Development of a Multidimensional Pain Measure for Persons with Dementia

描述（由申请人提供）： 对退伍军人医疗保健的预期影响：该项目将强烈影响VHA患者护理，因为：（a）VHA将大量资源用于长期护理，（B）长期护理机构中痴呆症的患病率很高，（c）退伍军人人群中痴呆症的患病率很高，并且正在增加，以及（d）VHA已将疼痛控制确定为优先临床和研究领域。 项目背景：本研究的目的是为痴呆症患者和自我报告疼痛能力有限的人制定一种疼痛强度测量策略。尽管许多可用的工具捕获关于自我报告能力有限的那些人的疼痛的信息，但是在为该脆弱人群开发实用的和临床相关的疼痛强度测量策略时仍然存在四个主要障碍：1）关于通常"计数"为疼痛指示的一些行为的特异性的不确定性; 2）缺乏对疼痛强度的测量的评估。 超出疼痛存在的识别以估计疼痛强度的测量; 3）缺乏不可侵犯的标准或"金标准";以及，4）与单独使用观察性疼痛行为检查表相比，关于临床医生对患者疼痛的globa评级是否增加有效性的不确定性。这里提出的研究解决了这些障碍。 目的：第一阶段：建立痴呆症患者的疼痛行为测量。具体目标1：开发一种有效和具体的测量方法，包括最好地区分疼痛与其他结构的行为观察（例如，激动、无聊）。具体目标2：评估项目反应理论校准的PIM-D得分的有效性在NH居民的横截面样本。第二阶段：疼痛测量的反应性和增量有效性。我们将测量疼痛和相关的其他变量前和镇痛治疗后的X养老院居民谁有痴呆症和自我报告能力有限。具体目标3：评价PIM-D对镇痛治疗的反应性。在接受镇痛治疗的50名NH居民的样本中，a）评估PIM-D评分的反应性，和B）比较PIM-D与现有行为疼痛测量的反应性。具体目标4：评价PIM-D评分与现有疼痛行为指标以及与护士和NA完形疼痛强度评分相比在预测专家临床医生疼痛评价变化方面的增量有效性。项目方法：项目缩减将通过一个专家小组使用一种改进的德尔菲方法来实现。总患者样本将由来自4个大型VA社区生活中心（CLC;费城、科茨维尔、亚特兰大、塔斯卡卢萨）的居民组成。我们将招募患有中度至重度痴呆症的退伍军人。研究措施将包括循证医学记录的疼痛指标（疼痛相关行为，临床完形疼痛评级），以及已知的 疼痛（睡眠、躁动和抑郁）。所有参与者还将由执业护士进行临床评估。

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.