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Pain Assessment in Impaired Cognition

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A special issue of Brain Sciences (ISSN 2076-3425). This special issue belongs to the section "Neuroscience of Pain".

Deadline for manuscript submissions: closed (31 August 2021) | Viewed by 24013

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Special Issue Editors

Dr. Joukje M. Oosterman

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Guest Editor

Donders Institute for Brain, Cognition and Behaviour, Radboud University
Interests: aging; neuropsychology; pain; dementia; cognitive reserve; MRI

Prof. Dr. Miriam Kunz

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Guest Editor

Department of Medical Psychology and Sociology, University of Augsburg
Interests: pain; facial expression; dementia; neuropsychology

Special Issue Information

Dear Colleagues,

Assessing pain in individuals with cognitive impairment is a major challenge. Cognitive impairment reduces reliability of subjective pain reports, the gold standard for assessing pain. As a result, there has been an upsurge in the use of observational scales for pain assessment purposes in cognitive impairment. Whereas these observations are in general more reliable compared to subjective reports of pain, we still know very little of how different underlying pathologies and cognitive changes may, or may not, influence pain assessed via these methods. Specifically, clinical conditions differ immensely with regard to their cognitive deficits; it remains yet to be clarified how these different profiles influence behavioural responses to pain, pain observations and subjective reports. Moreover, whereas cognitive decline has in general been associated with a decline in clinical pain being reported, preliminary work on pathological brain changes in aging and dementia shows a different line of results. Here, more brain white matter atrophy has been related to an increase in clinical pain report, despite the cognitive loss that is also associated with higher atrophy levels. This illustrates the complexity of assessing pain in patients with cognitive impairment.

The aim of this Special Issue is to provide further insight into how cognitive impairment and underlying neuropathological changes influence (findings from) pain assessment in patients with cognitive impairment. Ultimately, its aim is to further understand how pain assessment can be improved in different clinical conditions.

We are soliciting original experimental and observational studies addressing pain assessment in relation to cognitive impairment/clinical diagnosis/neuropathology. Research focussing on pain processing and pain assessment in individuals with different types of cognitive impairments by use of various pain assessment methods and by also considering underlying mechanisms such as brain pathology and neuropsychological profile is especially welcome.

Dr. Joukje M. Oosterman
Prof. Miriam Kunz
Guest Editors

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Keywords

Pain observations
Clinical pain report
Experimental pain
Dementia
Cognitive impairment
Neuropathology
Autonomic responses

Published Papers (10 papers)

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Editorial

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2 pages, 176 KiB

Open AccessEditorial

Towards a Better Understanding on How Cognitive Impairment Affects Pain

by Joukje M. Oosterman and Miriam Kunz

Brain Sci. 2022, 12(2), 170; https://doi.org/10.3390/brainsci12020170 - 27 Jan 2022

Viewed by 1580

Abstract

When judging whether someone is suffering from pain, the simplest and most reliable solution is to ask that person about it [...] Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

Research

Jump to: Editorial

13 pages, 966 KiB

Open AccessArticle

Observing Pain in Individuals with Cognitive Impairment: A Pilot Comparison Attempt across Countries and across Different Types of Cognitive Impairment

by Miriam Kunz, Petra Crutzen-Braaksma, Lydia Giménez-Llort, Sara Invitto, Gaya Villani, Marina deTommaso, Laura Petrini, Lene Vase, Susan Tomczak Matthiesen, Hanne Gottrup, Jone Ansuategui Echeita, Stefan Lautenbacher and Ruth Defrin

Brain Sci. 2021, 11(11), 1455; https://doi.org/10.3390/brainsci11111455 - 2 Nov 2021

