Pain assessment in individuals with dementia and communication problems in Spain. A systematic review

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"apellidos" => "Fuster Linares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universitat Internacional de Catalunya, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Enfermería, Universidad de Navarra, Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Navarra's Health Research Institute (IdiSNA), Pamplona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Cátedra WeCare, Facultad de Medicina y Ciencias de la Salud, Universitat Internacional de Catalunya, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración del dolor en personas con demencia y problemas de comunicación en España. Revisión sistemática" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2685 "Ancho" => 2492 "Tamanyo" => 301388 ] ] "descripcion" => array:1 [ "en" => "Flow diagram following the PRISM recommendations." ] ] ] "textoCompleto" => "BackgroundThe current aging of the population and the increased life expectancy and longevity are leading to an increase in chronic diseases in the elderly. Chief among these diseases is dementia,<a class="elsevierStyleCrossRefs" href="#bib0195">1,2</a> due to its high incidence rate and to being one of the main causes of disability.<a class="elsevierStyleCrossRef" href="#bib0205">3</a> In advanced ages, diseases that progress with chronic pain occur often (e.g., degenerative and inflammatory joint diseases, fractures secondary to senile osteoporosis, malignancies and neuropathic pain in type 2 diabetes mellitus).<a class="elsevierStyleCrossRef" href="#bib0210">4</a>The combination of pain and dementia is one of the most common causes of suffering and disability, because it greatly affects both the quality of life of those who have the condition and their caregivers and relatives. This process also significantly increases healthcare costs,<a class="elsevierStyleCrossRef" href="#bib0215">5</a> because the presence of pain in individuals with dementia can worsen their cognitive impairment, increase their functional impairment and lengthen their hospital stay, among other issues.<a class="elsevierStyleCrossRefs" href="#bib0215">5,6</a> Despite the importance of a correct approach to pain, this symptom is underdiagnosed and undertreated, especially in individuals with communication problems.<a class="elsevierStyleCrossRefs" href="#bib0225">7–9</a>To assess the presence and intensity of pain, self-reporting is considered the gold standard. Although self-reporting can be useful in the initial phases of dementia and even during moderate phases, when patients have significant difficulties in communicating and are incapable of remembering, understanding and responding to their experience of pain, these reports are not applicable.<a class="elsevierStyleCrossRef" href="#bib0210">4</a> To assess pain in these conditions, various approaches and tools have been proposed. One of these approaches is to assess autonomic reactions such as sweating, increased blood pressure, increased heart rate and breathing rate and the release of stress hormones and endorphins. These parameters can indicate the presence of acute pain, although they are not specific for assessing pain.<a class="elsevierStyleCrossRef" href="#bib0210">4</a> These reactions are also attenuated in individuals with dementia and are therefore not useful for identifying persistent pain.<a class="elsevierStyleCrossRef" href="#bib0240">10</a> Another problem is that measuring some of these reactions can be invasive, slow and expensive.<a class="elsevierStyleCrossRef" href="#bib0210">4</a>Other directed tools have therefore been proposed to identify behavioral changes (vocal and body) in the presence of pain. Several systematic reviews have been conducted comparing the psychometric properties of these tools and their scope of use.<a class="elsevierStyleCrossRefs" href="#bib0220">6,7</a> Most of the tools have been developed and validated for English settings,<a class="elsevierStyleCrossRefs" href="#bib0245">11–16</a> although some have been translated and validated to other languages,<a class="elsevierStyleCrossRefs" href="#bib0275">17–21</a> which is important because the interpretation of the behavior of pain can differ dramatically from one culture to the next.<a class="elsevierStyleCrossRef" href="#bib0300">22</a> A cultural adaptation and validation of the various instruments designed to assess pain in individuals with dementia and communication problems is therefore especially important.In 2014, a systematic review was published on pain assessment scales for patients with dementia.<a class="elsevierStyleCrossRef" href="#bib0225">7</a> Although this review was published in Spanish, it analyzed scales published in their original language and did not examine the Spanish validation of these scales. To date, we have found no specific systematic review on what instruments have been validated in the Spanish context. Therefore, this study's objective was to determine, through a systematic literature review, what instruments are available for assessing pain in individuals with dementia and communication problems in the Spanish healthcare setting.MethodsDesign, protocol and recordingFrom September to December 2017, we conducted a systematic literature review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Declaration.<a class="elsevierStyleCrossRefs" href="#bib0305">23,24</a> To manage the references, we used the Mendeley Reference Manager, version 1.17.12.Eligibility criteria<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">(1)Inclusion criteria: We included studies published up to December 31, 2017, on tools developed in Spain to assess pain in individuals with dementia and communication problems. We also included methodological studies of scales translated and validated to Spanish.</li><li class="elsevierStyleListItem" id="lsti0010">(2)Exclusion criteria: We excluded studies that covered nonspecific instruments for assessing pain.</li></ul>Information sourcesWe consulted the following databases: PubMed, Web of Science, CINAHL, Scopus, Dialnet and Cuitatge.Search strategyOur search strategy included all terms potentially related to the study topic and that produced results in the Spanish context. We opted for a broad strategy that ensured good sensitivity and sufficient specificity, thereby avoiding losing relevant publications on the topic. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the search strategy used for PubMed. This strategy was adapted for each database mentioned above.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Strategies to minimize selection biasTo minimize selection bias, we clearly defined the inclusion and exclusion criteria. In addition, the entire process of searching and selecting articles was conducted in pairs. Each pair of authors was responsible for replicating the search in a database. We employed a single reference manager in which the first author removed the duplicates. The selected articles were divided by title and abstract into 3 groups, such that each pair of evaluators, the first author and each of the other 3 authors performed this selection. Lastly, the selection by full text was once again divided among pairs, discussing with the entire team the questions regarding the selection of a specific article.Data analysisFor the data analysis, we designed a table to perform a thematic synthesis of the included articles.To assess the methodological quality and psychometric properties of each identified instrument, we followed the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) method. This method enables the assessment of instruments that measure patient-perceived results.<a class="elsevierStyleCrossRefs" href="#bib0315">25,26</a> The tool was requested of the authors, and permission was obtained to use it in this study. The standard measurement of the EMPRO score could not be applied due to the different characteristics between the assessed tools and EMPRO. However, we did use the tool as a reference for the items it includes and the areas it incorporates, because it provides a standard for examination based on the ideal recommendations of the Scientific Advisory Committee of the Medical Outcomes Trust.<a class="elsevierStyleCrossRef" href="#bib0325">27</a>ResultsUltimately, the sample included for the thematic synthesis analysis consisted of 10 articles. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the article selection process and the results.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Of the 10 selected studies, 5 were publications on the development or validation of scales to Spanish. We also identified 5 studies conducted in the Spanish healthcare context, which used some pain assessment instrument for individuals with dementia and communication problems. We performed a descriptive synthesis of each article. A meta-analysis could not be performed due to the heterogeneity of the selected studies.Studies on the development or validation to Spanish of pain assessment instruments for individuals with dementia and communication problemsWe identified 4 studies that covered the process of adapting and validating a scale to Spanish: the Spanish versions of the Abbey,<a class="elsevierStyleCrossRef" href="#bib0330">28</a> PAINAD,<a class="elsevierStyleCrossRef" href="#bib0290">20</a> Doloplus<a class="elsevierStyleCrossRef" href="#bib0335">29</a> and Algoplus<a class="elsevierStyleCrossRef" href="#bib0295">21</a> scales. We also included a doctoral thesis that covered the development and validation process of the Spanish Assessment of Pain in Elderly with Dementia (EDAD) scale.