This essay will present the case of Mr. A., a 73-year-old man with dementia and cognitive impairment. On a dentist visit a year previously, a lump was found in his mouth that was later diagnosed as mouth cancer. He received chemotherapy and radiotherapy and he was prescribed non-opioid analgesia for pain general pain. Six months later, Mr A. reported throat pain and difficulty swallowing. The CT scan was taken and the result shows oropharyngeal cancer and Mr A. opted for conservative management, with pain relief and palliative care when required, as the disease progressed. Mr. A’s levels of pain increased and his General Practitioner (GP) had prescribed oral morphine solution (10mg) to be taken as required, for breakthrough pain. Mr A. was living in a long-term care home for the elderly with special care needs, lacked any outside social support and was experiencing distress and anxiety daily. He currently had no difficulty in eating and swallowing, could speak in short sentences although very slowly. Informed consent was gained from all those involved in the care scenario presented in this report and a pseudonym has been adopted to protect their anonymity throughout (The Nursing and Midwifery Council (NMC), 2008). Key goals for Mr A.’s nursing care were pain management, promoting his social interaction and independence as part of his existing long-term care plan, while addressing his recent increase in distress and anxiety. A modified activities of daily living assessment tool was used in Mr A.’s case management history however, during the nursing interaction presented no other assessments were carried out.
A comprehensive assessment is the first stage of the nursing process and involves gathering information from a range of sources including the patient’s history, ongoing experience, and clinical data, to inform subsequent care planning (Coombs, Curtis, and Crookes, 2011, p.364). Nurses are ideally placed to manage care delivery, allowing patients to receive their care whilst staying in the community to maximise their quality of life and independence (Maybin, Charles, and Honeyman, 2016, pp.7). Pain management is an important role in nursing. The effects of pain are wide-ranging, affecting the endocrine and metabolic system, cardiovascular system, gastrointestinal system, and immune system; causing stress, loss of sleep and reduced quality of life (Dansie and Turk, 2013, pp.10). In patients with metastatic cancer such as Mr. A., pain suppresses immune functions that contribute to preventing tumour growth and controlling metastasis, therefore pain could significantly reduce life expectancy in the population (Page and Ben-Eliyahu, 1997, p.10). For cancer patients, “accurate and meaningful assessment and reassessment of pain is essential and optimises pain relief” (The British Pain Society, 2010, pp.25). Pain assessment should also occur on every visit to the patient and if possible, the patient or carers should be encouraged to keep a pain diary to monitor levels of pain, medication requirements, the effectiveness of pain interventions and any side-effects of their therapy (The British Pain Society, 2010, pp.25). Therefore, it was expected that pain management would be a key area of focus for nursing care during Mr. A.’s appointment. However, Mr. A. was asked how he was doing with his pain and he said “OK”, but no assessment tool or other discussion was used to gather any further information about his experiences. This was the aspect of his care that could have been most improved. However, his nurse did ask Mr. A.’s carers if he asked for his pain medication, how regularly and if they thought he may be experiencing chronic pain as well as breakthrough pain but they said they were not sure.
There are numerous tools for pain assessment. Visual analogue scales (VAS), numerical rating scales (NRS), and verbal rating scales are three tools have all been shown to be both reliable and valid for use during cancer pain assessment (Hartrick, Kovan, and Shapiro, 2003, pp.312; Ohnhaus and Adler, 1975, pp.279-383). However, research suggests that the elderly population tend to prefer the NRS and it has a lower failure of completion rate compared to the VAS when used in the population (Jensen and Karoly, 2011, pp.16). The NRS is a frequently used and an effective tool in assessing pain, easily understood by patients and healthcare professionals alike and as noted in his care plan, had been used on previous occasions to successfully assess Mr. A.’s pain. It could also be modified for Mr. A. as speaking may be uncomfortable due to his condition, by drawing a number line and asking him to point at the relevant number on the scale. Because all pain assessment results and the effectiveness of analgesia should be recorded in his care plan, using the same methods of pain assessment over time adds to a continuity of care across his care team communicating his progress (The British Pain Society, 2010, pp.25; NMC, 2008, pp.7). If a pain diary was also completed regularly by the patient or their carer, the nurses and other members of the care team have a “round the clock” picture of the patient’s daily experience of pain to inform care planning (The British Pain Society, 2010, pp.25).
