Observers' Misperception of Pain in Older Adults with Dementia

Undertreatment of pain in older adults with dementia is a serious concern. Though inadequate pain assessment in this population appears to underlie the problem, contributing factors remain unclear. It is unsurprising that communication interferes with understanding the experience of pain in individuals with dementia, as communicative ability decreases with dementia progression. This results in reliance on non-verbal cues to infer pain in individuals with dementia, particularly with severe dementia. The aim of this project was to determine the influence of patient non-verbal communicative changes related to advanced dementia (i.e., possible alterations in facial expressions during pain) and observer biases (i.e., negative attitudes and beliefs about pain, aging and dementia) on the effective detection of pain via facial expression in older adults with dementia. In two parts, this project investigated: a) via detailed analysis of facial muscle movements, whether facial expression during pain changes as a function of dementia; and b) via a judgment study, to what extent such expression changes or observer attitudes contribute to misperception of pain in older adults with moderate to severe dementia. One hundred older adults (48 with and 52 without dementia) underwent a videorecorded movement-based physical examination designed to identify painful areas. Their facial expressions were quantified using the Facial Action Coding System (FACS) and analyzed to determine expressive differences in individuals with and without dementia. Forty undergraduate participants then judged edited videos for pain, after completing measures of attitudes about aging and personhood in dementia. Individuals with and without dementia did not differ in emotional expressiveness during pain. In the judgment study, observers were sensitive and accurate judges of pain. Overall, observers were substantially more accurate when judging the pain of individuals with dementia, with observers’ age and scores on a measure of ascribing personhood to individuals with dementia capturing a significant amount of variance in accuracy. When viewing patients with dementia, younger females were more accurate. When viewing patients without dementia, ageism was associated with reduced accuracy, while personhood beliefs were associated with increased accuracy. Observers saw individuals they perceived as having dementia as being in more pain but were not differentially accurate based on this perception. Observers were correct in classifying dementia diagnosis based on visual video cues alone 61% of the time. Classification accuracy did not vary based on the actual diagnosis of dementia, and the only observer variable affecting accuracy was tendency to ascribe personhood to individuals with dementia. In sum, the presence of dementia appeared to increase the clarity of the nonverbal pain message independent of intensity of expression or changes in expressed emotion. Younger age and female gender conferred an advantage in decoding older adults’ non-verbal pain communication. Ageist beliefs were associated with lower pain judgment accuracy, and personhood beliefs were associated with increased accuracy in judging pain and dementia diagnosis. Believing that a person has dementia was associated with rating pain higher but not with accuracy. In other words, while thinking that a target has dementia leads to higher pain ratings, it is believing that people with dementia are worthy of respect as persons that predicts accurately inferring their inner experience. This adds specificity to the communications model of pain, suggesting a communication breakdown at the observer rather than the sufferer level.

Name thesis:degree_name

Doctor of Philosophy (PhD)

Level thesis:degree_level

Doctoral -- first

Discipline thesis:degree_discipline

Clinical Psychology

Grantor dc:publisher

Faculty of Graduate Studies and Research, University of Regina

Year dc:date.issued

2021

Author dc:creator

• Browne, Margaret Erin

Advisor dc:contributor.advisor

• Hadjistavropoulos, Thomas

Committee members dc:contributor.committeemember

• Gordon, Jennifer
• Loucks, Jeff
• Gregory, david

Language dc:language.iso

en

DOI

https://doi.org/10.82465/3944

OAI identifier oai:identifier

oai:uregina.scholaris.ca:10294/14932