Assessment of pain: can caregivers or relatives rate pain in nursing home residents?

Aim. To compare pain reports of nursing home residents to ratings by proxies. Background. It is not easy to assess pain in cognitively impaired residents. For residents who are unable to report pain intensity themselves, proxies (i.e. relatives or caregivers) might serve as sources of information. The utility of these proxies in assessing residents' pain is not clear however. Design. A multicenter cross-sectional study. Methods. Pain intensity was rated on a Numeric Rating Scale; proxies were asked how certain they were about their observations. Agreements on ratings were computed by means of intra class correlation (ICC) coefficients for continuous variables and multiple linear regression analyses were performed with the level of pain intensity by proxies as the dependent variable. Results. The sample consisted of 174 residents (median age 82 years), of whom 124 were cognitively impaired and 50 intact, and 293 proxies: 171 caregivers and 122 relatives. All three parties reported median pain intensity during the preceding week as 6.0. Data were consistent with low-to-moderate correlation coefficients between residents and caregivers (ICC = -0.12 to 0.25), residents and relatives (ICC = -0.51 to 0.48) and caregivers and relatives (ICC = 0.03 to 0.31). Residents themselves judged pain intensity at rest significantly higher than did proxies (p = 0.05). Caregivers scored significantly higher ratings for residents on analgesics (p = 0.001) and significantly lower pain ratings if they were more satisfied with the prescribed analgesics (p = 0.01). Conclusions. Proxy report of relatives and caregivers on presence and intensity of pain is unreliable, especially for cognitively impaired persons. The use of a standardised pain observation scale could be helpful. Relevance to clinical practice. Pain management in nursing home residents could be improved by educating caregivers about assessment and treatment of chronic pain. Relatives should be informed about chronic pain and learn how to alleviate pain through non-pharmacological interventions.