Additional considerations when assessing pain in people with impaired cognition
This section provides specific advice on assessing pain in people with impaired cognition and should be considered alongside the general approach to assessing pain described in this topic.
Impaired cognition makes assessment of a patient’s pain complicated. If the patient’s pain assessment is imprecise, pain may be inadequately managed. While patients may be able to report pain, their ability to give an accurate history of the pain, including onset and response to past therapies, may be impaired. Collateral history should be sought.
The approach to assessing pain in a patient with impaired cognition depends on the severity of cognitive impairment. Verbal descriptor scales (using descriptors such as no pain, mild pain, moderate pain, severe pain, or worst-ever pain) may be easier to complete than numerical or visual analogue scales. However, if a patient is unable to verbalise effectively, it may be necessary to rely on surrogate markers and behavioural observation.
A reduction in the patient’s function or the onset of a behavioural disturbance (eg agitation, resisting care, aggression, abnormal vocalisations) may be due to pain, but misinterpreted as a behavioural or psychological symptom of impaired cognition. In a patient who is unable to verbalise effectively, moaning, grimacing, guarding, or being reluctant to mobilise or participate in usual activities can indicate pain.
Reports from families and carers, direct observation and observational instruments (eg the Abbey Pain Scale 1, PAINAD tool 2) are essential when assessing pain in these patients.