Beyond Words: Evaluating PAINAD Use in Dementia Patients on Surgical Wards

1. Introduction

Patients with advanced dementia admitted to surgical wards may experience pain that goes unrecognised due to communication barriers. The PAINAD (Pain Assessment in Advanced Dementia) tool, recommended for non-verbal pain assessment, was rarely or never used. This concern was identified through clinical observation and a retrospective review of surgical dementia patients. This audit sought to assess current use of PAINAD, evaluate adherence to local recommendations, and implement changes to improve pain assessment and outcomes.

2. Method

A retrospective review was conducted using EPIC EPR. Patients admitted under surgical specialties between May and August 2022 with a documented diagnosis of dementia were identified. After exclusions (length of stay <1 day and low suspicion of pain), 37 patients were analysed. Records were reviewed for pain score documentation and PAINAD use. A questionnaire was distributed to nursing staff to identify barriers to using PAINAD. Following this, a multi-faceted intervention was introduced, including staff education, awareness campaigns, collaboration with pain specialist nurses, and improvements to electronic documentation systems. Post-intervention data were collected between November 2023 and January 2024 (31 patients).

3. Results

Pre-intervention, 258 pain scores were recorded over 451 inpatient days (0.8/day), with no documented use of PAINAD. Despite an estimated 35% of patients likely requiring PAINAD, none received it. Staff awareness was low, with only 2 of 9 nurses familiar with the tool. Post-intervention, pain score recording improved significantly to 608 scores over 273 days (2.3/day). PAINAD use increased from 0/37 to 3/31 patients, though still below expectations (≈11 patients). Manual review suggested 12 patients may have benefited from PAINAD. There was also evidence of broader cultural change, with increased awareness and use across admissions.

4. Conclusion

PAINAD remains underutilised in surgical patients with dementia, though improvements in documentation and awareness were observed following intervention. A multi-disciplinary approach addressing education, culture, and EPR systems led to better pain assessment practices. Ongoing efforts are required to further integrate PAINAD into routine care and optimise pain management in this vulnerable population.