Although Mr. A could communicate with short responses during his assessments, observational pain behaviors can also be used by nurses to assess patients suffering from progressed dementia (Ammaturo, Hadjistavropoulos, and Williams, 2016, pp. 1894). Conditions such as dementia, that impair a patient’s ability to communicate, can be problematic for assessment. Additionally, although many patients with mild to moderate dementia can engage with the simple scales described, in those with progressed, late-stage disease these methods are not an option (McClean, 2003, pp. 428). Consequently, pain is frequently cited as under-diagnosed and poorly managed in patients with dementia, in long-term care settings such as Mr. A.’s (Sampson et al., 2006, pp.187). Notably, in patients with dementia, pain thought to be one of the most important causes of behavioural disturbances (Corbett et al., 2012, pp.264). Therefore, using observational techniques to assess pain in patients with dementia, alongside other tools requiring verbal or physical interaction, may be advisable even if they are still able to participate during the assessment (The British Pain Society, 2010, pp.26). Moreover, this demonstrates the wide-ranging benefits of successful pain management, with the potential to alleviate behavioural disturbances for patients with dementia (Corbett et al., 2012, pp.264). Potentially, Mr. A.’s increased anxiety and distress was due to pain but he was unable to communicate it.
Pain assessment of non-verbal patients including those with dementia was discussed by the Nursing Home Pain Collaborative who recommended the use of two tools: The Pain Assessment Checklist for Seniors with Limited Ability to Communicate II (PACSLAC-II) and the Pain Assessment in Advanced Dementia (PAINAD) Scale (Herr et al., 2010, pp.29; Sawhney et al., 2017, pp.18). These could be particularly useful in the future when Mr A.’s dementia does progress and interfere with pain assessment. They seem easy to use, although it is highlighted that they should be used alongside the practitioner’s broader knowledge of the patient and the findings of examination (see Appendix A for the link to PACSLAC-II) (Chan, Hadjistavropoulos, and Fuchs-Lacelle, 2017, p.1). However, it should be highlighted that involving the patient in their assessment whenever possible is preferred, so his nurse could go back to using the scale assessments when Mr. A. is having a better day and able to participate.
Further, core nursing assessments that are recommended for cancer patients include a psychosocial assessment, physical examination and a detailed history of any persistent pain, breakthrough pain and their effect on function (The British Pain Society, 2010, pp.25). This effect on function could be assessed through activities of daily living assessment, for example, Breakthrough pain can be defined as: “the transient exacerbation of pain occurring in a patient with otherwise stable, persistent pain” (Rudowska, 2012, pp.498). It is estimated that between 40-86% of patients with cancer are reported to experience breakthrough pain, depending on the study (Hwang, Chang, and Kasimis, 2003, pp.56; Mercadante et al., 2002, pp.32; Mishra et al., 2009, pp.12). Cancer pain has been described as having two components, persistent pain, lasting more than 12 hours per day and breakthrough pain. Breakthrough pains are so called because they break through the regular pain medication. Other features of breakthrough pain include its predictability, precipitating events, temporal features and its relation to the fixed dose of opioid medication (Fine and Busch, 1998, pp.179; Mishra et al., 2009, pp.8). The cause of breakthrough pain is shown to differ from patient to patient. Research has reported that 67-76% of breakthrough pains are caused by cancer itself, 20-33% are due to the cancer treatment such a chemotherapy, and up to 4% of breakthrough pains are of an unknown cause (Portenoy, Payne and Jacobsen, 1999, pp.129). Mr. A.’s nurse did not enquire specifically about whether his prescription for breakthrough pain was being successfully managed, or ask his carers. Interestingly, a recent study reported that the NRS was also a valid and reliable assessment tool for breakthrough pain and that it should perhaps be preferred over the other scale assessments described (Brunelli et al., 2010, pp.42). With proper nursing assessment and therapy, breakthrough pain can be successfully treated as was seemingly the case for Mr. A., although lacking thorough assessment to say conclusively (Davis, 2012, pp.277). For example, a recent Cochrane review confirmed that oral fentanyl was successful in treating breakthrough pain across 15 studies, totaling 1699 participants (Zeppetella and Davies, 2013 n.p.).
The Bristol Activities of Daily Living Scale (BADLS) assessment was completed for Mr. A. on many previous occasions and was noted in his case file (Bucks et al., 1996, pp. 113). Based on Roper, Logan and Tierney’s (1980) model for nursing, the BADLS is a 20-item checklist that is specifically designed for patients with dementia, aiming to assess functional capacity in everyday life and therefore indicate the person’s level of independence. The BADLS have been shown to be effective in assessing the functional status of patients with dementia and as a tool for evaluating and monitoring the efficacy of interventions (Desai, Grossberg and Sheth, 2004, pp. 853). Again, using a tool that is designed for patients with dementia is important. The cognitive impairment that accompanies disease disrupts communication and therefore tools such as the “traditional” ADL assessment, reliant on patient interaction may gather little information and not detect changes. The BADLS assessment is also part of a holistic, patient-centered approach, that incorporates the psychosocial aspects of a person’s life in its examination of their health, such as how a person’s disease is affecting their ability to socialise, as well as their ability to complete tasks such as washing (Bucks et al., 1996, pp. 113). Assessment tools such as the ADL can support nurses in using a systematic method of gathering all the complex and extensive information that can influence a person’s health and management of their disease Furthermore, for patients with dementia, gathering information on their ability to undertake the ADL’s is essential for diagnosis and in evaluating the progression of disease. The BADLS assessment had been initiated by Mr. A.’s dementia nurse and was also a good choice of assessment because it could also be completed by Mr. A.’s carers, due to its ease of use (Bucks et al., 1996, pp. 113). Consequently, it was being carried out every other week, across his care team so Mr. A. was regularly assessed for changes in his functioning and progression in his disease. A holistic assessment is also recommended when managing cancer patients and their pain (The British Pain Society, 2010, pp.25). Mr. A.’s nurse noted that there had been no change in his BADLS score since his last assessment two weeks previously.