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Advanced dementia pain management protocols
Protocolos de gestión del dolor en demencia avanzada
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=> "194" "paginaFinal" => "204" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Mercedes Montoro-Lorite, Montserrat Canalias-Reverter" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Mercedes" "apellidos" => "Montoro-Lorite" "email" => array:1 [ 0 => "mmontoro@clinic.ub.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Montserrat" "apellidos" => "Canalias-Reverter" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Oncología Médica, Instituto Clínico de Enfermedades Hematológicas y Oncológicas, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Enfermería del Instituto de Medicina y Dermatología, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Protocolos de gestión del dolor en demencia avanzada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1947 "Ancho" => 3178 "Tamanyo" => 376499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Stages of standardised protocols of pain management in people suffering from advanced dementia.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Dementia is a progressive debilitating disease characterised by serious cognitive decline, loss of language and the ability to carry out everyday activities.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> The loss of superior cognitive functions is the main cause of the difficulty in quantifying pain, leading to a lack of its detection and treatment.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> Pain management is a critical factor in the treatment and effective care of this patient group.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> Pain is the principal symptom of many diseases which affect this population group.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a> The estimated prevalence of pain at a national level is 25–40% within the community, and this figure rises to 50–80% in the institutionalised population.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> The main causes of the persistence of pain are muscular and skeletal conditions, upper airway infections, urinary infections, pressure ulcers, injuries from falls and the worsening of chronic illnesses.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">6,7</span></a> They are also the main reasons for this patient group to be admitted into hospital.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> Ineffective pain management may lead to greater suffering, discomfort and the use of healthcare resources.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">9,10</span></a> Prognosis affects well-being and leads to a reduction in the life expectancy of this group.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> In contrast, pain which is properly treated is associated with a reduction in risk or delay in the development of delirium and a shorter hospital stay.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Defining pain for advanced dementia is an unpleasant subjective experience, which may be communicated through self-reports whenever possible or a combination of behaviours relating to pain.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> Behaviours relating to pain which these advanced dementia patients present with may be difficult to interpret and this complicates its management. It is thus useful to use observational tools to improve management. Pain experts suggest that any observational tool may be used as part of an integral management protocol for pain, which includes interpretation of scores and verification of appropriate suggested treatments.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Over recent years, research has focused on the development of observational tools and their systematic reviews. In one previous review of the literature<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a> the need for guidance was detected regarding the best possible available evidence on the development of supportive interventions when taking decisions to aid pain assessment and management in patients suffering from advanced dementia in an acute care setting. As a result of this need we initiated this literature searching project so that a future pain management protocol could be established, based on the best scientific evidence and later implemented in standard care of people with dementia in our hospital environment.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Observational scales for advanced dementia pain assessment</span><p id="par0020" class="elsevierStylePara elsevierViewall">The first step towards correct pain management is to detect the presence or suspicion of pain. The most reliable and precise indicator for this is a description from the person concerned aided by validated and reliable tools. The tool selected by the nurse will depend on the patient's characteristics.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> The gold standard for expressing pain is the self-report. However the communication challenges presented by people with advanced dementia, with cognitive and verbal impairments make it impossible to use this resource.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Instead, these patients may communicate they have pain or discomfort through different behaviours, including restless physical movements and verbal message of difficulty such as groaning and shouting. Pain behaviours presented by elderly patients with advanced dementia may be complex to interpret. As a result of this, in 2002 the American Geriatric Society organised an integral framework of guidelines indicating behaviour patterns of persistent pain in elderly people with advanced dementia.