Although Mr. A could communicate with short responses during his assessments, observational pain behaviors can also be used by nurses to assess patients suffering from progressed dementia (Ammaturo, Hadjistavropoulos, and Williams, 2016, pp. 1894). Conditions such as dementia, that impair a patient’s ability to communicate, can be problematic for assessment. Additionally, although many patients with mild to moderate dementia can engage with the simple scales described, in those with progressed, late-stage disease these methods are not an option (McClean, 2003, pp. 428). Consequently, pain is frequently cited as under-diagnosed and poorly managed in patients with dementia, in long-term care settings such as Mr. A.’s (Sampson et al., 2006, pp.187). Notably, in patients with dementia, pain thought to be one of the most important causes of behavioural disturbances (Corbett et al., 2012, pp.264). Therefore, using observational techniques to assess pain in patients with dementia, alongside other tools requiring verbal or physical interaction, may be advisable even if they are still able to participate during the assessment (The British Pain Society, 2010, pp.26). Moreover, this demonstrates the wide-ranging benefits of successful pain management, with the potential to alleviate behavioural disturbances for patients with dementia (Corbett et al., 2012, pp.264). Potentially, Mr. A.’s increased anxiety and distress was due to pain but he was unable to communicate it.
Pain assessment of non-verbal patients including those with dementia was discussed by the Nursing Home Pain Collaborative who recommended the use of two tools: The Pain Assessment Checklist for Seniors with Limited Ability to Communicate II (PACSLAC-II) and the Pain Assessment in Advanced Dementia (PAINAD) Scale (Herr et al., 2010, pp.29; Sawhney et al., 2017, pp.18). These could be particularly useful in the future when Mr A.’s dementia does progress and interfere with pain assessment. They seem easy to use, although it is highlighted that they should be used alongside the practitioner’s broader knowledge of the patient and the findings of examination (see Appendix A for the link to PACSLAC-II) (Chan, Hadjistavropoulos, and Fuchs-Lacelle, 2017, p.1). However, it should be highlighted that involving the patient in their assessment whenever possible is preferred, so his nurse could go back to using the scale assessments when Mr. A. is having a better day and able to participate.
Further, core nursing assessments that are recommended for cancer patients include a psychosocial assessment, physical examination and a detailed history of any persistent pain, breakthrough pain and their effect on function (The British Pain Society, 2010, pp.25). This effect on function could be assessed through activities of daily living assessment, for example, Breakthrough pain can be defined as: “the transient exacerbation of pain occurring in a patient with otherwise stable, persistent pain” (Rudowska, 2012, pp.498). It is estimated that between 40-86% of patients with cancer are reported to experience breakthrough pain, depending on the study (Hwang, Chang, and Kasimis, 2003, pp.56; Mercadante et al., 2002, pp.32; Mishra et al., 2009, pp.12). Cancer pain has been described as having two components, persistent pain, lasting more than 12 hours per day and breakthrough pain. Breakthrough pains are so called because they break through the regular pain medication. Other features of breakthrough pain include its predictability, precipitating events, temporal features and its relation to the fixed dose of opioid medication (Fine and Busch, 1998, pp.179; Mishra et al., 2009, pp.8). The cause of breakthrough pain is shown to differ from patient to patient. Research has reported that 67-76% of breakthrough pains are caused by cancer itself, 20-33% are due to the cancer treatment such a chemotherapy, and up to 4% of breakthrough pains are of an unknown cause (Portenoy, Payne and Jacobsen, 1999, pp.129). Mr. A.’s nurse did not enquire specifically about whether his prescription for breakthrough pain was being successfully managed, or ask his carers. Interestingly, a recent study reported that the NRS was also a valid and reliable assessment tool for breakthrough pain and that it should perhaps be preferred over the other scale assessments described (Brunelli et al., 2010, pp.42). With proper nursing assessment and therapy, breakthrough pain can be successfully treated as was seemingly the case for Mr. A., although lacking thorough assessment to say conclusively (Davis, 2012, pp.277). For example, a recent Cochrane review confirmed that oral fentanyl was successful in treating breakthrough pain across 15 studies, totaling 1699 participants (Zeppetella and Davies, 2013 n.p.).