<a class="elsevierStyleCrossRef" href="#bib0340">30</a> This scale was originally designed in Spanish and used in the Spanish healthcare context. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> synthesizes the main characteristics of each of the aforementioned scales in their Spanish version.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In terms of their usefulness, all discriminated the presence/absence of pain; however, the Abbey, Algoplus and PAINAD-Sp scales also measured intensity. However, the use of Algoplus and PAINAD-Sp required prior training.The Algoplus and Doloplus scales have been used in the Spanish context, not only in individuals with dementia but also in other conditions in which communication disorders occur.Of the questionnaires that specified the estimated time of application, all were rapid-use tools because they required between 1 and 5min to apply.The pain assessment with the EDAD scale, the Spanish version of the PAINAD scale (PAINAD-Sp) and Algoplus were conducted in the validation studies interchangeably by physicians and nurses. In the first 2 scales, other health professionals were also employed (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the methodological quality of each instrument, according to the EMPRO structure.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Studies conducted in the Spanish healthcare context that used pain assessment instruments in individuals with dementia and communication problemsWe included 5 studies conducted in the Spanish healthcare context that mentioned having used some pain assessment instrument in individuals with advanced dementia and communication problems. The most relevant aspects of these studies are shown below and can be seen in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. Alaba and Arriola,<a class="elsevierStyleCrossRef" href="#bib0215">5</a> Garré-Olmo et al.<a class="elsevierStyleCrossRef" href="#bib0345">31</a> and de la Rica Escuín and González Vaca<a class="elsevierStyleCrossRef" href="#bib0350">32</a> (in studies conducted in San Sebastian, Girona and Albacete, respectively) employed the translation of the original version of the PAINAD scale.<a class="elsevierStyleCrossRef" href="#bib0270">16</a> The validation of this scale to Spanish<a class="elsevierStyleCrossRef" href="#bib0290">20</a> was published in 2014 (online since June 2013). In 2015, Rodríguez-Mansilla et al.<a class="elsevierStyleCrossRef" href="#bib0355">33</a> published a study conducted in Extremadura that used, among other instruments, the Doloplus2 scale. The study referred to the original scale<a class="elsevierStyleCrossRef" href="#bib0360">34</a> but not to the publication of the validation in Spanish in 2009.<a class="elsevierStyleCrossRef" href="#bib0335">29</a> Additionally, a study<a class="elsevierStyleCrossRef" href="#bib0365">35</a> was identified on the adaptation and psychometric validation of the Spanish version of the quality-of life-scale in advanced dementia, which used the PAIN-VAS. This visual analog scale was completed by the nearby informants, indicating (on a scale of 0–100) the degree of pain they thought the patient had at that time.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Discussion and conclusionsThere are currently 4 available Spanish-validated scales for assessing pain in individuals with dementia and communication problems: Abbey,<a class="elsevierStyleCrossRef" href="#bib0330">28</a> PAINAD-Sp,<a class="elsevierStyleCrossRef" href="#bib0290">20</a> Doloplus<a class="elsevierStyleCrossRef" href="#bib0335">29</a> and Algoplus.<a class="elsevierStyleCrossRef" href="#bib0295">21</a> Despite the topic's considerable relevance, we found only a small number of studies in the Spanish context that employed some pain assessment instrument for individuals with dementia and communication problems.With respect to the scales employed in the studies conducted in Spain,<a class="elsevierStyleCrossRefs" href="#bib0215">5,31–33,35</a> it is noteworthy that no reference was made in any case to the instruments already validated in Spanish but rather to the original scale (in another language) or even to secondary sources. These studies also provide insufficient data on the process of adapting to the new context and language. These findings could further hinder our understanding of Spanish-validated instruments and perpetuate a significant problem: the underdiagnosis and undertreatment of pain in individuals with a high incidence of pain.<a class="elsevierStyleCrossRefs" href="#bib0225">7,8</a> We also need to consider that the characteristics of the Spanish-validated scales might not coincide with the characteristics of the original scales. The recommendations and conclusions obtained after the analysis of the original scales might therefore differ<a class="elsevierStyleCrossRefs" href="#bib0220">6,7,9</a> from those of the present review.With regard to the scales validated to the Spanish context,<a class="elsevierStyleCrossRefs" href="#bib0290">20,21,28,29</a> we found that the validation processes were not always completely explicit and had various limitations that hinder their replicability. In this respect, all authors provided data on the scales’ reliability but not on their validity. The Abbey and PAINAD-Sp scales provided the most complete data on this process, although the sample used in the PAINAD-Sp scale was much smaller.Taking into account the criteria of application time, training, usefulness, applicability and psychometric properties, the Spanish-validated Abbey scale appears to be the best option.<a class="elsevierStyleCrossRef" href="#bib0330">28</a> However, the observer profile (the individual who uses the scale) has been limited to medical professionals with extensive clinical experience. Therefore, if other professionals want to use the scale, it would be advisable to analyze the scale's psychometric properties for this new observer profile.Various international authors have recommended the use of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC),<a class="elsevierStyleCrossRef" href="#bib0250">12</a> due its good psychometric properties. However, this scale has yet to be validated to Spanish. In fact, in the Spanish palliative care setting,<a class="elsevierStyleCrossRef" href="#bib0370">36</a> the use of Doloplus, PACSLAC (for the nursing home context)<a class="elsevierStyleCrossRef" href="#bib0250">12</a> and PAINAD-Sp (for the hospital setting)<a class="elsevierStyleCrossRef" href="#bib0220">6</a> are recommended.Based on our results, it is important to recommend the use of already validated instruments, instead of creating new ones that might lack rigorous validation. However, the validation processes should also be rigorous and provide sufficient data so that authors may choose the scale that best adapts to their context, thereby generating results that can show the efficacy of the interventions, and that are comparable in our context and with other countries.We would also recommend including (in the continuing education of healthcare practitioners and caregivers) the assessment of pain in individuals with dementia and communication problems, training in the use of these instruments and in selecting the most appropriate instrument depending on the setting in which they work.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1100576" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1041569" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1100577" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1041570" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design, protocol and recording" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Eligibility criteria" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Information sources" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Search strategy" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Strategies to minimize selection bias" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Data analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion and conclusions" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-22" "fechaAceptado" => "2018-05-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1041569" "palabras" => array:5 [ 0 => "Pain" 1 => "Dementia" 2 => "Spain" 3 => "Review" 4 => "Communication problems" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1041570" "palabras" => array:5 [ 0 => "Dolor" 1 => "Demencia" 2 => "España" 3 => "Revisión" 4 => "Problemas de comunicación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and objectivePain assessment in individuals with advanced dementia and communication problems continue to be underdiagnosed and undertreated due to the difficulty in performing this assessment. This review explores and synthesizes how pain in individuals with advanced dementia and communication problems are being assessed in the context of Spanish healthcare. Materials and methodsA systematic review of the literature was conducted following the PRISMA criteria. We reviewed the databases of PubMed, Web of Science, Cinahl, Scopus, Dialnet and Cuitatge up to December 2017. Four independent reviewers identified studies that included instruments to assess pain in individuals with dementia and communication problems in the Spanish healthcare context. We performed a narrative synthesis of the included articles. ResultsAfter applying the inclusion criteria, 10 studies were included. Of these, 4 were methodological studies validating Spanish versions of scales (Abbey, Algoplus, Doloplus and PAINAD-Sp), and 1 was on the development of the original EDAD scale. We also identified 3 studies conducted in Spain that used a translation of the PAINAD, 1 study that used a Spanish translation of Doloplus2 and 1 publication that included the use in Spain of a scale not validated for this patient profile (Pain-VAS). ConclusionsThere are currently several instruments validated in Spanish to assess pain in individuals with advanced dementia and communication problems (Abbey, Algoplus, Doloplus y PAINAD-Sp). However, these instruments have still not been widely used in research, and their psychometric properties could be improved." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes y objetivoLa valoración del dolor en personas con demencia avanzada y problemas de comunicación continúa siendo infradiagnosticada e infratratada debido a la dificultad que conlleva realizar esta valoración. Esta revisión pretende explorar y sintetizar cómo se está valorando el dolor en personas con demencia avanzada y problemas de comunicación en el contexto sanitario español. Materiales y métodosRevisión sistemática de la literatura siguiendo los criterios PRISMA. Se revisaron las bases de datos Pubmed, Web of Science, Cinahl, Scopus, Dialnet y Cuitatge hasta diciembre de 2017. Cuatro revisores independientes identificaron los estudios que incluían instrumentos para evaluar el dolor en personas con demencia y problemas de comunicación, en el contexto sanitario español. Se realizó una síntesis narrativa de los artículos incluidos. ResultadosDespués de aplicar los criterios de inclusión se seleccionaron 10 estudios. De estos 4 fueron estudios metodológicos de validaciones de escalas al español (Abbey, Algoplus, Doloplus y PAINAD-Sp) y uno del desarrollo de la escala original EDAD. Además, se identificaron 3 estudios realizados en España, que utilizaban una traducción de la PAINAD, un estudio que utilizó una traducción al español de la Doloplus2 y una publicación que incluyó el uso en España de una escala no validada para este perfil de pacientes (Pain-VAS). ConclusionesActualmente, existen varios instrumentos validados en español para valorar el dolor en personas con demencia avanzada y problemas de comunicación (Abbey, Algoplus, Doloplus y PAINAD-Sp). Aunque aún estos instrumentos no han sido muy utilizados en investigación y las propiedades psicométricas de los mismos pueden mejorar." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: de Juan Pardo MÁ, Saracibar-Razquin M, Crespo I, Fuster Linares P. Valoración del dolor en personas con demencia y problemas de comunicación en España. Revisión sistemática. Rev Clín Esp. 2018;218:435–444." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2685 "Ancho" => 2492 "Tamanyo" => 301388 ] ] "descripcion" => array:1 [ "en" => "Flow diagram following the PRISM recommendations." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Search \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Terms used in PubMed \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain[Title/abstract] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">“Cognitive dysfunction”[Title/abstract] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">“Cognitive impairment”[Title/abstract] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">“Cognitive deficits”[Title/abstract] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dementia[Title/abstract] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">#2 OR #3 OR #4 OR #5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spanish[Text Word] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain[Text Word] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">#7 OR #8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">#10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">#1 AND #6 AND #9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883056.png" ] ] ] ] "descripcion" => array:1 [ "en" => "PubMed search strategy." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scales \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference of the original scale \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference of the Spanish validation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population/setting \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Evaluator profile/training on the use of the scale \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration of the observation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abbey \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abbey et al.<a class="elsevierStyleCrossRef" href="#bib0255">13</a>, 2004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chamorro and Puche, 2013<a class="elsevierStyleCrossRef" href="#bib0330">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain intensity in elderly patients with advanced dementia. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients admitted to the geriatric unit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Physicians with extensive clinical experience/without training. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1min approximately \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Algoplus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rat et al., 2010<a class="elsevierStyleCrossRef" href="#bib0375">37</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pickering et al., 2017<a class="elsevierStyleCrossRef" href="#bib0295">21</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Presence/absence of pain in elderly patients with communication disorders. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not indicated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Physician/nurse specialists in geriatric medicine and pain assessment in individuals with communication problems/with training. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doloplus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wary et al., 2001<a class="elsevierStyleCrossRef" href="#bib0360">34</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pickering et al., 2010<a class="elsevierStyleCrossRef" href="#bib0335">29</a> (online, 10 Sep 2009) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain intensity in elderly individuals with communication disorders. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Long-stay units; rehabilitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Physician specialists in geriatric medicine and pain assessment in patients with communication disorders. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unspecified \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EDAD Pain Assessment Scale in elderly patients with dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Baeza Lanuza, 2006<a class="elsevierStyleCrossRef" href="#bib0340">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Original in Spanish \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Presence/absence of pain in elderly patients with communication disorders and severe cognitive impairment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Residences and healthcare centers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Health professionals<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> who provide standard care to the evaluated individuals/without training. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not specified (includes the observation before and during the care and during the last 48h) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAINAD-Sp Pain Assessment in Advanced Dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Warden and Hurley, 2003<a class="elsevierStyleCrossRef" href="#bib0270">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">García-Soler et al., 2014<a class="elsevierStyleCrossRef" href="#bib0290">20</a> (online, 7 Jun 2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain intensity in elderly patients with communication disorders and severe cognitive impairment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gerontological center \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Health professionals<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> and researchers/with considerable training. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5min \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883055.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Assistants, nurses, physiotherapists, physicians, psychologists, occupational therapists." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Assistants, nurses, psychologists, social workers." ] ] ] "descripcion" => array:1 [ "en" => "Spanish validation studies and studies on the development of observational scales to assess pain in individuals with dementia and communication problems." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "All values shown are statistically significant (p<0.05).Abbreviations: CCC: Lin's concordance correlation coefficient; ICC: intraclass correlation coefficient; Kappa i.: kappa index; Pearson r: Pearson's correlation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Spanish Ref. Scales \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Validation process<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a>/development \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Sample \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reliability</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Validity</th><th class="td" title="table-head " align="left" valign="top" scope="col">Sensitivity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Translation-cultural adaptation<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Internal consistency \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stability \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Of content \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Of criteria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Of construct \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abbey, Chamorro and Puche, 2013<a class="elsevierStyleCrossRef" href="#bib0330">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Validation of Spanish version \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">119 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">α Cronbach 0.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intraobserver ICC 0.77 Intraobserver Kappa i. 0.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Expert committee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Predictive 100% (ROC 0.94) Concurrent Pearson's r 0.82 (between researcher holistic impression and Abbey) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Convergent: Sensitivity 96% (Youden index 0.96) Divergent: Specificity 100% Value Z No factorial analysis Predictive validity ROC curve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Z=5.35 for measures before and after analgesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partially described \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Algoplus Pickering et al., 2017<a class="elsevierStyleCrossRef" href="#bib0295">21</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Validation of Spanish version \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Kudder-Richardson 0.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Test–retest CCC 0.85 Intraobserver Kappa i. 0.69–0.84 (5 items) CCC 0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sufficient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doloplus Pickering et al., 2010<a class="elsevierStyleCrossRef" href="#bib0335">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Validation of Spanish version \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intraobserver Pearson's r 0.92 ICC 0.84 Kappa i. 0.47–0.85 (10 items) Test–retest Pearson's r 0.96 ICC 0.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sufficient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EDAD Baeza Lanuza, 2006<a class="elsevierStyleCrossRef" href="#bib0340">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Development of original scale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Different for each analysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">α Cronbach 0.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intraobserver ICC 0.51–0.97 (8 items) ICC 0.94 (total scale) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Delphi Expert committee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Concurrent Analysis of variance/Duncan between EDAD and assessment of no pain by experts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Exploratory factor analysis and confirmatory factor analysis 3 Factors (8-item scale) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Discriminates between presence/absence of pain in acute and chronic pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not applicable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAINAD-Sp García Soler et al., 2014<a class="elsevierStyleCrossRef" href="#bib0290">20</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Validation of Spanish version \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cronbach α for the 3 rest conditions 0.727–0.811 Pleasant activity 0.59–0.82 Pain 0.46–0.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intraobserver ICC for the 3 conditions Rest 0.58–0.88 Pleasant activity 0.73–0.84 Pain 0.70–0.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Convergent: Spearman Rho (PAINAD-Sp/EVA) Rest 0.52–0.67 Pleasant activity 0.37–0.72 Pain 0.54–0.92 Divergent: differences between mean score in the 3 conditions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No data provided. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partially described \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883054.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Cultural translation-adaptation: sufficient (including the translation, back-translation, pre-test); partially described (includes only some of the previous items)." ] ] ] "descripcion" => array:1 [ "en" => "Psychometric properties of the Spanish validation and development of observational scales to assess pain in individuals with dementia and communication problems according to EMPRO structure." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scale used \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scale reference \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population/setting \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Evaluator profile \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alaba and Arriola,<a class="elsevierStyleCrossRef" href="#bib0215">5</a> 2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Translation of the PAINAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Warden and Hurley, 2003<a class="elsevierStyleCrossRef" href="#bib0270">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Individuals with cognitive impairment/in nursing homes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Geriatric care assistants (caregivers for the elderly) Standard care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Garré-Olmo et al.,<a class="elsevierStyleCrossRef" href="#bib0345">31</a> 2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Translation of the PAINAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Warden and Hurley, 2003<a class="elsevierStyleCrossRef" href="#bib0270">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Individuals with advanced dementia/in nursing homes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurses Standard care/with training on the use of the scale. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De la Rica Escuín and González Vaca, 2014<a class="elsevierStyleCrossRef" href="#bib0350">32</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Translation of the PAINAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Warden and Hurley, 2003<a class="elsevierStyleCrossRef" href="#bib0270">16</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Individuals with advanced dementia/in nursing homes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nursing assistants Standard care/with training on the use of the scale. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rodríguez Mansilla et al., 2015<a class="elsevierStyleCrossRef" href="#bib0355">33</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Translation of the Doloplus2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wary and Doloplus, 1999<a class="elsevierStyleCrossRef" href="#bib0360">34</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Garré-Olmo et al., 2010<a class="elsevierStyleCrossRef" href="#bib0365">35</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain-VAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Teenier and Sender, 2007<a class="elsevierStyleCrossRef" href="#bib0380">38</a> (secondary source) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Individuals with advanced dementia/ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nearby informants \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883057.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Studies that use a pain assessment instrument for individuals with dementia and communication problems in the Spanish context." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Worldwide trends in the prevalence of dementia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "I. 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Pain assessment in individuals with dementia and communication problems in Spain. A systematic review

Valoración del dolor en personas con demencia y problemas de comunicación en España. Revisión sistemática

M.Á. de Juan Pardoa,

Corresponding author

mdejuan@uic.es

Corresponding author.

