Psychometric properties of pain measurements for people living with dementia: a COSMIN systematic review

Key summary points Aim To determine the psychometric properties of the most frequently used pain measurement tools in research of people living with dementia. Findings There was strong and moderate level evidence to support the use of the facial action coding system, PACSLAC and PACSLAC-II, CNPI, DOLOPLUS-2, ALGOPLUS, MOBID and MOBID-2 tools for the assessment of pain with people living with dementia. There was limited evidence to support the use of the Abbey Pain Scale, PAINAD and self-reported pain through verbal rating pain score. Message This study has identified which outcome measures are the most robust to assess pain in older people with dementia. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-022-00655-z.


Introduction
Dementia is a major, worldwide health challenge predominantly affecting older people. It has an estimate global prevalence of 45 million people [1]. Pain is frequently reported in older people with approximately 20-50% living with chronic pain [2]. Managing pain can be difficult. There are challenges surrounding adherence and adoption of interventions such as exercise and medication taking. Detecting pain can also be difficult for people with dementia. Accordingly, pain in people with dementia is often under-detected and under-treated [3].
Self-reported pain scales such as numerical rating scales (NRS) are most frequently used to assess pain. For these patients, self-reported pain alone may not be sufficient [3]. Observed behavioural indicators of pain such as verbal complaints, sighing, moaning, agitation, crying, grimacing, rapid blinking, restlessness, rubbing, disorientation, or aggression may be valuable [4,5].
Lichtner et al. [6] previously identified eight literature reviews reporting measurements and psychometric properties of tools assessing pain in people with dementia. No single tool was identified as more reliable and valid than others, with a wide variation in the reliability and validity. However, the search from the most recent review was performed in 2013. Furthermore, no studies have assessed the psychometric properties of outcome measures against the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. This is a major limitation as the COSMIN checklist [7] is a robust assessment of both methodological quality of studies assessing measurement properties, with the quality of the outcome measure itself. Through this, the COSMIN checklist offers a robust, evidence-based recommendation on the quality of outcome measures selection in research and clinical practice [7].
The assessment of pain using a valid and accurate measurement is the basis for successful pain management [8]. However, there remains uncertainty on the appropriateness of these measures. Accordingly, the purpose of this systematic review was to determine the psychometric properties of the most frequently used pain measurement tools in research of people living with dementia.

Methods
This systematic review was conducted according to the COSMIN guidance [7] and reported in accordance with the PRISMA statement [9]. The study protocol was registered prior to commencing (PROSPERO registration: CRD42021282032).

Search strategy
Search 1: To identify the measurement tools currently used to measure pain in clinical trials of people living with dementia, we performed a search of the databases Clinical-Trial.gov and ISRCTN from inception to 01 October 2021. We used the search terms "Dementia OR cognitive impairment" AND "pain".
Search 2: A systematic review was undertaken of published and unpublished sources to identify potentially eligible studies assessing the psychometric properties of pain measurement tools identified from Search 1. We searched the published databases: Medline, CINHAL, EMBASE, AMED, PsycINFO, and DARE from database inception to 01 November 2021. We also searched the trial registry and unpublished literature databases OpenGrey, Clinicaltrials. gov, and ISRCTN registries from inception to 01 November 2021. The search terms used for the EMBASE database are presented in Supplementary File 1. These were based on the COSMIN search filters to identify studies of psychometric properties linked to terms related to dementia, cognitive impairment, and pain. The search strategy was optimised for each electronic database search. The reference lists of all potentially eligibility studies were reviewed, and the corresponding authors from each included study were contacted and asked to review the search results.

Eligibility assessment
For both Search 1 and 2, studies were included if they recruited people, aged 60 years and older, with dementia. Dementia criteria such as the Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition (DSM IV) [10], National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) [11], and the National Institute for Neurological Disorders and Stroke-Association Internationale pour la Recherche et Enseignement en Neurosciences (NINCDS-AIREN) [12] were considered appropriate. Where self-reported dementia was reported, further scrutiny of the characteristics of the population in relation to severity of cognitive impairment, age, and comorbidities were considered. Where uncertain, corresponding authors were asked to verify the approach used to define dementia. All stages and severities of dementia were eligibility, i.e., mild, moderate, and severe. Whilst it is acknowledged that pain assessment tools have been developed for other, non-dementia, patient groups with cognitive impairment [13], these were excluded from this review unless there was sufficient evidence that participants presented with dementia.
We did not restrict the form, cause, or pathology causing pain. Through this, participant's pain arise from 1 3 musculoskeletal, post-surgery, medical, and cancer-related sources.
We included studies regardless of setting, i.e., acute, community, residential, or nursing home. We excluded studies not published in English, narrative, and systematic reviews, although reviewed the reference lists of these publications to identify any previously omitted studies.
For Search 2, we included all full-text publications which reported any assessment of the psychometric properties of measurement tools identified from Search 1. Papers which included findings on pain management were considered if they also provided data on the psychometric properties of a pain measurement tool. We only included studies which reported one or more of the COSMIN taxonomy of: internal consistency, test-retest reliability, measurement error, content validity, structural validity, construct validity/hypotheses testing, cross-cultural validity, criterion validity, or responsiveness [7].

