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This page was last updated: November 13, 2007
Assessing pain in cognitively impaired non–verbal older adults:
A problem analysis.
Debra Larsen RGN ONC DHSM
About the Author:
Debra Larsen RGN DHSM ONC
Debra's professional background is in orthopaedic and trauma nursing and three years as a pain specialist nurse. She has always had a great interest in pain management in the elderly confused and particularly in how professionals assess pain in the cognitively impaired non-verbal elderly patient.
As part of the RCN’s BSc (Hons) Nursing Studies, which she is currently studying she used this clinical problem to complete a problem analysis.
The problem analysis uses two theoretical frameworks to analyse what knowledge, and what frames of reference, nurses use when assessing pain in this group. In searching for new knowledge, which may provide potential solutions to the practice problem she chose to search philosophy for a different view point, having previously reviewed research literature pertaining to pain assessment tools (Murdoch, J. and Larsen, D. (2004) Assessing pain in cognitively impaired older adults, Nursing Standard, 18 (38), pp. 33 – 39).
Although this is a personal reflection of the practice issue as she sees it, Debra hopes that the knowledge she uncovered and frameworks used will help others managing pain in this group of patients to reflect on their own practice and provide some alternative solutions to this practice problem.
Statement of problem.
Pain management is a key component of nursing care. Pain assessment and documentation is performed predominately for in-patients by ward nurses who uniquely spend the most time with patients and are therefore relied upon to raise concerns to other multidisciplinary team members. A significant number of cognitively, impaired older adults present with painful conditions in secondary care. They are unable to localise, interpret, or communicate their pain to us. Pain assessment is a complex nursing skill (Briggs, 2001) and is particularly challenging amongst individuals with advanced dementia who lack the ability to formulate and express their experience of discomfort (Smith, 2005). Although this group of patients are most at risk of poor pain management we seem least prepared to cater for their needs.
Despite scientific advances in pain management, pain is under – treated according to McCaffery & Pasero (1999). Acute pain calls for rapid interpretation, decision making and action to prevent the adverse affects of untreated pain, for example depression of immune system increasing the risks of infections, immobility leading to venous stasis, deep vein thrombosis, pulmonary embolism, decreased ability to deep breathe and cough, sleeplessness, anxiety and fear, (McCaffery & Pasero, 1999).
Pain among people with cognitive impairment can lead to increased care demand and is associated with the presence of depression and challenging behaviour, including aggression and ‘disruptive’ vocalisations (Ryden et al, 1991, Cohen – Mansfield & Marx, 1993).
Problems related to pain assessment in these patients in secondary care are that it is:
•
Infrequent
Infrequent•Poorly monitored
Poorly monitored•Poorly documented
Poorly documented•Insensitive to the needs of the patient.
Insensitive to the needs of the patient.The clinical context.
Carper’s (1978) fundamental patterns of knowing are used to explore our knowledge, Parker & Wilshire’s (1995) modes of nursing are used to explore our frames of reference and Elstein’s et al (1978, cited in Taylor, 1997) model of diagnostic reasoning to explore our professional judgement in practice with these patients.
From its first self – conscious texts, nursing has been concerned with the management of control of place; ‘reconnoitre’ (Parker & Wiltshire, 1995). Emphasis on risk management makes reconnoitre our priority with these patients where the term ‘confused’ is used to describe them. We are concerned about the patients risk to themselves and their potential to disrupt the ward environment. Pre-encounter data e.g. medical diagnosis, (empirical knowledge, Carper, 1978) are highly valued. Payne et al (2000) found that older people were largely depicted as ‘bio medically defined bodies’ requiring to be processed.
The gate control theory (Melzach & Wall, 1965, cited in Melzach & Wall, 1991) forms the theoretical basis for pain assessment on the ward. Local policy advocates verbal ratings for pain assessment and the analgesic ladder (World Health Organisation, 1986), a practice theory, to determine what analgesia is given. Vital sign changes are considered significant. Schön (1987) recognises scientific knowledge is not always easily transformed into solutions in the messy day-to-day world of real life practice, as with these patients. This empirical knowledge forms the basis of cue acquisition in exercising professional judgement and for our second frame of reference ‘savoir’ (Parker & Wiltshire, 1995) where the risks of post-operative/trauma complications are foremost in our minds.
