The Bolton Pain Assessment Tool: Development & Initial

Testing

Dr Julie Gregory

Nurse Lecturer (Acute Pain Nurse)

Julie.gregory@manchester.ac.uk

• Pain common symptom

• Management of pain

– improves function, reduces complications and hospital stay

• need to recognise and assess pain

• Ethical and professional responsibility to assess and treat pain

• Need to be aware of:

• strategies to assess pain

• Barriers to assessment

• Communication difficulties are a major barrier

Nurses

• “An unpleasant sensory and emotional

experience associated with actual or potential

tissue damage or described in terms of such

damage.” (IASP, 1994, p210)

• Pain is composed of highly interactive emotional cognitive and sensory components

• It is Subjective

OR

“Pain is whatever the patient says it is”

Pain Perception

• The Gold Standard

Or

• Most reliable indicator of pain intensity and experience is Self Report

• Use of numerical score, verbal descriptor score

Pain Assessment

Pain Assessment and Cognitive Impairment

• Self-report of pain should always be attempted & found

to be suitable for many people:

• 68% with moderate to severe impairment (n = 59). Attempt initially and adopt wording if necessary (instruction s up to 3 times)

(Closs et al. 2004)

• 60% to 70% mild to moderate cognitive impairment Verbal Descriptor Scale can be used

(Kaasalainen & Crook 2004)

• Moderate dementia 60% NRS and 90% VDS (No repeated instructions) (Lukas et al 2013)

But ………..

• Communication

• Conscious level

• Understanding of the pain rating

• Memory of a painful event

• Interpretation of noxious stimuli

(Buffum et al 2007)

Self Report Requires

Problem

• Undetected – misinterpreted – inaccurately assessed under-treated.

• Hip fracture patients with cognitive impairment – one third amount of morphine administered compared to cognitively intact.

• 76% - no prescription for post operative analgesia

(Scherder et al 2009)

Indicators of pain

• What behaviours may indicate pain?

Behaviour

Pacing, crying out, aggression, confusion,

social withdrawal, apathy

Some Symptoms of Pain

• Difficulties in assessment of pain identified

• 158 indicators of pain

• Identified by 109 nurses

• Variation (Zwakhalen et al 2004)

Literature

• Vocalisation – Shout

• Facial grimace • Body language

– Rubbing, guarding

• Changes in behaviour – aggression, resists movement

• Physiological change – Increase HR, BP, sweating

• Physical changes – Skin damage, fractures,

Behaviours associated with pain (AGS 2002)

• Various available

• Numerous concerns – Validity etc

• Not used in practice – Lacks user friendly

Behavioural pain assessment tools

Pilot survey of the use of Behavioural or

Observational Pain Assessment Tools

BEHAVIOURAL

SCALE ABBEY PAINAD FLACC ICU ABBEY /ICU NONE

Pain meeting 10 1 1 2 5

University 1 1 17

Total 10 2 1 1 2 22

• 58% used an observational pain assessment tool • Three hospitals use the Abbey pain scale,

(The two nurses indicated they used the PAINAD did not record which hospital they represented.)

(Gregory and Richardson 2014)

Assessment Tool

Area of practice Type of pain

The Abbey Scale

Long Term Care (LTC)

Acute & Chronic

ADD (Assessment of

Discomfort in Dementia)

LTC

Acute & Chronic

CNVI ( Checklist of Non Verbal

Pain Indicators )

Acute Care

LTC

Acute &Chronic

MOBID ( Mobilization

Observation Behaviour

Intensity Dementia Pain Scale)

LTC Excluded acutely ill

PACSLAC ( Pain Assessment

Scale for Seniors with Severe

Dementia )

LTC Chronic pain

PAINAD (Pain Assessment in

Advanced Dementia )

LTC Acute & Chronic

PADE (Pain Assessment in

Dementing Elderly)

LTC 24 items

PATCOA (Pain Assessment To

Confused Older Adults)

Acute Care 22 items

DEVELOPMENT OF BEHAVIOURAL PAIN ASSESSMENT SCALES

ABBEY PAINAD CNPI

Australia Care Homes 61 residents Staff (n=61) completed the pain scale Development based on the assumption caregivers reliably rate the intensity of pain Nurses’ holistic impression of pain severity was used as the gold standard.

USA Long-Term 19, white male residents Good construct reliability and validity PAINAD able to detect differences in pain associated with different medical conditions and analgesic administration. Positive correlation between verbal report and observation with PAINAD in 25 # nof pts (12 cog impaired, 13 intact pts)

USA Acute – trauma 88 cognitively impaired (53) and cognitively intact hip fracture (35) Each of the 6 items is scored on a dichotomous two point scale (0= not present; 1=present). Pain present on movement

17

The Abbey Pain tool Scale

No behaviour is unique to pain

• Behaviour is unique to individuals

• Do carers pick up on behaviour?

