A novel pain assessment tool incorporating automated facial analysis: interrater reliability in advanced dementia

Clinical Interventions in Aging, Jul 2018

A novel pain assessment tool incorporating automated facial analysis: interrater reliability in advanced dementia Mustafa Atee,1 Kreshnik Hoti,1,2 Richard Parsons,1 Jeffery D Hughes1 1School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia; 2Division of Pharmacy, Faculty of Medicine, University of Pristina, Prishtina, Kosovo Objectives: Regardless of its severity, dementia does not negate the experience of pain. Rather, dementia hinders self-reporting mechanisms in affected individuals because they lose the ability to do so. The primary aim of this study was to examine the interrater reliability of the electronic Pain Assessment Tool (ePAT) among raters when assessing pain in residents with moderate-to-severe dementia. Secondly, it sought to examine the relationship between total instrument scores and facial scores, as determined by automated facial expression analysis. Study design: A 2-week observational study. Setting: An accredited, high-care, and dementia-specific residential aged care facility in Perth, Western Australia. Participants: Subjects were 10 residents (age range: 63.1–84.4 years old) predominantly with severe dementia (Dementia Severity Rating Scale score: 46.3±8.4) rated for pain by 11 aged care staff. Raters (female: 82%; mean age: 44.1±12.6 years) consisted of one clinical nurse, four registered nurses, five enrolled nurses, and one care worker. Measurements: ePAT measured pain using automated detection of facial action codes and recordings of pain behaviors. Results: A total of 76 assessments (rest =38 [n=19 pairs], movement =38 [n=19 pairs]) were conducted. At rest, raters’ agreement was excellent on overall total scores (coefficient of concordance =0.92 [95% CI: 0.85–0.96]) and broad category scores (κ=1.0). Agreement was moderate (κ=0.59) on categorical scores upon movement, while it was exact in 68.4% of the cases. Agreement in actual pain category scores gave κw=0.72 (95% CI: 0.58–0.86) at rest and κw=0.69 (95% CI: 0.50–0.87) with movement. All raters scored residents with higher total scores post-mobilization compared to rest. More facial action unit codes were also detected during pain (mean: 2.5 vs 1.9; p<0.0012) and following mobilization (mean: 2.5 vs 1.7; p<0.0001) compared to no pain and rest, respectively. Conclusions: ePAT, which combines automated facial expression analysis and clinical behavioral indicators in a single observational pain assessment tool, demonstrates good reliability properties, which supports its appropriateness for use in residents with advanced dementia. Keywords: interrater reliability, ePAT, pain, pain assessment, PainChek®, dementia, facial action units, automated facial expression analysis, total pain scores

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A novel pain assessment tool incorporating automated facial analysis: interrater reliability in advanced dementia

Clinical Interventions in Aging A novel pain assessment tool incorporating automated facial analysis: interrater reliability in advanced dementia Mustafa Atee 1 Kreshnik hoti 0 1 richard Parsons 1 Jeffer y D hughes 1 0 Division of Pharmacy, Faculty of Medicine, University of Pristina , Prishtina, Kosovo 1 school of Pharmacy and Biomedical sciences, Faculty of health sciences, Curtin University , Bentley, WA , Australia PowerdbyTCPDF(ww.tcpdf.org) Objectives: Regardless of its severity, dementia does not negate the experience of pain. Rather, dementia hinders self-reporting mechanisms in affected individuals because they lose the ability to do so. The primary aim of this study was to examine the interrater reliability of the electronic Pain Assessment Tool (ePAT) among raters when assessing pain in residents with moderateto-severe dementia. Secondly, it sought to examine the relationship between total instrument scores and facial scores, as determined by automated facial expression analysis. Study design: A 2-week observational study. Setting: An accredited, high-care, and dementia-specific residential aged care facility in Perth, Western Australia. Participants: Subjects were 10 residents (age range: 63.1-84.4 years old) predominantly with severe dementia (Dementia Severity Rating Scale score: 46.3±8.4) rated for pain by 11 aged care staff. Raters (female: 82%; mean age: 44.1±12.6 years) consisted of one clinical nurse, four registered nurses, five enrolled nurses, and one care worker. Measurements: ePAT measured pain using automated detection of facial action codes and recordings of pain behaviors. Results: A total of 76 assessments (rest =38 [n=19 pairs], movement =38 [n=19 pairs]) were conducted. At rest, raters' agreement was excellent on overall total scores (coefficient of concordance =0.92 [95% CI: 0.85-0.96]) and broad category scores (κ=1.0). Agreement was moderate (κ=0.59) on categorical scores upon movement, while it was exact in 68.4% of the cases. Agreement in actual pain category scores gave κw=0.72 (95% CI: 0.58-0.86) at rest and κw=0.69 (95% CI: 0.50-0.87) with movement. All raters scored residents with higher total scores post-mobilization compared to rest. More facial action unit codes were also detected during pain (mean: 2.5 vs 1.9; p0.0012) and following mobilization (mean: 2.5 vs 1.7; p0.0001) compared to no pain and rest, respectively. Conclusions: ePAT, which combines automated facial expression analysis and clinical behavioral indicators in a single observational pain assessment tool, demonstrates good reliability properties, which supports its appropriateness for use in residents with advanced dementia. - 8 1 0 2 l u J 6 1 n o 3 7 . 7 1 1 . 7 3 . 4 5 y b / m o c . s s e r .vdoepw l.syeon w u /w la / :s on ttp rs h ep from roF d e d a o l n w o d g n i g A n i s n o it n e v tr e n lI a c ili n C or emotional aggression from residents.5 This problem is in part due to lack of self-report and inadequate identification of pain resulting in its subsequent poor management in this vulnerable population.6 There is strong evidence to suggest that behavioral and psychological symptoms of dementia (BPSD) are often associated with uncontrolled underlying pain from clinical and observational studies.7–9 Moreover, in a large Swedish cohort (n=120,067) study of older adults (75 years) with advanced dementia, 38.6% received at least one medication of questionable benefit including psychotropic drugs in their final year of life.10 Delayed identification of pain may also influence drug-prescribing patterns. In a recent Italian study of nursing home patients, psychotropic drugs were among the top 10 most commonly prescribed drugs (quetiapine ranked fifth).11 Pain has also been reported to be significantly associated with BPSD, higher number of antipsychotic prescriptions, reduced quality of life, and premature mortality.12 Regardless of its severity, dementia does not negate the experience of pain although there is evidence that pain processing may be altered.13–15 It is inferred that pain experience might be increased in individuals with Alzheimer’s dementia as evident in pain responses recorded from brain activity and facial expressions.13,16–19 Of particular importance, patients with dementia are more facially expressive than healthy subjects when they display pain.20 In the absence or lack of self-rating report, facial expressions become an essential component of communicating the existence of pain, particularly for those with dementia.20 Facial expressions provide instant and brief signals to alert the onlooker. Facial descriptors are also valid indicators in observational pain scales for nonverbal patients with dementia.21 However, reliability of observers in identifying these descriptors is often low because included items are generic, vague, and not able to be consistently recorded.22 Further, these descriptors such as “grimacing” in the Pain Assessment Checklist for Seniors with Lim (...truncated)


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Mustafa Atee, Kreshnik Hoti, Richard Parsons, Jeffery D Hughes. A novel pain assessment tool incorporating automated facial analysis: interrater reliability in advanced dementia, Clinical Interventions in Aging, 2018, pp. 1245-1258, DOI: 10.2147/CIA.S168024