Ward philosophies often purport to provide holistic, individualised care but engaging with, understanding the perceptions, needs and preferences of these patients is challenging. Some nurses ‘sense’ that the patient is in pain and instinctively perform tasks involving movement skilfully and use touch and reassurance. Aesthetic knowledge (Carper, 1978) may be linked to those actions we call intuitive (Berragan, 1998) and Benner (2001) identifies touch and person-to–person contact as an example of expert nursing practice. Personal knowledge (Carper, 1978) gained from the nurses’ life experiences, clinical practice, personal beliefs and attitudes informs our assessment of pain and consequential intervention. ‘Connaissance’ (Parker & Wiltshire, 1995) as a mode of nursing is not held in such high esteem as savoir. We have difficulty emphasising with the patients’ distress and understanding their behaviour and consequently accurately communicating and acting as an advocate for these patients. As a consequence our aesthetic and personal knowledge does not feature largely in cue acquisition, hypothesis generation or cue interpretation.
In determining appropriate ethical action, the practitioner must always pay attention to conflicts of values within herself and between herself and others (Johns, 1995) which relates to our personal knowledge. There are concerns about informed consent since we do not know the wishes of the patient and we are challenged to decide whether treating the patient as though they are in pain and providing analgesia results in beneficence or harm. Pain among people with cognitive impairments is a pressing ethical issue (Ferrell et al, 2001). This ethical knowledge (Carper, 1978) is a consideration in hypothesis generation when various hypotheses may be formulated, e.g. that the patient is distressed because of the change in environment, that the patient has developed a complication or that the patient may be in pain. Inaccurate hypothesis generation can lead to untreated pain.
‘Reconnaissance’ (Parker & Wiltshire, 1995) reveals that priority is given to reconnoitre and savoir in attempting to avoid any immediate threat to the patient’s well-being. Patients who are quiet and do not present with concerning empirical cues do not feature as a risk in our initial frames of reference, which means pain may not be detected. Reflection of practice reveals that many patients exhibiting distress are offered a wide range of interventions to solve the problem, with nurses seeking all the solutions they think most likely, with pain being quite a long way down the list (Simons & Malabar, 1995). As cues cannot be confirmed by the patient in describing their symptoms they can be interpreted differently. This coupled with the limited amount of cues and subjective interpretation of them means that communicating, documenting pain assessment and hypothesis evaluation are problematic.
New knowledge available.
In searching the literature for new knowledge I discovered that patients with cognitive impairment are often excluded from studies of pain in the elderly and even studies specifically studying pain in dementia tend to exclude non-communicative patients. Little research has examined the care older people receive in the acute surgical setting, most concentrate on chronic pain in the primary care setting.
Noting the absence of philosophic basis in our current knowledge I investigated this form of knowledge and discovered work by Malloy & Hadjistavropoulos (2004) who discuss the problem of pain management by examining the ontology of relationships and concept of personhood. Malloy & Hadjistavropoulos (2004) challenge the traditional ontological view of persons with dementia (mind-body dualism) and address the fundamental ontological assumptions of personhood and personal relationships from traditional and existential philosophical perspectives. Malloy & Hadjistavropoulos (2004) purport that despite the recognition of difficulties with pain management practices in this group of patients, writers have not adequately addressed the ontology of personhood and how this relates to the problem and argue that a person’s ontological position defines the groundwork for all human interaction, including how the caregiver perceives the patient as a person and the extent to which the caregiver is able and willing to acknowledge pain and its relief (Scarry, 1985). The absence of a relationship with these patients is evident in our current knowledge base, frames of reference and professional judgement resulting in an inability to provide individualised and holistic pain assessment.
