An integral concern across care settings is the prompt intervention for patients suffering with pain. Long-term care (LTC) settings present with unique challenges to assess and manage pain in resident populations. Pain assessment is especially challenging, because residents have varying degrees of cognition to communicate their pain, and clinician/staff knowledge of pain symptoms may be lacking. The purpose of this research was to improve the measurement of pain and outcomes of care for the elderly residing in skilled nursing care, especially those with cognitive-impairment. The specific aims of this study were to: 1) Determine the magnitude of the relationship between pain behaviors and a measurement model hypothesized for pain; 2) Test the construct validity of a pain measurement model; 3) Examine the concomitance of pain and cognition in a three-year longitudinal analysis. The research questions answered: 1) Is there a difference in the prevalence of pain in cognitively intact versus cognitively-impaired residents; 2) Can a theoretically derived model of pain aid in detecting pain across all cognitive levels; and 3) Do pain and cognitive status concomitantly correlate? The goal was to examine the covariance model of concomitance of pain and cognition to more accurately construct theoretical models of pain to then include additional resident care factors in future research. Traditional self-reports of pain are often under-assessed and under-treated in the cognitively-impaired (CI) elderly resident. Having additional measures to detect pain beyond self-reports of pain intensity and frequency increases the likelihood of detecting pain in populations with complex symptom presentation. Data collected from skilled nursing facilities offer exceptional opportunities to study resident demographics, characteristics, symptoms, medication use, quality indicators, and care outcomes. The Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0, a nationally required resident assessment tool, must be completed on every resident in a Medicare LTC facility within 14 days of admission, quarterly, annually and with significant changes in resident status. Because the MDS is widely used and recognized in LTC settings, core items from MDS [i.e., pain frequency (J2a) and pain intensity (J2b)] along with additional MDS items hypothesized to signify pain were analyzed in the pilot measurement model. Ten core items from MDS were used: 1) Inappropriate behavior frequency (E4da); 2) Repetitive physical movements; 3) Repetitive verbalizations (E1c); 4) Sad facial expressions (E1l); 5) Crying (E1m); 6) Change in mood (E3); 7) Negative statements (E1a); 8) Pain frequency (J2a); 9) Pain intensity (J2b); and 10) Cumulative pain sites scores. All indicators of pain were significant at the <.01 level. A longitudinal cohort design was used to answer if a concomitance exists between pain and cognition. Data were collected from MDS annual assessments from 2001, 2002 and 2003 for residents across the United States. The sample consisted of 56,494 residents age 65 years and older with an average age of 83 [plus or minus] 8.2 years. Descriptive statistics, ANOVA and a covariance model were used to evaluate cognition and pain at the three time intervals. ANOVA indicated a significant effect (<.01) for pain and cognition with protected t-tests indicating scores decreased significantly over time with resident measures of pain and cognition. Results from this study suggest that: 1) Using only pain intensity and frequency, pain prevalence was found in 30% of the pilot population, while 47.7% of cognitively intact residents had documented pain and only 18.2% of the severely CI had documented pain, supporting previous research that pain is potentially under-reported in the CI; 2) Parsimonious measurements models of pain should include dimensions beyond self-reports of pain (i.e., cognitive, affective, behavioral and inferred pain indicators); 3) Model fit was improved by using specific MDS items in the pain construct; 4) Longitudinal analysis revealed relative stability for pain and cognition measures over time (e.g., larger stability or consistency was found in cognitive measures than the measures of pain over the three-year period); 5) Crossed-legged effects between pain and cognition were not consistent; 6) A concomitant relationship was not found between pain and cognition. The relationship was significant (<.01), but associations were weak (r=0.03 to 0. 08). Pain or cognition should not be used as a predictor of the other in theoretical models for similar populations. The MDS is a reliable instrument to follow resident attributes, quality of care, and patient outcomes over time. The development of more accurate assessments of pain may improve resident care outcomes. Ineffectively intervening on the pain cycle is posited to cause secondary unmet needs that affect the resident's quality of life. Findings support the importance of improving clinical outcomes in the management of pain in the elderly residing in long-term care. Deficits in the treatment of pain highlight the impetus to support health policy change that includes pain treatment as a top health priority and a quality indicator for federally funded programs supporting eldercare.

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Percevoir la douleur d’autrui présente des intérêts considérables, autant pour la personne qui exprime une douleur, que pour la personne qui y fait face. A ce jour, l’évaluation de la douleur d’autrui demeure sous-estimée. Il apparait donc nécessaire d’approfondir la connaissance des déterminants de l’évaluation de la douleur d’autrui. Ce travail doctoral s’intéresse à l’évaluation, par des observateurs, des comportements prototypiques émis par les personnes qui ressentent des douleurs. Dans un premier temps, il examine dans quelle mesure les observateurs s’appuient sur des comportements particuliers (i.e., comportements de communication : expressions faciales et paraverbales, et de comportements de protection : cinématiques lombopelviennes et boiterie d’esquive) lorsqu’ils doivent juger l’intensité de la douleur d’autrui. Les contributions de l’expertise clinique et de la familiarité avec la douleur y sont examinées. Dans un deuxième temps, il interroge la contribution des traits de personnalité du Big Five dans la réponse sociale à la douleur d’autrui. Les résultats montrent que lorsqu’il s’agit d’estimer l’intensité de la douleur lombaire d’autrui, les expressions faciales de la douleur priment sur les cinématiques lombopelviennes (étude 1). Toutefois, lorsqu’il s’agit d’évaluer l’intensité de la douleur podale d’autrui, l’expression paraverbale de douleur ne prime pas sur les comportements de boiterie (étude 2). Les études 1 et 2 ne font pas émerger de consensus relatif aux règles d’intégration utilisées par les observateurs. Par ailleurs, le caractère consciencieux (études 3 et 4), l’agréabilité (étude 3) et le névrosisme (étude 4) contribuent à la réponse sociale à la douleur d’autrui. La contribution de ces trois traits s’exprimerait à un niveau contrôlé, i.e., top-down (étude 5). Les résultats des études menées sont susceptibles d’enrichir le Modèle de la Communication de la Douleur et étendent le champ d’application des traits de personnalité du Big Five. / Recognizing and interpreting other’s pain can be of great importance to the person in pain as well as to the person witnessing the other’s distress. According to recent studies other’s pain remains underestimated. Thus, it appears necessary to better understand the knowledge of variables that contribute to other’s pain assessement. On one hand, this doctoral project aimed at determining if observers rely more on communicative than on protective pain behaviors (facial and paraverbal expressions) when estimating other’s pain. It also questioned how observers integrate information from pain behaviors. On the other hand, the contribution of Big Five personality trait in the social response to other’s pain has been examined. When assessing low back pain, observers particularly relied on facial expression than on lumbopelvic kinematics (study 1). Nevertheless, when estimating heel pain, paraverbal expression did not contribute more than limping behaviors to observers’ pain estimates (study 2). No concensus has emerged regarding the way observers integrated information from the different pain behaviors (studies 1 and 2). In addition, conscientiousness (studies 3 and 4), agreableness (study 3), and neuroticism (study 4) contributed to the social response to other’s pain. The contribution of these traits seems to be driven by top-down processes (study 5). These results are likely to expand the communication model of pain, and the contribution of Big Five personality traits.