노인간호학회지제 18 권제 3 호, 2016 년 12 월 J Korean Gerontol Nurs Vol.18 No.3, 147-158 pissn 2384-1877 eissn 2383-8086 http://dx.doi.org/10.17079/jkgn.2016.18.3.147 노인을위한비언어적통증사정도구에관한문헌고찰 이경미 송준아 고려대학교간호대학 Nonverbal Pain Measurement for Elders: A Literature Review Lee, Kyung Mi Song, Jun-Ah College of Nursing, Korea University, Seoul, Korea Purpose: The aim of this was to review studies on nonverbal pain measurement for elderly people. Methods: Through a literature search of the databases including RISS, Medline, and the Cumulative Index to Nursing and Allied Health Literature, a total of 41 studies published between January 2000 and June 2016 were identified. A comprehensive review was performed guided by a framework developed by the researchers. Results: Nine nonverbal pain measurement scales that were mentioned more than twice in the selected studies were identified. Facial expression, verbalization and vocalization, and body movements were categories presented in all of the scales. The Pain Assessment In Advanced Dementia Scale (PAINAD) was most frequently reported in studies and the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) showed the highest internal consistency (Cronbach's =.73~.92) while the Doloplus-2 showed the highest inter-rater reliability (r=.77~.97) and the PAINAD and the highest concurrent validity (r=.65~.95). Conclusion: The PAINAD, PACSLAC, and Doloplus-2 are useful scales for use with elders. However, it is difficult to conclude which scale is the most appropriate because of insufficient evidence. More methodological studies are necessary to examine reliability, validity and clinical utility of the measures identified above. Key Words: Aged, Pain measurement, Review 서론 1. 연구의필요성 전세계적으로 65세이상노인인구가증가하고있어인구중 65세이상비율은 2015년 8.2% 에서 2060년 17.6% 로증가할전망이다. 더구나우리나라의고령화는급속도로진행되고있어, 2015년고령인구의비중은 13.1% 로 1960년에비해 4.5 배증가한수준이며, 2030년에는 24.3% 로 2060년에는 40.1% 로증가할것으로보고되고있다 [1]. 이렇게급속도로고령화사회에접어들고평균수명의증가에따라노년기의건강관리및삶의질에대한관심또한증가하고있다 [2]. 통증이란실제로일어나거나혹은아직은잠재적인조직손상과관련되어나타나는불쾌한감각적및정서적경험을말한다 [3]. 이러한통증은주관적이고개인적인것으로, 기억 감정 문화등에도연관되는복합적현상이다. 통증은급성통증과만성통증으로분류되며, 만성통증은 3개월이상지속되는통증을의미한다 [4]. 전체노인인구의약 89.2% 는한가지 주요어 : 노인, 통증사정도구, 문헌고찰 Corresponding author: Song, Jun-Ah College of Nursing, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Korea. Tel: +82-2-3290-4921, Fax: +82-2-927-9107, E-mail: jasong@korea.ac.kr Received: Oct 5, 2016 / Revised: Nov 4, 2016 / Accepted: Nov 21, 2016 This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2016 Korean Gerontological Nursing Society http://jkgn.org
이경미 송준아 이상의만성질환을앓고있는것으로조사되었는데 [5], 노인들이가지고있는만성질환과노화로인한신체변화로노인의 89% 정도가통증을경험하는것으로보고되고있다. 지역사회거주노인들의 35~45% 가일상적인통증을겪고있으며, 노인요양시설거주노인의 45~85% 가만성통증을겪는것으로나타났다 [6]. 노인의만성통증은우울, 불안, 낙상, 영양불균형, 인지능력저하, 수면부족, 일상생활과사회적활동능력저하, 의료비증가, 삶의질감소등을유발한다 [6]. 이렇게노인의만성통증은신체적인문제뿐아니라심리적, 사회적인기능장애를초래하므로지속적이고체계적인만성통증관리의필요성이부각되고있다 [7]. 정확한통증사정은통증을체계적으로관리하고치료하기위해필수적이다. 하지만대부분의노인이만성통증을겪고있음에도노인의통증사정은어려운부분이다 [8]. 노인의정확한통증사정을가로막는문제는노인환자측면, 의료진측면, 구조적측면에서존재한다 [9]. 노인환자의측면에서가장큰문제는인지장애이며, 이외에도성인을위한통증사정도구사용의어려움이보고되었다. 의료진의문제는노인의통증을정상적인노화과정또는망상이나치매로만간주하는것이며, 또한, 구조적인문제로노인의적절한통증사정및조절에대한논의가제대로이루어지지않는것으로제시되었다. 이러한다양한문제로인한부정확한통증사정은결과적으로노인이겪고있는만성통증에대한적절한처치가이루어지지않게한다 [6]. 따라서간호사는노인의통증을정확하게사정하고이를적절하게관리하여노인의삶의질을높이도록도와주어야한다 [10]. 통증은주관적이고개인적인것으로, 기억 감정 문화등에도연관되는복합적현상이다 [11]. 따라서대상자의통증에 대한자가보고가통증사정에가장정확하고중요한자료이다 [8,11]. 일반적인성인대상자에게사용하는자가보고식통증사정도구로는숫자척도도구 (Numeric Rating Scale, NRS), 언어적서술형척도 (Verbal Descriptive Scale, VDS), 얼굴표정척도 (Face Pain Scale, FPS) 등이있다. 하지만이러한자가보고식통증사정도구들은노인에게적용하는데에많은어려움이있는데, 이는인지능력의저하, 의사소통의어려움등을가진노인에게정확한통증을언어로전달하는것은어렵기때문이다 [12]. 그런이유로인지능력의저하로인해통증사정도구에대한이해도가낮아지고의사소통이불가능한노인에게자가보고식통증사정도구는신뢰도가떨어져사용이추천되지않고있다 [13]. 이러한문제를해결하기위해 1990년대중반이후부터세계적으로다양한비언어적통증사정도구가개발되어왔다. 비언어적통증사정도구는행동변화의관찰을기본으로하고있다. 이러한행동과기능의변화를관찰하는것은수면, 식욕, 신체활동, 얼굴표정및몸짓언어등을포함한다 [14]. 미국노인병학회에서는비언어적통증사정시얼굴표정, 구두 / 발성, 신체움직임, 상호작용변화, 일상생활패턴변화, 정신상태변화의 6가지행동지표영역 (Table 1) 을포함할것을권유하고있다 [15]. 