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a> Many observational scales are based on these indicators for people suffering from advanced dementia, with these pain behaviour observations replacing that of self-reporting. Choosing the most appropriate observational tool has to include consideration of the clinical context. In a hospital setting they must be quick and easy to complete because they must be more frequently used due to acute treatment. In residential environments that are larger and more multidimensional a more complete list of behaviours may be assessed, less commonly related to pain but more to changes in activities, interaction and the patient's mental state. Due to their complexity they are useful for monthly or quarterly assessment (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">28 observational tools are mentioned in the scientific literature<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a> and due to their heterogeneity; it is difficult to provide a complete summary comparing all the tools. The main tools summarised in the principal systematic reviews are the: Abbey Pain Scale, Assessment of Discomfort in Dementia protocol (Protocol ADD), Checklist of Nonverbal Pain Indicators, Disability Distress Assessment Tool, Doloplus-2, Nursing Assistant-Administered Instrument to Assess Pain in Demented Individuals, Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC), Pain Assessment for the Dementing Elderly y Pain Assessment in Advanced Dementia (PAINAD) summarised in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,17–20</span></a> They all require nursing skills to ensure their correct usage. Also, all of them except the ADD<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,20</span></a> protocol are based on American Geriatric Society guidelines.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">During the last 10 years, a series of systematic reviews<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">9,12,13,17–21</span></a> were published on the assessment of pain in people with dementia. The author Lichtner et al.,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a> after carrying out a meta-review of the systematic reviews of pain assessment concluded that no tool in particular could be recommended for use, due to the lack of exhaustive tests on the reliability, validity, viability or the clinical usefulness of the tools and Corbett et al. conclude the same.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> Notwithstanding, these authors differ in how to resolve the lack of a gold standard. Lichtner et al.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a> suggest that further research is necessary on the psychometric properties in clinical practiced whilst Corbett et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> conclude that it would be necessary to create a meta-tool using the available tools as the base in scientific evidence. Of those scales we have at our disposal now, with the best psychometric properties we would highlight the PACSLAC for the residential area and the PAINAD for the hospital area,<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,19,20,23</span></a> although in 2013, García-Soler carried out the adaptation and validation into Spanish (PAINAD Sp) in the residential area.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">22</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The PACSLAC was developed by Fuchs-Lacelle et al.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">24</span></a> and is an integral, systematic and periodic tool for assessing changes in behaviours related to pain. The scale has a high internal Cronbach (<span class="elsevierStyleItalic">α</span>) 0.85 alpha reliability and a moderate Pearson (<span class="elsevierStyleItalic">r</span>) 0.35 correlation between observers. 60 items are assessed in four dimensions: facial expression, body movements, physiological indicators and psychosocial indicators. All the articles are classed as present or absent. It is useful as a monthly or quarterly tool since it incorporates a more complete list for identifying specific behaviours. It has been validated and adapted into Korean and Brazilian but not into Spanish.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">25,26</span></a> In 2014 the authors adapted a briefer version of 31 items: PACSLAC-II recommending further research to test its usefulness in acute settings.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">PAINAD was developed by Warden et al.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a> to provide a clinically relevant and easy-to-use tool for pain evaluation in people with advanced dementia. This validated and reliable scale presents with good internal consistency (<span class="elsevierStyleItalic">α</span> 0.69-), strong reliability between observers (<span class="elsevierStyleItalic">r</span> 0.75–0.97), and a strong reliability test–retest (<span class="elsevierStyleItalic">r</span> 0.88–0.90). There was also a strong correlation between observers, with self-report tools and other observational tools for pain (<span class="elsevierStyleItalic">r</span> 0.81–0.85).<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a> PAINAD assesses five articles: breathing, negative vocalisation/verbalisation, facial expression, body language and solace. Each element is levelled on a scale of 3 points from 0 to 2, depending on intensity. The total score may be 0 (no pain) to 10 (maximum pain), equivalent to self-report tools as the numerical scale. The authors state that this scale is easy to use and they only need one to 3<span class="elsevierStyleHsp" style=""></span>min to complete it. In recent years it has been validated into different languages: Portuguese, German, Chinese, Spanish, and Italian. And into different care environments (critical care, care homes, emergency services, etc.). To conclude, this is a useful tool for daily assessments, including follow-up of the evaluation of surgery for pain, and the assessment of the efficacy of different therapies. This tool is also recommended by the only systematic review carried out in Spain.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical intervention protocols for pain management in advanced dementia</span><p id="par0050" class="elsevierStylePara elsevierViewall">Pain management is not a single act comprising the twofold assessment-treatment dynamics, but a complex, cyclical process which begins with pain assessment, followed by planning and acting and later the re-assessment of the presence of pain, followed by planning and action and so on and so forth. It must also be appropriately recorded so that it serves as a source of information for the whole multidisciplinary team.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">This complex process must follow the Good Clinical Practice Guidelines (GCP). These are systematically developed to help nurses take decisions and offer a general view of the best scientific evidence. They are especially useful in the development of policies, procedures, protocols, interventions, documentation tools and educational programmes.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> The GCP may thus improve the quality of care and of the people suffering from dementia because they help to develop integral effective plans.