• Suggestion - Need to ‘know the person’.

• Other reasons for distress

– Fear and anxiety, anger and frustration

– Distress from environment, others, change

– Low mood, boredom, hallucinations

Problems with behavioural assessment

Trial of 3 tools in acute care

Practice development project

• Examined some of the pain assessment tools available

• Decided to use:

– Abbey pain assessment

– PAINAD (Pain Assessment in Advanced Dementia)

– CNPI (Checklist of Non Verbal Pain Indicators )

Scale Vocalisation Facial grimace

Body

language

Behaviour change

Physiological change

Physical change

Abbey

CNVI

Restless

Rubbing × ×

PAINAD Breathing

× (consolability)

Comparison of scales content

ABBEY PAINAD CNPI

• Easy to use and understandable

• 1-5 mins to complete

• ‘gives prompts’, • ‘effective’ • justifies analgesia’ • ‘like the

documentation’

• ‘Subjective ‘

• Easy to use and understandable

• 1-5 mins to complete

• ‘easy to follow’ • ‘good to use especially

in those who cannot communicate’

• ‘ a very good pain assessment tool’

• 44% easy to use and understandable

• 1-5 mins to complete

‘ not clear what the numerical scores should action’ ‘nowhere to document findings’

• RATED • Mean = 8.0

Mean = 8.6

Mean = 4.5

Evaluation by nurses following use in acute care

• From literature CNPI appears to be suitable for acute care – trauma

• In practice and when compared to other tools not useful

• During the trials some patients had pain identified by relatives.

• Tools did not always capture pain.

• Need to be included in an assessment tool

Evaluation of 3 scales

• Combined the Abbey scale with PAINAD

• Included a section for relatives and / or carers to comment or rate an individuals pain

• Physiotherapy comments for pain on movement.

Bolton Pain Assessment Tool

SCORE ABSENT

0

MILD 1 MODERATE 2 SEVERE 3 SCORE

VOCALISATION

none

Occasional moan or groan Low level speech with a

negative or disapproving

quality

Repeatedly crying out, loud

moaning or crying

FACIAL EXPRESSION

Smiling

or relaxed

Looking tense, Sad

Frowning,

Grimacing and looks frightened

CHANGE IN BODY

LANGUAGE

None Tense, fidgeting

Guarding part of the body, Withdrawn, rigid, fists clenched.

Knees pulled up

BEHAVIOURAL

CHANGE

None

Increased confusion

Refusing to eat, alterations

in usual pattern

Pulling or pushing away, striking

out

PHYSIOLOGICAL

CHANGE

Normal

Occasional laboured

breath, increased heart

rate

Hyperventilation, increased

heart rate and BP

Change in pulse BP, respiratory rate

and perspiring, flushed or pallor

PHYSICAL CHANGES

None

Skin tears

Pressure sores, arthritis

Post surgery, trauma,

TOTAL SCORE:

Comments by family or

usual care givers

Pain on movement/

physiotherapy

0-2

NO PAIN

3-7

MILD PAIN

9-13

MODERATE PAIN

14+

SEVERE PAIN

BOLTON PAIN ASSESSMENT TOOL

(For patients with communication problems)

NAME OF PATIENT……………………………………………………………….

NAME AND DESIGNATION OF PERSON COMPLETING SCORE:…………………………………. DATE AND TIME

……………..

• Audit identified no observational tool used

• 4 wards involved

• Trauma, medical, stroke unit and long term care

• Meeting held with senior staff

• Assessment tool adjusted

• Information file produced and some educational input

• Used BPAT for 6 weeks

• Completed an evaluation sheet

Proof of concept at UHSM

• Easy to use • 1-5 mins • Useful – identified pain • Led to analgesia administration • Request for analgesic review • Average rating of scale = 8/10 • Low involvement of family

• Not as positive in long term unit • Appeared to resent use of a formal assessment

tool

Evaluation

Cognitive Impairment Pain Assessment Scale (For patients with communication difficulties i.e. Dementia, Stroke, Learning Disability, Acute confusion)

Date Time

Score Absent 0 Mild 1 Moderate 2 Severe 3 Score

Vocalisation

None Occasional moan /

groan

Low level speech

with a negative

or disapproving

quality

Repeatedly crying

out loud, moaning

or crying

Facial Expression Smiling /

relaxed

Looking tense Sad, frowning Grimacing & looks

frightened

Change to body language None Tense, fidgeting Guarding part of

the body

Withdrawn, rigid,

fists clenched,

knees pulled up

Behavioural change None Increased

confusion

Refusing to eat,

alterations in

usual pattern

Pulling or pushing

away, striking out.

