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The psychometric properties, feasibility and utility of behavioural‐observation methods in pain assessment of cognitively impaired elderly people in acute and long‐term care: A systematic review

Background The key factor to improving pain management for cognitively impaired elderly patients is accurate pain assessment. Behavioural‐observation methods are required for individuals who cannot communicate their pain verbally. A thorough understanding of the key components of behavioural pain assessment and the use of valid and reliable behavioural pain assessment tools would enhance the assessment of pain in this vulnerable population. Objectives To identify the key components involved in behavioural pain assessment in cognitively impaired elderly people and to analyse the reported psychometric properties, feasibility and utility of behavioural pain assessment tools. Selection criteria Types of studies: Studies using descriptive, correlation and comparative designs were included. Types of participants: Cognitively impaired elderly people older than 65 years in aged care, acute care or nursing home settings were included. Criteria for evaluation: Components measured in behavioural pain assessment; psychometric properties, feasibility and utility of behavioural pain assessment tools used to assess pain in cognitively impaired elderly people in acute or long‐term care settings. Types of outcome measures: Identification of behavioural criteria for assessment of pain and investigation of any aspect of the psychometric properties of behavioural pain assessment tools. Search strategy An initial limited search of MEDLINE and CINAHL to find published studies between 1990 to 2010 in the English Language was undertaken, following an analysis of the text words contained in the title and abstract. A second search using all identified keywords and index terms was undertaken and extended to a further seven relevant databases. Thirdly, the reference lists of all identified reports and articles were searched for additional studies. Methodological quality Studies selected for retrieval were assessed for inclusion by two independent reviewers for methodological validity using the Critical Appraisal Tool for Psychometric Studies adapted from Fallon, Westaway, and Moloney1. Data extraction Quantitative data were extracted from included studies using the Data Extraction Tool for Psychometric Studies adapted from Fallon, Westaway, and Mahoney1. Data synthesis As statistical pooling was not possible, evidence in relation to psychometric properties, was analysed and presented in narrative summary. Results Twenty three studies were included in the review. No tool has been found suitable for use across both acute and long‐term care settings. Nevertheless, three tools show the most promising outcomes and potential for use. Conclusions Implications for practice Although behavioural measures may inform healthcare providers on the presence of pain in an individual, they do not provide information about the aetiology of pain. Hence, pain assessment should not depend solely on behavioural observation conducted using standardised behavioural pain assessment tools, but regarded as an essential component of a multifaceted approach to pain assessment. Clinicians may select tools which show promising qualities and pilot them in their respective clinical settings and populations. In particular, the MPS, the PACSLAC and the PAINAD are recommended for potential use in the cognitively impaired elderly in acute and long‐term care settings. Implications for research Several tools show promise for use in acute or long‐term care settings. These tools require tool revisions to strengthen their psychometric properties. Instead of developing new tools, modification of existing tools and conducting further psychometric evaluations on them can provide more evidence of their psychometric properties.