Development of a Multidimensional Pain Measure for Persons with Dementia

描述(由申请人提供)： 对退伍军人医疗的预期影响：该项目将对退伍军人管理局的病人护理产生重大影响，因为：(A)退伍军人管理局在长期护理方面投入了大量资源，(B)长期护理机构中痴呆症的患病率很高，(C)退伍军人中痴呆症的患病率很高，而且还在上升，(D)退伍军人管理局已将疼痛控制确定为优先临床和研究领域。项目背景：本研究的目标是为痴呆症患者和自我报告疼痛能力有限的人开发一种疼痛强度测量策略。尽管许多可用的仪器记录了那些自我报告能力有限的人的疼痛信息，但在为这一脆弱人群开发实用的和临床相关的疼痛强度测量策略方面仍然存在四个主要障碍：1)不确定某些通常被视为指示疼痛的行为的特异性；2)缺乏 与单独使用观察性疼痛行为检查表相比，临床医生对患者疼痛的Globa评级是否增加了有效性的不确定性。这里提出的研究解决了这些障碍。目标：第一阶段：为痴呆症患者建立疼痛行为测量。具体目标1：制定一种由行为观察组成的有效和具体的测量方法，最好地将疼痛与其他概念(例如，激动、无聊)区分开来。具体目标2：评价项目反应理论校正的PIM-D评分在NH居民横断面样本中的效度。第二阶段：疼痛测量的反应性和递增有效性。我们将对患有痴呆症和自我报告能力有限的X疗养院居民在止痛治疗前后测量疼痛和相关的附加变量。具体目标3：评价PIM-D对止痛治疗的反应性。在50名接受止痛治疗的NH居民样本中，a)评估PIM-D评分的反应性，以及b)将PIM-D的反应性与现有的行为疼痛测量进行比较。具体目标4：评估PIM-D评分与现有疼痛行为测量方法相比的增量有效性，并与护士和NA格式塔疼痛强度评分相比较，以预测专家临床医生疼痛评估的变化。项目方法：将使用改进的德尔菲法和一个专家小组来实现项目减少。总的患者样本将由来自4个大型退伍军人管理局社区生活中心(CLCS；费城、科茨维尔、亚特兰大、塔斯卡卢萨)的居民组成。我们将招收中度至重度痴呆症退伍军人。研究措施将包括基于证据的观察者记录的疼痛指标(疼痛相关行为、临床格式塔疼痛评级)，以及 疼痛(睡眠、烦躁和抑郁)。所有参与者还将由执业护士对其进行临床评估。

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.