The Bristol Activities of Daily Living Scale (BADLS) assessment was completed for Mr. A. on many previous occasions and was noted in his case file (Bucks et al., 1996, pp. 113). Based on Roper, Logan and Tierney’s (1980) model for nursing, the BADLS is a 20-item checklist that is specifically designed for patients with dementia, aiming to assess functional capacity in everyday life and therefore indicate the person’s level of independence. The BADLS have been shown to be effective in assessing the functional status of patients with dementia and as a tool for evaluating and monitoring the efficacy of interventions (Desai, Grossberg and Sheth, 2004, pp. 853). Again, using a tool that is designed for patients with dementia is important. The cognitive impairment that accompanies disease disrupts communication and therefore tools such as the “traditional” ADL assessment, reliant on patient interaction may gather little information and not detect changes. The BADLS assessment is also part of a holistic, patient-centered approach, that incorporates the psychosocial aspects of a person’s life in its examination of their health, such as how a person’s disease is affecting their ability to socialise, as well as their ability to complete tasks such as washing (Bucks et al., 1996, pp. 113). Assessment tools such as the ADL can support nurses in using a systematic method of gathering all the complex and extensive information that can influence a person’s health and management of their disease Furthermore, for patients with dementia, gathering information on their ability to undertake the ADL’s is essential for diagnosis and in evaluating the progression of disease. The BADLS assessment had been initiated by Mr. A.’s dementia nurse and was also a good choice of assessment because it could also be completed by Mr. A.’s carers, due to its ease of use (Bucks et al., 1996, pp. 113). Consequently, it was being carried out every other week, across his care team so Mr. A. was regularly assessed for changes in his functioning and progression in his disease. A holistic assessment is also recommended when managing cancer patients and their pain (The British Pain Society, 2010, pp.25). Mr. A.’s nurse noted that there had been no change in his BADLS score since his last assessment two weeks previously.
The Plan of Care
Mr. A. had a long-term care plan in place that covered all aspects of his dementia care involving his dementia nurse, GP, carers and social worker. As mentioned, the key nursing goals were promoting his independence and social interaction to improve his quality of life and reduce his anxiety and distress, with pain management for cancer. Due to his progressing cancer, he was under the care of an oncologist, saw specialist oncology nurses during outpatient appointments and was now referred for additional nursing assessment in his care home. His dementia nurse saw him every 6 months and provided summarised notes and key points in his care plan every three months. Mr. A’s carers were most involved in his daily care at the nursing home and contributed to the care plan, so far supporting any nursing interventions and providing information for assessments. As noted by Mr. A’s nurse, the progression of his cancer was a complex addition to his case management and now needed to be considered in his future care planning. This meant maintaining consistent pain management and introducing assessments for swallowing as his cancer progressed further and his symptoms got worse. It was already highlighted in his care plan that carers should observe for any difficulties in swallowing due to his dementia; however, as Mr. A.’s dementia nurse only visited every 6 months and he now had two serious conditions that can affect speech and swallowing, Mr. A.’s community nurse thought assessments should be each month. This was amended in his care plan accordingly. The nurse also spoke to a senior carer and explained that staff should pay greater attention to Mr. A’s swallowing now his cancer was progressing, outlining the risks and additional assessments that would take place. Managing this risk was a crucial part of the nurse’s role in Mr. A’s care, increasing assessments to reflect the increasing risk (NMC, 2008, pp.2).
Throughout Mr. A.’s care plan and the nursing appointment, there was evidence of engagement with his carers at the long-term home and this was an aspect of care that appeared to be managed very well. Collaboration with primary caregivers as well as other healthcare professionals during the care planning process supports the professional values of nursing (NMC, 2008, pp.8). Moreover, nursing collaboration with carers of patients with dementia improves caregiver and patient satisfaction while reducing hospital admission rates for the latter (Dang, Badiye, and Kelkar, 2008, pp.1246). Regarding Mr. A’s distress and anxiety, his care plan noted that he was being encouraged to spend time in the resident’s day room and take part in some of their activities and trips but only spent a limited amount of time in the day room. His room was also quite sparse and didn’t have many personal items or photos to look at. He did have a window with a nice view of the gardens. Mr. A.’s carers had moved his chair next to the window and had been encouraging him to look outside, talking to him about the weather. They said this seemed to calm him at times so his nurse also highlighted this in his care plan as a regular daily routine. Interestingly, recent research has shown that scenic views can reduce agitation in patients with dementia, as a form of art therapy. Images can also be used where natural views are not possible (Chancellor, Duncan, and Chatterjee, 2014, pp.1). Displaying images of nature has been reported to improve neuropsychiatric symptoms, social behaviour and self-esteem in patients with dementia while positively influencing well-being (Hannemann, 2006, pp.60). Although evidence is still emerging, art therapy could be a useful, easy and cost-effective way of improving the well-being of patients with dementia who struggle to interact.