</p><p id="par0060" class="elsevierStylePara elsevierViewall">There are only three GCP which meet with these requisites, those carried out by the Australian Society of Geriatric Medicine,<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> the North American Association of Geriatric Nursing<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> and the Registered Nurses’ Association of Ontario<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> (Canada), summarised in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. On a European level there is the EU Cost action project whose main aim is the development of a widespread and agreed set of international tools for assessing pain in adults with cognitive impairment, particularly with dementia. At present they are being translated and assessment on the PAIC scale.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> In Spain we have not found any GCP, only recommendations on tools to assess pain at the end of life.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The hierarchy of pain assessment techniques by McCaffery and Pasero<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">30</span></a> was recommended as a conceptual framework to develop protocols based on scientific evidence which forms part of the existing GCP in the literature.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">15,28,29</span></a> These standardised protocols which are used in daily healthcare routines for people suffering from advanced dementia have demonstrated the reduction in pain scores of this group and the increase in the use of non-pharmacological interventions for their relief.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">31–33</span></a> The stages forming part of the standardised protocols of pain assessment are as follows (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>): pain assessment, planning and action, re-assessment and documentation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pain assessment</span><p id="par0070" class="elsevierStylePara elsevierViewall">The following steps are required for accurate pain assessment: (1) try to obtain a self-report on the person's pain; (2) search for possible potential causes of the pain; (3) use an observational tool; and (4) obtain replacement information from a family member or carer whenever possible. The three GCP coincide in that the previous steps must be included but there is no consensus on the use of an observational tool. The Abadía pain tool and the PAINAD tool are recommended by Savvas<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> whilst the RNAO<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> and Herr<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> recommend several, among which are: PAINAD, PACSLAC and DOLOPLUS-2. Several recent clinical trials use the PAINAD scale for assessing the presence of pain.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">10,32–34</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Planning and action</span><p id="par0075" class="elsevierStylePara elsevierViewall">In this second stage, the literature suggests the inclusion of non-pharmacological interventions and those based on the recommendation of the International Association for the Study of Pain: a multimodal focus. The most recommended drug for people of advanced age due to its risk–benefit profile is paracetamol. Using a standardised focus for pain treatment was beneficial in improving pain management, significantly reducing agitation and neuropsychiatric symptoms in the intervention group compared with the control group which received their usual analgesic for pain relief.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">31</span></a> The benefits of combining pharmacological actions and non-pharmacological actions are described in the systematic review carried out by Pieper<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> and consolidated by the recommendation of the three GCP: planning must be individualised and focused on the person establishing a care plan which includes their objectives and expectations.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">28,30</span></a> There is a need for further controlled clinical trials that include non-pharmacological interventions, but the results of the latest ones published are of note. They show a significant reduction in scores regarding the presence of observational pain with the increase in the use of non-pharmacological interventions compared with a responsible consumption of analgesics and antipsychotics.<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">32–34</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Re-assessment</span><p id="par0080" class="elsevierStylePara elsevierViewall">Following implementation of the personalised action plan, re-assessment is required, always with the use of the same tool as in the initial evaluation. The final aim of re-assessment is to guarantee optimum control over pain. For this, the efficacy of actions should be assessed and the ability to discriminate their effectiveness to adjust strategies and assess through observation, control and reducing adverse effects to a minimum.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">15,28,30</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Documentation</span><p id="par0085" class="elsevierStylePara elsevierViewall">Documentation must be continuous, regular, systematic, standardised and accessible to all people involved in care. The register should include: date, time, type, intensity, classification, location and quality, the tool used for assessing the pain, the pharmacological and non-pharmacological interventions, the person's response, the possible adverse effects and actions for their prevention. This exhaustive documentation will be a source of communication for the whole multidisciplinary team which will in turn continue to manage pain. The GCP by Savvas presents a structured procedure for recording pain management.