Malloy & Hadjistavropoulos (2004) argue that once cognition is severely impaired, there is an ontological tendency to transform the person as an individual capable of a relationship into an object–of–care, perceiving our relationship as being between ‘us’ and ‘them’ and not between ‘me’ and ‘you.’ In our current perceptions we tend to categorise these patients in terms of their physiological status and risk assessments. Malloy & Hadjistavropoulos (2004) suggest the implications could result in perceptions that a non-autonomous individual might be considered as not having the same rights (i.e. not the same urgency) for pain management as others. This view is supported by Feldt et al, (1998), Morrison & Siu, (2000) and Herr & Decker, (2004) who found that older adults with cognitive impairment receive less pain medication than those who are unable to communicate, even though they are just as likely to experience painful illnesses.
Malloy & Hadjistavropoulos (2004) purport that the second theme that emerges in philosophical views of human relationships is the belief that questions about human nature can or will be found as a result of empirical investigation of matter (Farran, 1997). Malloy & Hadjistavropoulos (2004) suggest that the patient with dementia is perceived at best to be a host of neurological pathology. The patient is not only an object–of–care, but also an object–for–investigation – ‘a riddle’ to be solved (Nuland, 1994). This resonates with our emphasis on the use of empirical knowledge. This concern becomes more salient in the pain management context because of the subjective nature of pain. Malloy & Hadjistavropoulos (2004) suggest that an object–of–care, strictly speaking, requires no unique interpretation of emotion, of behaviour, of expression, or of pain and requires maintenance of physical health. This relationship according to existential thinkers is inauthentic because it fails to incorporate the whole person, regardless of how this relationship is defined in terms of levels of cognition. As stated in the problem statement our current practice in pain assessment is insensitive to the needs of these patients. Malloy & Hadjistavropoulos (2004) purport that once cognitive decline is observed, the nature of the relationship between individual caregiver as well as between the institution and the patient, shifts to an ‘us’ versus ‘them’ scenario, in which there is a lack of engagement with the patient. This detached relationship may well contribute to the failure to properly consider and assess each patient’s unique experiences, expressions and fears of his/her pain (Malloy & Hadjistavropoulos, 2004). This is apparent in the difficulties we expressed in being able to apply our aesthetic, personal and ethical knowledge to these patients and the lack of consideration for the patient as an individual in exercising professional judgement.
Malloy & Hadjistavropoulos (2004) propose an existential ontology for caregiver – patient relationships and pain management. Rather than focusing on rational, empirical and objective metavalues (i.e. unquestioned and perceived truisms), existentialism is intensely interrelational and subjective. Malloy & Hadjistavropoulos (2004) counter the traditional perspective with the view that if the caregiver were to perceive the patient regardless of the degree of dementia, as an individual with whom he or she is in a genuine living dialogue, then the caregiver’s awareness of pain and willingness to address it, will improve. They suggest that the existential perspective may be the key in providing an environment in which the patient with dementia would receive adequate pain management as a result of the caregiver’s effort to know him/her in a deeper authentic manner than is the norm and that adopting an existential ontology for this patient group can result in:
•More meaningful work for caregivers
More meaningful work for caregivers•A deeper understanding of the patient and the subsequent enhanced attention to his/her intellectual, social and physical (including the relief from pain) needs.
A deeper understanding of the patient and the subsequent enhanced attention to his/her intellectual, social and physical (including the relief from pain) needs.To foster this existential relationship the culture must move from the calculative ‘I- it’ relationship to the ‘I –thou’ (Malloy & Hadjistavropoulos, 2004). They acknowledge that more systematic efforts are required to understand subtle forms of pain communications by patients with more severe cognitive impairment but suggest that nonverbal behaviours, characterised by reflexive automaticity (Hadjistavropoulos & Craig, 2002), are likely to be seen in patients with dementia and provide the caregiver with a deeper understanding of the patient. I discovered a growing body of evidence that there are a number of pain behaviours that can be reliably used to indicate the presence of pain:
•Vocalisations, e.g. whimpering,
Vocalisations, e.g. whimpering,•Facial expressions, e.g. grimacing, frowning
Facial expressions, e.g. grimacing, frowning•Rigid body position
Rigid body position•Guarding or rubbing painful part
Guarding or rubbing painful part•Aggressive behaviour
Aggressive behaviour•Pulling at tubes
Pulling at tubesFeldt et al (1998), McCaffery & Pasero (1999), Herr & Mobily (1991), Herr & Decker, (2004). Smith (2005) purports that observable behaviours, or signs, are the foundation of pain assessment in advanced dementia.
