Tools for Evaluating Pain in Older Adults

The overarching goal of pain assessment in older adults is to provide appropriate and successful pain management.  Unique characteristics of older adults need to be considered in the assessment process. These include sensory and cognitive impairments, reluctance of older adults to report pain, and the assumption that pain is a normal part of aging.  Coupled with the fact that mood, physical functioning, and social interaction can influence the pain experience, pain assessment is a multidimensional process.

The World Health Organization,³ the American Geriatric Society, ⁴,⁵ and the American Medical Directors Association⁶ have developed guidelines for the management of pain in older adults.  Commonly, they outline steps that will yield a treatment plan to ultimately decrease pain and improve function and quality of life.  These steps include 1) determining the presence and cause of pain, 2) identifying exacerbating comorbidities, 3) reviewing beliefs, attitudes, and expectations regarding pain, and 4) gathering information that assists and impacts an individualized treatment plan. 

Hadjistavropoulos et al⁷ identify 3 broad assessment domains. The first is the initial determination of pain and ongoing monitoring.  The single most reliable way to accomplish this is by patient self report of pain.  There are several tools available to assist clinicians in conducting a comprehensive pain assessment in this older population (Click here for a list of tools with links). Uni-dimensional measures such as the numeric rating scale or verbal descriptor scale are commonly used. Older adults tend to prefer verbal descriptor scales,⁸ but individual patients should be asked to determine which tool is preferred.  Multidimensional measures such as the McGill Pain Questionnaire⁹ or the Brief Pain Inventory¹⁰ are helpful.  If patients are unable to self report pain or have moderate to severe cognitive impairment, behavioral observation of pain instruments should be employed.  This approach will be discussed in a companion interactive newsletter.

The second domain includes assessment of medical, pharmacological, and functional (including sensory impairment) concerns. This can be accomplished through physical examination, but the Functional Pain Scale¹¹ or the Timed “Up and Go” Test¹² can be helpful for an objective assessment. Additionally, the Mini-Mental State Examination¹³ is a brief screen for cognitive function. Some have noted limitations to this screening; therefore, if this test is suggestive for dementia more detailed neuropsychological testing should be pursued.

Finally, assessment of psychological factors contributing to pain need to be addressed. Under this domain, assessment of ability to cope with pain, affective processes, and pain-related disability are to be considered. The Coping Strategies Questionnaire¹⁴ and Chronic Pain Coping Inventory¹⁵ can assist in assessing coping skills. Specific to the older population, the Geriatric Depression Scale¹⁶ and the Survey of Activities and Fear of Falling in the Elderly¹⁷ can address affective processes.

There is a broad scope of tools available for pain assessment in cognitively intact older adults. Additionally, there is a wide variation of reliability and validity reported on these instruments, and these should be reviewed prior to choosing which instruments to use.⁷,¹⁸ Very often the setting in which the assessment takes place determines the approach to assessment. In an acute care situation, the physical examination and a verbal descriptor scale take precedence. For community dwelling older adults or those in long-term care facilities, a comprehensive assessment is warranted. This can be accomplished in several assessment periods if necessary. One recommended approach⁷ is to use the Brief Pain Inventory¹⁰ and the Short Form McGill Pain Questionnaire,¹⁹ which together take approximately 10 minutes to administer.