Study identification
The search results were screened against the eligibility criteria by two reviewers (TS, KH). This was initially by title and abstract, and then by full-text version. Screening was performed by each reviewer independently. When consensus on study eligibility could not be reached, agreement was reached through discussion.

Data extraction
For each included study, data were extracted independently by one reviewer (TS). This was then verified for accuracy by a second reviewer (KH). Where disagreements occurred, these were resolved through discussion.
Data were extracted onto a bespoke data extraction table. Data extracted included: measurement tool name, setting tested, country of assessment, method of administration, person administered, duration between testing (if appropriate), patient participant characteristics (number and response rate), age, gender, diagnosis of pain, diagnosis of dementia, severity of dementia), and psychometric outcomes (reliability, validity, and responsiveness).

Risk of bias
To assess the methodological quality of the included studies, the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist [14] was used. The COSMIN checklist assesses the following measurement properties: content validity, structural validity, internal consistency, cross-cultural validity/ measurement invariance, reliability, measurement error, criterion validity, hypotheses testing for construct validity, and responsiveness. The overall quality of how each measurement property was evaluated on a four-point scale: very good, adequate, doubtful, or inadequate, as per the COSMIN guidance. The methodological quality score per property was then obtained by taking the lowest rating of any item in each box-worst score counts principle. Two reviewers (TS, KH) assessed each study using this approach independently with disagreements resolved through consensus.

Data analysis
The psychometric properties of each measurement tool were reported narratively. Through this descriptive statistics, inferential statistics and degrees of variance were reported from included studies. Analysis was made following Chiarotto et al. [15] best evidence synthesis approach where 'strong' was a measurement tool which demonstrate consistent findings in multiple studies of good methodological quality OR in one study of excellent methodological quality; 'moderate' demonstrated consistent findings in multiple studies of fair methodological quality OR in one study of good methodological quality, 'limited' demonstrated on study of fair methodological quality, conflicting demonstrated conflicting findings and 'unknown' was only for studies of poor methodological quality or no studies reporting a measure.

Search 1: identification of measurement tools
In total, 188 individual clinical trials were identified from Search 1. Of these, 56 were identified which reported measuring pain with participants living with dementia. A summary of these studies is presented in Table 1.
From the list generated from Search 1, we excluded all measures which did not specifically assess pain but included pain as a sub-domain of an instrument, e.g., SF-36, WOMAC, and EQ-5D. From this, seven outcomes were excluded (Comfort Assessment in Dying with Dementia,

Search 2: Psychometric tools analysis
A summary of the Search 2 results is presented in Fig. 1.
In total, 1173 individual citations were identified. Fifty-one studies reported data on the psychometric properties of one or more of the nine measurement tools identified in Search 1. These studies were included in the analysis.

Abbey pain scale
Eight studies reported data on the psychometric properties of the Abbey Pain Scale [35-40, 43, 46]. Overall, there was limited evidence for the use of the Abbey Pain Scale (Table 3). There was inadequate evidence on PROM development, internal consistency (Cronbach: 0.65-0.74), crosscultural validity, and responsiveness (p < 0.001). There was adequate evidence for the assessment of construct validity (R = 0.49-0.91) and very good evidence for reliability (interrater: 0.75-0.88; intra-rater: 0.66-0.68). The level of evidence for structural validity was doubtful (Cronbach: 0.76).

Pain assessment in advanced dementia (PAINAD)
Twelve studies assessed the PAINAD [16, 20-24, 40, 44-47, 65]. Overall, the level of evidence for the PAINAD tool was limited (Table 3). Whilst there was an adequate level of evidence for construct validity (R = 0.48-0.88), very good level of evidence for internal consistency (Cronbach alpha:

Self-reported pain through verbal rating pain score
Ten studies assessed the psychometric properties of selfreported/verbal rating pain measures [27-29, 33-35, 42, 45, 51, 54]. Overall, there was limited evidence supporting the use of these tools (

ALGOPLUS
One study, performed in a French hospital setting, presented data on the psychometric properties of the ALGO-PLUS instrument [29]. This provided strong evidence for this tool (Table 3). Data reported very high construct validity (r 2 = 0.81; p < 0.001), very high inter-rater
Two studies reported data on the MOBID-2 [57,59] instrument. It demonstrated moderate evidence for use (Table 3). There was adequate evidence for PROM development and construct validity (R = 0.61), and measurement error (Standard Error of Measurement (SEM): 1.4). Whilst there was inadequate evidence for the responsiveness, the minimally clinically important difference (MCID) was reported as three points and reported to be responsive to treatment (p < 0.001). There was very good evidence for the MOBID-2 for internal consistency (Cronbach: 0.82-0.84) and reliability (inter-rater: 0.94; intra-rater: 0.85-0.92).

