Observational pain relief tool for cognitively impaired older people

Clinical Question: Does the use of an observational pain assessment tool reduce the time to analgesia for (non-verbal) older people with advanced dementia presenting to the ED with a suspected long bone fracture?

Title of the Paper: Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial

Authors: Fry et al.

Published: EMJ, January 2018

Population: Adults >65 with a clinically suspected long bone fracture, and cognitive impairment (defined as score <4 on Six-Item Screening (SIS)), with exclusions, in 8 EDs in Sydney Australia

Intervention: Pain Assessment in Advanced Dementia (PAINAD) is an observational pain assessment tool, which scores 0-2 across 5 domains, giving a total pain score /10

Comparator: “standard methods of pain assessments”, such as a verbal rating scale or visual analogue scale

Outcome: time from arrival in ED to first dose of analgesia

Summary: The authors note that the most common form of ED pain assessment is patient self-report; however, for patients who are unable to communicate pain intensity verbally, clinicians often rely on subjective assessment, which can be unreliable. Observational pain scoring is widely used in paediatric EM. PAINAD is designed to give a pain score /10 for people with advanced dementia; it is is quick and easy (MDCalc!) but has not been formally trialled in ED.

This is a multi-centre (single city) study, which aimed to investigate whether using an observational pain score would improve time to first (any) analgesia for elderly people with cognitive decline, compared to standard practice. It is cluster randomised by 8 different EDs in the Sydney region. All sites were asked to screen their potentially eligible patients (>65y, suspected long bone fracture) with the SIS scale to identify those with cognitive impairment. At the 4 intervention EDs, those identified to have cognitive impairment would also be pain scored using the observational PAINAD score. The analysis of a cluster randomised trial compares all the people in the intervention clusters to all the people in the control clusters, regardless of whether the intervention was actually applied to all people in the intervention cluster.

The main analysis conducted was intention-to-treat, which means that all the eligible patients in the intervention clusters were compared to all the eligible patients in the control clusters, regardless of whether the nurse or clinician had time to use the SIS score, and the PAINAD score. There were 602 eligible patients, and after adjusting for age, fracture type, arrival mode, and triage category, they were unable to demonstrate a difference in time to analgesia between the two groups (HR 0.97, 95% CI 0.80 – 1.17, p 0.74).

A second sensitivity analysis was conducted including only patients in the study who had a documented SIS score. There were a total of 271 patients with a SIS score <4 across all clusters. 87% of those in the intervention cluster had been PAINAD scored. The sensitivity analysis found that the intervention sites delivered analgesia median 13 mins earlier than control sites, but this was not statistically significant (90 vs 103 minutes, p 0.62).


Strengths, weaknesses, and clinical relevance

This is a recent paper, published online in the middle of last year. It seems to demonstrate a reliable and replicable way of trialling an intervention in a busy and complex environment such as the ED.

There are notable differences between the patients at the intervention clusters compared to the control clusters, and although these are acknowledged and attempts are made to adjust for them, the differences are not fully explained.

It is interesting that time to analgesia has been chosen as an outcome when testing a pain scoring system. As the discussion notes, that there was no difference between clusters suggests that time to analgesia is affected by so much more than just being aware of a patient’s pain score, and suggests other system changes are needed to reach national targets of time to analgesia.

I would like to know wether using an observational pain score provides more appropriate analgesia to patients with advanced dementia. This study looked only at time to first analgesia for suspected long bone fractures, but has not provided details on whether this is, for example, paracetamol or morphine.

Are there any other observational pain scores at use in UK EDs?

Would the >65 years PRUH ED population benefit from an observational pain score?

If so, how could this be implemented?


3 thoughts on “Observational pain relief tool for cognitively impaired older people

  1. Thanks for this Nicola

    Interesting study and relevant to the PRUH with our elderly population, many with cognitive impairment and presenting with a query fractured neck of femur.

    Good to see a paper being published that doesn’t show positive results as well. Although there are clearly some issues with the methodology which may have led to this, including the difference in baseline characteristics between intervention and control groups, and an underpowered sensitivity analysis on only 273 of the 603 that were scored and identified as having cognitive impairment.

    Also, interestingly, their initial audit of ‘time to analgesia’ showed a mean of 187 minutes. Following their education programme, the study median time reduced this to 82 minutes. They have interchanged between mean and median, which makes it difficult to compare, however, clearly the education session alone had reduced the ‘time to analgesia’. This outcome of ‘time to analgesia’ is interesting, surely a reduction in PAINAD score would be more appropriate, however, perhaps this was chosen as being more practical, on the presumption that 2/3 of the cohort would not actually get scored.

    It’s certainly an important topic to think about but perhaps increasing awareness about pain control in every patient, whether they have a cognitive problem or not, and acting on it, may be easier to do that spending time filling in more paperwork. Would a reminder tick box which asks whether you have thought about pain control on the nursing check list or ED notes work?

    Also, this study looks at bedside nurses. What about our patients who wait on ambulance trolleys? Surely the pain assessment should happen at triage?

    The study rightly concludes that in order to provide prompt analgesia to patients with cognitive impairment there clearly needs to be whole system involvement, and not just shoving a scoring system under nurses’ noses.


  2. It’s not a great paper, especially because the sensitivity analysis seems to be a post-hoc attempt to find some difference between the groups. The difference wasn’t significant, and could be explained entirely by the difference in pre-hospital analgesia anyway. So my basic take from the paper is that… it hasn’t really shown us anything helpful. Using PAINAD probably won’t make much difference to your times to analgesia. I suspect (as Ling says above) that the most interesting thing about this is the possible benefit of increased awareness and education, regardless of the tool used.


  3. I agree with all of you. Credit to the investigators in highlighting the weaknesses of the paper (baseline characteristics between groups and that only 45% patients actually had cognitive impairment).
    The education aspects highlighted in the paper are probably the most important element in this rather than the tool itself.
    Looking at the PAINAD tool, it is just basically common sense; if you look at any patient carefully enough, dementia or not, you will find the same scoring criteria.
    My take as with all of you is that education and awareness can often trump the use of yet another score/tool/proforma/Symphony tickbox! We do well on this with other aspects such as sepsis, chest pain and this seems to be no different.


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