, M. Saracibar-Razquinb,c, I. Crespod, P. Fuster Linaresa

a Departamento de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universitat Internacional de Catalunya, Spain

b Facultad de Enfermería, Universidad de Navarra, Pamplona, Spain

c Navarra's Health Research Institute (IdiSNA), Pamplona, Spain

d Cátedra WeCare, Facultad de Medicina y Ciencias de la Salud, Universitat Internacional de Catalunya, Barcelona, Spain

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            "entidad" => "Navarra&#39;s Health Research Institute &#40;IdiSNA&#41;&#44; Pamplona&#44; Spain"
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            "entidad" => "C&#225;tedra WeCare&#44; Facultad de Medicina y Ciencias de la Salud&#44; Universitat Internacional de Catalunya&#44; Barcelona&#44; Spain"
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        "titulo" => "Valoraci&#243;n del dolor en personas con demencia y problemas de comunicaci&#243;n en Espa&#241;a&#46; Revisi&#243;n sistem&#225;tica"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram following the PRISM recommendations&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">The current aging of the population and the increased life expectancy and longevity are leading to an increase in chronic diseases in the elderly&#46; Chief among these diseases is dementia&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">1&#44;2</span></a> due to its high incidence rate and to being one of the main causes of disability&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> In advanced ages&#44; diseases that progress with chronic pain occur often &#40;e&#46;g&#46;&#44; degenerative and inflammatory joint diseases&#44; fractures secondary to senile osteoporosis&#44; malignancies and neuropathic pain in type 2 diabetes mellitus&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The combination of pain and dementia is one of the most common causes of suffering and disability&#44; because it greatly affects both the quality of life of those who have the condition and their caregivers and relatives&#46; This process also significantly increases healthcare costs&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> because the presence of pain in individuals with dementia can worsen their cognitive impairment&#44; increase their functional impairment and lengthen their hospital stay&#44; among other issues&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;6</span></a> Despite the importance of a correct approach to pain&#44; this symptom is underdiagnosed and undertreated&#44; especially in individuals with communication problems&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To assess the presence and intensity of pain&#44; self-reporting is considered the gold standard&#46; Although self-reporting can be useful in the initial phases of dementia and even during moderate phases&#44; when patients have significant difficulties in communicating and are incapable of remembering&#44; understanding and responding to their experience of pain&#44; these reports are not applicable&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> To assess pain in these conditions&#44; various approaches and tools have been proposed&#46; One of these approaches is to assess autonomic reactions such as sweating&#44; increased blood pressure&#44; increased heart rate and breathing rate and the release of stress hormones and endorphins&#46; These parameters can indicate the presence of acute pain&#44; although they are not specific for assessing pain&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> These reactions are also attenuated in individuals with dementia and are therefore not useful for identifying persistent pain&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> Another problem is that measuring some of these reactions can be invasive&#44; slow and expensive&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Other directed tools have therefore been proposed to identify behavioral changes &#40;vocal and body&#41; in the presence of pain&#46; Several systematic reviews have been conducted comparing the psychometric properties of these tools and their scope of use&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;7</span></a> Most of the tools have been developed and validated for English settings&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#8211;16</span></a> although some have been translated and validated to other languages&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#8211;21</span></a> which is important because the interpretation of the behavior of pain can differ dramatically from one culture to the next&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> A cultural adaptation and validation of the various instruments designed to assess pain in individuals with dementia and communication problems is therefore especially important&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2014&#44; a systematic review was published on pain assessment scales for patients with dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> Although this review was published in Spanish&#44; it analyzed scales published in their original language and did not examine the Spanish validation of these scales&#46; To date&#44; we have found no specific systematic review on what instruments have been validated in the Spanish context&#46; Therefore&#44; this study&#39;s objective was to determine&#44; through a systematic literature review&#44; what instruments are available for assessing pain in individuals with dementia and communication problems in the Spanish healthcare setting&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design&#44; protocol and recording</span><p id="par0030" class="elsevierStylePara elsevierViewall">From September to December 2017&#44; we conducted a systematic literature review following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses &#40;PRISMA&#41; Declaration&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">23&#44;24</span></a> To manage the references&#44; we used the Mendeley Reference Manager&#44; version 1&#46;17&#46;12&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Eligibility criteria</span><p id="par0035" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Inclusion criteria&#58; We included studies published up to December 31&#44; 2017&#44; on tools developed in Spain to assess pain in individuals with dementia and communication problems&#46; We also included methodological studies of scales translated and validated to Spanish&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Exclusion criteria&#58; We excluded studies that covered nonspecific instruments for assessing pain&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Information sources</span><p id="par0050" class="elsevierStylePara elsevierViewall">We consulted the following databases&#58; PubMed&#44; Web of Science&#44; CINAHL&#44; Scopus&#44; Dialnet and Cuitatge&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Search strategy</span><p id="par0055" class="elsevierStylePara elsevierViewall">Our search strategy included all terms potentially related to the study topic and that produced results in the Spanish context&#46; We opted for a broad strategy that ensured good sensitivity and sufficient specificity&#44; thereby avoiding losing relevant publications on the topic&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the search strategy used for PubMed&#46; This strategy was adapted for each database mentioned above&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Strategies to minimize selection bias</span><p id="par0060" class="elsevierStylePara elsevierViewall">To minimize selection bias&#44; we clearly defined the inclusion and exclusion criteria&#46; In addition&#44; the entire process of searching and selecting articles was conducted in pairs&#46; Each pair of authors was responsible for replicating the search in a database&#46; We employed a single reference manager in which the first author removed the duplicates&#46; The selected articles were divided by title and abstract into 3 groups&#44; such that each pair of evaluators&#44; the first author and each of the other 3 authors performed this selection&#46; Lastly&#44; the selection by full text was once again divided among pairs&#44; discussing with the entire team the questions regarding the selection of a specific article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">For the data analysis&#44; we designed a table to perform a thematic synthesis of the included articles&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To assess the methodological quality and psychometric properties of each identified instrument&#44; we followed the Evaluating the Measurement of Patient-Reported Outcomes &#40;EMPRO&#41; method&#46; This method enables the assessment of instruments that measure patient-perceived results&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">25&#44;26</span></a> The tool was requested of the authors&#44; and permission was obtained to use it in this study&#46; The standard measurement of the EMPRO score could not be applied due to the different characteristics between the assessed tools and EMPRO&#46; However&#44; we did use the tool as a reference for the items it includes and the areas it incorporates&#44; because it provides a standard for examination based on the ideal recommendations of the Scientific Advisory Committee of the Medical Outcomes Trust&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">Ultimately&#44; the sample included for the thematic synthesis analysis consisted of 10 articles&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the