이중구두 / 발성은통증이있음을언어로적절하게표현하기보다는통증과관련된행동의일부로한숨쉬기, 신음소리내기, 거친숨소리, 단순하고반복적인중얼거림, 누군가를지속적으로부르기, 욕하기등의의미없는음성 ( 예 : 등 ) 을내는경우를의미하는것으로언어적표현이제한된노인환자에서주의깊게관찰해야할통증관련행동으로제시되어있다. 심각한인지장애를겪고있는노인환자에게는비언어적통증사정도구를통한통증사정이효과적인것으로나 Table 1. Pain Behavior and Indicators Facial expressions Verbalizations, vocalizations Body movements Change in interpersonal interactions Change in activity patterns or routines Slight frown, sad, frightened face, grimacing, wrinkled forehead, closed or tightened eyes, any distorted expression, rapid blinking Sighing, moaning, groaning, grunting, chanting, calling out, noisy breathing, asking for help, verbally abusive Rigid, tense posture, guarding fidgeting, increased pacing, rocking, restricted movement, gait or mobility changes Aggressive, combative, resisting care, decreased social interactions, socially inappropriate, disruptive, withdrawn Refusing food, appetite change, increase in rest periods or sleep, changes in rest patterns, sudden cessation of common routines, increased wandering Mental status changes Crying or tears, increased confusion, irritability or distress Source: American Geriatrics Society Panel on Persistent Pain in Older Persons. Journal of the American Geriatrics Society. 2002. 148 Journal of Korean Gerontological Nursing
노인을위한비언어적통증사정도구에관한문헌고찰 타났다 [16]. 이렇게개발된다양한도구들은여러나라의언어로번역되어사용되어지고도있다 [14]. 하지만우리나라에서비언어적통증사정도구에관한연구는한국어판 Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) 에대한논문이한편있을뿐 [13], 비언어적통증사정도구에관한논문을체계적으로살펴본연구는없으며비언어적통증사정도구를적용함에있어발전적방향을제시하는연구는아직까지부족한편이다. 이러한제한점을보완하기위해국내 외의선행연구들을분석하고검토하는것이필요하다. 이에본연구는노인을위한비언어적통증사정도구에관련된국내 외연구를분석하고검토하여, 향후우리나라노인을위한비언어적통증사정도구의개발및연구가이루어질수있도록하기위한기초자료를제공하기위하여실시되었다. 2. 연구목적본연구는 2000년에서 2016년까지국내 외전문학술지에개제된노인을위한비언어적통증사정도구에관한문헌들을고찰하고이를바탕으로향후연구방향을제시하고자하였으며, 구체적인목적은다음과같다. 비언어적통증사정도구에관한연구들의일반적인특성을파악한다. 분석대상문헌들이채택한비언어적통증사정도구를비교검토한다. 연구방법 1. 연구설계 본연구는노인을위한비언어적통증사정도구에대한선행연구들을비교 분석하는서술적조사연구이다. 2. 연구대상및자료수집본연구는문헌고찰연구로생명윤리심의위원회의심의면제대상연구이다. 본연구의대상논문의선정기준은 2000년 1 월부터 2016년 6월까지국내 외학술지에개제된논문들로, 문헌검색은한국교육학술정보원 (RISS), Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL) 의데이터베이스를이용하여이루어졌다. 자료수집기간은 2016년 7월부터 8월까지였다. 자료수집을위해문헌을검색할때사용한검색어는 aged, pain measurement 를주요개념으로하였다. 또한, 자료의누락방지를위해 old, elderly, senior, older people 과 pain scale, 'pain assessment 를추가검색어로사용하였다. 이렇게검색된문헌내에서 nonverbal, observational, behavioral 등을포함하는문헌을검색하였다. 1차적으로 RISS에서 3편, Medline에서 1073편, CINAHL 에서 574편의논문이검색되었다. 이중제목을통해포함기준에부합하지않는논문 1166편을제외하였다. 이후 RISS에서 1편, Medline에서 338편, CINAHL에서 145편의논문이선정되었다. 다음으로중복되는 127편의논문이제외되었으며, 추가적으로제목과초록고찰을통해본연구의주제와관련이없다고판단되는논문을제외하였다. 최종적으로총 54편의논문이분석대상으로선정되었으나, 분석과정중결과에혼돈을줄수있는문헌고찰연구 13편을제외하였다. 최종적으로 41편의연구가선정되었다. 자료수집절차의흐름도는 Figure 1과같다. 3. 연구의분석틀및자료분석본연구의분석틀은선행연구 [14,17,18] 들을참조하고본연구의목적에맞게수정하여작성하였다. 분석틀은크게 4가지의요소로구성되어있으며구체적인내용은다음과같다. 첫째, 선정된연구들의일반적인특성을분석하기위한변수로발표년도, 출판국가, 연구설계, 표본수, 연구에사용된도구들을포함하였다. 둘째, 문헌고찰연구는분석과정중결과에혼돈을줄수있다고판단되어최종적으로제외되었다. 그이유는문헌고찰연구의경우언급되어지는통증사정도구가많아본연구의주제와일치하지않는도구들이포함되었으며, 도구들의신뢰도및타당도에대한보고가연구자의분석기준에따라변형되어있어본연구의결과에혼돈을줄수있기때문이다. 셋째, 비언어적통증사정도구는분석한연구들내에서적어도 2회이상언급된도구들로선정되었다. 이는노인에게주로사용되어연구가많이진행된도구들을위주로분석하기위한연구자의의도에의한것이었으며, 따라서, 1회만언급된도구들은분석대상에서제외되었다. 넷째, 비언어적통증사정도구의비교분석을위해도구의개발자및개발년도, 항목수, 점수범위, 타당도및신뢰도등 Vol. 18 No. 3, 2016 149
이경미 송준아 Table 2. General Characteristics of the Selected Literature (N=41) Year Author Nation Method Sample (size) Tools 2000 Feldt USA Prospective B(83) CNPI comparative 2003 Warden et al. USA Instrument Villanueva et al. USA Instrument 2004 Abbey et al. Australia Instrument Fuchs-Lacelle & Hadjistavropoulos Canada Instrument 2005 Hølen et al. Norway Methodological 2006 Cohen-Mansfield USA Instrument Hutchison et al. USA Randomized A(19) A (25 & 40)* A (52 & 61)* A (28 & 80 & 80)* A(59) A(80) B(80) PAINAD PADE Abbey PACSLAC Doloplus-2 PAINE PAINAD Zwakhalen et al. Netherlands Observational A (128) PAINAD, PACSLAC, Doloplus-2 Leong et al. Singapore Validation