Assessing Pain in Dementia Patients

Individuals with moderate-to-severe dementia have difficulty in reporting pain to caregivers and other care providers. Because of this, a number of observational pain assessment measures have been developed in recent years. Since these are all relatively new, further evaluation and validation of these measures is called for.

A forthcoming article in the Clinical Journal of Pain compares six of these measures taken during two different pain conditions: the administration of a vaccine shot and potentially uncomfortable physical movements. Both conditions were experienced during routine care to older adults in a long-term care setting.

The American Geriatrics Society (AGS) identifies six behavioral domains that should be used to identify pain in individuals with dementia: facial expressions, verbalizations and vocalization, body movements, change in interpersonal interactions, change in routines, and apparent changes in mental status. It is not clear, however, which or how many of these domains are needed to assess pain. Further complicating pain assessment is the fact that some of these domains are also affected by delirium, which often coincides with dementia. Thus, in comparing the six pain assessment measures, the authors of the study also analyzed how well they worked after eliminating questions that could be related to delirium.

After obtaining caregiver consent and patient assent, the researchers recorded the study by observing participants at rest, then those experiencing the above-mentioned pain conditions. Videos were recorded then edited so that both conditions lasted the same duration of time. The videos were then coded by a trained research assistant unfamiliar with the study hypotheses. The researchers performed statistical measures to assess the consistency and reliability of each measure.

Each of the six scales, described in the article, had adequate statistical properties and were easily distinguishable as painful and non-painful states. Five of the scales were able to identify pain after delirium-related questions were eliminated. One scale, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)[1] incorporated all six of the AGS domains and appeared the most statistically robust in the authors’ own analysis. These findings offer support for the validity of observational pain assessments for individuals with dementia, and are useful for further research on pain in dementia.



Lints-Martindale, A.C., Hadjistavropoulos, T., Lix, L.M., and Thorpe, L. (2011). “A Comparative Investigation of Observational Pain Assessment Tools for Older Adults With Dementia.” Clinical Journal of Pain, epub ahead of print.

[1] The authors acknowledge that this was a self-developed scale and that their findings should thus be cross-validated by independent researchers.

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