized by both the patient and the nurse.

Geriatric nurses play a vital role in giving care to patients. Most of the time, nurses focus their assessment only on what they can observe from the patients. They only see what the geriatric patients overtly show. Because their patients are diagnosed with dementia, the nurses need not feel that they too, suffer pain. Their cognition may not perceive the pain that they may be experiencing so nurses overlook this assessment. This is primarily because of the length of their experience and knowledge about assessing their patients. The nurses who volunteered to be samples commit themselves in deciding what interventions may be used and what pain management may be effective to the geriatric patients in the nursing homes. They deliver their care and give out medications based on their understanding and the prescriptions of doctors, not on the needs of the patients. The nurses tend to miss out in assessing the subjective data that the geriatric patients have but cannot express thoroughly.

Research has identified nurses have knowledge deficits and incorrect beliefs regarding pain assessment, management, and treatment. This finding is an important hindrance to effective pain management. Assessing persistent pain becomes difficult so pain management and treatment is inadequate.

For me, we nurses should go beyond what is observable. Our lack of experience and knowledge can be factors that hinder us from making favorable assessment and interventions. We also cannot establish good patient outcome if we only have our observations. We need to learn to empathize with our patients, may it be a child or an older adult. We must be able to express our concern for them without prejudice. We need to undergo more training and practice so we can apply and give out the quality care patients should be receiving regardless of their status. After all, nursing is always patient-based so it is always their cognitive and affective aspects that should be our priority.


Guide Questions:
1. What variable strike you most? Why?
2. What are ways that nurses can assess the pain their patients are feeling without even telling them?
3. What do you think can hinder nurses from providing care to their patients?
4. How can you give quality of care to patients who suffer from Dementia?


References:

Gauwitz, D (2007). Complete Review for NCLEX-RN. Delmar Learning,
pp. 997-1002

Podewils, L., Guallar, E., Kuller, L., et al. [2005]. Physical Activity, APOE
Genotype and Dementia Risk: findings from the Cardiovascular Health Cognition Study. from http://aje.oxfordjournals.org/cgi/content/full/161/7/639?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=dementia&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Kemp, C., Ersek, M., and Turner, J. [2005]. A Descriptive Study of the older
adults with persistent pain: Use and perceived effectiveness of pain
management strategies. from
http://ukpmc.ac.uk/articlerender.cgi?accid=pmcA1298294&tool=pmcentrez

Aging entails not only a decrease in the ability to be active, but also a trend toward increased dependence to sustain basic life functions. An important factor for appropriately elucidating an individual's care needs is the ability to measure them both simply and reliably. [1]

To reduce inappropriate medication prescribing pharmacologic guidelines are available to assist primary care physicians in medication management, however, patients with comorbid illness and accompanying complications and drug-drug interactions may require adapting general guidelines . For example, for older adults with pain symptoms, combining antidepressant and pain pharmacotherapy may be indicated. Poor patient adherence, as well as social factors can negatively affect treatment response . To address adherence and social problems that negatively affect treatment response, patient education and sometimes brief counseling is required. [2]

Reference:
[1] Thorsell, KB, Nordström, B, Nyberg, P, Sivberg, BV. (2008, September 25). Measuring care of the elderly: psychometric testing and modification of the Time in Care instrument for measurement of care needs in nursing homes.

[2] Ell, K (2006, July 13). Depression Care for the Elderly: Reducing Barriers to Evidence Based Practice.

The topic with which this study touches is a very broad subject where no one has ever even dared to touch or study in more depth.
Nursing care, can only give much to a dementia patient but the palliative measures with which our profession is greatly known for. A study conducted by Hebert et al (2006) stated that “while it is important to note that caregivers are unique individuals with their own set of needs who are not mere extensions of the patient, we do believe that caregiver well-being is intricately related to their loved one's suffering. Although we suggest that caregiver well-being can be improved by interventions that relieve patient suffering, there remain unanswered questions.” [1] In my opinion, genuine empathy with which nurses are widely known for are the only genuine care we could offer to horribly suffering dementia patient. Doing the only thing we do at a higher standard and a consistent manner can never beat any other palliative intervention that science can offer. As was written in a study conducted by Sampson et al. (2008), “It could be argued that much of what comprises this intervention is just good quality care and should be part of routine clinical practice; it is too much like what professionals believe they "do already". Naturally, some elements of the intervention will occur in usual care, although all the evidence published to date suggests that it is rarely carried out in a consistent manner. Furthermore, this sort of concern hardly ever interferes with a careful, controlled evaluation. In addition to evaluating the intervention itself, we will also assess its implementation in terms of change management within a complex health system.” [2]
Pain assessment in dementia may be based on objective reports and subjective reports from significant others primarily because primary subjective reports may be distorted or otherwise highly unreliable considering the condition of the patients. It is also, in this light, that I believe the establishment of an assessment scale specifically designed to be based solely on answers dementia patients is a ridiculously insane idea. The more sane line of thought in my opinion would be a combination of objective assessment data and significant other’s (more accurate will be the primary caregiver) assessment data would provide a more accurate pain assessment data. Sampson et al’s (2008) statement will further shed light on the argument, “we do not know what constitutes a good outcome in these patients with advanced dementia who are generally unable to express their needs and wishes. We will use the views of proxies which may not accurately reflect patients' wishes when they last had capacity.” [2] Should someone develop a mixed assessment criteria it would be more helpful in learning more about the quality of their pain.

