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Pain Assessment IN Advanced Dementia- PAINAD (Warden, Hurley, Volicer, 2003)

 

ITEMS

 

0

 

1

 

2

 

SCORE

Breathing

Independent of vocalization

Normal

 

Occasional labored breathing. Short period of hyperventilation

Noisy labored breathing. Long period of hyperventilation. Cheyne-stokes respirations.

 

 

Negative vocalization

 

None

 

Occasional moan or groan. Low- level of speech with a negative or disapproving quality

Repeated troubled calling out. Loud moaning or groaning. Crying

 

 

Facial expression

Smiling or inexpressive

Sad, frightened, frown

 

Facial grimacing

 

 

 

Body language

 

Relaxed

Tense. Distressed pacing.

Fidgeting

Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out

 

 

Consolability

 

No need to console

Distracted or reassured by voice or touch

Unable to console, distract or reassure

 

 

                                                                                                                                                                                                TOTAL*

 

*Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0=”no pain” to 10=”severe pain”).

Instructions: Observe the older person both at rest and during activity/with movement.  For each of the items included in the PAINAD, select the score (0, 1, or 2) that reflects the current state of the person’s behavior.  Add the score for each item to achieve a total score. Monitor changes in the total score over time and in response to treatment to determine changes in pain. Higher scores suggest greater pain severity.

Note: Behavior observation scores should be considered in conjunction with knowledge of existing painful conditions and surrogate report from an individual knowledgeable of the person and their pain behaviors.

Remember that some patients may not demonstrate obvious pain behaviors or cues.

Reference: Warden, V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc, 4:9-15. Developed at the New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA.

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