A (88) PAINAD 2007 Morello et al. France Randomized B (340) EPCA-2 Horgas et al. USA Validation B(40) NOPPAIN Hølen et al. Norway Methodological B(73) Doloplus-2 Zwakhalen et al. Netherlands Observational A (128) PACSLAC Husebo et al. Norway Instrument Pautex et al. Switzerland Prospective clinical Cervo et al. USA Instrument Costardi et al. Italy Methodological A(26) A (180) A (182) A(20) MOBID Doloplus-2 CPAT PAINAD 2008 DeWaters et al. USA Validation B (25) PAINAD Choeng & choi New Observational A (50) PACSLAC Zealand Mahoney & Peters Australia Randomized A (112) 2009 Zwakhalen et al. Netherlands Observational A (117) PACSLAC Cervo et al. USA Instrument A (145) CNPI=Checklist of nonverbal pain indicators; PAINAD=Pain assessment in advanced dementia scale; PADE=Pain assessment for the dementing elderly; Abbey=The abbey pain scale; PACSLAC=Pain assessment checklist for seniors with limited ability to communicate; PAINE=Pain assessment in noncommunicative elderly persons; EPCA=The elderly pain caring assessment; NOPPAIN=Non-communicative patient's pain assessment instrument; MOBID=Mobilization-observation-behavior-intensity-dementia pain scale; CPAT=The certified nursing assistant pain assessment tool; MPS=The mahoney pain scale; A=Elderly with dementia; B=Elderly with cognitive impairment; *More than two separate studies. MPS CPAT 150 Journal of Korean Gerontological Nursing
노인을위한비언어적통증사정도구에관한문헌고찰 Total 1,650 identified -3 through RISS -1,073 through MEDLINE -574 through CINAHL Total 484 screened -1 through RISS -338 through MEDLINE -145 through CINAHL 1,166 removed as not meeting inclusion criteria 127 removed as duplication studies 357 studies 54 studies 303 excluded mainly due to - not older adults - not nonverbal assessment scales - not in English 13 literature review studies removed 41 studies Figure 1. Flow chart of the literature selection. 을포함하였다. 또한, 미국노인병학회에서비언어적통증사정시포함하도록권고하는 6가지의행동지표영역 [15] 의포함여부를추가하였다. 도구의타당도와신뢰도는분석한논문들의결과의범위로포함하였으며, 각각의도구의특성, 유용성과제한점등에대해분석하였다. 연구결과 1. 분석대상문헌들의일반적인특성 분석에포함된연구들의일반적인특성을파악하기위하여발표년도, 저자명, 출판국가, 연구설계, 표본대상자및표본수, 연구에포함된도구들로분류하였고그결과는 Table 2와같다. 발표년도를살펴본결과 2007년이 8편 (19.5%) 으로가장많이발표되었다. 2000년부터 2005년사이에 6편 (14.6%), 2006 년부터 2010년사이 23편 (56%) 의연구가발표되었다. 2011년부터현재까지 12편 (29.2%) 이발표되었다. 출판국가를보면총 41편중미국이 10편 (24.3%) 으로가장많았으며, 다음으로노르웨이 5편 (12.1%), 캐나다와네덜란드 가 4편 (9.7%) 를차지하였다. 유럽의다양한나라에서많은연구가진행되었으며총 15편 (36.5%) 를차지하였다. 반면, 아시아에서진행된연구는일본 3편, 중국 2편, 싱가포르와말레이시아, 한국에서각 1편으로총 8편 (19.5%) 에불과하였다. 오세아니아역시연구가많이진행되지않았는데, 호주 3편 (7.3%), 뉴질랜드 1편 (2.4%) 에불과하였다. 연구설계는도구개발연구가 10편 (24.3%) 으로가장많았고, 도구의신뢰도와타당도를검증하는방법론적연구가 8편 (19.5%) 을차지하였다. 표본대상자는치매노인이 27편 (65.8%) 으로가장많았으며, 다음으로인지장애를가진노인이 12편 (29.2%) 을차지하였다. 그외에언어능력이손상된노인을대상으로한연구 1편 (2.4%) 과수술을받은노인환자를대상으로한연구 1편 (2.4%) 이있었다. 표본수는최소 19명에서최대 600명까지다양하였고 ( 평균 136.6명 ), 이중 30명미만을대상으로한연구가 4편 (9.7%) 이었다. 2. 비언어적통증사정도구의특성분석대상연구들에서언급된비언어적통증사정도구는총 14개였다. 이중 2회이상언급된도구를선정하여분석하였 Vol. 18 No. 3, 2016 151
이경미 송준아 Table 2. General Characteristics of the Selected Literature (Continued) (N=41) Year Author Nation Method Sample (size) Tools 2010 Takai et al. Japan Methodological A (171) Abbey Pickering et al. France Multicentre C (342) Doloplus-2 Lin et al. China Methodological Ersek et al. USA Randomized Husebo et al. Norway Instrument Ando & Hishinuma Japan Methodological A (156) B (60) A (770 A (21 & 31)* PAINAD CNPI, PAINAD MOBID-2 Doloplus-2 2011 Jordan et al. UK Observational A(79) PAINAD 2012 Lints-Martindale et al. Canada Randomized A (124) ADD, CNPI, PADE, PACSLAC, PAINAD, NOPPAIN Mosele et al. Italy Prospective B (600) PAINAD Zwakhalen et al. Netherlands Observational A (22) PACSLAC 2013 Kaasalainen et al. Canada Observational A (338) PACSLAC, PACI Lukas et al. Australia Randomized B (125) Abbey, PAINAD, NOPPAIN 2014 Guo et al. China Prospective D (93) PAINAD, CNPI Chan et al. Canada Instrument Takai et al. Japan Methodological Husebo