title: The relative meaning of absolute numbers: the case of pain intensity scores as decision support systems for pain management of patients with dementia.
abstract: BACKGROUND
  Assessment and management of pain in patients with dementia is known to be challenging, due to patients' cognitive and/or communication difficulties. In the UK, pain in hospital is managed through regular assessments, with the use of pain intensity scores as triggers for action. The aim of this study was to understand current pain assessment practices, in order to later inform the development of a decision support tool designed to improve the management of pain for people with dementia in hospital.
  
  
  METHODS
  An exploratory study was conducted in four hospitals in the UK (11 wards), with observations of patients with dementia (n = 31), interviews of staff (n = 52) and patients' family members (n = 4) and documentary analysis. A thematic analysis was carried out, structured along dimensions of decision making. This paper focuses on the emergent themes related to the use of assessment tools and pain intensity scores.
  
  
  RESULTS
  A variety of tools were used to record pain intensity, usually with numerical scales. None of the tools in actual use had been specifically designed for patients with cognitive impairment. With patients with more severe dementia, the patient's body language and other cues were studied to infer pain intensity and then a score entered on behalf of the patient. Information regarding the temporality of pain and changes in pain experience (rather than a score at a single point in time) seemed to be most useful to the assessment of pain.
  
  
  CONCLUSIONS
  Given the inherent uncertainty of the meaning of pain scores for patients with dementia, numerical scales were used with caution. Numerical scores triggered action but their meaning was relative - to the patient, to the clinician, to the time of recording and to the purpose of documenting. There are implications for use of data and computerized decision support systems design. Decision support interventions should include personalized alerting cut-off scores for individual patients, display pain scores over time and integrate professional narratives, mitigating uncertainties around single pain scores for patients with dementia.
authors.affiliation: School of Healthcare, University of Leeds, Leeds, UK. v.lichtner@leeds.ac.uk.
authors.forename: Valentina
authors.initials: V
authors.lastname: Lichtner
authors.affiliation: Columbia University School of Nursing, New York, NY, USA. dd2724@columbia.edu.|Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY, USA. dd2724@columbia.edu.
authors.forename: Dawn
authors.initials: D
authors.lastname: Dowding
authors.affiliation: School of Healthcare, University of Leeds, Leeds, UK. s.j.closs@leeds.ac.uk.
authors.forename: S José
authors.initials: SJ
authors.lastname: Closs
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020000:Decision Support Systems, Clinical / Q000592:standards*; D003704:Dementia; D005260:Female; D006801:Humans; D008297:Male; D059408:Pain Management / Q000379:methods / Q000592:standards*; D010147:Pain Measurement / Q000379:methods / Q000592:standards*; D010865:Pilot Projects