article selection process and the results&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Of the 10 selected studies&#44; 5 were publications on the development or validation of scales to Spanish&#46; We also identified 5 studies conducted in the Spanish healthcare context&#44; which used some pain assessment instrument for individuals with dementia and communication problems&#46; We performed a descriptive synthesis of each article&#46; A meta-analysis could not be performed due to the heterogeneity of the selected studies&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Studies on the development or validation to Spanish of pain assessment instruments for individuals with dementia and communication problems</p><p id="par0090" class="elsevierStylePara elsevierViewall">We identified 4 studies that covered the process of adapting and validating a scale to Spanish&#58; the Spanish versions of the Abbey&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> PAINAD&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> Doloplus<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> and Algoplus<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> scales&#46; We also included a doctoral thesis that covered the development and validation process of the Spanish Assessment of Pain in Elderly with Dementia &#40;EDAD&#41; scale&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> This scale was originally designed in Spanish and used in the Spanish healthcare context&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> synthesizes the main characteristics of each of the aforementioned scales in their Spanish version&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">In terms of their usefulness&#44; all discriminated the presence&#47;absence of pain&#59; however&#44; the Abbey&#44; Algoplus and PAINAD-Sp scales also measured intensity&#46; However&#44; the use of Algoplus and PAINAD-Sp required prior training&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The Algoplus and Doloplus scales have been used in the Spanish context&#44; not only in individuals with dementia but also in other conditions in which communication disorders occur&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Of the questionnaires that specified the estimated time of application&#44; all were rapid-use tools because they required between 1 and 5<span class="elsevierStyleHsp" style=""></span>min to apply&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The pain assessment with the EDAD scale&#44; the Spanish version of the PAINAD scale &#40;PAINAD-Sp&#41; and Algoplus were conducted in the validation studies interchangeably by physicians and nurses&#46; In the first 2 scales&#44; other health professionals were also employed &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the methodological quality of each instrument&#44; according to the EMPRO structure&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Studies conducted in the Spanish healthcare context that used pain assessment instruments in individuals with dementia and communication problems</p><p id="par0125" class="elsevierStylePara elsevierViewall">We included 5 studies conducted in the Spanish healthcare context that mentioned having used some pain assessment instrument in individuals with advanced dementia and communication problems&#46; The most relevant aspects of these studies are shown below and can be seen in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Alaba and Arriola&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> Garr&#233;-Olmo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> and de la Rica Escu&#237;n and Gonz&#225;lez Vaca<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a> &#40;in studies conducted in San Sebastian&#44; Girona and Albacete&#44; respectively&#41; employed the translation of the original version of the PAINAD scale&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> The validation of this scale to Spanish<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> was published in 2014 &#40;online since June 2013&#41;&#46; In 2015&#44; Rodr&#237;guez-Mansilla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a> published a study conducted in Extremadura that used&#44; among other instruments&#44; the Doloplus2 scale&#46; The study referred to the original scale<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> but not to the publication of the validation in Spanish in 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> Additionally&#44; a study<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> was identified on the adaptation and psychometric validation of the Spanish version of the quality-of life-scale in advanced dementia&#44; which used the PAIN-VAS&#46; This visual analog scale was completed by the nearby informants&#44; indicating &#40;on a scale of 0&#8211;100&#41; the degree of pain they thought the patient had at that time&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion and conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are currently 4 available Spanish-validated scales for assessing pain in individuals with dementia and communication problems&#58; Abbey&#44;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> PAINAD-Sp&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> Doloplus<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> and Algoplus&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> Despite the topic&#39;s considerable relevance&#44; we found only a small number of studies in the Spanish context that employed some pain assessment instrument for individuals with dementia and communication problems&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">With respect to the scales employed in the studies conducted in Spain&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;31&#8211;33&#44;35</span></a> it is noteworthy that no reference was made in any case to the instruments already validated in Spanish but rather to the original scale &#40;in another language&#41; or even to secondary sources&#46; These studies also provide insufficient data on the process of adapting to the new context and language&#46; These findings could further hinder our understanding of Spanish-validated instruments and perpetuate a significant problem&#58; the underdiagnosis and undertreatment of pain in individuals with a high incidence of pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;8</span></a> We also need to consider that the characteristics of the Spanish-validated scales might not coincide with the characteristics of the original scales&#46; The recommendations and conclusions obtained after the analysis of the original scales might therefore differ<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">6&#44;7&#44;9</span></a> from those of the present review&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">With regard to the scales validated to the Spanish context&#44;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;21&#44;28&#44;29</span></a> we found that the validation processes were not always completely explicit and had various limitations that hinder their replicability&#46; In this respect&#44; all authors provided data on the scales&#8217; reliability but not on their validity&#46; The Abbey and PAINAD-Sp scales provided the most complete data on this process&#44; although the sample used in the PAINAD-Sp scale was much smaller&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Taking into account the criteria of application time&#44; training&#44; usefulness&#44; applicability and psychometric properties&#44; the Spanish-validated Abbey scale appears to be the best option&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> However&#44; the observer profile &#40;the individual who uses the scale&#41; has been limited to medical professionals with extensive clinical experience&#46; Therefore&#44; if other professionals want to use the scale&#44; it would be advisable to analyze the scale&#39;s psychometric properties for this new observer profile&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Various international authors have recommended the use of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate &#40;PACSLAC&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> due its good psychometric properties&#46; However&#44; this scale has yet to be validated to Spanish&#46; In fact&#44; in the Spanish palliative care setting&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> the use of Doloplus&#44; PACSLAC &#40;for the nursing home context&#41;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> and PAINAD-Sp &#40;for the hospital setting&#41;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a> are recommended&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Based on our results&#44; it is important to recommend the use of already validated instruments&#44; instead of creating new ones that might lack rigorous validation&#46; However&#44; the validation processes should also be rigorous and provide sufficient data so that authors may choose the scale that best adapts to their context&#44; thereby generating results that can show the efficacy of the interventions&#44; and that are comparable in our context and with other countries&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">We would also recommend including &#40;in the continuing education of healthcare practitioners and caregivers&#41; the assessment of pain in individuals with dementia and communication problems&#44; training in the use of these instruments and in selecting the most appropriate instrument depending on the setting in which they