By Heather Jeng
September is Pain Awareness Month. SLPs in skilled nursing/long-term care frequently work with patients who have acute and/or chronic pain. Yet we receive little training on characteristics of pain and how cognitively intact patients express it, let alone those with cognitive-communication disorders! Please comment below to share any experiences helping a patient with cognitive impairment communicate their pain.
One of the hardest things for me as a clinician is to see patients in pain. Once I’ve exhausted the concrete things I can do — adjusting pillows, closing the blinds, passing along a request for pain meds to their nurse — I feel pretty helpless, especially if the person is still in significant pain. Of course, some our most vulnerable patients are those with cognitive impairments. And so many elders have chronic pain, especially in skilled nursing/long-term care. How does cognitive impairment affect patients’ expression of pain?
A quick lit search turned up a helpful study titled Acute and Chronic Pain in Geriatrics: Clinical Characteristics of Pain and the Influence of Cognition. First off, there were some interesting differences between elders with chronic pain compared to those with acute pain. Those with chronic pain:
- named more pain sites
- used more descriptors for pain
- reported less pain reduction during treatment
- used more pain meds at discharge
- exhibited more anxious and depressive symptoms, and had more difficulty getting to sleep
A finding that really stood out to me was that cognitively impaired patients described the location of acute pain similarly to patients with chronic pain. They also described it in less precise terms than did less cognitively impaired patients. As the authors put it, “Cognitive impairment seems to change the ability to localize acute pain.”
Fortunately, patients with cognitive impairments did not appear to have a disadvantage in reporting pain intensity. Use of an ADL task administered at admit and discharge to judge improvement in pain also appeared to be reliable in both groups.
Reading this study reinforced for me the SLP’s role in helping patients with cognitive impairment communicate. How many instances of acute pain in patients with dementia are interpreted, even by well-meaning staff, as chronic pain? Individualized memory and communication cards, such as the card below, for pain localization and intensity can help caregivers differentiate between routine and unusual pain. And memory and communication cards for purposes other than social conversation have good evidence supporting them (Bourgeois & Hickey, 2007, 2009; Bourgeois, 2013).
We may not be the member of the team who can lessen our patient’s pain. But hopefully we can help them communicate more clearly with the team member who can.
Schuler, M., Njoo, N., Hestermann, M., Oster, P., & Hauer, K. (2004). Acute and chronic pain in geriatrics: clinical characteristics of pain and the influence of cognition. Pain Medicine, 5, 3, 253-262.