Malloy & Hadjistavropoulos (2004) make several recommendations that they argue could lead to authentic relationships and better pain management:
(i)That the caregiver, based on Hicks (2000), conduct an audit or self analysis of a variety of the ontological variables that will influence the nature and quality of the caregiver – patient relationship using for example, the following questions:
That the caregiver, based on Hicks (2000), conduct an audit or self analysis of a variety of the ontological variables that will influence the nature and quality of the caregiver – patient relationship using for example, the following questions:Does a human ever cease to be a person worthy of respect, dignity and authenticity?
Am I person first, then a caregiver? How do I feel about frail seniors? How do I perceive a patient with dementia? Do I react differently when I believe that a patient with dementia has pain compared to a patient without dementia?
(ii)Malloy & Hadjistavropoulos (2004) argue that healthcare professionals should be introduced to the notion of ontology and authenticity and the impact of these concepts on one’s relationships with patients.
Malloy & Hadjistavropoulos (2004) argue that healthcare professionals should be introduced to the notion of ontology and authenticity and the impact of these concepts on one’s relationships with patients.(iii)If caregivers are provided with time only to attend to physical concerns, then there is no hope for the formation of an authentic relationship between patient and caregiver. This should be considered when scheduling the workload of caregivers (Malloy & Hadjistavropoulos, 2004).
If caregivers are provided with time only to attend to physical concerns, then there is no hope for the formation of an authentic relationship between patient and caregiver. This should be considered when scheduling the workload of caregivers (Malloy & Hadjistavropoulos, 2004). (iv)Value statements should include the notion of ontological awareness and the importance of authentic relationships in the workplace. Included in these statements and codes could be an unambiguous definition of personhood that would help clarify and enhance the questioned status of the patient with dementia.
Value statements should include the notion of ontological awareness and the importance of authentic relationships in the workplace. Included in these statements and codes could be an unambiguous definition of personhood that would help clarify and enhance the questioned status of the patient with dementia.(v)People with dementia should be assessed for pain problems on a regular basis using both physical examination and behavioural tools. I have found a number of behavioural tools which could be trialled in practice, e.g. Hurley et al (1992) produced and tested a discomfort scale for use in non-communicative Alzheimer patients – the DS-DAT . A French group (Lefebvre-Chapiro et al 2001) constructed the DOLOPLUS 2 score for the assessment of pain in the elderly. Feldt (2000) piloted the Checklist of Nonverbal Pain Indicators (CNPI).
People with dementia should be assessed for pain problems on a regular basis using both physical examination and behavioural tools. I have found a number of behavioural tools which could be trialled in practice, e.g. Hurley et al (1992) produced and tested a discomfort scale for use in non-communicative Alzheimer patients – the DS-DAT . A French group (Lefebvre-Chapiro et al 2001) constructed the DOLOPLUS 2 score for the assessment of pain in the elderly. Feldt (2000) piloted the Checklist of Nonverbal Pain Indicators (CNPI). (vi)Professionals should consider that pain is most probably present in patients who have conditions that usually accompany pain. Herr & Decker, (2004) also suggest that until evidence establishes that those with dementia experience less pain, we should assume that any condition that is painful to a cognitively intact person would also be painful to those with advanced dementia who cannot express themselves.
Professionals should consider that pain is most probably present in patients who have conditions that usually accompany pain. Herr & Decker, (2004) also suggest that until evidence establishes that those with dementia experience less pain, we should assume that any condition that is painful to a cognitively intact person would also be painful to those with advanced dementia who cannot express themselves. (vii)Professionals working with seniors who suffer from dementia should have specialised training in pain recognition and management in this population.
Professionals working with seniors who suffer from dementia should have specialised training in pain recognition and management in this population.Professional judgement.
In light of this new knowledge how professional judgement could be exercised is reviewed using Elstein’s et al (1978, cited in Taylor, 1997) model of diagnostic reasoning.
Cue acquisition.
