Knowledge

• Describe common verbal and nonverbal indicators of pain in individuals living with dementia.
• Recognize that pain is highly common in individuals living with dementia, even if they can’t express it in typical ways.
• Identify PAINAD as a tool used by nurses to assess pain in individuals living with dementia.
• Determine situations where reporting to a nurse is necessary for further assessment.

Skills

• Apply observation skills to detect signs of pain in individuals living with dementia.
• Implement a range of non-drug pain relief strategies under the direction of a nurse (per facility policy).
• Make informed decisions about when to escalate concerns to a nurse.

Attitudes

• Develop patience when working with individuals living with dementia.
• Develop a greater awareness of how pain might underlie behavioral changes in individuals with dementia, fostering empathy.

• Understand Pain Assessment Tools that Nurses Use:
  • Become familiar with validated tools like PAINAD or PACSLAC. These help you systematically assess potential pain.
  • Try non-drug Interventions: These are often effective and have minimal side effects (check your facility’s policies):
    • Repositioning and comfort measures
    • Gentle massage or touch
    • Calm, soothing environment
    • Distraction (music, familiar objects)
    • Placing hot/cold packs
    • Hand massages
  • Advocate for Your Resident:
    • Report your observations clearly to a nurse.
    • Don’t hesitate to ask questions about pain medication if you see signs of ongoing discomfort.

Key Takeaways

• Pain is REAL for persons living with dementia, even if they can't tell us in words.
• DIRECT CARE WORKERS are vital in observing and reporting signs of pain.
• A combination of medication AND non-drug strategies offers the most comfort.

Overview

• Client Name: Evelyn Thompson
• Age: 82
• Diagnosis: Moderate-stage Alzheimer's Disease
• Medical History: History of arthritis (most discomfort in hips and knees), mild hypertension
• Requires variable support to complete activities of daily living depending on the day

Current Situation: Evelyn Thompson has been a resident in a long-term care facility for the past 8 months. She has limited verbal communication but can sometimes follow simple instructions and express basic needs. She is usually cooperative with care but can become agitated in the mornings.

Scenario: You are the morning shift direct care worker assigned to Evelyn Thompson's room. Your task is to assess her wellbeing, identify any signs of pain or discomfort, and gently assist her in getting ready for breakfast.

Setting: Evelyn Thompson's single-occupancy room in the memory care unit of the nursing home. It is around 8:00 AM. The room is softly lit, and the curtains are partially open. Evelyn Thompson is in bed with the sheet pulled up.

Scenario Details: Upon entering, you find Evelyn Thompson curled up on her side, facing away from you. She is whimpering softly.

Things to Consider:

1. Possible Pain Sources
2. Communication Approach with Evelyn
3. Pain Assessment
4. Non-drug Interventions
5. Reporting to the Nurse
   1. Document your observations carefully using the PAINAD tool (pain cues, interventions, Evelyn Thompson's response).

Remember: Patience, gentle touch, and a focus on Evelyn Thompson's nonverbal cues are essential throughout this scenario.

Things to Notice:

• Roberta Bennett's nonverbal cues (facial expressions, body language, sounds).
• What triggers stronger resistance? Specific actions or words?
• Are there moments where she seems calmer or more receptive?

Evelyn Thompson’s (ET) Care Plan

Special Instructions: Assess for pain before movement, go slow, usually cooperative, but can become agitated in the mornings

• Direct care worker asks about pain: Shake your head slightly “no,” continue to seem uncomfortable.

Stage 3: Direct Care Worker Assessment and Care

• Gently turned: When the direct care worker tries to turn you, wince, stiffen your body slightly, and whimper more loudly.
• Change in behavior: Seem less cooperative; you may frown and try to pull away during tasks.
• Escalating discomfort: If the direct care worker presses on your hip area, moan or say "Ow!"

Variations Based on Direct Care Worker Actions:

• Comfort measures: If the direct care worker offers repositioning or warmth, relax your body slightly and decrease the vocalizations (showing it provides some relief).
• Continued lack of response: If the direct care worker seems unsure, increase agitation slightly (fidget, try to curl back up).

Debrief Notes for Evelyn:

• Share frustration: Talk about how frustrating it felt to be in pain but not able to say so clearly.
• Successes: If the direct care worker picked up on your cues, point out specific things they did well (gentle touch, observing your face).
• Importance of observation: Emphasize how even small changes in behavior can be clues.

Tips for Playing Evelyn:

• Consistency: Keep your portrayal aligned with moderate dementia throughout.
• Subtlety is key: Start with subtle signs of discomfort and escalate gradually.
• Respond to the direct care worker: Adjust your cues slightly based on their actions to make it a realistic interaction.

Instructions: Use this worksheet to guide your observation. Take notes here or on a whiteboard in the classroom. Be ready to share for the debrief and add to the discussion.

• Focus on specifics: Note details of both Evelyn’s behavior and the direct care workers’ actions.
  • Think critically: Don’t just list observations, analyze how they influenced your perception

of the situation.

1. Nonverbal Pain Cues:
   • Facial Expression: Relaxed / Grimacing / Frowning / Other:                   
   • Body Position: Relaxed / Favoring one side / Guarded (protecting a body area)/ Other:      
2. Response During Interactions / Care
   • Changes When Touched or Moved: Increase or decrease in vocalizations?

Stiffening? Pulling away? Where?                                                                          

• Changes in Behavior During Care Routines: More cooperative or more resistant compared to usual? Any specific tasks seem to cause discomfort?

3. Non-Drug Interventions: Response to comfort measures (if attempted):
   • Did repositioning, a warm compress, or distraction seem to lessen agitation or signs of pain?                                                    
   • Signs of escalating pain
4. Communication (with the resident, with each other, with deciding to report to a nurse)
   • Was the communication clear? YES / NO
   • Did they focus on what was observed? YES / NO
   • Did they communicate well with Evelyn? YES / NO
   • Were concerns reported to the nurse? YES / NO
5. Surprise: What was one thing you observed that you hadn't expected to see?
6. Key Takeaway: What is the most important thing you learned about pain assessment in dementia from observing this simulation?

Healthcare providers use the PAINAD tool to assess and manage pain in individuals with dementia. The tool was developed to assist providers in evaluating pain levels to determine the best course of action in caring for their patients. The PAINAD is a 2-point scale based on observing and assessing physical signs and non-verbal behavior associated with pain.

The PAINAD measures five categories:

1. breathing independent of vocalization
2. negative vocalization
3. facial expression
4. body language
5. consolability

Each category is scored on a scale of 0-2 for a total score of 0-10. A higher PAINAD score indicates increased levels of pain.

When assessing pain individuals with dementia, it is important to remember that there are no standard “cut-offs” for each symptom and that the scale should be used as a guide for observation and evaluation.