et al. Norway Randomized Kim et al. Korea Methodological B (124) B(88) A (352) A (307) PACSLAC, PACSLAC-II Abbey MOBID-2 PACSLAC 2015 Ngu et al. Malaysia Observational B (152) PAINAND CNPI=Checklist of nonverbal pain indicators; PAINAD=Pain assessment in advanced dementia scale; PADE=Pain assessment for the dementing elderly; Abbey=The abbey pain scale; PACSLAC=Pain assessment checklist for seniors with limited ability to communicate; PAINE=Pain assessment in noncommunicative elderly persons; EPCA=The elderly pain caring assessment; NOPPAIN=Non-communicative patient's pain assessment instrument; MOBID=Mobilization-observation-behavior-intensity-dementia pain scale; ADD=Assessment of discomfort in dementia; A=Elderly with dementia; B=Elderly with cognitive impairment; C=Elderly with communication disorder; D=Older surgical patients; *More than two separate studies. 다. 1회씩만언급된도구는총 5개로분석대상에서제외되었다. 따라서, 분석에포함된비언어적통증사정도구는총 9개였으며, 이도구들의특성을파악하기위해도구의이름, 항목수와점수범위, 미국노인병학회가권고하는행동지표 6가지영역, 신뢰도및타당도, 유용성및제한점등으로분류하였고그결과는 Table 3과같다. 분석대상연구들에서비언어적통증사정도구의용어는행 동관련통증척도 (behavioral pain scales), 관찰통증척도 (observational pain scales), 통증행동관찰도구 (pain behavior observational tools) 등으로각각다르게표현되었다. 가장많이언급된도구는 Warden 등 (2002) 이개발한 Pain Assessment In Advanced Dementia Scale (PAINAD) 로총 14편 (34.1%) 에등장하였다. 다음으로는 Fuchs-Lacelle과 Hadjistavropoulos (2002) 의 Pain Assessment Checklist for 152 Journal of Korean Gerontological Nursing
노인을위한비언어적통증사정도구에관한문헌고찰 Table 3. Nonverbal Pain Assessment Tools (N=41) Name of the tool, development author (year, nation) Dimensions & Items/total score range AGS guidelines Author (year) Paper reviewed in the present Reliability (Cronbach's ) Validity Clinical usefulness/ Limitations n(%) PAINAD (Pain Assessment In Advanced Dementia Scale), Warden, Hurley and Voliver. (2002, USA) 5items /0~10 1,2,3 Warden et al. (2003), Hutchison et al. (2006) Zwakhalen et al. (2006), Leong et al. (2006), Costardi et al. (2007), DeWaters et al. (2008), Lin et al. (2010), Ersek et al. (2010), Jordan et al. (2011), Lints-Martindale et al. (2012), Mosele et al. (2012), Lukas et al. (2013), Guo et al. (2014), Ngu et al. (2015) (n=8):.55~.90 Inter-rater (n=4):.70~.87 Intra-rater (n=3):.71~.89 Not found (n=5) (n=7): r=.65~.95, p <.001~.01 Discriminant validity (n=2): p <.001 Not found (n=6) Easytouseafterminimaltraining, takes less than 5 minutes to complete, English version available / Often clustered around 0 (reflecting absence of pain), Score interpretation not available 14 (34.1) PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability to Communicate), Fuchs-Lacelle & Hadjistavropoulos (2002, Canada) 60 items, 4dimensions /0~60 1,2,3,4,5,6 Fuchs-Lacelle & Hadjistavropoulos (2004), Zwakhalen et al. (2006), Zwakhalen et al. (2007), Choeng & Choi (2008), Zwakhalen et al. (2009), Lints-Martindale et al. (2012), Zwakhalen et al. (2012), Kaasalainen et al. (2013), Chan et al. (2013), Kim et al. (2014) (n=6):.73~.92 Inter-rater (n=6):.63~.96 Intra-rater (n=2):.86~.95 Not found (n=2) (n=5): r=.39~.89, p <.001~.05 Discriminant validity (n=2): p <.001 Not found (n=4) Comprehensive, significant, long but simple list, feasible for all nurses, takes 5 minutes to complete, English version available / Score interpretation not available 10 (24.3) Doloplus-2, Wary et al (1992, Frnace) 10 items, 3dimensions /0~30 1,2,3,4,5 Hølen et al. (2005), Zwakhalen et al. (2006), Hølen et al. (2007), Pautex et al. (2007), Pickering et al. (2010), Ando & Hishinuma (2010) (n=2):.70~.74 Inter-rater (n=3):.77~.97 Intra-rater (n=1):.95~.99 Not found (n=1) (n=2): r=.36, p <.01 Not found (n=4) French, English version available, takes a few minutes to complete, cut-off score given ( 5 indicates pain), reflects progression of pain / English version needs more testing, Some items seem difficult to interpret, cut-off score is too low 6 (14.6) Abbey (The Abbey Pain Scale), Abbey et al. (2004, Australia) 6items /0~18 1,2,3,4,5,6 Abbey et al. (2004), Takai et al. (2010), Lukas et al (2013), Takai et al. (2014) (n=3):.64~.76 Inter-rater (n=1):.82 Intra-rater (n=1):.65 Not found (n=1) (n=2): r=.49~.58, p <.001~.01 Not found (n=2) For people with end-stage dementia, English version available, Score interpretation available ( < 3 no pain, 3~7 mild pain, 8~13 moderate pain, >14 severe pain), takes only 1 minute / Lacks conceptual clarity, scoring instruction not available, item definitions are lacking, 4 (9.7) 1. Facial expressions; 2. Verbalizations, vocalizations; 3. Body movements; 4. Changes in interpersonal interactions; 5. Changes in activity patterns or routines; 6. Mental status changes. Vol. 18 No. 3, 2016 153
이경미 송준아 Table 3. Nonverbal Pain Assessment Tools (Continued) (N=41) Name of the tool, development author (year, nation) Dimensions & Items/total score range AGS guidelines Author (year) Paper reviewed in the present Reliability (Cronbach's ) Validity Clinical usefulness/ Limitations n(%) CNPI (The Checklist of Nonverbal Pain Indicators), Feldt (2000, USA) 6items (rest vs. movement) /0~6 1,2,3 Feldt (2000), Ersek et al. (2010), Lints-Martindale et al. (2012), Guo et al. (2014) (n=4):.06~.97 (rest),.60~.90 (movement) Inter-rater (n=2):.25~.70 (n=4): r=.33~.95, p <.001~.01 Designed to measure chronic pain, English version available, score interpretation available (1~2 mild pain, 3~4 moderate pain, 5~6 severe pain), Easy to use / Pain at rest correlated poorly, poor psychometric qualities, needs more testing, score range is too narrow 4 (9.7) NOPPAIN (The Non-Communicative Patient's Pain Assessment Instrument), Snow et al. (2004, USA) 4sections, 17 items /0~30 1,2,3 Horgas et al. (2007), Lints-Martindale et al. (2012), Lukas et al. (2013) (n=1):.41~.48 Inter-rater (n=2):.73~.91 Not found (n=1) (n=2): r=.39~.70, p <.001~.01 Not found (n=1) Easy to use and understanding, English version available for use by nursing assistants, Takes 30 seconds to score after 5 minutes for observation / Interpretation not available, unclear scoring procedures, 3 (7.3) MOBID-2 (Mobilization-Observation-Behavior-Int ensity-dementia Pain Scale), Husebo et al. (2007, Norway) 2sections, 10 items /0~10 1,2,3 Husebo et al. (2007), Husebo et al. (2010), Husebo et al. (2014) (n=2):.82~.89 Inter-rater (n=2):.86~.94 Intra-rater (n=1):.72~.92 (n=2): r=.38~.64, p <.005 Not found (n=1) Takes 5 minutes to complete, English version available, Including pain location / Scoring Interpretation not available, difficult scoring procedures 3 (7.3) PADE (Pain Assessment in Dementing Elderly), Villanueva et al. (2003, USA) 3parts, 24 items /0~96 1,2,3,4,5 Villanueva et al. (2003), Lints-Martindale et al. (2012) (n=2):.13~.88 Inter-rater (n=2):.54~.91 (n=2): r=.29~.71, p <.001~.01 Takes 10 minutes to score, English version available, / Difficult format due to different scoring methods, long list, scoring interpretation not available, 2 (4.8) CPAT (Certified Nurse Assistant Pain Assessment Too)l, Cervo et al. (2007, USA) 5items /0~5 1,2,3,5 Cervo et al. (2007), Cervo et al. (2009) (n=1):.75 Inter-rater (n=1):.71 Intra-rater (n=1):.67 Not Found (n=1) (n=1): r=.22 p=.076 Not found (n=1) Easy to use, Guideline on scoring available, Interpretation available ( 1 pain evaluation required), takes 1 minute to score, for use by nursing assistants / Score range is too narrow, Needs more testing 2 (4.8) 1. Facial expressions; 2. Verbalizations, vocalizations; 3. Body movements; 4. Changes in interpersonal interactions; 5. Changes in activity patterns or routines; 6. Mental status changes. 154 Journal of Korean Gerontological Nursing