Brockopp et al, (2004) suggest that preconceived notions can influence the nurses’ decision-making. Carper (1978) explores the idea that the nurse being aware of the ‘therapeutic use of
self’ can enhance the healing nature of a nurse-patient relationship. Self-analysis of the ontological variables influencing the nature and quality of the relationships that we have with these patients as suggested by Malloy & Hadjistavropoulos (2004) could facilitate reflection of our approach to the problem of pain assessment in the cognitively impaired. Rather than looking at patients in terms of risk management (reconnoitre) and in terms of their pathology (savoir),
establishing an existential ontology and authentic relationships may enable us to approach the problem of pain assessment in cognitively impaired patients using a different approach and thinking about the problem from a different perspective. This may enable us to use our aesthetic and personal knowledge (connaissance) more confidentially. Whilst risk management and the prevention and early detection of complications will remain priorities, establishing authentic relationships with the patient may enable us to provide more individualised and holistic care as stated in the ward philosophy.
Developing an understanding of personhood and adopting ontology and authentic relationships could underpin the development of a local policy for pain assessment more sensitive to the needs of the cognitively impaired. Adopting observation of the pain behaviours Malloy & Hadjistavropoulos (2004) highlight could provide us with more cues than those from empirical knowledge which we acknowledge are insensitive and inadequate for this patient group. Malloy & Hadjistavropoulos (2004) advocate regular pain assessment for these patients. One of the problems identified was infrequent assessment. More frequent assessments using a behavioural tool could allow us to recognise pain earlier as well as monitor it more frequently and provide documentation.
Hypothesis generation.
Trying to forge authentic relationships with these patients may open up new ways of thinking and hence different hypotheses in professional judgement. Malloy & Hadjistavropoulos (2004) suggestion of regular pain assessment and the use of a behavioural tool could facilitate the recognition of pain as a problem. Their recommendation that professionals should consider that pain is most probably present in patients who have conditions that usually accompany pain may help in the ethical dilemmas faced with these patients. A major misconception that affects recognition of pain in this population is the belief that cognitively impaired older adults do not experience pain as severely as those who are intact (Herr & Decker, 2004). Adopting their
recommendation of specialised training in pain recognition and management in this population may lead us to more new knowledge.
Cue interpretation.
Recognition of pain behaviours and the use of a behavioural pain assessment tool may help us in our subjectivity and interpretation of the behaviour observed and may also prevent those patients
who are quiet and withdrawn from being excluded in our current frames of reference. Carper (1978, p. 19) states that ‘the pattern of personal knowing develops when the nurse approaches the patient not as an object or category of illness but strives instead to actualise an authentic personal relationship between two persons.’ Yates et al (1998) found that nurses’ perceptions of pain are based on their own past experiences of pain. Understanding the perceptions, needs and preferences of these patients may be facilitated by the philosophical approach recommended by Malloy & Hadjistavropoulos (2004). This may assist in our difficulties with connaissance as a mode of nursing by helping us to practice advocacy and communicate the needs of these patients more confidentially.
Hypothesis evaluation.
The use of a behavioural tool may assist in the documentation of the pain in the cognitively impaired by enabling us to record changes in behaviour in response to pain management strategies and assist with the communication between staff, facilitating planning of care. For people with severe cognitive impairment it is essential that pain behaviours and vocalisations are documented as this may be the only pain assessment evidence available (Briggs, 2001).
Summary.
The development and analysis of knowledge for nursing practice are fundamental to the future of nursing (Berragan, 1998). Reflecting on our current knowledge and its application to this group of patients reveals that our emphasis on empirical knowledge and the positivist perspective has failed to enable adequate pain assessment and does not fit with our nursing philosophy of holistic and individualised care. Examining our frames of reference has provided information on how we see the problem, revealing that priority is given to ‘reconnoitre’ and ‘savoir.’ Cues on which professional judgement is exercised are limited, and nurses in generating hypothesis rely on all
types of knowledge, which are interrelated, individualised, and dependent on experience. There are also difficulties in communicating and documenting knowledge and professional judgement. Kovach et al (2000) suggest that the pain assessment and treatment strategies used by nurses working with patients with dementia are poorly understood.
