title: The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective.
abstract: Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group.
  
  
  
  A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory.
  
  
  
  Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time.
  
  
  
  There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.
authors.affiliation: School of Healthcare, University of Leeds, Leeds, UK. v.lichtner@leeds.ac.uk.
authors.forename: Valentina
authors.identifier: 0000-0003-3956-3743
authors.initials: V
authors.lastname: Lichtner
authors.affiliation: Columbia University School of Nursing, New York, NY, 10032, USA.|Center for Home Care Policy and Research, Visiting Nursing Service of New York, New York, NY, USA.
authors.forename: Dawn
authors.initials: D
authors.lastname: Dowding
authors.affiliation: School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.
authors.forename: Nick
authors.initials: N
authors.lastname: Allcock
authors.affiliation: School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
authors.forename: John
authors.initials: J
authors.lastname: Keady
authors.affiliation: Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.
authors.forename: Elizabeth L
authors.initials: EL
authors.lastname: Sampson
authors.affiliation: Centre for Pain Research, Leeds Beckett University, Leeds, UK.
authors.forename: Michelle
authors.initials: M
authors.lastname: Briggs
authors.affiliation: Wolfson Centre for Age-Related Diseases, King's College London, London, UK.
authors.forename: Anne
authors.initials: A
authors.lastname: Corbett
authors.affiliation: School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK.
authors.forename: Kirstin
authors.initials: K
authors.lastname: James
authors.affiliation: School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
authors.forename: Reena
authors.initials: R
authors.lastname: Lasrado
authors.affiliation: School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
authors.forename: Caroline
authors.initials: C
authors.lastname: Swarbrick
authors.affiliation: School of Healthcare, University of Leeds, Leeds, UK.
authors.forename: S José
authors.initials: SJ
authors.lastname: Closs
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017028:Caregivers; D000066491:Clinical Decision-Making; D003142:Communication; D003695:Delivery of Health Care / Q000592:standards; D003704:Dementia / Q000150:complications* / Q000628:therapy; D004739:England; D006760:Hospitalization; D006801:Humans; D008297:Male; D010146:Pain / Q000517:prevention & control*; D059408:Pain Management / Q000379:methods; D036301:Qualitative Research; D012606:Scotland
keywords: Aged; Decision making; Dementia; Hospitalization; Pain assessment; Pain management; Qualitative research