Few scales have been developed specifically with older individuals in mind. Almost none have been evaluated for responsiveness or sensitivity to changes in pain. Given the importance that hospitals and nursing homes are now mandated to place on pain assessment (and subsequent treatment and evaluation of that treatment), it is disturbing that most instruments to assess pain have not had such testing.
Many scales are variations of an identical concept; that is, the scale has one end that indicates "no pain," and the other end that indicates "very bad" pain (or some variation thereof). These scales are numbers, faces, thermometers, or simply lines (3,4) and are consistent in the speed with which they can be administered in an appropriate environment. It is vital to have instruments in a clinical environment that are standardized adequately and can be administered in less than a minute.
One scale that has the desired celerity in administration, that has been designed for seniors, and that has had appropriate standardization, including responsiveness testing, is the Functional Pain Scale (FPS; Table 1) (5). The FPS offers another advantage because of its ability to handle an
Table 1 Functional Pain Scale
1 = Tolerable (and does not prevent any activities)
2 = Tolerable (but does prevent some activities)
3 = Intolerable (but can use telephone, watch TV, or read)
4 = Intolerable (but cannot use a telephone, watch TV, or read because of pain)
5 = Intolerable (and unable to verbally communicate because of pain)
Ideally, all patients should reach a 0-2 level, preferably 0-1. It should be made clear to the respondent that limitations in function only apply if limitations are due to the pain being evaluated.
issue that has not had adequate study, but is recognized by most pain experts who wrestle with evaluating pain status: the issue of patients selecting the highest level on a pain scale regardless of changes (improvements) that occur in pain status.
It is easy to rationalize why such a phenomenon may occur. Inadequate pain control and analgesia administration go hand in hand. A patient who has experienced inconsistency in obtaining adequate analgesia may be reluctant to acknowledge improvement in pain due to anxiety about not maintaining sufficient medication. A physician colleague who had been in a severe motor vehicle accident with extensive trauma confided his reluctance in ever reporting his pain level at less than 7 points on a 10-point scale due to fear that his analgesics, which had finally started to provide some pain relief, would be decreased or even stopped. This was from someone who had extraordinary access to some of the most recognized physicians in the world. It is easy to understand how other patients might be moved to inflate their pain scale scores as well.
Regardless of the reasoning process, such manipulation provides a dilemma for the well-versed clinician who recognizes the importance of listening to patients, especially when they describe pain. However, the utility of a 0-10 scale may come under question on an individual basis when considering a patient who was writhing in bed due to excruciating pain and was unable to participate in providing a history, yet now appears calm and reports that the pain is "still a 10" in between bites of dinner. The FPS provides some objective components that augment a traditional numerical scale. For example, the highest level of pain on the FPS (see Table 1) is categorized as pain so intense that a person is unable to communicate because of the pain. This, of course, precludes anyone from consistently stating that the pain is at the highest level. The objective nature of the other functional components may contribute to understanding why this scale outperforms other scales in responsiveness, including the Faces Pain Scale and the Visual Analogue Scale (5-7).
Some circumstances continue to perplex clinicians who try to evaluate pain levels. Assessing the heavily subjective level of pain in an individual who has markedly impaired communicative capacity or who is otherwise cognitively impaired can be enigmatic. The bulk of publications related to this issue is found in the nursing literature (8,9). Unfortunately, attempts to meet this challenge have not produced a definitive solution. Ideally, such scales would be studied in a population that is cognitively intact and unable to communicate for a transient period of time. A transient ischemic attack that does not affect memory would provide such a setting; however, this study would be extremely difficult because of the inability to predict when someone is going to have such an event. Assessment of individuals when operations render them unable to communicate verbally or assessment of individuals involved in dental procedures may be somewhat helpful in the design of worthwhile trials. One also would like to standardize such instruments in a population that is cognitively impaired and unable to communicate verbally. Validation and responsiveness testing are particularly daunting in such circumstances.
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