Recognizing Pain In Elderly People With Dementia Who Are Living In The Nursing Home

Description of health issues

Discuss about the Recognizing Pain In Elderly People With Dementia Who Are Living In The Nursing Home.

Dementia is a common health issue in elderly people and it significantly interferes with normal daily life activities. The disease is associated with gradual deterioration in memory, communication, reasoning and judgment skills, ability to focus and visual perception. However, cognitive problem is not the only challenge for care givers of elderly people with dementia. In nursing homes, it has been found that 50% of elderly people have dementia and recognizing and assessing pain such people is very challenging (Hadjistavropoulos et al., 2014). Many barrier to pain assessment is seen because of personality changes, memory loss and impairment if judgment and abstract thinking skill in elderly people. Error in assessment might also occur because sometimes symptoms attributed with dementia are actually an indication of pain in patient. For example, dementia patients may display aggressive behavior when they experience pain and the care may mistake it as a symptom of dementia (Lichtner et al., 2014). Hence, considering unique challenges in recognizing pain in dementia patient, this report proposed developing a health promotion strategy to improve pain assessment of elderly people with dementia. The focus is mainly on female patients with dementia as women are at greater risk from dementia than men (Knapton, 2017). 

The evidence based strategy that is proposed for mitigating the barrier in pain assessment and managing pain in elderly patient with dementia is the use of sense-making theories to interpret pain in nursing homes. The strategy of using intuitive perception is considered important to mitigate the barrier to pain assessment because pain assessment tool does not provide the information that nurse need to recognize pain in patient.  Hence, using the sense making theory may help to develop the intuitive knowledge of carer in nursing homes and improve their decision making regarding pain recognition and management. The theories of sense-making focuses on giving meaning to experiences and interpreting information from those experiences (Dowding et al., 2016). Hence, this approach can be used in nursing home to use intuitive skills to recognize the characteristics of cognition in elderly women dementia. This form of decision-making is highly dependent on interaction with patient and the higher interaction, the more information is gained regarding level of pain in dementia patients. Mamykina, Smaldone, & Bakken, (2015) also support the benefits of the sense making theory in management of chronic disease by using the framework of sense making for diabetes self-management. Hence, instead of relying on the technology and clinical tools, this health promotion project encourages carers observe patient’s behavior and make sense of those information to manage chronic diseases.

Evidence-based strategy for health improvement

This health promotion strategy proposes developing the intuitive perception of nurse or care or elderly people with dementia by the application of the sense making theory and supporting them to recognize and assess pain in such patients. Sense making is mainly dependent on a person’s ability to make sense of the phenomena (patient’s behavior or expression in response to pain), construct mental representation of that phenomenon and using this to guide action. This enables developing a pattern related to behavior of dementia patients during pain, discovering connections associated with pain and then engaging in appropriate management activities to reduce pain interaction, the more information is gained regarding level of pain in dementia patients (Mamykina, Smaldone, & Bakken, 2015). Hence, in the context of recognizing pain the in dementia patient, the implementation of this health promotion intervention is dependent on extensive training of staffs and their experience in caring for dementia patients in nursing home.

In nursing home, sense making theory can be applied for recognition of pain in dementia patients in the following ways:

• Nurses must be trained to build mental patterns of the patient’s behavior with time. The advantage of this approach is that it will support the nurse to identify the behavior or characteristics that indicate pain.
• Three necessary sense making strategies that will be necessary for the nurse to recognize pain will include perception of new information related to expression of pain in patient, development of inferences from certain behavior of patient and carrying out appropriate strategies to manage pain (Dowding et al., 2016).
• There is also need for collective work of the team because cognitive activity cannot be individual person and group of individuals monitoring the patient’s behavior and health status may give good information regarding identification of pain and cause of pain (Goodwin et al., 2014).
• As pain assessment in elderly dementia patient requires more cognitive power, it is necessary that organization routines and boundaries also support carers to devote time in identifying behavioral patterns of dementia patient. Therefore, redesigning the system of care will be necessary to promote care of elder adults with dementia (Callahan et al., 2014).
• With the use of sense making approach, the nurse can collect cues related to patient patterns of pain. Some of the signs of pain may be recognized by behavior, vocalization of pain and scores on formal assessment tools. Hence, pain assessment tool is not totally excluded in this intervention, instead this also informs about the pattern related to pain event in elderly patient. In response to this information, clinician or nurse can identify the experience as pain and implement necessary action to manage such patient situation (Dowding et al., 2016).

The above mentioned strategy is mainly based on the model of recognition-primed decision model (RPD). This model defines the process needed for effective decision making during complex situations. It can regarded as an effective health promotion approach model for dementia patients because this model also supports taking intuitive strategies such as pattern recognition to take proper action. The role of cognition is critical in improving safety of patient in nursing home setting and the RPD model will support the nurse to effectively recognize and manage pain of elderly adults (Lighthall & Vazquez-Guillamet, 2015.