Effective pain management has been shown to improve mobility, lower hospital admission rates, increase patient satisfaction, reduce health care costs and can improve quality of life (Carr and Goudas, 1999, pp.2051; Glowacki, 2015, pp.33-41). It also reduces sleep deprivation, which is associated with fatigue, impaired cognitive and physical functioning, mood instability, emotional distress and an exacerbation of concurrent symptoms (Friese, 2008, p.697; Matthews, 2011, 205). Guidelines recommend a stepwise approach to pain management for patients with cancer, using the World Health Organisation’s analgesic ladder (Mercadante and Fulfaro, 2005. n.p.; National Institute for Health and Care Excellence, 2012. n.p.). Mr. A. had gone up the ladder from a single non-opioid medication for chronic pain to the addition of an opioid for breakthrough pain (Davis, Glare and Hardy, 2005, pp.126). This was maintained following Mr. A.’s nursing visit, although perhaps with a thorough assessment, Mr. A. may have needed an increase in his analgesia, receiving an opioid for chronic pain instead of only receiving stronger relief on demand from his oral morphine solution. Mr. A.’s nurse did, however, note in his care plan to see if he would enjoy cold or warm drinks or snacks such as ice lollies that may ease any discomfort in his throat caused by his tumour. This was also mentioned to the carer present who fetched Mr. A. an ice drink which he seemed to enjoy. Cold or warmth on painful areas has been shown to be effective in relieving pain and discomfort to injuries. Therefore, recommending interventions such as warm baths or ice compressions can be useful and easy non-pharmaceutical ways of providing some pain relief for any patient experiencing chronic or acute pain (Dehgan and Farahbod, 2014, LC01.
On subsequent nursing visits, Mr. A. grew increasingly agitated and disorientated. He was referred for an emergency appointment with his dementia nurse who diagnosed late-stage dementia. He died a few months following the nursing appointment presented.
In conclusion, effective pain management is essential for patients suffering from cancer and dementia, effecting a wide-range of health outcomes. In this case, pain may have significantly contributed to Mr. A’s anxiety and distress and was therefore potentially preventable and could have given him better quality of life in his last year. An effective nursing assessment is crucial in identifying care needs such as escalated pain management; however, it can be problematic with patients suffering from impaired communication. Consequently, in the dementia population pain is often undetected and poorly managed according to the literature. Mr. A.’s case exemplifies how a lack of regular and comprehensive assessments can lead to patients suffering serious outcomes. Non-observational tools are invaluable and recommended when assessing patients with dementia, are easy to use and can be carried out by carers who have the most contact with the patient. Interestingly, art therapy may be a useful addition to nursing practice, improving overall well-being. In future practice, such tools should always be used as part of a holistic assessment for patients with dementia, ensuring that an accurate nursing assessment informs a subsequent care plan that is tailored to the patient’s needs.
Appendix A – PACSLAC-II assessment tool.
Appendix B – Care plan
Increased frequency of swallowing assessments and informing carers to be aware and refer to nurse if Mr A. has any choking episodes or seems more bothered by his throat.
Mr A. has a risk of choking due to his dementia and with the increasing mass of his tumour so more assessments can help manage this risk by identifying changes quickly. Carers are with him the most so will be best placed to notice any sudden changes.
Continued pain management and monitoring
Increasing pain is likely as his cancer progresses and a step-wise approach can be used to address any additional pain.
Giving warm/cold drinks
May provide some relief to any throat discomfort Mr A. is experiencing to help in pain management. Mr A. appeared to get some relief from a cold drink.
Encourage to participate in group activities and sit in day room
To increase Mr A.’s social interaction and well-bring, which may reduce his anxiety and distress.
Encourage to sit in chair next to window every day
Mr A. seemed calm by looking at the garden. It is also a form of art therapy that reduces anxiety and distress.