Pain Assessment in Dementia: Evaluation of a Point-of-Care Technological Solution

Mustafa Atee, Kreshnik Hoti, Richard Parsons, Jeffery D Hughes, Mustafa Atee, Kreshnik Hoti, Richard Parsons, Jeffery D Hughes

Abstract

Pain is common among people with moderate to severe dementia, but inability of patients to self-report means it often goes undetected and untreated. We developed the electronic Pain Assessment Tool (ePAT) to address this issue. A point-of-care App, it utilizes facial recognition technology to detect facial micro-expressions indicative of pain. ePAT also records the presence of pain-related behaviors under five additional domains (Voice, Movement, Behavior, Activity, and Body). In this observational study, we assessed the psychometric properties of ePAT compared to the Abbey Pain Scale (APS). Forty aged care residents (70% females) over the age of 60 years, with moderate to severe dementia and a history of pain-related condition(s) were recruited into the study. Three hundred and fifty-three paired pain assessments (either at rest or post-movement) were recorded and analyzed. The ePAT demonstrated excellent concurrent validity (r = 0.882, 95% CI: 0.857-0.903) and good discriminant validity. Inter-rater reliability score was good overall (weighted κ= 0.74, 95% CI: 0.68-0.80) while internal consistency was excellent. ePAT has psychometric properties which make it suitable for use in non-communicative patients with dementia. ePAT also has the advantage of automated facial expression assessment which provides objective and reproducible evidence of the presence of pain.

Keywords: Automated; FACS; dementia; ePAT; facial recognition technology; older people; pain assessment; psychometric evaluation; reliability; validation.

Figures

Fig.1
Fig.1
The Abbey Pain Scale. Source: Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, Lowcay B. Funded by the JH & JD Gunn Medical Research Foundation 1998–2002.
Image 1
Image 1
Face detection and tracking in the ePAT App during a clinical encounter.
Image 2
Image 2
Facial features extraction of the ePAT App.
Image 3
Image 3
Detection of facial Action Units (AUs) codes in the ePAT App.
Image 4
Image 4
Domain 5 of the ePAT; The Activity.
Image 5
Image 5
Domain 6 of the ePAT; The Body.
Image 6
Image 6
Total score screen of the ePAT App depicting to pain intensity score.
Fig.2
Fig.2
Scatter plot of individual APS scores and ePAT scores. Black dots indicating pain score at rest and red dots pain score with movement. Note that some dots represent more than one observation.