The model will promote health promotion activities for dementia patients in nursing home because it also combines the intuitive and clinical information processing components to improve health status of individual. This is relevant to the sense making approach needed for recognition of pain and using this model as a framework will give direction to nurses or carer regarding the pain recognition and assessment process.

To successful develop the skills of nurse in pattern recognition related to pain recognition in elderly dementia patients, the following health promotion activities will be necessary:

• Firstly, it will necessary to develop the cognitive skills of nurse and carers so that they engage in pattern recognition and develop intuitions regarding the behavior that is an indication of pain in patient. Hence, training sessions will mainly use the cognitive forcing strategies to encourage nurse to monitor dementia patients and increase their competency in using heuristics for identification of pain (Lichtner et al., 2016).
• The key resource required for this health promotion activities include pain assessment tool, appropriate behavior characteristics form of patient, training materials related to strategies needed for pattern recognition and follow up form to inform about patient’s behavioral patterns. The training and material and pain assessment tool is critical for carers because training material will enable nurse or carer too characterize patient’s behavior related to pain and tools will give information regarding pain levels and type of pain (Newton et al, 2014). Secondly, behavior characteristics form will inform the staffs about the individual response of patients to pain and this will be useful in communicating the information to other staffs involved in care of that patients too.
• The training activities will be collected prior to the implementation of activities and the process of intuition to collected cues related to pain will be done in nursing home. This health promotion project will need investment in the area of relevant pain assessment tool for dementia patient and covering the training cost.

The main objective of the use of sense making in recognizing pain in elderly people with dementia is :

• Eliminate the barrier to recognition of pain and assessment of pain such as misinterpreting patient’s behavior in response to pain as symptom of dementia
• Getting all the cues related to specific behavior that is an indication of pain in patient
• Recognizing the factors that is the cause of pain in patients (Lichtner et al., 2016)

The success of the project will be determined by taking the feedback from the nurses or carers regarding the use of sense making approach for pain recognition. If they express that challenges in pain assessment has reduced after this approach, then this intervention can be continued for long term too. The next aspect is related to evaluating the outcome of dementia patient after the recognition of pain. Insufficient training or education regarding effective pain assessment is often a barrier to pain recognition and the outcome of patient may give an indication whether cares have been successful in conceptualizing pain situations of dementia patient or not. Secondly, the level of use of pain assessment tool is also critical for this pain assessment project because pattern recognition is also dependent on effectively measuring pain levels (Chacko, 2014).

References

Callahan, C. M., Sachs, G. A., LaMantia, M. A., Unroe, K. T., Arling, G., & Boustani, M. A. (2014). Redesigning systems of care for older adults with Alzheimer’s disease. Health affairs, 33(4), 626-632.

Chacko, V. (2014). A Project to Empower the Staff Awareness in Best Practice Approach to Pain Assessment in Dementia.

Dowding, D., Lichtner, V., Allcock, N., Briggs, M., James, K., Keady, J., … & Closs, S. J. (2016). Using sense-making theory to aid understanding of the recognition, assessment and management of pain in patients with dementia in acute hospital settings. International journal of nursing studies, 53, 152-162.

Goodwin, N., Dixon, A., Anderson, G., & Wodchis, W. (2014). Providing integrated care for older people with complex needs: lessons from seven international case studies. London: King’s Fund.

Hadjistavropoulos, T., Herr, K., Prkachin, K. M., Craig, K. D., Gibson, S. J., Lukas, A., & Smith, J. H. (2014). Pain assessment in elderly adults with dementia. The Lancet Neurology, 13(12), 1216-1227.

Knapton, S. (2017). Women at greater risk from dementia than men. Telegraph.co.uk. Retrieved 7 September 2017, from https://www.telegraph.co.uk/news/health/news/11754402/Women-at-greater-risk-from-dementia-than-men.html

Lichtner, V., Dowding, D., Allcock, N., Keady, J., Sampson, E. L., Briggs, M., … & Closs, S. J. (2016). The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective. BMC health services research, 16(1), 427.

Lichtner, V., Dowding, D., Esterhuizen, P., Closs, S. J., Long, A. F., Corbett, A., & Briggs, M. (2014). Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC geriatrics, 14(1), 138.

Lighthall, G. K., & Vazquez-Guillamet, C. (2015). Understanding Decision Making in Critical Care. Clinical medicine & research, 13(3-4), 156-168.

Mamykina, L., Smaldone, A. M., & Bakken, S. R. (2015). Adopting the sensemaking perspective for chronic disease self-management. Journal of biomedical informatics, 56, 406-417.

Newton, P., Reeves, R., West, E., & Schofield, P. (2014). Patient-centred assessment and management of pain for older adults with dementia in care home and acute settings. Reviews in Clinical Gerontology, 24(2), 139-144.