Contextual isolation has been described as possessing a socially salient characteristic (demographic, habit/preference, clinical condition with a social component) in a context where few others share that social characteristic.1 Contextual isolation may result in limited opportunities for solidarity, shared experiences, and connection with other nursing home residents, and contextual isolation may be particularly relevant to those residents with Alzheimer's disease and related dementias. Furthermore, residents with dementia symptoms are less likely to have pain recognized or treated.2,3 Undertreated pain in residents with dementia continues to be frequent occurrence.4

The experience of pain involves far more than the activation of cellular messenger proteins in response to adverse stimuli – nociception also involves cognitive processes influenced by socially-mediated factors, including distraction, rumination, perception of one's needs being cared for, and being “at home” in one's surroundings. Thus, the experience and expression of pain may be related to contextual isolation, through feelings of being included, valued and understood on the one hand, or excluded and marginalized on the other.

In addition to the experience of pain, the recognition of pain is crucial to the reverential and respectful care all people deserve to experience. Residents in a contextually isolated setting may receive care from staff who make assumptions about their cultural beliefs and practices, or whose empathic response may be less than total.5,6 Residents experiencing contextual isolation may be less likely to have their pain recognized by care staff, particularly in under-resourced settings.

Because both the experience of pain and the recognition of pain are necessary for the reporting of pain in nursing home resident assessments, competing hypotheses of the possible effects of contextual isolation on pain reporting were explored. The experience of pain may be more common among residents who have limited shared social solidarity with other residents. Alternately, the recognition of pain by nursing home staff may be reduced when caring for residents who are contextually isolated. The isolation of one or the other of these hypotheses may be possible through examination of informative sub-populations, and/or after stratifying or adjusting for factors more associated with the experience of, or recognition of, pain.

This analysis estimates the effect of contextual isolation on the reporting of pain in long-stay nursing home residents living with Alzheimer's disease and related dementias in a near census of nursing home residents in the United States, while exploring the populations in whom the two competing mechanisms described above may be more pronounced.