Assessment of pain in older adults with dementia - there's an app for that
Professor Pat Schofield leads research around pain, ageing and dementia at the University of Greenwich. She is the Chair of the Pain in Older People SIG at the British Pain Society. She describes the development and initial trial of a new Pain App that is targeted at frail, older patients.
Pain in the older population is a common problem, and can be under-recognised and under-treated. Recent prevalence studies suggest that chronic pain exists in over 50% of community dwelling older adults and this increases to over 80% when we look at those living in long term care. We also know that the incidence of dementia in the UK and the rest of the world is high and set to increase significantly over the next 20 years.
The first stage in the management of pain is assessment. But carrying out pain assessment is hampered when communication problems, such as dementia exist. In 2007, we published the pain assessment guidelines. The guidance followed a number of years of multidisciplinary collaboration and a large scale systematic review and resulted in a very comprehensive document that set out an algorithm for assessment of pain. Sadly, the guidelines have not been adopted widely. Particularly, in groups where pain assessment should be a priority in the light of the high incidence noted earlier.
In Greenwich, we decided to find a way to get the guidelines out into practice by adopting an approach that would perhaps appeal to the demographic of the carers, ie; the pain APP. Working with colleagues from Computing and Mathematical Science, we developed the APP. This was recently trialled by paramedic staff and feedback was very positive in that it improved assessment and management of pain in adults with dementia. Some comments were as follows;
} “the app makes a massive difference. From the start it guides you through speaking to the person, and what you can do if they can't communicate verbally or can't understand.”
- “Once the app is installed it doesn't need an internet connection to work.”
- “With it being on a smartphone it's always with you, whether in a person's house, the first aid room of a supermarket or an ambulance.”
- “The app provides that bit of additional confidence to actively manage the pain or recognise when it's appropriate to involve someone else who can.”
- “The app throws up questions that I wouldn't have thought to ask but which can be really useful in understanding the pain they're experiencing.”
The results have been positive so far. The APP has been well received in one particular practice area. But we need to get the APP used in other areas. There are some key issues which we need to consider for the future;
- The APP provides a foundation on which to measure pain, but it is important that the responsibility does not end there. Once pain has been assessed, we need to incorporate guidance on what to do when pain has been identified. It may be that the three step analgesic ladder could be incorporated in some way.
- We need to find ways of reaching staff who currently do not have the resources to assess pain, in particular, amongst the care home population and this is where, the next stages could be added to support with management guidelines. But it is not just about throwing an APP at a problem and hoping that it works. Whilst, the APP is fairly well self-explanatory, it does need to be supported with education, or it will become another strategy that people do not understand.
- We could also find a way to enable the data collected through the APP to be downloaded and stored to monitor the impact of the assessment. But this raises issues of confidentiality and data protection which will need to be addressed first.
So, there is still work to be done. The APP has promise, but we cannot be complacent.
Thanks to the Computing and Mathematical Science group for help and direction in developing the APP and the South East Coast Ambulance Service for testing the APP.