Cited by 5 | Viewed by 2626

Abstract

Facial expression is a key aspect in observational scales developed to improve pain assessment in individuals with cognitive impairments. Although these scales are used internationally in individuals with different types of cognitive impairments, it is not known whether observing facial expressions of pain might differ between regions or between different types of cognitive impairments. In a pilot study, facial responses to standardized experimental pressure pain were assessed among individuals with different types of cognitive impairments (dementia, mild cognitive impairment, Huntington’s disease, and intellectual disability) from different countries (Denmark, Germany, Italy, Israel, and Spain) and were analyzed using facial descriptors from the PAIC scale (Pain Assessment in Impaired Cognition). We found high inter-rater reliability between observers from different countries. Moreover, facial responses to pain did not differ between individuals with dementia from different countries (Denmark, Germany, and Spain). However, the type of cognitive impairment had a significant impact; with individuals with intellectual disability (all being from Israel) showing the strongest facial responses. Our pilot data suggest that the country of origin does not strongly affect how pain is facially expressed or how facial responses are being scored. However, the type of cognitive impairment showed a clear effect in our pilot study, with elevated facial responses in individuals with intellectual disability. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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12 pages, 1441 KiB

Open AccessArticle

Pain Processing in Cognitive Impairment and Its Association with Executive Function and Memory: Which Neurocognitive Factor Takes the Lead?

by Stefan Lautenbacher, Annegret Hoos, Göran Hajak, Wolfgang Trapp and Miriam Kunz

Brain Sci. 2021, 11(10), 1319; https://doi.org/10.3390/brainsci11101319 - 4 Oct 2021

Cited by 4 | Viewed by 1790

Abstract

It is well established that individuals with cognitive impairment present with disturbed forms of pain processing of still unknown origin. As a neurocognitive factor, executive functions have become favored candidates for explanation. For further insights, we aimed at comparing executive functions and memory in their association with parameters indicating onset and escalation of pain perception. Subjective ratings of experimentally induced pressure pain applied in ascending series were assessed in older individuals with (N = 32) and without mild cognitive impairments (MCI) (N = 32). We investigated whether executive functioning (Trail Making Test-B (TMT-B), semantic fluency) or memory (word list and figure recall) were more closely linked to the onset and the escalation of pain. For the MCI group, a strong linkage between pain responses and the TMT-B could be found, i.e., poor test performance was associated with weak pain onset but strong pain escalation. The contribution of memory functions was less substantial and systematic. The prominent role of executive function for pain processing in individuals with MCI could be replicated by a test of cognitive flexibility. This lack of adaptability let individuals with MCI be less vigilant to pain at the beginning but allows for escalating pain in the further course. Thus, being first not sufficiently prepared and later overwhelmed as regards pain may be an early problem in MCI individuals with reduced executive functioning. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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14 pages, 927 KiB

Open AccessFeature PaperArticle

Pain Behavior of People with Intellectual and Developmental Disabilities Coded with the New PAIC-15 and Validation of Its Arabic Translation

by Ruth Defrin, Heba Beshara, Tali Benromano, Kutaiba Hssien, Chaim G. Pick and Miriam Kunz

Brain Sci. 2021, 11(10), 1254; https://doi.org/10.3390/brainsci11101254 - 22 Sep 2021

Cited by 4 | Viewed by 1787

Abstract

Pain management necessitates assessment of pain; the gold standard being self-report. Among individuals with intellectual and developmental disabilities (IDD), self-report may be limited and therefore indirect methods for pain assessment are required. A new, internationally agreed upon and user-friendly observational tool was recently published—the Pain Assessment in Impaired Cognition (PAIC-15). The current study’s aims were: to test the use of the PAIC-15 in assessing pain among people with IDD and to translate the PAIC-15 into Arabic for dissemination among Arabic-speaking professionals. Pain behavior following experimental pressure stimuli was analyzed among 30 individuals with IDD and 15 typically developing controls (TDCs). Translation of the PAIC followed the forward–backward approach; and reliability between the two versions and between raters was calculated. Observational scores with the PAIC-15 exhibited a stimulus–response relationship with pressure stimulation. Those of the IDD group were greater than those of the TDC group. The overall agreement between the English and Arabic versions was high (ICC = 0.89); single items exhibited moderate to high agreement levels. Inter-rater reliability was high (ICC = 0.92). Both versions of the PAIC-15 are feasible and reliable tools to record pain behavior in individuals with IDD. Future studies using these tools in clinical settings are warranted. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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9 pages, 216 KiB

