Determining the biopsychosocial factors of chronic pain in older adults to inform the development of a risk appraisal checklist for use in long term care: a Delphi study

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Clifford, Michelle
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University College Cork
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Background: In long term care (LTC), the prevalence of pain is 43% (van Kooten et al., 2017), and this, coupled with the high prevalence of dementia (Zimmerman et al., 2014), lends itself to complex practice issues in terms of pain assessment. The American Society of Pain Management Nursing published the hierarchy of pain assessment techniques developed by Pasero and McCaffery (2011) to guide pain assessment in people unable to self-report. The first step of this framework focuses on awareness of potential causes of pain, hence the importance of identifying the biopsychosocial factors associated with chronic pain in older adults. Improving pain assessment can improve older adults' quality of care and the ultimate quality of life. However, very little research has supported the early identification of older persons at risk of unreported chronic pain due to communication impairment or a neurodegenerative disease such as dementia. Using a multi-dimensional lens, this research aims to identify the biopsychosocial factors of chronic pain in older adults to inform the development of a risk appraisal checklist for use in long-term care. Methods: Chen et al. (2016) proposed a four-phase process when employing a Delphi technique to develop a quality instrument. These phases include identifying an expert panel, generating initial factors, and identifying the final factors and instrument development. The first three phases were the focus of this study. Following the identification of an expert panel in chronic pain, phase two involved completing a scoping review to create a list of the initial factors. There was a total of fifty-nine biopsychosocial factors identified from the empirical literature. These factors were used to inform round one of the modified e-Delphi surveys. A consensus agreement rate of 50% was applied for this study for round one, median ≥4 for round 2 and ≥90% agreement for inclusion in round three. Thematic analysis of open-ended responses also took place. Results: Thirteen experts in gerontology and chronic pain participated in a minimum of two rounds. There was a desirable international spread from eight countries, and 68.4% of the experts had >21 years of experience in their field of expertise. The 59 initial factors identified from the scoping review were presented to the experts in round one. Fifty (84.7%) biopsychosocial factors achieved a 50% or greater agreement of factor importance. Sixty-three factors were presented to the expert panel in round two, 33 factors were rerated from round one, nine factors were modified, and the experts identified 21 new factors. The results from round two, a total of fifty-one factors, achieved a median of ≥4 and were presented in round three. The final twenty-two factors that achieved ≥90% consensus agreement in round three for inclusion included; age, female gender, arthritis, lower back pain, malignancy, family history of chronic pain, multiple comorbidities, trauma and/or accident, multiple sites, anxiety and depression, social isolation/loneliness, post-traumatic stress, childhood physical/sexual abuse, maladaptive beliefs, poor sleep hygiene and/or insomnia, substance abuse, low socioeconomic background, chemotherapy medication, history of opioid use and poor access to health care. Conclusion: This study has laid the foundations for future research and innovation in comprehensive pain assessment in older adults, focusing on identifying risk factors in older persons for whom accurate self-report of chronic pain is challenging due to communication and/or cognitive impairment. The twenty-two factors identified from this study will inform the development and testing of the Chronic Pain Risk Appraisal Checklist (C-PRAC) for LTC use.
Chronic pain , Gerontology , Long term care , Pain assessment , Modified e-Delphi study , Older adults
Clifford, M. 2021. Determining the biopsychosocial factors of chronic pain in older adults to inform the development of a risk appraisal checklist for use in long term care: a Delphi study. MRes Thesis, University College Cork.
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