노인을위한비언어적통증사정도구에관한문헌고찰 Seniors with Limited Ability to Communicate (PACSLAC) 가 10편 (24.3%) 언급되었다. 그외에도 Doloplus-2 (6편, 14.6 %), Abbey (4편, 9.7%), The Checklist of Nonverbal Pain Indicators (CNPI)(4편, 9.7%), The Non-Communicative Patient's Pain Assessment Instrument (NOPPAIN)(3편, 7.3%), Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (MOBID-2)(3편. 7.3%), Pain Assessment in Dementing Elderly (PADE)(2편, 4.8%), Certified Nurse Assistant Pain Assessment Tool (CPAT)(2편, 4.8%) 의도구들이연구되었다. 분석된비언어적통증사정도구들의항목수는 5개부터 60 개까지다양하였으며, 이중 PACSLAC가 60개로가장많은항목수를가진도구로나타났다. 미국노인병학회에서권고하는 6가지행동지표영역을포함하는지여부와관련하여서는비언어적통증사정도구들이최소 3가지영역은모두포함하였으며, 가장많은영역을포함하는도구는 PACSLAC와 Abbey로상기 6가지영역을모두포함하는것으로나타났다. 분석된도구들은모두얼굴표정, 구두 / 발성, 신체움직임의세영역을포함하고있었다. 분석대상문헌들은대부분도구들의신뢰도와타당도를검증하여제시하고있다. 41편의연구에서 11편을제외한연구에서신뢰도와타당도를제시하였다. 신뢰도는내적일관성, 평가자간신뢰도, 평가자내신뢰도가검증되었으며, 타당도는동시타당도와변별타당도로검증되었다. 각연구에서검증된모든신뢰도와타당도는최솟값과최댓값의범위로제시하였다. 총 9개의도구들의내적일관성신뢰도는.06부터.97, 평가자간신뢰도는.25~.97로다양하게나타났다. 동시타당도는.22부터.95로나타났다. 각도구의내적일관성신뢰도는 PACSLAC (.73~.92), PAINAD (.55~.90) 순으로높게나타났으며, 평가자간신뢰도는 Doloplus-2 (.77~.97), PACSLAC (.63~.96) 순으로높게나타났다. 동시타당도의경우 PAINAD (.65~.95) 와 CNPI (.33~.95) 가높은것으로나타났다. 문헌들에서는각도구들의유용성및제한점을제시하고있었다. 도구를이용하여통증을측정하는데걸리는시간은 5 분에서 10분으로나타났으며, Abbey와 CPAT가 1분으로가장적은시간이걸렸다. 반면에 PADE는 10분으로가장많은시간이걸리는것으로나타났다. 특히, MOBID-2와 PADE는점수를측정하는과정이복잡하고어려워훈련이필요한것으로보고되었다. 측정된점수에대한해석은 Abbey, CNPI, CPAT만이가진것으로나타났으며, Doloplus-2의경우는통 증여부를판별하는 Cut-off score만을가지고있었다. 도구들은대부분간호사를위해개발된것이었으며, NOPPAIN과 CPAT의경우간호조무사를위해개발된도구였다. 총 9개의비언어적통증사정도구중문헌에서의언급횟수, 신뢰도및타당도, 유용성및제한점을조합해보면, PAINAD, PACSLAC, Doloplus-2의세도구가전세계적으로연구가많이진행되며유용한것으로확인되었다. 논의 본연구는 2000년부터최근까지노인을대상으로한비언어적통증사정도구에대한선행연구를고찰하고, 연구들에서언급되어진비언어적통증사정도구의특성에대해분석하였다. 본분석을통하여최근까지의노인을위한비언어적통증사정도구에대한전세계적연구동향을파악할수있었으며, 향후노인대상자의비언어적통증사정을위해진행되어야할연구를위한기초자료를제공하고자하였다. 본연구의분석대상문헌 41편중 2006년부터 2010년사이에발표된연구가 23편 (56%) 으로절반을차지하였다. 이것은 2000년대초반에는도구의개발이시작되는시기라많은연구가진행되지않았으나, 여러도구들이개발된 2006년부터후속연구가진행된것을알수있었다. 이것은 2000년대에노인을위한비언어적통증사정도구들이개발되었음에도실무에서의사용은많이이루어지지않아다양한후속연구가진행되고있는것으로보인다 [6]. 전세계적으로노인인구의증가와더불어통증관리에대한관심이늘어나고있어, 이러한비언어적통증사정도구에대한요구는지속적으로증가할것으로보인다 [19]. 하지만전세계적으로꾸준히연구가이루어지는것에비해국내에서이루어진연구는단 1편에불과해국내에서의추가적연구가필요하다는것을보여준다. 총 9개의비언어적통증사정도구들을비교 분석한결과문헌에가장많이언급된도구는 PAINAD, PACSLAC, Doloplus-2의순이었으며, 내적일관성신뢰도는 PACSLAC, PAINAD 순으로높게나타났으며, 평가자간신뢰도는 Doloplus-2, PACSLAC 순으로높았다. 이것으로현재까지많은연구가진행되고사용이유용한도구는 PAINAD, PACSLAC, Doloplus-2로볼수있었으며, 이것은다수의선행연구 [14,18, 20-23] 의결과와일부일치하였다. PAINAD는여러연구에서임상적으로유용하며, 신뢰도와타당도가높게나타났다 [18,21]. PAINAD는 5가지항목 ( 호흡, 부정적음성화, 얼굴표정, 몸짓언어, 달램 ) 을각각 0,1,2 Vol. 18 No. 3, 2016 155
이경미 송준아 점을매겨통증점수를내는도구이다. PAINAD는사용이간단하여 2시간정도의훈련만이필요하며, 점수측정에 5분내외로걸리는것으로나타났다 [18]. 본연구에서분석한결과가장많은문헌에언급되었으며, 높은신뢰도와타당도를보여줬다. 하지만점수측정시통증이없는것을의미하는 0 점으로나타나는경우가많았으며, 점수에대한자세한해석이없어추가적인연구가필요하다 [14,18]. 또한통증이있다고판단하고중재를할수있는 cut-off score가없는것이아쉬우며 [18] 추가적인연구가진행되어야할필요가있겠다. PACSLAC는여전히개발단계에있음에도다양한연구에서실무유용성이높은것으로밝혀졌다. 특히 PACSLAC는미세한행동변화를발견하는부분에서가장정확한것으로나타났다 [24]. PACSLAC는네가지영역총 60개의문항으로이루어져있다. 얼굴표정 (13문항), 활동 / 신체움직임 (20문항), 사회성 / 인격 / 기분 (12문항), 생리적변화 / 식욕과수면변화 / 음성표현 (15문항) 으로구성되어있다. 항목이많지만측정이간단하여 5분정도로소요되며, 실제임상에서사용한연구에서도높은신뢰도를보였다 [13,25]. 또한기존형태의축소판인 PACSLAC-II도개발되었으며원본과동질성이입증되고통증과관련이없는항목들이삭제되어사용이더용이해졌다 [26]. 하지만 PACSLAC의점수가증가하는것이통증의증가를의미하지만, 점수에대한보다정확한해석이없어이부분에대한추가적인연구가필요하다 [14]. 또한 PAINAD와마찬가지로 cut-off score가없는것이제한점이며 [18] 추가적인연구가필요한것으로사료된다. Doloplus-2 역시신뢰도와타당도및임상적유용성이모두높은것으로보고되었다 [14,23]. Doloplus-2는통증을유발할수있는 10가지상황을관찰하고통증점수를내는것으로신체적반응, 정신운동성반응, 정신사회적반응의세가지영역으로분류된다. 각항목들을 0점에서 3점까지점수를매기는것이며, cut-off score는 5점으로그이상부터통증이있다고판단하였다. 하지만이 cut-off score와관련된정확한근거가부족하며, 점수에대한자세한해석이없어이부분에대한추가적인연구가필요한것으로제시되었다 [14]. 또한도구의세가지영역중정신사회적반응은판단하기어려운부분으로재평가가필요하다 [23]. 하지만많은연구가진행되고도구가개발되고있음에도불구하고여전히특정한도구가가장유용하다고할수있는확실한증거가부족하며 [27], 그어떤도구도가장좋은기준이된다고주장하기어렵다 [23]. 본연구에서 PAINAD, PACSLAC, Doloplus-2를유용한도구라고결론을내렸지만, 이것이모든 국가와모든대상자에게적절한것은아니다. 통증은개인적이며문화적인요소에도영향을받는부분이기때문에각나라에알맞은통증사정도구도다를수있다. 통증사정도구의선택은임상적환경, 통증사정과정, 사용자등을모두고려해서결정해야한다 [24]. PAINAD는간단하게측정이가능하고통증과관련된행동에초점을맞추기때문에즉각적인중재가필요한임상적환경에서적용이용이하다 [21]. PASCLAC는포괄적인행동을관찰하는도구로써지속적으로통증을관찰하는환경에서적합하며, 통증에대해기준으로삼거나월별또는분기별로측정시에사용하는것이좋다 [21]. Doloplus-2는대상자의특성에대해잘알고있어야사용이가능하므로노인요양시설또는요양병원과같은환경에서적용이용이하다 [28]. 