Original Study
Which Score Most Likely Represents Pain on the Observational PAINAD Pain Scale for Patients with Dementia?

https://doi.org/10.1016/j.jamda.2011.04.002Get rights and content

Abstract

Objectives

We sought to determine a cutoff score for the observational Pain Assessment in Advanced Dementia (PAINAD), to adequately assess pain in clinical nursing home practice and research.

Design and Setting

We used data from multiple sources. We performed a literature review on PAINAD, performed secondary data analysis of a study examining psychometric properties of PAINAD in nursing home patients with dementia, and performed another study in nursing home patients with dementia specifically aimed at determining a cutoff score for PAINAD.

Participants

Patients with dementia in long term care facilities.

Measurements

We related PAINAD scores (range 0 to 10) to (1) self-reported and proxy-reported pain by global clinical judgment and (2) scores on another pain assessment instrument (DOLOPLUS-2), and (3) we compared scores between painful and supposedly less painful conditions.

Results

Findings from this study showed that a cutoff value of 2 should serve as a trigger for a trial with pain treatment. Although the majority of patients scoring 1 or 0 were not in pain, pain could be ruled out.

Conclusion

Based on the findings of multiple available data sources, we recommend that a PAINAD score of 2 or more can be used as an indicator of probable pain. A score of 1 is a sign to be attentive to possible pain. Future work may focus on cutoff scores for the presence of pain and severe pain in other frequently used pain tools, and on further development of methodology to assess cutoff scores.

Section snippets

Strategies and Data Sources

We used 3 strategies to determine a cutoff score for the presence of pain on the PAINAD: (1) we related PAINAD observations to self-reported and proxy-reported pain, (2) we compared PAINAD scores between painful and supposedly less painful conditions, and (3) we related PAINAD scores to other observational pain scales with established cutoff scores for pain. These 3 strategies were applied to three data sources. The first data source was published reports, reviewing the literature on PAINAD,

Source 1: Cumulative Data From the Literature

The literature search revealed 2 studies that related PAINAD scores to a patient’s self-report17 and/or nurses’ report.17, 22 In the study by Leong and colleagues,17 nurses and 88 nursing home patients estimated PAINAD scores over 1 week. Based on self-report, mean PAINAD scores for patients who reported “no pain” was 1.0 (SD 1.4) versus 1.4 to 3.7 for patients reporting pain (Table 2). Not surprisingly, nurses’ proxy reports were more discriminative, with a mean of 0.1 for “no pain” and mean

Discussion

With the use of 3 strategies and based on 3 sources, a cutoff score between 1 and 2 on the PAINAD most likely represents pain in patients with dementia. A score above 2 probably represents pain in almost all patients and is most likely the cutoff value with optimal sensitivity and specificity.

Some limitations regarding this study must be considered. First, sample sizes of selected patients were small (data sources 2 [n = 75] and 3 [n = 30]) and consisted of mainly mildly and moderately demented

Conclusion

Although the majority of patients scoring 0 or 1 are not in pain, an important minority of patients are in pain, which implies that with low PAINAD scores, pain cannot be ruled out. This concurs with the literature, showing a tendency to underestimate pain in nonverbal patients,25 which may even extend the use of pain scales such as the PAINAD if implicitly relatively high cutoff scores are being used. Our findings concur with how the PAINAD is still in use in the nursing home where it was

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    The authors have declared no conflicts of interest.

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