Open AccessFeature PaperArticle

Faces of Pain during Dental Procedures: Reliability of Scoring Facial Expressions in Print Art

by Frank Lobbezoo, Xuan Mai Lam, Savannah de la Mar, Liza J. M. van de Rijt, Miriam Kunz and Maurits K. A. van Selms

Brain Sci. 2021, 11(9), 1207; https://doi.org/10.3390/brainsci11091207 - 14 Sep 2021

Cited by 1 | Viewed by 1545

Abstract

Background: Observational tools have been developed to assess pain in cognitively impaired individuals. It is not known, however, whether these tools are universal enough so that even pain depicted in print art can be assessed reliably. Therefore, the aim of this study was to assess the reliability in scoring facial expressions of pain in dental print art from the 17th, 18th, and 19th century, using a Short Form of the 15-item Pain Assessment in Impaired Cognition (PAIC15-SF) tool. Methods: Seventeen prints of patients undergoing dental procedures were scored twice by two inexperienced observers and an expert and once by a Gold Standard observer. Results: All observers achieved high intra-observer reliability for all four items of the category “facial expressions” and for three items of the category “body movements” (ICC: 0.748–0.991). The remaining two items of the category “body movements”, viz., “rubbing” and “restlessness”, were excluded from further research because it was not possible to calculate a reliable ICC. Overall, the intra-observer reliability of the expert was higher than that of the inexperienced observers. The inter-observer reliability scores varied from poor to excellent (ICC: 0.000–0.970). In comparison to the Gold Standard, the inter-observer reliability of the expert was higher than that of the inexperienced observers. Conclusion: The PAIC15-SF tool is universal enough even to allow reliable assessment of facial expressions of pain depicted in dental print art. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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18 pages, 1805 KiB

Open AccessFeature PaperArticle

Association between Self-Reported Pain, Cognition, and Neuropathology in Older Adults Admitted to an Outpatient Memory Clinic—A Cross-Sectional Study

by Víctor I. Madariaga, Eduard Overdorp, Jurgen A. H. R. Claassen, Inti A. Brazil and Joukje M. Oosterman

Brain Sci. 2021, 11(9), 1156; https://doi.org/10.3390/brainsci11091156 - 31 Aug 2021

Cited by 5 | Viewed by 2377

Abstract

Cognitive impairment has been linked to reduced self-reporting of pain. However, it is unclear whether the various cognitive functions are similarly and/or independently associated with such pain report measures. In the present study, we explored how executive functioning (EF), memory, and global cognition relate to self-reported pain and investigated whether underlying neuropathology partially accounts for these results. We used Lasso categorical regression to analyze data from 179 individuals visiting a memory clinic. The data included the self-reported pain occurrence, intensity, severity and frequency, clinical diagnoses, neuropsychological scores, white matter hyperintensities, medial temporal lobe atrophy, depressive symptoms, and demographics. Our results showed that worse memory and EF performance predicted a lower pain occurrence. In those individuals who did report pain, worse memory predicted lower pain intensity, severity, and frequency levels, but for EF reversed effects were found, with worse EF predicting higher pain scores. These relationships were only partially explained by reductions in white matter and medial temporal lobe integrity. Similar effects were found for depressive symptoms. Our findings highlight the distinct associations of EF and memory with self-reported pain. A similar pattern of relationships found for both self-reported pain and depressive symptoms may reflect shared latent affective components. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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16 pages, 851 KiB

Open AccessArticle

Probable Pain on the Pain Assessment in Impaired Cognition (PAIC15) Instrument: Assessing Sensitivity and Specificity of Cut-Offs against Three Standards

by Jenny T. van der Steen, Andrew Westzaan, Kimberley Hanemaayer, Muhamad Muhamad, Margot W. M. de Waal and Wilco P. Achterberg

Brain Sci. 2021, 11(7), 869; https://doi.org/10.3390/brainsci11070869 - 29 Jun 2021