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a></p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">At present, there are no national GCP nor any single observational tool which serves as a gold standard. The most highly recommended tool for the hospital environment is PAINAD because it is a fast tool which enables longitudinal assessments and it is not necessary for the observer to be previously familiar with the person suffering from dementia. For the residential care home environment PACSLAC is recommended because it incorporates a more complete list of behaviours and it is useful as a monthly or quarterly tool. Scientific evidence suggests that any observational tool should be used as part of a integral pain management protocol, provided that it focuses on the person and the family/carer. The hierarchy of pain assessment techniques of Pasero and McCaffery provide us with a tool aimed at improving decision-making for individualised care and that it may be a conceptual framework for the development of GCP, which include standardised protocols for pain management advanced dementia with algorithms which aid interpretation of scoring and verification and with the appropriate suggested treatments. In order to be able to introduce the pain management protocols the nurses need training and skills in the use of observational tools and action algorithms, due to the continuous advances and development of new tools and strategies.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Financing</span><p id="par0095" class="elsevierStylePara elsevierViewall">This article was made possible thanks to the financing received for the project: <span class="elsevierStyleItalic">Comprehensive pain management in advanced dementia</span>, which obtained 1st prize in the <span class="elsevierStyleGrantSponsor" id="gs1">“Convocatoria dels Ajuts Programa TALENTS” of the Fundació Catalunya – La Pedrera</span>.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1031991" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec989034" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1031992" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec989035" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Observational scales for advanced dementia pain assessment" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Surgical intervention protocols for pain management in advanced dementia" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Pain assessment" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Planning and action" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Re-assessment" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Documentation" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Financing" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack348523" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-12" "fechaAceptado" => "2017-06-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec989034" "palabras" => array:3 [ 0 => "Pain" 1 => "Dementia" 2 => "Pain management" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec989035" "palabras" => array:3 [ 0 => "Dolor" 1 => "Demencia" 2 => "Manejo del dolor" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pain management in advanced dementia is complex because of neurological deficits present in these patients, and nurses are directly responsible for providing interventions for the evaluation, management and relief of pain for people suffering from this health problem. In order to facilitate and help decision-makers, pain experts recommend the use of standardised protocols to guide pain management, but in Spain, comprehensive pain management protocols have not yet been developed for advanced dementia.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This article reflects the need for an integrated management of pain in advanced dementia. From the review and analysis of the most current and relevant studies in the literature, we performed an approximation of the scales for the determination of pain in these patients, with the observational scale PAINAD being the most recommended for the hospital setting. In addition, we provide an overview for comprehensive management of pain in advanced dementia through the conceptual framework “a hierarchy of pain assessment techniques by McCaffery and Pasero” for the development and implementation of standardised protocols, including a four-phase cyclical process (evaluation, planning/performance, revaluation and recording), which can facilitate the correct management of pain in these patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La gestión del dolor en demencia avanzada es compleja debido a los déficits neurológicos presentes en este tipo de pacientes, siendo las enfermeras directamente responsables de proporcionar intervenciones para la evaluación, manejo y alivio del dolor a las personas que sufren este problema de salud. Para facilitar y ayudar a la toma de decisiones, los expertos en dolor recomiendan la utilización de protocolos estandarizados que guíen en el manejo del dolor, pero en España no se han desarrollado protocolos integrales de gestión de dolor en demencia avanzada.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El presente artículo reflexiona sobre la necesidad de que exista una gestión integral del dolor en demencia avanzada. De la revisión y análisis de los estudios más actuales y relevantes de la literatura, realizamos una aproximación a las escalas para la determinación del dolor en estos pacientes, siendo la escala observacional PAINAD la más recomendada para ámbito hospitalario. Además, proporcionamos una visión general para la gestión integral del dolor en la demencia avanzada, a través del marco conceptual «la jerarquía de evaluación del dolor de McCaffery y Pasero», para el desarrollo e implementación de protocolos estandarizados, que incluye un proceso cíclico formado por cuatro fases (evaluación, planificación/actuación, revaloración y registro), lo que puede facilitar el correcto manejo del dolor en estos pacientes.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Montoro-Lorite M, Canalias-Reverter M. Protocolos de gestión del dolor en demencia avanzada. Enferm Clin. 2018;28:194–204.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1947 "Ancho" => 3178 "Tamanyo" => 376499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Stages of standardised protocols of pain management in people suffering from advanced dementia.