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Recommendations for Pain Assessment in Cognitively Impaired Older Adults

General Recommendations

  1. Take into account the older adult’s history, interview information and results of physical examinations.

  2. Use assessment approaches that include both self-report and observational measures when possible.

  3. The Numeric Rating Scale (NRS) and the Verbal Descriptor Scale (VDS) or Pain Thermometer should be attempted with older adults whose cognitive functioning ranges from intact to mildly or moderately impaired. The Faces Pain Scale-Revised (FPS-R) is an alternate tool that is preferred by some older adults, particularly African-Americans and Asians.

  4. The Pain Assessment in Advanced Dementia (PAINAD) is recommended for monitoring directly observable behaviors on a regular basis in older adults with chronic pain.  The Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) is recommended as a screening tool to monitor older adults for development of behaviours that may be pain-related and thus is not a definitive indicator of pain. 

  5. Pain assessment during a movement (such as transferring, bathing, dressing, and ambulating) is more likely to identify an underlying persistent pain problem than observation at rest.

  6. Attempt an analgesic trial to help determine if pain is the cause of behaviour that may be pain-related.  If the use of analgesic medications leads to a reduction of potential behavioral indicators of pain, continue to treat the behaviors as if they are pain related.

  7. A comprehensive pain assessment should also include evaluations of impact of pain on related aspects of the older adult’s functioning (e.g. associated symptoms, sleep disturbance, appetite changes, physical activity changes, concentration, and relationships with others).

  8. Among persons with dementia, it would be important to solicit the assistance of a knowledgeable informant to accomplish this goal and identify typical pain behaviors for the individual older adult.

  9. Several instruments contain items that need to be assessed over time (e.g., changes in sleeping, eating).  A tool that screens for changes in behavior, such as the PACSLAC, can be helpful in monitoring these changes. 

Specific Recommendations Following the Selection of Suitable Assessment Tools

  1. Use an individualized approach collecting baseline scores for each individual older adult.

  2. Solicit the assistance of caregivers familiar with the older adult.

  3. If assessment tools are used to monitor pain levels over time, they must be used under consistent circumstances (e.g., during a structured program of physiotherapy, over the course of a typical evening).


Adapted from:  Hadjistavropolous, T., Herr, K., Turk, D., Fine, P., Dworkin, R., Helme, R., Jackson, K., Parmelee, P., Rudy, T., Beattie, B., Chibnall, J., Craig, K., Ferrell, B., Ferrell, B., Fillingim, R., Gagliese, L., Gallagher, R., Gibson, S., Harrison, E., Katz, B., Keefe, F., Lieber, S., Lussier, D., Chmader, K., Tait, R., Weiner, D., & Williams, J. (2007).  An interdisciplinary expert consensus statement on assessment of pain in older persons.  Clinical Journal of Pain, 23(1), S1-43. Used with permission of Wolters Kluwer Health.

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