As a senior clinician and Medical Director, I have lived through the “underrecognition” and “undertreatment” of pain and am now practicing in the time of the “overperception” and “over-treatment” of pain.  The development of the 5th vital sign was a major advance in pain care.  The hope was that quality of life and function would improve with better pain management.  Over time, it has become standardized into a 0-10 scale that has been supported by numeric pain, faces, and barometer scales in multiple forms and languages.  Unfortunately, a pain intensity score doesn’t capture the complexity of pain which has not only peripheral inputs, but also multiple other components including:  genetics, coping skills, delirium effects, depression, anxiety, dementia, social experiences, hypersensitivity syndromes, and cultural beliefs.   Acute pain is far more easily recognized and managed than persistent (formerly chronic) pain.  Unfortunately, persistent pain is the common form of pain in the LTC setting.  This category of pain is much more complex, commonly multifactorial, varies in expression over time, and may remain disabling despite aggressive interventions.

In recent years, I commonly receive requests from nurses quite concerned that the pain # is too high and the pain plan isn’t working.  Nurses and facilities are under intense pressure in this situation to address unrelieved pain with fears of future adverse DHS survey, adverse public quality reporting, and the real possibility that future payments and partnerships will be adversely affected by alleged substandard pain care.  In addition real patient harm may occur when strong pain interventions are applied unnecessarily.  We are finding the risk of addiction to be much greater than once thought.  In addition, opioids in older patients have greater risks for impaired cognition, delirium, aspiration pneumonia, falls, anorexia with malnutrition, increased length of stay, urinary retention, fecal impaction, and reduced ADL/IADL function and quality of life.

A pain intensity # score doesn’t capture the complexity of pain and doesn’t normalize the pain intensity to reflect the impact of pain at that time on a patient’s quality of life and function.  Depending on the contribution of various components of their pain, patients with persistent pain may over-report their perception of pain.  I recall how my father-in-law would tell my wife that he would report his persistent pain as a 10 if he wanted quicker a quicker and more predictable response to his pain.  I’m particularly concerned about this possibility when someone reports an 8-10 pain intensity, but is functioning at their normal ADL/IADL and social level.

In my brief review of the literature looking for objective ways to help front line CNAs and licensed nurses improve the reliability of this sign, I’ve discovered a few aids that may improve real time pain assessments. These are public domain tools and include:

1. Kaiser Permanente Functional Pain Assessment Tool .  1-10 scoring system, but more for home and community based setting.  It’s likely helpful in the SNF setting.
2. University of Iowa Functional Pain Assessment Tool .  1-5 scoring system which is evidenced based in SNF setting (JAMDA 2001), but would need to be modified to 1-10 scale to work with our current external metrics.
3. Checklist for Non-Verbal Pain Indicators (CNPI) .  A good tool for CNAs to recognize and report pain at rest and with movement in our patients with low verbal reporting capacity.
4. PAINAD Scale for assessing pain in dementia, but the pain score may not reflect the intensity of pain
5. Wong-Baker Faces Scale – for dementia patients who are able to express their pain intensity by pointing to pictures
6. Modified Pain Symptom Assessment Acronym (OQPRSTUV) for assessing the character of pain.
7. PACSLAC tool is a great tool for recognizing the possibility of pain in persons with dementia, but is labor intensive and likely to be valuable when pain is suspected, but the behaviors are infrequent and subtle.
8. Pain Disability Index – helpful for community and home based patient.  Identifies the adverse impact on pain for 7 domains of function.
9. Pain Diary – helpful for cognitively intact patient.  Restores sense of control and helps develop a partnership for managing their pain.
10. Modified WHO Pain Ladder in JAMDA 13(2012)316-318; John E. Morley;  Pain – God’s Megaphone (figure 2).  The latter emphasizes trying the safest strategies first for pain management with nonpharmacological treatments at the base.  This is exactly what we are learning in dementia and diabetes care.  (This article is made available by permission of JAMDA.
11. www.geriatricpain.org  A LTC specific web site with free tools and educational modules for LTC staff.

In my facilities, I’m recommending the KP tool and Iowa tool back to back on Med carts for teaching cognitively intact patients about reporting their pain score.

In cognitively impaired patients, I’m recommending the Checklist for Nonverbal Pain Indicator (CNPI) for recognition of pain and the Wong Baker Scale for estimating pain intensity (extrapolation may be necessary on the part of  licensed nurses in the non-verbal patient who can’t make a choice).

For improving nursing assessment of the characteristics of a patient’s pain, I’m recommending the Pain Symptom Assessment Acronym which parallels what physicians do when we assess pain.  This may improve the SBAR process of nurse to physician communication.

For patient and family education and empowerment, I’m recommending the pain disability index and Pain Diary.

For developing a care plan for managing pain, I recommend a comprehensive inter-professional approach starting with innovative services in the Non-pharmacologic, Psychologic, and localized treatment domains (Broad Base of the Modified WHO Pain Pyramid.)

I started this article with the term “We”.  I’m not aware of an evidence base in the LTC setting for what I have recommended to my facilities.  I hope they will improve the reliability of this “5th” sign and an appropriate pain management program.

Please view this article as a call for dialogue on how we can better deliver appropriate pain care in the LTC setting.  I and the WAVE editorial staff look forward to your comments in future WAVE editions.