References

    1. AGS Panel on Persistent Pain in Older Persons (2002) The management of persistent pain in older persons. J Am Geriatr Soc 50, S205–S224.
    1. Achterberg WP, Pieper MJC, van Dalen-Kok AH, de Waal MWM, Husebo BS, Lautenbacher S, Kunz M, Scherder EJA, Corbett A (2013) Pain management in patients with dementia. Clin Interv Aging 8, 1471–1482.
    1. Maxwell CJ, Dalby DM, Slater M, Patten SB, Hogan DB, Eliasziw M, Hirdes JP (2008) The prevalence and management of current daily pain among older home care clients. Pain 138, 208–216.
    1. Cipher DJ, Clifford PA, Roper KD (2006) Behavioral manifestations of pain in the demented elderly. J Am Med Dir Assoc 7, 355–365.
    1. Cohen-Mansfield J, Thein K, Marx MS, Dakheel-Ali M (2012) What are the barriers to performing nonpharmacological interventions for behavioral symptoms in the nursing home? J Am Med Dir Assoc 13, 400–405.
    1. Castle NG, Engberg J (2005) Staff turnover and quality of care in nursing homes. Medical Care 43, 616–626.
    1. Zwakhalen SMG, Hamers JPH, Peijnenburg RHA, Berger MPF (2007) Nursing staff knowledge and beliefs about pain in elderly nursing home residents with dementia. Pain Res Manag 12, 177–184.
    1. Sheu E, Versloot J, Nader R, Kerr D, Craig KD (2011) Pain in the elderly: Validity of facial expression components of observational measures. Clin J Pain 27, 593–601.
    1. Ekman P, Friesen WV (1978) Facial Action Coding System, Consulting Psychologists Press, Palo Alto, CA.
    1. Ekman P, Friesen WV, Hager J (1978) The Facial Action Coding System (FACS): A technique for the measurement of facial action, Consulting Psychologists Press, Palo Alto, CA.
    1. van Herk R, van Dijk M, Baar FP, Tibboel D, de Wit R (2007) Observation scales for pain assessment in older adults with cognitive impairments or communication difficulties. Nurs Res 56, 34–43.
    1. Rojo R, Prados-Frutos JC, Lopez-Valverde A (2015) Pain assessment using the Facial Action Coding System. A systematic review. Med Clin (Barc) 145, 350–355.
    1. Kunz M, Scharmann S, Hemmeter U, Schepelmann K, Lautenbacher S (2007) The facial expression of pain in patients with dementia. Pain 133, 221–228.
    1. Hadjistavropoulos T, LaChapelle DL, MacLeod FK, Snider B, Craig KD (2000) Measuring movement-exacerbated pain in cognitively impaired frail elders. Clin J Pain 16, 54–63.
    1. Kunz M, Mylius V, Schepelmann K, Lautenbacher S (2009) Effects of age and mild cognitive impairment on the pain response system. Gerontology 55, 674–682.
    1. Kunz M, Rainville P, Lautenbacher S (2011) Operant conditioning of facial displays of pain. Psychosom Med 73, 422–431.
    1. Hughes J, Hoti K, Atee MAW, Inventors (2016) Electronic Pain Assessment Technologies (ePAT) Pty Ltd, assignee. A pain assessment method and system, World Intellectual Property Organization (WIPO), Patent 025989, 2016-02-25.
    1. Australian Pain Society (2005) Pain in Residential Aged Care Facilities: Management Strategies, Australian Pain Society, North Sydney.
    1. Herr K, Bjoro K, Decker S (2006) Tools for assessment of pain in nonverbal older adults with dementia: A state-of-the-science review. J Pain Symptom Manage 31, 170–192.
    1. Zwakhalen SMG, Hamers JPH, Abu-Saad HH, Berger MPF (2006) Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools. BMC Geriatr 6, 3.
    1. Park J, Castellanos-Brown K, Belcher J (2010) A review of observational pain scales in nonverbal elderly with cognitive impairments. Res Social Work Prac 20, 651–664.
    1. Qi S, Diane J, Kay D (2012) The psychometric properties, feasibility and utility of behavioural-observation methods in pain assessment of cognitively impaired elderly people in acute and long-term care: A systematic review. JBI Libr Syst Rev 10, 977–1085.
    1. Corbett A, Husebo B, Malcangio M, Staniland A, Cohen-Mansfield J, Aarsland D, Ballard C (2012) Assessment and treatment of pain in people with dementia. Nat Rev Neurol 8, 264–274.
    1. Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L, Lowcay B (2004) The Abbey pain scale: A 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs 10, 6–13.
    1. Merskey H, Bogduk N (1994) IASP Task Force on Taxonomy: Classification of chronic pain: Description of chronic pain syndromes and definition of pain terms, IASP Press, Seattle.
    1. Lichtner V, Dowding D, Esterhuizen P, Closs SJ, Long AF, Corbett A, Briggs M (2014) Pain assessment for people with dementia: A systematic review of systematic reviews of pain assessment tools. BMC Geriatr 14, 138.
    1. Hadjistavropoulos T, Herr K, Prkachin KM, Craig KD, Gibson SJ, Lukas A, Smith JH (2014) Pain assessment in elderly adults with dementia. Lancet Neurol 13, 1216–1227.
    1. Lam M, Webb KA, O’Donnell DE (1999) Correlation between two variables in repeated measures. In American Statistical Association, Proceedings of the Biometric Section; 1999 213-18; Alexandria, Virginia, pp. 213–218.
    1. Hamlett A, Ryan L, Wolfinger R (2004) On the use of PROC MIXED to estimate correlation in the presence of repeated measures. SAS Users Group International, Proceedings of the Statistics and Data Analysis Section SAS Institute Inc, pp. 1–7.
    1. Portney L, Mary P (2009) Foundations of clinical research: Applications to practice, Pearson/Prentice Hall, Upper Saddle River, NJ.
    1. Viera AJ, Garrett JM (2005) Understanding interobserver agreement: The kappa statistic. Fam Med 37, 360–363.
    1. Neville C, Ostini R (2014) A psychometric evaluation of three pain rating scales for people with moderate to severe dementia. Pain Manag Nurs 15, 798–806.
    1. Ersek M, Herr K, Neradilek MB, Buck HG, Black B (2010) Comparing the psychometric properties of the Checklist of Nonverbal Pain Behaviors (CNPI) and the Pain Assessment in Advanced Dementia (PAIN-AD) instruments. Pain Med 11, 395–404.
    1. Lints-Martindale AC, Hadjistavropoulos T, Lix LM, Thorpe L (2012) A comparative investigation of observational pain assessment tools for older adults with dementia. Clin J Pain 28, 226–237.
    1. Feldt KS (2000) The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs 1, 13–21.
    1. Fuchs-Lacelle S, Hadjistavropoulos T (2004) Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Manag Nurs 5, 37–49.
    1. Warden V, Hurley AC, Volicer L (2003) Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 4, 9–15.
    1. Fuchs-Lacelle S, Hadjistavropoulos T (2005) Inter-rater reliability and additional psychometric information on the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). In IASP Poster presented at the 2005 World Congress on Pain, Sydney, Australia.
    1. Villanueva MR, Smith TL, Erickson JS, Lee AC, Singer CM (2003) Pain Assessment for the Dementing Elderly (PADE): Reliability and validity of a new measure. J Am Med Dir Assoc 4, 1–8.

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