Martijn P. F. Berger

Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools

BackgroundPain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.MethodsThis systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.ResultsTwenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.ConclusionBased on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.

The psychometric quality and clinical usefulness of three pain assessment tools for elderly people with dementia

&NA; In view of the need for valid, reliable, and clinically useful scales to assess pain in elderly people with dementia, this study evaluated the psychometric properties of translated versions of the PAINAD, PACSLAC, and DOLOPLUS‐2 scales. In an observational study design, two raters simultaneously assessed the nursing home residents (n = 128) for pain during influenza vaccination and care situations. The PACSLAC was valued as the most useful scale by nurses. Cronbachs alpha was high (>.80) for the total scale at T2 and T3 and adequate for the ‘Facial expression’ and ‘Social/personality/mood’ subscales. IC scores for the ‘Activity/body movement’ and ‘Physiological indicators/eating/sleeping changes/vocal behaviors’ subscales were low. It demonstrated good validity and reliability, although the scale should be further refined. This refinement should increase homogeneity. The PAINAD showed good psychometric qualities in terms of reliability, validity, and homogeneity (&agr; ranged .69–.74 at T2 and T3) (except for the ‘Breathing’ item). The PAINAD scale had lower scores for clinical usefulness in this sample. The Dutch version of the DOLOPLUS‐2 was considered more difficult to use but showed acceptable psychometric qualities in terms of the issues assessed, except for the ‘psychosocial reactions’ subscale. IC of the DOLOPLUS were adequate for the total scale (&agr; ranged .74–.75) and almost all subscales (&agr; ranged .58–.80). Findings of this study provide evidence of validity and reliability of the three pain assessment scales. Now that a pain scale is available, future studies also need to focus on its implementation in nursing practice.

The prevalence of pain in nursing home residents with dementia measured using an observational pain scale.

Background: Studies on pain and pain prevalence in older people with dementia are limited compared to those on cognitively intact older people. Pain prevalence rates in older people with dementia are estimated to be between 28% and 83%.

A comparison between traditional methods and multilevel regression for the analysis of multicenter intervention studies

This article reviews three traditional methods for the analysis of multicenter trials with persons nested within clusters, i.e., centers, namely naïve regression (persons as units of analysis), fixed effects regression, and the use of summary measures (clusters as units of analysis), and compares these methods with multilevel regression. The comparison is made for continuous (quantitative) outcomes, and is based on the estimator of the treatment effect and its standard error, because these usually are of main interest in intervention studies. When the results of the experiment have to be valid for some larger population of centers, the centers in the intervention study have to present a random sample from this population and multilevel regression may be used. It is shown that the treatment effect and especially its standard error, are generally incorrectly estimated by the traditional methods, which should, therefore, not in general be used as an alternative to multilevel regression.

Design Issues for Experiments in Multilevel Populations

For the design of experiments in multilevel populations the following questions may arise: What is the optimal level of randomization? Given a certain budget for sampling and measuring, what is the optimal allocation of units? What is the required budget for obtaining a certain power on the test of no treatment effect? In this article these questions will be dealt with for populations with two or three levels of nesting and continuous outcomes. Multilevel models are used to model the relationship between experimental condition and the outcome variable. The estimator of the regression, coefficient associated with treatment condition, a parameter assumed to be fixed in this paper; is of main interest and should be estimated as efficiently as possible. Therefore, its variance is used as a criterion for optimizing the level of randomization and the allocation of units.

Some New Item Selection Criteria for Adaptive Testing

In this study some alternative item selection criteria for adaptive testing are proposed. These criteria take into account the uncertainty of the ability estimates. A general weighted information criterion of which the usual maximum information criterion and the proposed alternative criteria are special cases is suggested. A small simulation study was conducted to compare the different criteria. The results showed that the likelihood weighted information criterion is a good alternative to the maximum information criterion. Another good alternative is a maximum information criterion with the maximum likelihood estimator of ability replaced by the Bayesian expected a posteriori estimator.

Nursing staff knowledge and beliefs about pain in elderly nursing home residents with dementia

BACKGROUND Aging is known to be associated with a high prevalence (up to 80%) of persistent pain among residents of nursing homes. However, even with high pain prevalence rates, nursing home residents are at risk for undertreatment. Knowledge deficits and beliefs among nurses influence staff behaviour in pain assessment and management. OBJECTIVES To develop a psychometrically sound questionnaire and to gather information about knowledge and beliefs of nursing staff regarding various aspects of pain in elderly patients with dementia. In addition, the differences among several categories of nurses (based on educational level and work experience) with respect to beliefs about pain were investigated. METHODS Participants were 123 staff members of psychogeriatric wards in two nursing homes in the Netherlands (mean of 11.4 years of experience). Their results were compared with those of two groups of nurses, one consisting of 25 registered nurse PhD students in nursing science and the other consisting of 20 trainee pain nurse specialists. RESULTS The main findings indicate that nursing home staff respondents showed knowledge deficits about several aspects of pain, even though they were satisfied about the way pain was assessed and treated at their wards. Specific knowledge deficits were found regarding pain treatment and medication in elderly nursing home residents. Staff educational level seemed to influence their beliefs and knowledge about pain in elderly nursing home patients.

A Cluster-Randomized Trial of an Educational Intervention to Reduce the Use of Physical Restraints with Psychogeriatric Nursing Home Residents

OBJECTIVES: To investigate the effects of an educational intervention on the use of physical restraints with psychogeriatric nursing home residents.

Optimal allocation of time points for the random effects model

In this article the problem of the optimal selection and allocation of time points in repeated measures experiments is considered. D‐ optimal designs for linear regression models with a random intercept and first order auto‐regressive serial correlations are computed numerically and compared with designs having equally spaced time points. When the order of the polynomial is known and the serial correlations are not too small, the comparison shows that for any fixed number of repeated measures, a design with equally spaced time points is almost as efficient as the D‐ optimal design. When, however, there is no prior knowledge about the order of the underlying polynomial, the best choice in terms of efficiency is a D‐ optimal design for the highest possible relevant order of the polynomial. A design with equally‐spaced time points is the second best choice

Optimal experimental designs for multilevel models with covariates

In this paper optimal experimental designs for multilevel models with covariates and two levels of nesting are considered. Multilevel models are used to describe the relationship between an outcome variable and a treatment condition and covariate. It is assumed that the outcome variable is measured on a continuous scale. As optimality criteria D-optimality, and L-optimality are chosen. It is shown that pre-stratification on the covariate leads to a more efficient design and that the person level is the optimal level of randomization. Furthermore, optimal sample sizes are given and it is shown that these do not depend on the optimality criterion when randomization is done at the group level.