하지만이에대한근거를제시하는후속연구들이더필요할것으로사료된다. 결론 본연구는 2000년부터 2016년까지노인을대상으로한비언어적통증사정도구에대한선행연구들을분석하여연구동향을파악하고향후노인을위한비언어적통증사정도구에대한연구및임상활용에대한기초자료를제공하고자실시되었다. 본연구를통해, 2006년이후노인을위한비언어적통증사정도구와관련된연구가많이진행된것을알수있었으며요구도의증가에따라지속적인연구가필요한것으로확인되었다. 또한노인의통증관리에대한관심이증가함에도불구하고국내에서이루어진연구는단 1편에불과하여, 국내에서노인의비언어적통증사정도구에관련된연구는미흡한실정이었다. 국외의다양한연구결과를토대로국내에서도우리나라노인의특성및임상현장의특성을반영하여적용이용이할수있도록많은후속연구가진행되어야할필요가있겠다. 특히, 본연구에서비언어적통증사정도구를분석한결과 PAINAD, PACSLAC, Doloplus-2가현시점에서유용한도구로판단되어지지만, 여전히확실한증거가부족하며어떤도구가가장적절한지에대한결론을내리기어렵다. 따라서향후우리나라노인을대상으로이세가지도구에대한번안, 신뢰도및타당도평가, 및임상유용성등에대한연구가우선시되어야할것으로사료된다. 본연구는국내 외노인을위한비언어적통증사정도구를종합적으로고찰함에있어다음의제한점이있으며, 이는본논문의결과를해석할때고려되어야할것이다. 첫째, 검색어 156 Journal of Korean Gerontological Nursing
노인을위한비언어적통증사정도구에관한문헌고찰 와검색데이터베이스의제한으로주제에맞지만분석대상에서누락된문헌이있을수있다. 둘째, 논문을선정하는과정에서제외된문헌들 ( 예 : 문헌고찰연구 ) 이있어이와함께누락된도구들도있었다. 셋째, 선정된문헌내에포함된도구이지만본연구에서는적어도 2회이상언급된도구들만을분석하였기때문에누락된유용한도구가있을수있다. 넷째, 영어로작성된논문만을포함하였기때문에다른언어로작성된논문들과함께누락된도구들도있었다. 위와같은제한점에도불구하고본연구는노인을위한비언어적통증사정도구에대해체계적으로분석했다는점에서큰의의가있다고사료되며, 본연구결과를토대로다음과같이제언하고자한다. 첫째, 의사소통이불가능한노인을위한통증사정및관리에대한추가적인연구와국내 외선행연구들에대한문헌고찰이더필요하다. 둘째, 국내노인에게적절하다고생각되는비언어적통증사정도구를선택 번안하여신뢰도및타당도를검증하는연구가우선시되어야할것이다. 셋째, 현재우리나라임상현장에서노인을위한비언어적통증사정도구가따로사용되지않기때문에이를보급화하고적절한사용이필요하다. 또한, 임상에서사용후필요한부분을보완, 개선하여발전시켜야할것이다. 넷째, 노인의통증과비언어적통증사정도구에대한간호사의인식개선이필요하다. 비언어적통증사정도구가적절히사용되기위해서는간호사의도구에대한인지도와수행도에관한연구가필요할것이다. REFERENCES 1. Statistics Korea. 2015 world and Korea population prospects [Internet]. Daejeon: 2015 Jul 8 [updated 2015 Jul 8;cited 2016 Aug 21]. Available from: http://kostat.go.kr/portal/korea/kor_nw/2/1/index.board?bmode=read&aseq=347102 2. Cha BK, Park CS. A comparison of pain, pain interference and fatigue according to the level of physical activity in the elderly with chronic pain. Journal of Korean Academy Community Health Nursing. 2011;22(2):162-72. http://dx.doi.org/10.12799/jkachn.2011.22.2.162 3. International Association for the Study of Pain. IASP Taxonomy [Internet]. Seattle: IASP Press; 1994 Dec 31 [Updated 2012 May 22; cited 2016 Sep 3]. Available from: http://www.iasp-pain.org/taxonomy#pain 4. Kaye AD, Baluch A, Scott JT. Pain management in the elderly population: a review. The Ochsner Journal. 2010;10(3):179-87. 5. Ministry of Health and Welfare. 2014 Investigation of elderly and its reality [Internet]. Sejong: Korea Institute for Health and Social Affairs; 2015 Oct 14 [Updated 2015 Oct 14; cited 2016 Sep 3]. Available from: http://meta.narastat.kr/metasvc/index.do?confmno=117071 &inputyear=2014 6. Herr K. Pain assessment strategies in older patients. The Journal of Pain. 2011;12(3):S3-S13. http://dx.doi.org/10.1016/j.jpain.2010.11.011 7. Kim GM, Lee YM, Chang SO. Factors influencing fatigue in elderly people with chronic pain. Journal of Korean Academy of Psychiatric and Mental Health Nursing. 2011;20(1):61-70. http://dx.doi.org/10.12934/jkpmhn.2011.20.1.61 8. Hadjistavropoulos T, Herr K, Turk DC, Fine PG, Dworkin RH, Helme R, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. The Clinical Journal of Pain. 2007;23(1):S1-S43. http://dx.doi.org/10.1097/ajp.0b013e31802be869 9. Egan M, Cornally N. Identifying barriers to pain management in long-term care: Mary Egan and Nicola Cornally discuss to what extent patient, organisational and caregiver factors hamper the delivery of best practice. Nursing Older People. 2013; 25(7):25-31. http://dx.doi.org/10.7748/nop2013.09.25.7.25.e455 10. Kim EK, Park MH. Nurses' awareness and performance about evidence-based pain management in older adults. Korean Journal of Adult Nursing.2012;24(1):20-30. http://dx.doi.org/10.7475/kjan.2012.24.1.20 11. Herr K, Coyne PJ, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Management Nursing.2011;12(4):230-50. http://dx.doi.org/10.1016/j.pmn.2011.10.002 12. Booker SQ, Haedtke C. Assessing pain in nonverbal older adults. Nursing 2016. 