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scales \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of pain \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AGS guidelines \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Evaluator \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration in time \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Area \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Assessment moment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Psychometric properties \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abbey Pain Scale<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Created in Australia<br>Was assessed in 24 care homes with a sample of 61 adults with advanced dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chronic-acute \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-specific \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-specific \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Residential \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Movement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach's alpha reliability 0.74<br>Reliability between coefficient evaluators of intraclass correlation 0.63 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02) and 0.44 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.12)<br>Test–retest not available<br>Gamma 0.586 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) concurrent validity<br>Predictive validity<br>Pre-intervention (9.02; SD 0.48)<br>Post-intervention (4.21; SD 0.41 <span class="elsevierStyleItalic">T</span>-test (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001)) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ADD protocol<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systematic protocol for creating an assessment and treatment plan for physical pain and discomfort in people with advanced dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-specific \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hospital environment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unavailable reliability<br>Reliability between unavailable evaluators<br>Unavailable test–retest<br>Unavailable concurrent validity. Predictive validity<br>Pre-intervention 32.9 (SD 16.8)<br>Post-intervention 23.5 (SD 16.5)<br><span class="elsevierStyleItalic">T</span>-test (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CNPI<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,13,34</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Detailed list designed to measure pain behaviour patterns in elderly adults with cognitive impairment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chronic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-specific \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hospital environment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Movement<br>Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach's alpha reliability 0.54<br>Reliability between kappa statistical evaluators 0.625–0.819<br>Unavailable test–retest<br>Concurrent validity<br>Spearman rest correlation 0.37 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001)<br>Spearman movement correlation 0.43 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001)<br>Unavailable predictive validity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DS DAT<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,13,17,20,34</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Developed for the research area, aimed at measuring the discomfort in adults with advanced dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discomfort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–15<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Research \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach's alpha reliability 0.79<br>Reliability between Pearson correlation evaluators 0.61 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001)<br>Unavailable test–retest<br>Unavailable concurrent validity. Unavailable predictive validity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doloplus-2<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,19,22,34</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multi-dimensional assessment of pain in non-verbal adults \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chronic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse's aides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Residential aged care facilities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Movement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach's alpha reliability 0.82<br>Reliability between coefficient evaluators of intraclass correlation 0.77–0.90<br>Unavailable test–retest<br>Unavailable concurrent validity. Unavailable predictive validity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PACSLAC<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,13,17,20,34</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Assessment and follow-up of changes in behaviour relating to pain in people with dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Behavioural changes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Residential aged care facilities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Movement<br>Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach's alpha reliability 0.85<br>Reliability between coefficient evaluators of intraclass correlation 0.77–0.96<br>Unavailable test–retest<br>Unavailable concurrent validity. Unavailable predictive validity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PADE<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Assess the behaviour of people with advanced dementia who indicate pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Behaviour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse's aides \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–10<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Residential aged care facilities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Movement<br>Rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach's alpha reliability 0.76<br>Reliability between coefficient evaluators of intraclass correlation 0.54–0.96<br>Test–retest coefficients of intraclass correlation 0.34–0.98<br>Unavailable concurrent validity. Unavailable predictive validity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAINAD<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,12,13,17,20,34</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adaptation of the DS – DAT and The Face, Legs, Activity, Cry, Consolability scale (FLACC) was developed to provide pain assessment in people of advanced age and dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acute-chronic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consistent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurses<br>Nurse's aides Doctors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1–3<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hospital environment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Movement<br>Rest<br>Pleasant activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach's alpha reliability 0.69<br>Reliability between coefficient evaluators of intraclass correlation 0.77–0.97<br>Test–retest coefficients of intraclass correlation 0.88–0.90<br>Unavailable concurrent validity. Predictive validity<br>Pre-intervention 6.7 (SD 1.8) Post-intervention 1.8 (SD 2.2) <span class="elsevierStyleItalic">T</span>-test (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1757155.