Cited by 6 | Viewed by 2695

Abstract

Observational pain scales can help to identify pain in persons with dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) covers 15 items that indicate pain, but it is unclear how probable pain is, for each summed score (range 0–45). We aimed to determine sensitivity and specificity of cut-offs for probable pain on the PAIC15 against three standards: (1) self-report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut-off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with re-assessment after 2 months in 137 residents. The area under the ROC curve was excellent against the PAINAD cut-off (≥0.8) but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, PAIC15 scores of 3 and higher represent possible pain for screening in practice, with sensitivity and specificity against self-report in the 0.5 to 0.7 range. While sensitivity for screening in practice may be too low, a cut-off of 4 is reasonable to indicate probable pain in research. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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11 pages, 563 KiB

Open AccessArticle

Paediatricians’ Views on Pain in Children with Profound Intellectual and Multiple Disabilities

by Lucie Petigas and Christopher J. Newman

Brain Sci. 2021, 11(3), 408; https://doi.org/10.3390/brainsci11030408 - 23 Mar 2021

Cited by 13 | Viewed by 2736

Abstract

Pain is a frequent issue in children with profound intellectual and multiple disabilities (PIMD). Its identification and treatment can prove highly challenging for primary care physicians, mainly because of the children’s limited communication abilities. We used an online survey to explore paediatricians’ views regarding the experience and management of pain in children with PIMD and invited 480 professionals working in the canton of Vaud, Switzerland, to take part. We received 121 responses (participation rate 25.5%). A large majority of respondents provided care to children with PIMD. All paediatricians considered that these children feel pain at least as much as typically developing children. However, paediatricians had mixed views on their tolerance to pain. More than 90% held the view that their pain is under-assessed and undertreated. The principal barriers they reported to appropriate management were communication limitations with the child, difficulties in pain assessment, lack of knowledge about children with disabilities and lack of experience. Paediatricians have complex opinions regarding how children with PIMD experience pain and how to manage this problem. Professional education and training on the specificities of children with PIMD, including how to address their pain, seem necessary to foster paediatricians’ ability and confidence in approaching this complex issue. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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19 pages, 1515 KiB

Open AccessArticle

Specific Behavioral Responses Rather Than Autonomic Responses Can Indicate and Quantify Acute Pain among Individuals with Intellectual and Developmental Disabilities

by Ruth Defrin, Tali Benromano and Chaim G. Pick

Brain Sci. 2021, 11(2), 253; https://doi.org/10.3390/brainsci11020253 - 18 Feb 2021

Cited by 8 | Viewed by 2683

Abstract

Individuals with intellectual and developmental disabilities (IDD) are at a high risk of experiencing pain. Pain management requires assessment, a challenging mission considering the impaired communication skills in IDD. We analyzed subjective and objective responses following calibrated experimental stimuli to determine whether they can differentiate between painful and non-painful states, and adequately quantify pain among individuals with IDD. Eighteen adults with IDD and 21 healthy controls (HC) received experimental pressure stimuli (innocuous, mildly noxious, and moderately noxious). Facial expressions (analyzed with the Facial Action Coding System (FACS)) and autonomic function (heart rate, heart rate variability (HRV), pulse, and galvanic skin response (GSR)) were continuously monitored, and self-reports using a pyramid and a numeric scale were obtained. Significant stimulus-response relationships were observed for the FACS and pyramid scores (but not for the numeric scores), and specific action units could differentiate between the noxious levels among the IDD group. FACS scores of the IDD group were higher and steeper than those of HC. HRV was overall lower among the IDD group, and GSR increased during noxious stimulation in both groups. In conclusion, the facial expressions and self-reports seem to reliably detect and quantify pain among individuals with mild-moderate IDD; their enhanced responses may indicate increased pain sensitivity that requires careful clinical consideration. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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16 pages, 817 KiB

Open AccessArticle

Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration

by Bettina S. Husebo, Robert D. Kerns, Ling Han, Melissa Skanderson, Danijela Gnjidic and Heather G. Allore

Brain Sci. 2021, 11(1), 86; https://doi.org/10.3390/brainsci11010086 - 11 Jan 2021

Cited by 6 | Viewed by 2975

Abstract

Alzheimer’s disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain—accompanied by evidence about the analgesic efficacy of opioids—has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012–30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered. Full article

(This article belongs to the Special Issue Pain Assessment in Impaired Cognition)

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