The Common Sense Guide to Improving Palliative Care > Assuring Comfort > 5.9 Some Special Cases: Older or Cognitively Impaired Patients
According to the American Geriatrics Society Panel on Chronic Pain in Older Persons (1998, http://www.americangeriatrics.org/staging/education/executive_summ.shtml), chronic pain in the long-term care setting is generally underrecognized and undertreated. In addition, the ways in which older people communicate about their pain may be different. Older adults may deny that they are in pain if you ask them directly, "Are you in pain?" They may even appear to be comfortable, smiling and responsive, and still be very uncomfortable. Older adults may expect that they will have unpleasant symptoms in later life or be afraid of its consequences (more tests, another illness, more burdens on family). So it is important to use words that they may use to describe their pain, such as hurt, ache, discomfort, or sore: "Do you hurt anywhere?" may be a better way to ask about pain; and "What keeps you from enjoying the day?" may give insight into symptoms generally.
Older adults and others with cognitive impairments may still be able to respond to questions about their discomfort even with limited use of language skills. Ask yes-or-no questions, and ask the patient to point to what hurts.
When patients can not communicate about their symptoms, the healthcare practitioner has to find other ways to assess signs and symptoms of distress. You will have to depend on your other senses, your knowledge of how the person usually acts, and the insights of family and staff to determine whether a noncommunicative person is in distress.
Observe the patient for signs of rapid or distressed breathing, curled up body positioning, repetitive movements, or resistance to being moved or helped. The face may reveal grimacing, teeth clenching, tears, or eyes opened widely, all signals that the person is in distress.
Behaviors may change when the person is uncomfortable; the person may become loud, call out, be verbally or physically abusive, or be resistant to caregiving. Assess whether this has happened before and what might trigger this behavior (the need to urinate or move the bowels; being too cold or too hot; hunger; loneliness; fear of caregiving procedures; experiencing harmful stimuli from the environment). If the cause of the behavior is not identified, try pain-relief measures, and then observe to see whether the person acts and appears better after the treatment.
Some measurement tools allow aides to rate pain for people with dementia, including the PAIN AD Scale (see the resources listed at the end of this chapter).