Pain assessment in a geriatric psychiatry program.

BACKGROUND: The assessment of pain in older persons with psychiatric illness is particularly challenging for health care professionals. There are few well-tested pain assessment tools for this population. OBJECTIVES: A study was conducted to explore pain assessment and management issues in geriatric psychiatry. METHODS: Seventy-four staff members of a geriatric psychiatry service at Regional Mental Health Care London, St Joseph's Health Care London, London, Ontario completed a survey to assess current pain assessment and management practice for geriatric psychiatry patients, and to identify indicators used to assess pain in this population. The results of the survey were later shared with members of the program's pain management team in a focus group discussion to explore opportunities on how to transfer these findings into clinical practice. RESULTS: The majority of survey respondents (91.8%) agreed that pain assessment and management could be improved for patients; only 14.9% reported that there was a consistent approach to pain management. Misconceptions and attitudes about pain, lack of easily administered pain tools, inconsistent monitoring of pain, and lack of documentation of pain symptoms and indicators were identified as significant barriers to optimal pain management for their patients. A number of behaviours indicative of pain were identified but emphasis was placed on recognition of changes from usual behaviour. CONCLUSIONS: The findings of the present study highlight the need for a comprehensive, practical and consistent approach to pain assessment and management, and provide insight into the critical components, including behavioural indicators, that could be incorporated into a pain protocol to be used with this population.

Mother-adult daughter relationships within dementia care: a critical analysis.

Evidence suggests that intergenerational caregiving between mothers and daughters will become increasingly common, and yet, we know very little about the specific relationships between adult daughters and their mothers with dementia. Guided by socialist-feminist theory and a life-course perspective, 15 mother-adult daughter dyads participated in two individual, semistructured interviews. Data analysis revealed four dynamic types of mother-daughter relationships: custodial, combative, cooperative, and cohesive. Custodial and cooperative relationships mainly focused on the provision of and receipt of tasks, whereas combative and cohesive are emotion focused. At the same time, custodial and combative relationships are based on deficits compared with strength based cohesive and cooperative relationships. In addition, certain contextual factors, such as expectations of care and levels of support, shaped the development of these relationships. Moreover, study findings highlight a number of implications for practice, policy, and research necessary to support individuals with dementia and their families.

Perspectives of women with dementia receiving care from their adult daughters.

The caregiving experience within Alzheimer disease is fairly well documented. However, little research has been conducted from the perspective of the person living with dementia. The purpose of this study, part of a larger qualitative investigation of mother-daughter relationships within the care process of dementia, was to elicit the perceptions and experiences of mothers receiving care from their adult daughters. Guided by feminist and life-course perspectives, the researchers conducted in-depth, semi-structured interviews with a diverse sample of 10 community-dwelling women with mild to moderate cognitive impairment. In general, the health perceptions and experiences of the women were shaped by gender and how its meaning is constructed. While mothers reported mostly positive relationships with their daughters, cultural ideologies of individualism and familism manifested in feelings of "grateful guilt." Participants managed their contradictory experiences of receiving care from their daughters by doing care, undemanding care, determining care, and accepting care. The authors recommend changes in practice, policy, and research, with the aim of addressing relevant social determinants of health such as gender and social support, thereby promoting the health and well-being of women with dementia.

Pain reports by older adults in long-term care: a pilot study of changes over time.

PURPOSE: To document self-reported pain descriptions throughout residency in a long-term care facility for a convenience sample of older adults (Canadian war veterans). DESIGN AND METHODS: The present study was a longitudinal, fixed-cohort study with anticipated attrition. Participants (n = 33) were assessed every three months from admission until attrition or end of study (three years). The assessments included standardized measures of psychosocial functioning and a comprehensive pain questionnaire for residents who reported a pain problem. RESULTS: On average, respondents completed five assessments before attrition and reported pain in 69% of assessments. The likelihood of pain report decreased as the number of assessments increased. Cross-sectional analysis indicated that, at admission, pain duration was greater and nonverbal pain expression less prominent than later in residency. Longitudinal analysis indicated greater than 50% within-subject variability across three consecutive pain reports for nonpharmacological pain relief, pain expression and functional impact of pain. CONCLUSION: The present study highlights the need for patient-centred, longitudinal investigations of both the natural progression of pain and environmental factors that mediate pain management in the interests of improving pain control for this population.

Instruments for the assessment of pain in older persons with cognitive impairment.

Pain in older persons with cognitive impairment is often unrecognized and inadequately treated. A major problem associated with this undertreatment is the challenging nature of pain assessment and in particular the selection of accurate and useful assessment instruments. The purpose of this study was to review pain measurement instruments for acute and chronic pain suggested for use with cognitively impaired older persons and to summarize available evidence on their reliability and validity. A systematic search for pain instruments was conducted using several bibliographic databases, supplemented by a manual search of the bibliographies of retrieved articles and review chapters and by articles received from experts and clinicians in the field. Instruments were retained for review when the pain instrument was used or recommended for use with older persons with cognitive impairment. Thirty-nine instruments were reviewed; nine were excluded for various reasons. Of the remaining 30, 18 were self-report and 12 were staff administered. There were no instruments for which all major tests of reliability or validity were reported. Reliability and validity data were basic or unavailable for many instruments. One instrument had excellent validity but no reliability data. The remaining instruments had weak or adequate reliability and validity. The authors conclude that there is a need for further rigorous development and testing of pain instruments for use with cognitively impaired older persons. An adequate instrument would be one component of an effective program for assessment and management of pain in this population.

Beyond knowledge transfer: a model of knowledge integration in a clinical setting.

Current conceptualizations of knowledge transfer reinforce the notion of a linear process between researchers and clinicians, who are seen as operating separately with different agenda. This paper uses a case study to illustrate a dynamic model of knowledge integration involving integrated and interdependent relationships among researchers, clinicians, and decision-makers. We believe the principles of this model are more likely to lead to effective use of research evidence in clinical practice.

Resident and family perspectives. The first year in a long-term care facility.

The purpose of this longitudinal study was to explore perspectives, needs, and expectations of residents (N = 6) and family members (N = 3) of the resident's first year in a long-term care facility. The narrative method and a semi-structured interview guide were used to obtain participants' views at 2 and 6 weeks, and 3, 6, 9, and 12 months after admission. During data analysis, six themes emerged, which suggest implications for gerontological nursing education and practice. The authors conclude that by listening to residents and family members, nurses can use this information to improve life for residents and dignify them as individuals.

Relationships between families and registered nurses in long-term-care facilities: a critical analysis.

Although much has been written about the relationship between families and nurses, little systematic analysis has been undertaken of this dyadic relationship in long-term care (LTC). Using a critical ethnographic approach, the researchers conducted separate in-depth interviews with 17 family-nurse dyads caring for residents with Alzheimer disease or a related disorder in one LTC setting. Analysis of interview transcripts and fieldnotes revealed 4 types of family-nurse relationships--conventional, competitive, collaborative, and "carative"--each reflecting the roles of nurse and family, negotiating strategies, and consequences. In addition, it became apparent that intrinsic and extrinsic factors influence the development of certain types of relationships. The findings have implications for nursing practice, policy development, and further research within LTC settings.