The multiplicity of factors that influence the perception and expression of pain take on special importance in the healthcare setting, where pain becomes an interpersonal experience between the sufferer and the reliever. How pain is signified by the patient and understood by the provider determines in large measure how it is valued, and ultimately, how it is treated (Post et al, 1996). Walker (2003) purports that the philosophical stance taken will influence the clinical practitioner’s approach to assessing pain in the patient. Introducing Malloy & Hadjistavropoulos (2004) suggestion of fostering existential relationships with these patients and a cultural move from the ‘I-it’ to ‘I-thou’ philosophy of care may help us to think about and approach the difficulties of assessing pain in the cognitively impaired in a different way and in developing a local policy for pain assessment more sensitive to the needs of these patients.
Adopting the recommendations of Malloy & Hadjistavropoulos (2004) in practice may help us to recognise negative preconceptions, enable us to use all types of nursing knowledge more confidentially and hence provide us with more cues, hypotheses and enable us to interpret the cues in a more holistic and individualised manner. Communicating and documenting pain assessment in these patients may also be facilitated by their recommendations.
Introducing the changes in practice to adopt an existential ontology for nurse-patient relationships and pain management will require the use of a change management strategy, key to which will be collaborative working amongst the nursing team. There is a strong correlation between the work environment and the capability of individuals and teams to respond to issues they encounter in a creative and innovative manner (McNichol, 2002).
References.
Benner, P (2001) From novice to expert: excellence and power in clinical nursing practice, (commemorative edition) Menlo Park: Addison-Wesley.
Berragan, L. (1998) Nursing practice draws upon several different ways of knowing, Journal of Clinical Nursing,7 (3), pp. 209 – 217.
Briggs, E. (2001) Principles of pain assessment in older people, Nursing Older People, 13 (9), pp. 27 – 28.
Brockopp, D.Y., Downey, E., Powers, P., Vanderverr, B., Warden, S., Ryan, P. And Saleh, U. (2004) Nurse clinical decision-making regarding the management of pain, International Journal of Nursing Studies, 41 , pp. 631 – 636.
Carper, B.A. (1978) Fundamental patterns of knowing in nursing, Advances in Nursing Science, 1 (1), pp. 13-23.
Cohen - Mansfield, J. and Marx, M.S. (1993) Pain and depression in the nursing home: Corroborating results, Journal of Gerontology, 48 (2), pp. 96 – 97.
Elstein A.S., Shulman, L.S. and Sprafka, S.A. (1978) Medical Problem Solving: An Analysis of Clinical Reasoning. Harvard University Press, Cambridge, Massachusetts cited in Taylor, C. (1997) Problem solving in clinical practice, Journal of Advanced Nursing, 26 (2), pp. 329 – 336.
Farran, C.J. (1997) Theoretical perspectives concerning positive aspects of caring for elderly persons with dementia: stress/adaptation and existentialism, Gerontologist, 37 (2), pp. 250 – 256.
Feldt, K.S., Ryden, M.B. and Miles, S. (1998) Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip fracture, Journal of the American
Geriatric Society, 46, pp. 1079 – 1085.
Feldt, K.S. (2000) Improving assessment and treatment of pain in cognitively impaired nursing home residents, Annals of Long – term Care: Clinical Care and Aging, 8 (9), pp. 36 – 42.
Ferrell, B.R., Novy, D. & Sullivan, M.D., Banja, J., Dubois, M.Y., Gitlin, M.C., Hamaty, D., Lebovits, A., Lipman, A.G. Lippe, P.M. and Livovich, J. (2001) Ethical dilemmas in pain management, Journal of Pain, 2 (3), pp. 171- 180.
Hadjistavropoulos, T. and Craig, K.D. (2002) A theoretical framework for understanding self-report and observational measures of pain: a communications model, Behavior Research and Therapy, 40, pp. 551 – 570.
Herr, K. and Decker, S. (2004) Older adults with severe cognitive impairment: Assessment of pain, Annals of Long-term care, 12 (4), pp. 46 – 52.