work&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pain assessment in individuals with advanced dementia and communication problems continue to be underdiagnosed and undertreated due to the difficulty in performing this assessment&#46; This review explores and synthesizes how pain in individuals with advanced dementia and communication problems are being assessed in the context of Spanish healthcare&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A systematic review of the literature was conducted following the PRISMA criteria&#46; We reviewed the databases of PubMed&#44; Web of Science&#44; Cinahl&#44; Scopus&#44; Dialnet and Cuitatge up to December 2017&#46; Four independent reviewers identified studies that included instruments to assess pain in individuals with dementia and communication problems in the Spanish healthcare context&#46; We performed a narrative synthesis of the included articles&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">After applying the inclusion criteria&#44; 10 studies were included&#46; Of these&#44; 4 were methodological studies validating Spanish versions of scales &#40;Abbey&#44; Algoplus&#44; Doloplus and PAINAD-Sp&#41;&#44; and 1 was on the development of the original EDAD scale&#46; We also identified 3 studies conducted in Spain that used a translation of the PAINAD&#44; 1 study that used a Spanish translation of Doloplus2 and 1 publication that included the use in Spain of a scale not validated for this patient profile &#40;Pain-VAS&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There are currently several instruments validated in Spanish to assess pain in individuals with advanced dementia and communication problems &#40;Abbey&#44; Algoplus&#44; Doloplus y PAINAD-Sp&#41;&#46; However&#44; these instruments have still not been widely used in research&#44; and their psychometric properties could be improved&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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        ]
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La valoraci&#243;n del dolor en personas con demencia avanzada y problemas de comunicaci&#243;n contin&#250;a siendo infradiagnosticada e infratratada debido a la dificultad que conlleva realizar esta valoraci&#243;n&#46; Esta revisi&#243;n pretende explorar y sintetizar c&#243;mo se est&#225; valorando el dolor en personas con demencia avanzada y problemas de comunicaci&#243;n en el contexto sanitario espa&#241;ol&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n sistem&#225;tica de la literatura siguiendo los criterios PRISMA&#46; Se revisaron las bases de datos Pubmed&#44; Web of Science&#44; Cinahl&#44; Scopus&#44; Dialnet y Cuitatge hasta diciembre de 2017&#46; Cuatro revisores independientes identificaron los estudios que inclu&#237;an instrumentos para evaluar el dolor en personas con demencia y problemas de comunicaci&#243;n&#44; en el contexto sanitario espa&#241;ol&#46; Se realiz&#243; una s&#237;ntesis narrativa de los art&#237;culos incluidos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Despu&#233;s de aplicar los criterios de inclusi&#243;n se seleccionaron 10 estudios&#46; De estos 4 fueron estudios metodol&#243;gicos de validaciones de escalas al espa&#241;ol &#40;Abbey&#44; Algoplus&#44; Doloplus y PAINAD-Sp&#41; y uno del desarrollo de la escala original EDAD&#46; Adem&#225;s&#44; se identificaron 3 estudios realizados en Espa&#241;a&#44; que utilizaban una traducci&#243;n de la PAINAD&#44; un estudio que utiliz&#243; una traducci&#243;n al espa&#241;ol de la Doloplus2 y una publicaci&#243;n que incluy&#243; el uso en Espa&#241;a de una escala no validada para este perfil de pacientes &#40;Pain-VAS&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Actualmente&#44; existen varios instrumentos validados en espa&#241;ol para valorar el dolor en personas con demencia avanzada y problemas de comunicaci&#243;n &#40;Abbey&#44; Algoplus&#44; Doloplus y PAINAD-Sp&#41;&#46; Aunque a&#250;n estos instrumentos no han sido muy utilizados en investigaci&#243;n y las propiedades psicom&#233;tricas de los mismos pueden mejorar&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Antecedentes y objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiales y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; de Juan Pardo M&#193;&#44; Saracibar-Razquin M&#44; Crespo I&#44; Fuster Linares P&#46; Valoraci&#243;n del dolor en personas con demencia y problemas de comunicaci&#243;n en Espa&#241;a&#46; Revisi&#243;n sistem&#225;tica&#46; Rev Cl&#237;n Esp&#46; 2018&#59;218&#58;435&#8211;444&#46;</p>"
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram following the PRISM recommendations&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Search&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Terms used in PubMed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&#91;Title&#47;abstract&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8220;Cognitive dysfunction&#8221;&#91;Title&#47;abstract&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8220;Cognitive impairment&#8221;&#91;Title&#47;abstract&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8220;Cognitive deficits&#8221;&#91;Title&#47;abstract&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dementia&#91;Title&#47;abstract&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#35;2 OR &#35;3 OR &#35;4 OR &#35;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spanish&#91;Text Word&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&#91;Text Word&#93;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#35;7 OR &#35;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#35;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#35;1 AND &#35;6 AND &#35;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => "xTab1883056.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PubMed search strategy&#46;</p>"
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      ]
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scales&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference of the original scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference of the Spanish validation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population&#47;setting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Evaluator profile&#47;training on the use of the scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration of the observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abbey&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Abbey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a>&#44; 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chamorro and Puche&#44; 2013<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain intensity in elderly patients with advanced dementia&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Patients admitted to the geriatric unit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Physicians with extensive clinical experience&#47;without training&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>min approximately&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Algoplus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rat et al&#46;&#44; 2010<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pickering et al&#46;&#44; 2017<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Presence&#47;absence of pain in elderly patients with communication disorders&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not indicated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Physician&#47;nurse specialists in geriatric medicine and pain assessment in individuals with communication problems&#47;with training&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doloplus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wary et al&#46;&#44; 2001<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pickering et al&#46;&#44; 2010<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a> &#40;online&#44; 10 Sep 2009&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain intensity in elderly individuals with communication disorders&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Long-stay units&#59; rehabilitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Physician specialists in geriatric medicine and pain assessment in patients with communication disorders&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unspecified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EDAD<br>Pain Assessment Scale in elderly patients with dementia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baeza Lanuza&#44; 2006<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Original in Spanish&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Presence&#47;absence of pain in elderly patients with communication disorders and severe cognitive impairment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Residences and healthcare centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Health professionals<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> who provide standard care to the evaluated individuals&#47;without training&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not specified &#40;includes the observation before and during the care and during the last 48<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAINAD-Sp<br>Pain Assessment in Advanced Dementia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Warden and Hurley&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Garc&#237;a-Soler et al&#46;&#44; 2014<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a><br>&#40;online&#44; 7 Jun 2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain intensity in elderly patients with communication disorders and severe cognitive impairment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gerontological center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Health professionals<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> and researchers&#47;with considerable training&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Assistants&#44; nurses&#44; physiotherapists&#44; physicians&#44; psychologists&#44; occupational therapists&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Assistants&#44; nurses&#44; psychologists&#44; social workers&#46;</p>"
