The assessment of pain intensity in patients with cognitive failure: a preliminary report

We reviewed our experience with 14 consecutive patients with cancer pain who developed severe cognitive failure that reverted either spontaneously or after specific treatment. In 3 patients who developed a nonagitated cognitive failure episode (CFE), there was no difference in the pain intensity measured by the patient before and after the episode and that measured by the nurse during the episode. In 11 patients who developed an agitated CFE, pain intensity assessed by a nurse during the CFE was significantly higher than the patient's assessment, both before and after the CFE. Patients who developed agitated CFE received a mean of 5 +/- 2 extra doses of narcotics per day, versus a mean of 2.17 +/- 1.6 doses in the average patient in our unit (P less than 0.01). Upon complete recovery, none of the 14 patients recalled having had any discomfort during the CFE. Problematic conflict between staff and family was detected in 4 of 11 cases of agitated CFE (36%), versus an expected 13 of 260 cases (5%, P less than 0.01). We conclude that (a) patients who recover from a severe CFE have no memory of pain; (b) medical and nursing staff are likely to overestimate the level of pain of patients with agitated CFE; and (c) agitated CFE in patients with cancer pain is a major source of distress for the patients' families and staff.