Valoración del dolor en pacientes con deterioro cognitivo y su implicación en el tratamiento

Resum

BACKGROUND: Pain is a very relevant problem in old people. In hospitalized patients, pain evaluation is performed by using scales based in the subjective perception of pain. These scales may be inadequate in the elderly, as they often show cognitive impairment, without verbal answers. HYPOTHESIS: The systematic evaluation of pain with an adequate scale may improve pain management in hospitalized old people with cognitive impairment. OBJECTIVES: 1.- To analyse if the systematic performance of the pain evaluation scale for advanced dementia (PAINAD) in hospitalized old people, with the subsequent information of the results to the medical staff, may contribute to a better pain management. 2.- To calculate the degree of pain, measured with the PAINAD, in hospitalized old people with cognitive impairment. 3.- To evaluate if the systematic performance of the pain evaluation scale for advanced dementia (PAINAD) in hospitalized old people, with the subsequent information of the results to the medical staff, determine a) drug administration, b) agitation, disorientation or functional capacity, c) number of days at hospital, and d) mortality. 5.- To measure the required time for performing the PAINAD. METHODS: The study was performed at the Internal Medicine Units of the Principe de Asturias University Hospital. Patients were over 65 year old, with cognitive impairment measured by the Pfeiffer Test, and they or their families gave an informed consent. Patients were randomized in two groups, control (they were managed as usual) and intervention (PAINAD was performed at the moment of hospitalization, and medical staff was informed about the results). At 5 days of hospitalization, PAINAD was performed in every patient. Moreover, the degree of functional impairment was measured by the Barthel Index and changes in behaviour by the Cummings NPI test. RESULTS: Pain is underrated and underdiagnosed by nurses, and the subjective scales do not let to evaluate adequately the pain degree in old patients with cognitive impairment. PAINAD performance let to evaluate pain in all the patients of the study, and the degree of pain observed with this test was higher than with the subjective tests. In general, patients living in geriatric residences, highly dependent patients, and patients with more cognitive impairment showed higher degree of pain. Indirect evidence suggests that PAINAD discriminate better the pain of patients with cognitive impairment. However, our results do not show any advantage, concerning the degree of pain at the 5th day of hospitalization, of the systematic PAINAD performance. Most of the studied patients become completely dependent at the 5th day of hospitalization. PAINAD performance is easy and not timeconsuming. CONCLUSSIONS: Pain must be evaluated in all hospitalized old patients with cognitive impairment, by using appropriate tools such as PAINAD. The use of these tools may improve pain management.