Abstract
Introduction
Pain is a major concern in cognitively impaired patients. Communication challenges contribute to poor recognition and undertreatment, negatively impacting prognosis and quality of life. The National Dementia Audit highlighted that structured pain assessment for people with dementia admitted to hospitals remains a significant area for improvement. The PAINAD (Pain Assessment in Advanced Dementia) scale aids in structured pain recognition through objective assessment. We implemented a quality improvement project aiming to improve PAINAD utilisation in inpatient geriatric wards.
Methods
Using the ‘Plan-Do-Study-Act' (PDSA) approach, baseline data was collected from inpatient wards at two large teaching hospitals: Queen’s Medical Centre (QMC), Nottingham and Royal Derby Hospital (RDH), where PAINAD is recommended by local trust guidelines. Frequency of PAINAD use in patients with dementia and/or delirium was observed. Based on gaps identified, the first cycle intervention was board-round discussions to improve awareness around pain recognition and identify high-risk patients and opportunities for PAINAD utilisation. In the second cycle, bite-sized teaching for ward staff was conducted across both sites, and posters highlighting use of PAINAD displayed on the wards.
Results
Baseline data of 60 patients showed inconsistent pain assessment documentation; neither site used PAINAD routinely, prompting the first cycle of action.
42 opportunities for PAINAD utilisation were identified in board-round meetings over 5 days.
PAINAD was completed in 14% of these opportunities. In some instances, the score was actioned with appropriate analgesia. Use of PAINAD remained inconsistent across both sites, prompting the second PDSA cycle, for which data collection is ongoing.
Conclusion
PAINAD utilisation remained suboptimal despite efforts to highlight the importance of recognising pain in inpatients with dementia. With consistent use, PAINAD could enable robust assessment and pain management in these patients. Future interventions to be considered include prompts on electronic prescription systems to encourage pain assessment in targeted patient groups.
Comments
I think pain is something…
I think pain is something that we definitely unrecognised in patients with cognitive impairment and also as a cause of delirium.
Can I ask what members of staff were expected to complete the PAINAD and where this was recorded? I recognise that nursing staff often have lots of paperwork to do already which may act as a barrier to completing further scores, and I also recognise there is rotation of medical staff which may prove a barrier. In addition it would be useful if it was recorded in a place where you could monitor the trend in the score.
Definitely a positive to highlight the issue of poor recognition/undertreatment of pain in these patients!
Agreed. It was primarily…
Agreed. It was primarily aimed at nursing/care staff in terms of the teaching intervention but for board rounds it was to raise the issue to everyone on the ward - so anyone could if appropriate!
Paperwork agreed is an issue, I think it's use could be beneficial in circumstances with unexplained symptoms where pain hadn't been considered before in those with cognitive impairment.
It was recorded in a mix of paper/electronic as this varied by trust either in nursing documentation or electronic assessments.
Thank you!
Really interesting...
Patients experiencing pain is extremely common.
But this is an interesting piece of research as it highlights that pain is missed frequently in those with cognitive impairment. Definitely, an area of healthcare that could do with more interventions.
Impact on analgesia
Did the increased use of PAINAD lead to changes in subsequent prescribing or relief of pain for patients?