Physiological change Normal Occasional

laboured breaths,

increased heart

rate

Hyperventilation

increased heart

rate & BP

Changes in pulse,

BP, respiratory rate

& perspiring,

flushed or pallor

Physical changes None Skin tears Pressure sores,

arthritis

Pre-op trauma &

post surgery < day 4

Pain on movement or

physiotherapy None

Mild

Moderate

Severe

Ask family or usual care giver about normal behaviours. Use ‘My Traffic Light’ / ‘Forget me Not’ these may change the scoring:

Patient Name

RM2

DOB

Total score 0 – 2 = no pain

3 – 8 = mild pain

9 – 14 = moderate

15+ = severe pain

Guidance overleaf

Analgesia given

( Y / N )

Signature

• Communication affects how people express pain

• Behaviour and changes to behaviour suggests pain or other problem

• Use self report- verbal descriptor initially

• Observation of behaviour when unable to obtain score

• Many tools available –need to choose one suitable for specific context

Discussion

• There are a large number of behavioural pain assessment tools available

• Not used in everyday practice

• Behaviour may indicate other causes for distress

• Should be used with other information

• Ideally with someone who knows the individual well

Discussion

Further Development

• Testing of BPAT required

• Inter-rater reliability

– Two nurses (HCP) observe and score pain independently but at same time

– Compare scores

• Concurrent Validity

– Observe behaviour in cognitively intact patients and score pain

– Ask for a pain score and compare

Let me know if interested

• Julie.gregory@manchester.ac.uk

• Happy to talk over lunch

• Any questions or comments???

• American Geriatric Society (2002) the management of persistent pain in older people. American Geriatric Society , 50 (6) supplement.

• Chen Y-H, Lin L-C and Watson R(2010) Validating nurses’ and nursing assistants report of assessing pain in older people with dementia. Journal of Clinical Nursing 19, 42-52 doi :10.1111/j.1365-2702.2009.02950.x

• Closs SJ, Barr B, Briggs M, cash K, Seers K (2004) A comparison of four pain assessment scales for Nursing home residents with varying degrees of cognitive impairment. Journal of Pain and Symptom management 27 (3) 196-205

• de Souto Barreto P.Lapeyre-Mestre M, Vellas B Rolland Y (2013) Potential underuse of analgesia for recognised pain in a nursing home residents with dementia: A cross- sectional study. PAIN 154, 2427-2431

• Gregory J (2012) How can we assess pain in people who have difficulty communicating? A Practice development project identifying a pain assessment tools for acute care. International Practice Development Journal 2 (2) 6-20

• Herr K (2011) Pain assessment strategies in older patients. The Journal of Pain 12 (3) s3-s13 • Lukas A, Nierecker T, Gunther I Mayer B Nikolaus T(2013) Self and proxy report from the assessment of pain in

patients with and without cognitive impairment. Experiences gained in a geriatric hospital. Z Gerontolicie and Geriatrie 3, 214-221.

• Schofield P (2008) assessment and management of pain in older adults with dementia: a review of current practice and future directions. Current Opinions in Supportive and Palliative Care. 2: 128-132

• Williamson A and Hoggart B (2005) Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing: 14, 798 – 804.

• Zwakhalen SMG, Dongen KAJ, Hamers JPH, ABU-Saad HH (2004) Pain assessment in intellectually disabled people: non-verbal indicators. Journal of Advanced Nursing 45 (3) 236-245.

References

• Alzheimer’s Society (2007) Dementia UK

• Buffum MD, Hutt E, Chang V T Craine MH Snow AL (2007) Cognitive impairment and pain management: review of issues and challenges. Journal of Rehabilitation Research and Development 44 (2) 315-330

• Department of Health (2010) Quality outcomes for people with dementia: Building on the

work of the National Dementia Strategy

• Department of Health (2009) Living well with dementia: A National Dementia Strategy

• Fuchs-Lacelle S, Hadjistavropoulos T (2004), Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC) Pain Management Nursing. Vol.5: pp37–49.

• Kaasalainen S and Crook J (2004) An exploration of seniors’ ability to report pain. Clinical Nursing Research 13, 2, 199-215.

• NICE/SCIE Dementia Guidelines (2006)

• NHS Confederation 2010 Acute awareness: improving hospital care

• Roherer, J & Warren, J. Fronto-temporal dementia (on-line) http://pdsg.org.uk/clinical_information (Accessed on 22 March 2011)

References