The effective management of chronic pain begins with pain assessment.

Assessing pain levels accurately and reliably is a highly complex task involving a number of symptoms and factors. To address these challenges, there have been a number of developments and progressions in pain assessment over the years — particularly for those suffering from chronic conditions or who have lost the ability to verbalise their pain.

The evolution of pain assessment over the years

Pain assessment is difficult. But is profoundly more difficult to assess for those living with dementia and those with cognitive impairment and who have lost the ability to reliably self-report their pain. In this portion of the population, pain often goes undetected or untreated, which can lead to incorrect prescriptions, behavioural and psychological issues, and decreased quality of life.

Over the years, a number of tools have been introduced to support carers in accurately assessing pain for patients living with dementia. Early pain assessment tools included one-dimensional assessment tools such as the visual analogue scale (VAS), numerical rating scale (NRS), verbal description scale (VDS). However, many tools were not used in isolation and there was no standardised approach to pain assessment.

In 2002, the American Geriatrics Society (AGS) provided the first clinical practice guidelines for the management of chronic pain in cognitively impaired elderly persons. These include common behaviours to look out for, including facial expressions, changes in interpersonal interactions, changes in mental status, and more.

Following the AGS guidelines, Victoria Warden, Ann C. Hurley, and Ladislav Volicer developed the Pain Assessment in Advanced Dementia Scale (PAINAD) in 2003. As a five-part, paper-based observational tool, PAINAD was specifically designed to help nurses assess pain in older adults with dementia or other cognitive impairments.

Building upon the work by AGS and PAINAD, Dr Jennifer Abbey developed the Abbey Pain Scale in 2004 — a breakthrough, standardised pain scale to assess pain for people with dementia who are unable to verbalise their needs in a meaningful way.

As a result of her innovation in pain care management, Dr Abbey has recently become a Member of the Order of Australia, an honour awarded for her significant service to the health of aged persons, particularly pain management.

The challenges facing nurses and carers today

The existing and established pain assessment tools for these populations are very well-validated to assess pain for these patients. However, they are manual, paper-based, and often not used at the point of care – and many require specialist nursing knowledge. As a result, they are rarely used by carers in aged care and hospitals – leaving staff to work out their own methods.

Some of the main challenges that have emerged include:

  • These types of physical ratings are subjective. One carer may interpret cues differently to another. Paper-based tools are also inefficient as the record needs to be manually entered into the resident’s digital record, taking valuable time away from clinical work.
  • Assessing pain is most accurate when the carer has a high familiarity with the patient, as they are able to pick up on changes in behaviour. However, in care homes, there are often multiple staff members caring for a single patient. As a result, residents may receive a variety of different pain assessments throughout an average week.
  • It’s often specialist and therefore underused. These manual methods require nurses to have a certain level of experience and confidence to use the tool. Although registered nurses may be trained in the Abbey Pain Scale, in many instances, other staff such as personal care assistants are often the ones who spend the most time with the resident. These carers may have less reliable assessment methods and, as a result, the Abbey Pain Scale is often underused — leading to inconsistent pain management.

During COVID-19, manual pain assessment has proven even more challenging. The elderly and non-verbal have been some of the most vulnerable to the pandemic, and accurate pain management is essential as chronic pain may have negative effects on the immune system. However, social distancing restrictions have made it challenging for staff to get close enough to patients to accurately decipher pain. Further to this, manual methods may also carry a greater risk of spreading infection.

PainChek®: Building the future of pain assessment

The widespread availability of digital technology, coupled with advancements in artificial intelligence and facial recognition, has opened up a plethora of possibilities in regards to pain assessment for residents living with dementia. While other tools have emerged that digitise existing manual observation tools, PainChek® has taken it one step further — paving the way for the future for pain assessment.

Building upon the exceptional accomplishments of previous tools, PainChek® automates the pain assessment process improving the clinical practice of pain management. It gives a voice to those who cannot verbalise pain, and empowers all carers to deliver accurate pain assessment at any time, anywhere.

PainChek® has intelligently automated the multidimensional pain assessment process and introduced artificial intelligence to assist in facial assessment, which is the most complex part of the pain assessment process. Using PainChek®, carers use their smart phone camera to record a short video of the individual’s face. The app then analyses the images using facial recognition analytics and automatically recognises the facial muscle movements that indicate pain. Next, the caregiver is guided through a digital binary questionnaire related to pain-related behaviours in five key areas:

  • Vocalisation
  • Movement
  • Behavioural change
  • Changes in activity
  • Physical change

From this information, PainChek® automatically calculates an overall pain score and pain severity level ranging from no pain to mild, moderate or severe pain. The data is also stored centrally via the cloud, and documented into the PainChek® portal and client care management system which eliminates the duplication of data and allows the caregiver to monitor the effect of medication and treatment over time.

The result is a fully mobile, clinically validated and regulated medical device that is downloadable for use on any smart-phone or mobile device.

PainChek® also brings pain assessment to the point of care, stores resident records on-line and helps carers improve their resident care.

According to Dr Jennifer Abbey, who has joined the PainChek® Clinical Advisory Board, it’s the next step in pain management – particularly following the ‘perfect storm’ of COVID-19: “The Abbey Pain Scale has been the standard tool used to overcome that problem for nearly 20 years in Australia and elsewhere. PainChek® introduces an innovative technology that does far more than the Abbey Scale could do, whilst remaining similar enough to allow staff to adapt to the new tool without difficulty.”

PainChek® has also proven invaluable during the pandemic, as a tool to enable accurate pain assessment while complying with infection control procedures.

“The PainChek® app has allowed IRT to provide employees with an innovative pain assessment and management tool that enables them to practice safe distancing whilst assessing and managing resident pain,” said Alex Reed, Strategic Projects Manager, Aged Care Centres at IRT.

How PainChek® is being used to transform pain management

As of 31st March 2020, 175 Providers and 588 Facilities have taken up a PainChek® license covering 49,811 Aged Care beds – of which 30,905 are dementia-specific beds. PainChek® is also being used in aged care facilities in the United Kingdom, Singapore, and New Zealand, and is currently on track to obtain FDA de novo clearance in the U.S.

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