Discussion
The findings indicate strong and moderate evidence to support the use of the facial action coding system, PACSLAC and PACSLAC-II, CNPI, DOLOPLUS-2, ALGOPLUS, MOBID, and MOBID-2 tools. There is limited evidence for the Abbey Pain Scale, self-reported pain measures, and the PAINAD tool.
The literature highlights the challenges of assessing pain with people living with dementia [3,4,67]. Challenges have included insufficient time to use measurement tools [68,69], user's uncertainty over the reliability of these [70], access to physically finding and using the measurement tools [71], and perceived superiority of observational methods of behaviors and physical manifestations of pain [70]. Whilst there is a bias to observational manifestation in a number of the supported measurement tools recommended, the time to complete and interpret these may act as a further barrier to adoption. Consideration of such potential challenges may be made when exploring the implementation of recommended measurement tools.
Under-treatment of pain in people with dementia has been attributed to challenges in recognition and assessment of pain, coupled with reservations on polypharmacy and side effects of analgesia [72]. Achterberg et al. [73] highlighted the frequently seen scenario where people with dementia are prescribed analgesics, but due to concerns around side effects, particularly regarding non-steroidal anti-inflammatory drugs, opioids, and adjunct analgesics, the medications are either not administer or are at a sufficient dosage to manage symptoms. This was clearly illustrated in Roitto et al.'s [74] survey where although 19% of their 327 cohort of people living in nursing homes with dementia were prescribed opioids, 79% were still in pain. Whilst this study has highlighted potentially robust pain measurement tools for this population, implementing both the assessment and subsequent treatment to improve pain management is required.
Pain assessment ideally considers several pain dimensions. These include: intensity, location, affect, cognition, behavior, and social accompaniments [72]. Measurement tools, most notably the DOLOPLUS-2, are multi-dimensional. Conversely, self-reported VAS/NRS of observation are unidimensional. However, it is acknowledged that assessment of some dimensions, notably pain cognition, can be more challenging due to communication and cognitive barriers. Focusing on single dimensions should be avoided to negate the risks of under-reporting/under-representing pain experienced by individuals.
Whilst reliability and construct validity were well explored, there remains limited evidence of the responsiveness, structural validity, and measurement error for many of the identified measures. This may be a reason for why pain measurement tools are poorly adopted into practice. Improving confidence around how measurement tools are used and interpreted may promote the implementation of such tools. Furthermore, as observational tools were most widely assessed, understanding the 'normal' or familiar behaviors of a person with dementia is important to recognise when something abnormal or noxious is being felt. No studies assessed the difference in reliability or validity when the assessment was performed by a healthcare professional versus a close relative or friend who may be more familiar with the individual. This may be an important area for future study, particularly when considering the adoption of pain assessment instruments in community and non-health or social care profession settings.
This systematic review presents with a number of strengths and limitations. A major strength is the adoption of the COSMIN evaluation. This approach ensured that the reader could be fully informed on the confidence with the recommendations made based on the evidence. Three important limitations should be considered. First, a comprehensive approach to reporting the psychometric properties of the most frequently used measurement instruments in research was adopted to aid prioritisation. However, this meant measurement tools used in clinical practice but not trials may have been omitted. Second, given the methods adopted through Search 1 to identify potential measurement tools, more recent tools such as the ePAT were not included in the analysis [39]. Consideration of this and inclusion of forthcoming evidence on psychometric properties should be made to update the findings as new evidence evolves in the field. Second, there was insufficient evidence to assess differences in recommendations based on severity of dementia. Evaluation on the impact of severity of cognitive impairment on the performance of the identified measurement tools would be warranted. Finally, there were challenges cause by poor reporting within included studies. There was insufficient detail within included studies to ascertain whether pain assessment instruments assessed acute or chronic pain, or whether individuals were taking analgesia or not. This may impact on the generalisability of the findings into practice and should be consider when reporting future studies in this area.
To conclude, there is strong and moderate evidence to support the use of the facial action coding system, PAC-SLAC and PACSLAC-II, CNPI, DOLOPLUS-2, ALGO-PLUS, MOBID, and MOBID-2 tools for the assessment of pain with people living with dementia. Whilst these reflect measurement tools used in research, further consideration on how these reflect clinical practice, and lessons on how to implement these tools into practice should be considered to improve the detection and management of pain for people with dementia.
Author contributions All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by TS and KH. The first draft of the manuscript was written by TS and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding No funding was received to conduct this work.

Declarations
Conflict of interest No author disclose any financial or non-financial interests that are directly or indirectly related to the work submitted for publication.
Ethical approval Ethical approval was not required in relation to this systematic review.
Informed consent Informed consent was not required for this systematic review as human participants were not recruited for this study design.
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