Assessment and management of acute pain in the older person with cognitive impairment: A qualitative study

• Older persons with cognitive impairment are vulnerable to inappropriate pain assessment.
• Different methods are used to assess pain intensity in the cognitively impaired older person.
• Cognitive impairment, a busy ED and a lack of assessment tools are the preconditions for inadequate analgesia.
• The Pain Assessment in Advanced Cognitive Impairment tool may improve pain management.

IntroductionOlder Australians experience health disparities in pain management compared to other groups. This article is focused on understanding the emergency nurses' perceptions of pain and pain management for older persons with cognitive impairment and presenting with a long bone fracture. This article is part of a larger study focusing on emergency nurses' pain management practices for older Australians with cognitive impairment.AimThe aim of the study was to understand emergency nurses' perceptions of the management of pain for older persons with cognitive impairment and presenting with a long bone fracture.MethodThis is part of a larger multicentre programme of research exploring pain management in older persons with cognitive impairment and who are experiencing pain from a long bone fracture. This study had a qualitative research design, with data collected through focus group interviews and a thematic method of analysis. The study is framed by a constructivist's paradigm, which enabled multiple realities to surface and be interpreted.ResultsEighty emergency nurses participated, with 67 (84%) females and 13 (16%) males, in 16 focus groups across four emergency departments. Nurses had an average of 12.5 years as a Registered Nurse (SD ± 10.06) and 8.6 years (SD ± 8.64) emergency experience. Five themes emerged from data analysis and included: 1) Belief in championing pain management; 2) Pain management and the ageing processes; 3) Lack of pain assessment tools for the cognitively impaired older person; 4) Delivering analgesia – a balancing act; and 5) Policy barriers to nurse initiated pain management.ConclusionThis study makes clear the challenges clinicians' face in managing pain in older patients presenting to emergency departments. More specifically, older persons with cognitive impairment face substantially greater obstacles in receiving effective pain relief given the lack of any standardised pain assessment screening tool within emergency departments. To improve pain management practices emergency clinicians need to test the utility of behavioural pain assessment tools for cognitively impaired older persons within the emergency context.