Development of a Multidimensional Pain Measure for Persons with Dementia

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DESCRIPTION (provided by applicant): Anticipated impact on Veterans' Healthcare: This project will strongly impact VHA patient care because: (a) VHA devotes significant resources to long term care, (b) the prevalence of dementia in long term care facilities is high, (c) the prevalence of dementia in the veteran population is high and is increasing, and (d) the VHA has identified pain control as a priority clinical and research area. Project Background: The goal of this study is to develop a pain intensity measurement strategy for persons with dementia and limited ability to self-report pain. Though many available instruments capture information about the pain of those with limited ability to self-report, there remain four major barriers in developing a practical and clinically relevant pain intensity measurement strategy for this vulnerable population: 1) uncertainty regarding the specificity of some behaviors typically "counted" as indicative of pain; 2) lack of a measure that goes beyond identification of pain presence to estimate pain intensity; 3) lack of an inviolable criterion or "gold standard;" and, 4) uncertainty regarding whether clinicians' globa ratings of patients' pain add incremental validity as compared to using observational pain behavior checklists alone. The research proposed here addresses these barriers. Objectives: Phase I: Building a Pain Behavior Measure for Persons with Dementia. Specific Aim 1: Develop an efficient and specific measure comprised of behavior observations that best discriminate pain from other constructs (e.g., agitation, boredom). Specific Aim 2: Evaluate the validity of item response theory-calibrated PIM-D scores in the cross-sectional sample of NH residents. Phase II: Responsiveness and Incremental Validity of Pain Measures. We will measure pain and relevant additional variables pre- and post-analgesic therapy in X nursing home residents who have dementia and limited ability to self-report. Specific Aim 3: Evaluate the responsiveness of the PIM-D to analgesic therapy. In a sample of 50 NH residents who receive analgesic therapy, a) evaluate the responsiveness of PIM-D scores, and b) compare responsiveness of the PIM-D to that of existing behavioral pain measures. Specific Aim 4: To evaluate the incremental validity of PIM-D scores compared to existing pain behavior measures and compared to nurse and NA gestalt pain intensity ratings in predicting changes in Expert Clinician Pain Evaluations. Project Methods: Item reduction will be achieved using a modified Delphi method with an expert panel. The total patient sample will be comprised of residents from 4 large VA Community Living Centers (CLCs; Philadelphia, Coatesville, Atlanta, Tuscaloosa). We will enroll veterans with moderate to severe dementia. Study measures will include evidence-based observer-recorded indicators of pain (pain-related behaviors, clinical gestalt pain ratings), and known correlates of pain (sleep, agitation, and depression). All participants will also be clinically assessed by a nurse practitioner.