2016;46(5):66-9. http://dx.doi.org/10.1097/01.nurse.0000480619.08039.50 13. Kim EK, Kim SY, Eom MR, Kim HS, Lee E. Validity and reliability of the Korean version of the pain assessment checklist for seniors with limited ability to communicate. Journal of Korean Academy of Nursing. 2014;44(4):398-406. http://dx.doi.org/10.4040/jkan.2014.44.4.398 14. Zwakhalen SM, Hamers JP, Abu-Saad HH, Berger MP. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BioMed Central Geriatrics. 2006;6(1):1-15. http://dx.doi.org/10.1186/1471-2318-6-3 15. American Geriatrics Society Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. Journal of the American Geriatrics Society. 2002;50(6):205-24. http://dx.doi.org/10.1046/j.1532-5415.50.6s.1.x Vol. 18 No. 3, 2016 157
이경미 송준아 16. MacSorley R, White J, Conerly VH, Walker JT, Lofton S, Ragland G, et al. Pain assessment and management strategies for elderly patients. Home Healthcare Now. 2014;32(5):272-85. http://dx.doi.org/10.1097/nhh.0000000000000065 17. Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. Journal of Pain and Symptom Management. 2006;31(2): 170-92. http://dx.doi.org/10.1016/j.jpainsymman.2005.07.001 18. Van Herk R, Van Dijk M, Baar FP, Tibboel D, De Wit R. Observation scales for pain assessment in older adults with cognitive impairments or communication difficulties. Nursing Research. 2007;56(1):34-43. http://dx.doi.org/10.1097/00006199-200701000-00005 19. Lukas A, Barber JB, Johnson P, Gibson SJ. Observer-rated pain assessment instruments improve both the detection of pain and the evaluation of pain intensity in people with dementia. European Journal of Pain. 2013;17(10):1558-68. http://dx.doi.org/10.1002/j.1532-2149.2013.00336.x 20. Zwakhalen SM, Hamers JP, Berger MP. The psychometric quality and clinical usefulness of three pain assessment tools for elderly people with dementia. Pain. 2006:126(1);210-20. http://dx.doi.org/10.1016/j.pain.2006.06.029 21. Herr K, Bursch H, Ersek M, Miller LL, Swafford K. Use of pain-behavioral assessment tools in the nursing home: expert consensus recommendations for practice. Journal of Gerontological Nursing. 2012;36(3):18-29. http://dx.doi.org/10.3928/00989134-20100108-04 22. Lints-Martindale AC, Hadjistavropoulos T, Lix LM, Thorpe L. A comparative investigation of observational pain assessment tools for older adults with dementia. The Clinical Journal of Pain. 2012;28(3):226-37. http://dx.doi.org/10.1097/ajp.0b013e3182290d90 23. Thuathail AN, Welford C. Pain assessment tools for older people with cognitive impairment. Nursing Standard. 2011;26(6): 39-46. http://dx.doi.org/10.7748/ns2011.10.26.6.39.c8756 24. While C, Jocelyn A. Observational pain assessment scales for people with dementia: a review. British Journal of Community Nursing. 2009;14(10):438-42. http://dx.doi.org/10.12968/bjcn.2009.14.10.44496 25. Zwakhalen SM, Hof CE, Hamers JP. Systematic pain assessment using an observational scale in nursing home residents with dementia: exploring feasibility and applied interventions. Journal of Clinical Nursing. 2012;21(21-22):3009-17. http://dx.doi.org/10.1111/j.1365-2702.2012.04313.x 26. Chan S, Hadjistavropoulos T, Williams J, Lints-Martindale A. Evidence-based development and initial validation of the pain assessment checklist for seniors with limited ability to communicate-ii(pacslac-ii). The Clinical Journal of Pain. 2014; 30(9):816-24. http://dx.doi.org/10.1097/ajp.0000000000000039 27. Lichtner V, Dowding D, Esterhuizen P, Closs SJ, Long AF, Corbett A, Briggs M. Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BioMed Central Geriatrics. 2014;14(1):138-76. http://dx.doi.org/10.1186/1471-2318-14-138 28. Hølen JC, Saltvedt I, Fayers PM, Hjermstad MJ, Loge JH, Kaasa S. Doloplus-2, a valid tool for behavioural pain assessment?. BioMed Central Geriatrics. 2007;7(1):1-9. http://dx.doi.org/10.1186/1471-2318-7-29 158 Journal of Korean Gerontological Nursing