Background. Acute and chronic pain is common in hospitalized demented elderly people, yet there are limited data about the performance of pain assessment tools in this population. The aim of this study was to evaluate the feasibility and reliability of four pain self-assessment scales in this population and compare their performance to an observational pain rating scale. Methods. Our prospective clinical study was conducted in an acute-care and intermediate-care geriatric hospital on 160 consecutive inpatient referrals to the dementia consultation who met Diagnostic and Statistical Manual of Mental Disorders–IV criteria for dementia. Exclusion criteria were delirium, terminal care, and severe sensory impairment. Four unidimensional self-assessment tools—the verbal, horizontal visual, vertical visual, and faces pain scales—were administered in randomized order to mild, moderate, and severely demented patients. An observational pain rating scale was independently completed by the nursing team. Results. Only 12% of the 160 patients (mean age 85 years, 71% women) understood no scale. Respectively, 97%, 90%, and 40% of patients with mild, moderate, and severe dementia understood at least one scale (p <.05). There was a nonsignificant trend toward poorer comprehension of the faces scale. Test–retest reliability was high for all four self-assessment scales, and the correlation between these scales was very strong (Spearman's r_s = 0.81–0.95; p <.001). Observational rating correlated moderately with self-assessment and tended to underestimate pain intensity (r_s = 0.31–0.40; p <.05). Conclusions. Self-assessment pain scales can be used reliably in the vast majority of older hospitalized patients with mild to moderate dementia and in nearly half of those with severe dementia. Observational pain rating scales correlate only moderately with self-assessment and should be reserved for those few patients who have demonstrated that they cannot complete a self-assessment.

In many countries more than 1 in 4 people die in a nursing home,^1,2 and this is expected to increase substantially in the future.^3,4 Research has consistently shown that the quality of end-of-life care and dying is suboptimal in many nursing homes. A considerable proportion of residents die with unrecognized, undertreated symptoms, and after multiple hospitalizations and/or burdensome life-prolonging treatments in the final months,^3-9 yet access to palliative care services is usually low,^10,11 as is staff palliative care knowledge.¹²

Advance directives (ADs) might be useful in achieving improved communication and satisfaction with decision making at the end-of-life. Our aims were to better characterise patients with advanced oncological disease who decided to complete ADs and to measure the effect of ADs completion on the satisfaction level with end-of-life care from both patients and their relatives. A prospective study was conducted in three palliative care units. Patients with advanced cancer were included if they met the following criteria: an estimated life expectancy of 20 and not yet completed ADs. All the patients received information about ADs and decided whether to complete ADs or not. The level of satisfaction with involvement in the decision process concerning end-of-life care was assessed by means of a written questionnaire. In all, 53 of 228 patients were included, and 12 decided to complete ADs. Patients who completed ADs had statistically less depression one week after inclusion (P = 0.030), had a lower anxiety score on the second week and had a lower depression score on the third week. There was a trend towards a higher satisfaction level with the involvement of the patients in end-of-life care for those completing ADs (P = 0.878). In conclusion, each patient with an advanced progressive disease should be informed about ADs and be encouraged to complete the ADs with the aim to ease many fears as well as to improve communication.

Self-report is the "gold standard" for pain assessment, however, observational pain scales, such as Doloplus-2 must be used for patients who cannot communicate. In this follow-up study, we report the psychometric properties of the observational Doloplus-2 scale using the visual analog scale (VAS) pain score as a gold standard and evaluate its performance. Prospective clinical study of 180 hospitalized older patients who demonstrated good comprehension and reliable use of the VAS: 131 participants with dementia and 49 without. All participants assessed their chronic pain using the VAS. Doloplus-2 was independently completed by the nursing team. Mean age of patients (133 women, 47 men) was 83.7+/-6.5. Median mini-mental state examination of patients with diagnosis of dementia was 18.0+/-7.7. Nearly half of the patients (49%) reported that they experienced pain in response to a direct question. The administration of Doloplus-2 was possible in all 180 patients. Doloplus-2 correlated moderately with self-assessment (Spearman coefficient: 0.46). In a multiple regression model, Doloplus-2 predicted 41% of the variability in pain intensity measured by VAS. The somatic dimension alone explained 36% of the variance, the psychosocial bloc 5% with no better contribution of the psychomotor bloc. To shorten Doloplus-2, we constructed a version with only the 5 items that were significantly associated with the VAS score in the multiple regression models. The observational Doloplus-2 scale correlates moderately with self-assessment pain score and has adequate internal consistency. Our data also suggest that Doloplus-2 could be substantially shortened as the brief version performed similarly to the complete Doloplus-2.