Assessing Pain in the Cognitively Impaired Elderly

In your clinical experience, what measures do you rely on to assess pain in the cognitively impaired elderly person?

Ilona Kopits MD, MPH:

Ilona Kopits MD, MPH is a geriatrics fellow at Boston Medical Center’s Geriatrics Section, Boston, MA.

In order to assess pain in a cognitively impaired elder, it is crucially important to have a discussion with the patient’s primary care giver, or someone who sees the patient regularly such as a day nurse. The care giver can provide valuable information about changes in behavior. For example, the care giver will know if the patient is not getting out of bed, or walking, or perhaps not eating as much or as often. Care givers will also have insights into which types of treatments seem to be helping, hurting, or causing side effects. Additionally, the primary care giver is most often the person that is giving the patient his or her medications. A clinician is dependent on primary care givers not only for successful assessment but also successful treatment of pain.

A thorough exam is the next step in pain assessment. Often clinicians will rely on scales with numbers, faces, or colors for a patient to rate his or her pain. Although cognitively impaired patient s can often differentiate between mild and severe pain, in my experience, these patients are unable to rate their pain on any kind of scale because following the command, “Rate your pain” is too difficult a task. Instead of using a scale, you can examine the patient in terms of maneuver. You may ask a patient to try to get up and walk across a room, for example. The way I examine a patient depends on the type of pain that they have experienced. For patients with musculoskeletal pain, I may ask them or help them to flex joints and move around. For other patients I may try strength checking. It is also important to consider any underlying issues such as osteoporosis when conducting an exam. A patient experiencing new onset back pain may actually be suffering from a vertebral fracture due to osteoporosis.

Another way to assess for pain is to look at vital signs. If a patient’s heart rate is up that might indicate that he or she is experiencing pain. For the most part, however, a discussion with the primary care giver and a thorough exam is the most reliable method for assessing pain in a cognitively impaired elder.