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          ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Spanish validation studies and studies on the development of observational scales to assess pain in individuals with dementia and communication problems&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">All values shown are statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CCC&#58; Lin&#39;s concordance correlation coefficient&#59; ICC&#58; intraclass correlation coefficient&#59; Kappa <span class="elsevierStyleItalic">i</span>&#46;&#58; kappa index&#59; Pearson <span class="elsevierStyleItalic">r</span>&#58; Pearson&#39;s correlation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Spanish Ref&#46; Scales&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Validation process<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&#47;development&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Sample&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reliability</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Validity</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Sensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Translation-cultural adaptation<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Internal consistency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Of content&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Of criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Of construct&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abbey&#44; Chamorro and Puche&#44; 2013<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Validation of Spanish version&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">119&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">&#945;</span> Cronbach 0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraobserver ICC 0&#46;77<br>Intraobserver Kappa <span class="elsevierStyleItalic">i</span>&#46; 0&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Expert committee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Predictive 100&#37; &#40;ROC 0&#46;94&#41; Concurrent Pearson&#39;s <span class="elsevierStyleItalic">r</span> 0&#46;82 &#40;between researcher holistic impression and Abbey&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Convergent&#58; Sensitivity 96&#37; &#40;Youden index 0&#46;96&#41; Divergent&#58; Specificity 100&#37; Value Z No factorial analysis<br>Predictive validity ROC curve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Z<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;35 for measures before and after analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partially described&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Algoplus Pickering et al&#46;&#44; 2017<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Validation of Spanish version&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Kudder-Richardson 0&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Test&#8211;retest<br>CCC 0&#46;85<br>Intraobserver<br>Kappa <span class="elsevierStyleItalic">i</span>&#46; 0&#46;69&#8211;0&#46;84<br>&#40;5 items&#41;<br>CCC 0&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sufficient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Doloplus Pickering et al&#46;&#44; 2010<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Validation of Spanish version&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraobserver<br>Pearson&#39;s <span class="elsevierStyleItalic">r</span> 0&#46;92<br>ICC 0&#46;84<br>Kappa <span class="elsevierStyleItalic">i</span>&#46; 0&#46;47&#8211;0&#46;85 &#40;10 items&#41;<br>Test&#8211;retest<br>Pearson&#39;s <span class="elsevierStyleItalic">r</span> 0&#46;96<br>ICC 0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sufficient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EDAD Baeza Lanuza&#44; 2006<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Development of original scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Different for each analysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">&#945;</span> Cronbach 0&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraobserver<br>ICC 0&#46;51&#8211;0&#46;97 &#40;8 items&#41;<br>ICC 0&#46;94 &#40;total scale&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Delphi<br>Expert committee&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Concurrent<br>Analysis of variance&#47;Duncan between EDAD and assessment of no pain by experts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exploratory factor analysis and confirmatory factor analysis<br>3 Factors &#40;8-item scale&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Discriminates between presence&#47;absence of pain in acute and chronic pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not applicable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAINAD-Sp Garc&#237;a Soler et al&#46;&#44; 2014<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Validation of Spanish version&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cronbach <span class="elsevierStyleItalic">&#945;</span> for the 3 rest conditions 0&#46;727&#8211;0&#46;811<br>Pleasant activity<br>0&#46;59&#8211;0&#46;82<br>Pain<br>0&#46;46&#8211;0&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intraobserver<br>ICC for the 3 conditions<br>Rest 0&#46;58&#8211;0&#46;88<br>Pleasant activity 0&#46;73&#8211;0&#46;84<br>Pain 0&#46;70&#8211;0&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Convergent&#58;<br>Spearman Rho &#40;PAINAD-Sp&#47;EVA&#41;<br>Rest 0&#46;52&#8211;0&#46;67<br>Pleasant activity 0&#46;37&#8211;0&#46;72<br>Pain 0&#46;54&#8211;0&#46;92<br>Divergent&#58;<br>differences between mean score in the 3 conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No data provided&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Partially described&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Cultural translation-adaptation&#58; sufficient &#40;including the translation&#44; back-translation&#44; pre-test&#41;&#59; partially described &#40;includes only some of the previous items&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Psychometric properties of the Spanish validation and development of observational scales to assess pain in individuals with dementia and communication problems according to EMPRO structure&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scale used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Scale reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population&#47;setting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Evaluator profile&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alaba and Arriola&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Translation of the PAINAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Warden and Hurley&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Individuals with cognitive impairment&#47;in nursing homes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Geriatric care assistants &#40;caregivers for the elderly&#41; Standard care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Garr&#233;-Olmo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> 2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Translation of the PAINAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Warden and Hurley&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Individuals with advanced dementia&#47;in nursing homes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nurses<br>Standard care&#47;with training on the use of the scale&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De la Rica Escu&#237;n and Gonz&#225;lez Vaca&#44; 2014<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Translation of the PAINAD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Warden and Hurley&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Individuals with advanced dementia&#47;in nursing homes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nursing assistants<br>Standard care&#47;with training on the use of the scale&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rodr&#237;guez Mansilla et al&#46;&#44; 2015<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Translation of the Doloplus2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wary and Doloplus&#44; 1999<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Garr&#233;-Olmo et al&#46;&#44; 2010<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain-VAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Teenier and Sender&#44; 2007<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> &#40;secondary source&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Individuals with advanced dementia&#47;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nearby informants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Studies that use a pain assessment instrument for individuals with dementia and communication problems in the Spanish context&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2018.05.007

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