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The main observational tools for assessing pain in advanced dementia analysed in systematic reviews.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: Registered Nurses’ Association of Ontario RNAO<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a>, Savvas et al.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> and Herr et al.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Objective \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Conclusions \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Herr et al.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">General recommendations to assess pain in those who cannot use self-reporting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">n/p \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The hierarchy of pain assessment (Pasero and McCaffery, 2011)<br>a. First tries to obtain a self-report from the patient and if they are incapable of this, report why a self-report cannot be used.<br>b. Identify conditions, pathologies or procedures which may cause pain.<br>c. Number the behaviours which may indicate pain (use of tools).<br>d. Identify the behaviours that carers think may indicate pain.<br>e. Try an analgesic test.<br>Re-assess and record in document \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Evaluation of pain used in a hierarchy framework for the people who cannot self-report. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Savvas et al.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Assessment and treatment of pain based on evidence programme \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">n/p \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Assessment<br>Structured procedures to identify the causes of pain, when the resident cannot report on pain and to record the behaviour patterns relating to pain.<br>Multi-disciplinary collaboration between all staff members for pain assessment.<br>Use of self-reporting for pain assessment in residents with cognitive capacity and the Abadía Pain Scale for residence with cognitive impairment.<br>Treatment<br>Pharmacological therapies and non-pharmacological therapies in pain management plans.<br>Institution/Residential aged care facilities<br>Have explicit pain management policies throughout the guidelines of the Australian Pain Society.<br>Programme for pain education management for residents and families.<br>Systematic pain education management programme for all staff. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The training provides clear and unequivocal evidence that it improves the practices based on the evidence in caring for elderly people in old peoples’ homes. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RNAO 2014<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete document which provides resources for the practice of nursing based on evidence and aimed at improving decision-making for individualised care \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GCP<br>No.<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11<br>EC<br>No.<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Assessment<br>Carry out an integral evaluation of pain using a validated tool. Steps to follow:<br>(1) Try to get the person to describe it.<br>(2) Assess behavioural indicators through validated scales for older people with cognitive impairment (PAINAD, PACSLAC, DOLOPLUS-2).<br>(3) Obtain information from family members or carers on behaviour which may indicate pain.<br>Record patient pain characteristics.<br>Planning<br>Establish a comprehensive care plan which incorporates the aims of the person and professionals.<br>Introduction<br>Introduce the pain management plan using principles which maximise efficacy and minimise adverse effects of pharmacological interventions and include non-pharmacological interventions.<br>Assessment<br>Re-assess the person's response to the interventions for pain management constantly using the same assessment tool.<br>Communicate and record answers of the person and pain management plan.<br>Education<br>Incorporate the contents on strategies and transfer of knowledge into training programmes for nurses to put pain management evidence into practice. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The incorporation of evaluation and pain management in programmes aimed at the staff.<br>The use of standardised and valid pain assessment tools. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1757154.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Summary of good clinical practice guidelines for pain management.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. 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Kovach" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jgs.13868" "Revista" => array:6 [ "tituloSerie" => "J Am Geriatr Soc" "fecha" => "2016" "volumen" => "64" "paginaInicial" => "261" "paginaFinal" => "269" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26804064" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack348523" "titulo" => "Acknowledgements" "texto" => "<p id="par0105" class="elsevierStylePara elsevierViewall">The authors would like to thank Doctor. Adelaida Zabalegui, RN, PhD, FEANS, Subdirector of Research and Education in the nursing area of the Hospital Clinic in Barcelona, for her contribution as director of this project's thesis, within the framework of the University Master's programme on Chronicity and Dependency of the Tecnocampus. Also to all the nursing professionals and care coordinators of the <span class="elsevierStyleGrantSponsor" id="gs2">Institute of Medicine and Dermatology of the Hospital Clínic of Barcelona</span>, for their support in this research project.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24451479/0000002800000003/v1_201805300410/S2445147917301170/v1_201805300410/en/main.assets" "Apartado" => array:4 [ "identificador" => "67198" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24451479/0000002800000003/v1_201805300410/S2445147917301170/v1_201805300410/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445147917301170?idApp=UINPBA00004N" ]