Herr, K. & Mobily, P. (1991) Pain assessment in the elderly, Journal of Gerontological Nursing, 17 (4), pp. 12 – 18.
Hicks, T.J. (2000) Ethical implications of pain management in a nursing home: a discussion, Nursing Ethics, 7 (5), pp. 392 – 397.
Hurley A., Volicer B., Hanrahan P., Houde S., Volicer L., (1992) Assessment and discomfort in advanced alzheimers patients, Research in nursing and health, 15, pp. 369- 377.
Johns, C. (1995) Framing learning through refelction with Carper’s fundamental ways of knowing, Journal of Advanced Nursing, 22 (2), pp. 226 – 234.
Kovach. C.R., Griffe, J., Muchka, S., Nonnan, P.E. and Weissman, D.E. (2000) Nurses’ perceptions of pain assessment and treatment in the cognitively impaired elderly. It’s not a guessing game, Clinical Nurse Specialist, 14 (5), pp. 215 – 220.
Lefebvre-Capiro, S. (2001) The DOLOPLUS 2 scale – evaluating pain in the elderly, Eurpean Journal of Palliative Care, 8 (5), pp. 191 – 194.
Malloy, D.C. and Hadjistavropoulos, T. (2004) The problem of pain management among persons with dementia, personhood and the ontology of relationships, Nursing Philosophy, 5 (2), pp.147 – 159.
McCaffery, M. & Pasero, C. (1999) Pain clinical manual,(second edition), Mosby, St.Louis, MO, USA.
McNichol, E. (2002) Thinking outide the box: encouraging flexible thinking for problems and decisions, Journal of Nursing Management, 9 (4), pp. 19 – 22.
Melzack, R. and Wall, P.D (1965) Pain mechanisms: A new theory, Science, 19 (150), pp. 971-979 cited in Melzack, R. and Wall, P.D. (1991) The challenge of pain, (third edition) Penguin Books.
Morrisson, R.S. and Siu, A.L. (2000) A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture, Journal of Pain and Symptom Management, 19 (4), pp. 240 – 248.
Nuland, S. (1994) How we Die, Alfred Knopf, New York.
Parker, J. and Wiltshire, J. (1995) ‘The handover: three modes of nursing practice knowledge in Gray, G. and Pratt, R. (editors) Scholarship in the discipline of nursing, Melbourne: Churchill Livingstone, pp. 151 – 168.
Payne, S., Hardey, M. and Coleman, P. (2000) Interactions between nurses during handovers in elderly care, Journal of Advanced Nursing, 32 (2), pp. 277 – 285.
Post, L.F., Blustein, J., Gordon, E. and Dubler, N.N. (1996) Pain: Ethics, culture and informed consent to relief, Journal of Law, Medicine and Ethics, 24, pp. 348 – 359.
Ryden, M., Bossenmair, M. And McLaclan, C., (1991) Aggressive behaviour in cognitively impaired nursing home residents, Research in Nursing and Health, 14 (2), pp. 87 – 95.
Scarry, E. (1985) The Body in Pain: The Making and Unmaking of the world, University Press, Oxford.
Schön, D. (1987) Educating the refelctive practitioner. San Francisco, CA: Jossey-Bass.
Simons, W. And Malabar, R. (1995) Assessing pain in elderly patients who cannot respond verbally, Journal of Advanced Nursing,22 (4), pp. 663 – 669.
Smith, M. (2005) Pain assessment in nonverbal older adults with advanced ddementia, Perspectives in psychiatric care,41 (3), pp. 99 – 114.
Walker, J. (2003) Philosophy, knowledge and theory in the assessment of pain, British Journal of Nursing, 12 (8), pp. 494 – 501.
World Health Organisation (1986) Analgesic ladder
Last accessed 17/05/06.
Yates, P., Dewar, A., Edwards, H. Fentiman, B., Najman, J. Nash, R., Richardson, V. And Fraser, J. (1998) The prevelance and perception of pain amongst hospital in – patients, Journal of Clinical Nursing, 7 (6 ), pp. 521 – 530.
Debra Larsen asserts her moral rights to be identified as the author of this work.
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