1 - Randy S. Hebert, MD, MPH, Robert M. Arnold, MD, and Richard Schulz, PhD (2006), Improving Well-Being in Caregivers of Terminally Ill Patients: Making the Case for Patient Suffering as a Focus for Intervention Research, lifted from the National Institutes of Health Author Manuscripts, accessed June 22, 2009 retrieved from www.pubmedcentral.nih.gov
2 - Elizabeth L Sampson, Ingela Thuné-Boyle, Riitta Kukkastenvehmas, Louise Jones, Adrian Tookman, Michael King, and Martin R Blanchard (2008), Palliative care in advanced dementia; A mixed methods approach for the development of a complex intervention, lifted from the Bio Med Central Palliative Care, accessed June 22, 2009 retrieved from www.pubmedcentral.nih.gov

Dementia as one of the cognitive disorders greatly affects an individuals perception, cognition and judgment. Because of these alterations, the care giver should appropriately render care to the client so as for them to feel that they are given attention and importance. By this mean, the client may be able to be at ease.
Assessing the level of pain in a client who is suffering from cognitive disorders such as dementia is quite complicated for the care provider. Expecting that the client has problem in judgment and perception, he will not be able to give the needed information in assessing pain because of their condition. If in any case the client has significant others, they can be a source of information though pain is known to be highly subjective, this would help in order to acquire data.
Appropriate nursing care and intervention should be done by health care providers so as to alleviate the pain experienced by the client suffering from dementia. Mileu management is one of the interventions that could be done, as simply as the temperature regulation and lighting should be on the preference of the client.

Reference:
Saunders, Comprehensive Review for the NCLEX-RN Examnination (4th ed.) p. 1163 Missouri, Elsevier Inc.

Quote:

4. How can you give quality of care to patients who suffer from Dementia?

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Care for the severely demented geriatric patients poses as a difficult challenge to Psychiatric Nurses. Oftentimes, dementia patients who experience subjective pain is overlooked by the nurse since "(Zwakhalen, et al. 2007) pain assessment in people with severe dementia with limited ability to communicate is sometimes a matter of guessing". Thus, tools on pain assessment and reassessment should be utilized further to render proper pain management towards the patient.


In a research conducted in 2007 on "Nursing staff knowledge and beliefs about pain in elderly nursing home residents with dementia" by authors Zwakhalen, et al., the following statements were suggested:





Therefore, the quality of care given to elderly patients with dementia should involve a more profound perspective and understanding by the nurse. Quality of care should not only include the basic nursing practices and pertinent medical advices but also the nurse's ability to strengthen one's self-awareness and empathy towards this heartwrenching condition.





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REFERENCES:


1. Zwakhalen, S.; Hamers, J.; Abu-Saad, H.H. & Berger, M. 2006. Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools. BMC Geriatrics. Retrieved on June 23, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1397844&tool=pmcentrez

2. Zwakhalen, S.; Hamers, J.; Peijnenburg, R.; H.H. & Berger, M. 2007. Nursing staff knowledge and beliefs about pain in elderly nursing home residents with dementia. Pain Research and Management. Retrieved on June 23, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2670708&tool=pmcentrez

“…persistent pain is the least recognized by both the patient and the nurse.”

Assessment of pain in the geriatric patients is challenging due to changes in physiologic, psychosocial, and cognitive areas (Brunner and Suddarth, 2004). Therefore it is more difficult to assess those elderly who have a dementia. Deterioration of mental performance would entail difficulty in communicating what the patient really feels. So, assessing and communicating to the elderly with dementia need patience. Talk to them in a slow and use simple words. And try to manipulate the environment by making them comfortable and decease distraction and noise. And be sensitive to the non verbal cues they convey.



Reference:
Brunner, L.S. & Suddarth, D.S. (2004). Brunner and Suddarth textbooks of medical- surgical Nursing 10th edition. Lippincott Williams & Wilkins.

Older adults with dementia are frequently hospitalized, and a substantial minority present with pain during hospitalization. Although general pain management guidelines are available, care can prove challenging in the setting of dementia.

Chronic pain can lead to further cognitive impairment, accidents and behavioral problems which can be minimized if the pain is properly assessed and managed. Patients with dementia receive fewer analgesics than any other patient group, but the likelihood of pain in this group is as high as in other older people.

The facial expression of pain has emerged as an important pain indicator in demented patients, who have difficulties in providing self-report ratings.Moreover, facial responses were closely related to the intensity of stimulation, especially in demented patients.

References:

1.Kelley, Amy S (AS); Siegler, Eugenia L (EL); Reid, M Carrington (MC); (2008). “Pitfalls and recommendations regarding the management of acute pain among hospitalized patients with dementia.”. Retrieved June 23,2009 from http://www.find-health-articles.com/rec_pub_18565001-pitfalls-recommendations-regarding-management-acute-pain-hospitalized.htm

2.Kunz, Miriam (M); Scharmann, Siegfried (S); Hemmeter, Uli (U); Schepelmann, Karsten (K); Lautenbacher, Stefan (S); (2007). “The facial expression of pain in patients with dementia”. Retrieved June 23,2009 from http://www.find-health-articles.com/rec_pub_17949906-the-facial-expression-pain-patients-dementia.htm.

3. Cunningham, Colm (C); (2007). “Managing pain in patients with dementia in hospital”. Retrieved June 23, 2009 from http://www.find-health-articles.com/rec_pub_16898198-managing-pain-patients-dementia-hospital.htm

When a person with dementia finds that their mental abilities are declining, they often feel vulnerable and in need of reassurance and support. The people closest to them, including their carers, friends and family, need to do everything they can to help the person to retain their sense of identity and feelings of self-worth.

REFERENCE:
www.alzheimers.org.uk/dementiacatalogue