SYSTEMATIC REVIEW

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Pain assessment tools for older adults

with dementia in long-term care facilities:
a systematic review
Selina Chow1, Ronald Chow1, Michael Lam1, Leigha Rowbottom1, Drew Hollenberg1,
Erika Friesen1, Olivia Nadalini1, Henry Lam1, Carlo DeAngelis1 & Nathan Herrmann*,1

Practice points
Dementia is common in long-term care residents, and significantly reduces residents ability to articulate their pain.
T he under-recognition and undertreatment of pain in older adults with dementia is likely rooted in key issues related
to pain assessment in this cohort of patients.
T raditional tools rely on the ability of older adults to self-report their pain, but may be difficult to employ across the
entire population.
I nvestigators have since advocated for the development of observer-rated pain assessment tools to more accurately
capture pain.
eveloping a valid and reliable scale to assess pain, that is also sensitive to change, has proven to be a challenge due
D
to a highly heterogeneous population.

Aim: The aim of this review is to document pain assessment tools used primarily for older
adults in long-term care facilities and compare self-report and observer-rated tools. Methods:
A literature search was conducted in Ovid MEDLINE, Embase, Cochrane and PsycINFO.
Keywords included dementia, pain management and managing pain. Results: Of 1033
references, 23 articles were selected for inclusion. Six tools were self-rated and 18 tools were
administered by an observer. 13 studies evaluated the reliability/validity of their scales; four
studies compared different scales against each other. Conclusion: Self-report should be the
first-line approach when possible, with observational assessment used as a supplementary
tool. Reliable observational tools have been shortened, and shown to maintain high
reliability/validity, and positive psychometric properties.

First draft submitted: 26 July 2016; Accepted for publication: 12 September 2016; Published
online: 18 November 2016

Dementia is common in long-term care (LTC) residents, and significantly reduces residents ability KEYWORDS
to articulate their pain[13] . Coupled with the fact that up to 80% of residents suffer from pain[1] , dementia long-term care
a large percentage suffers from both dementia and pain. Pain is under-reported and undertreated facilities pain assessment
in nursing home residents[2,46] . The suboptimal management of pain results in poor quality of questionnaires tools
life for institutionalized older adults and may lead to undesirable physiological and psychological
consequences[79] . The undermanagement could ultimately foster pain-induced neuropsychiatric
symptoms such as agitation and aggression, which are major management issues in LTC.
The under-recognition and undertreatment of pain in older adults with dementia is likely rooted
in key issues related to pain assessment in this cohort of patients. Traditional tools, such as the
Visual Analog Scale (VAS), rely on the ability of older adults to self-report their pain. However,
Ferrell etal. recognized that 17% of a sample population could not respond to VAS[10] , and

1
Sunnybrook Health Sciences Centre, University of Toronto, Room FG19, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
*Author for correspondence: Tel.: +1 416 480 6133; nathan.herrmann@sunnybrook.ca part of

10.2217/nmt-2016-0033 2016 Future Medicine Ltd Neurodegener. Dis. Manag. (Epub ahead of print) ISSN 1758-2024
Systematic Review Chow, Chow, Lam et al.
Krulewich etal. found that 33% of another
group of elderly people were incapable of self-
reporting pain[11] . Investigators have since advo-
cated for the development of observer-rated pain
assessment tools to more accurately capture pain.
The existence of a highly heterogeneous popula-
tion has proven to be a challenge; dementia is
characterized by progressive decline in cortical
functions [12] and hence leads to great variabil-
ity in pain response and behavior from person
to person. As a result, developing a valid and
reliable scale to assess pain, that is also sensi-
tive to change, has proven to be a challenge[13] .
Moreover, novel tools that passed through early
stages of construction, development and test-
ing with reasonable psychometric qualities face
the challenge of easy translation into everyday
clinical practice[14,15] .
Many observational tools with varying char-
acteristics have been developed with the purpose
to assess pain in the elderly with dementia. With
the ever-increasing number of tools, it may be
challenging for medical professionals to explore
new tools while also delivering holistic care
through their present tool of choice. Recent
systematic reviews[1424] have documented the
increased efforts over the past 25years to develop
tools to assess pain in people with dementia.
Although previous reviews have focused on
analyzing the components of observational
tools or draw connections to pain medication,
this systematic review aims to document pain
1033 articles identified from
database search
1033 title and abstracts screened
55 full-text articles assessed
for eligibility
23 studies included in review
Figure 1. Preferred reporting items for systematic reviews and meta-analyses flow diagram.
10.2217/nmt-2016-0033 Neurodegener. Dis. Manag. (Epub ahead of print)
assessment tools used for elderly in LTC facilities
and compare self-report and observer-rated tools
in that setting.
Methods
A literature search was conducted in Ovid
MEDLINE (1946 to June 2016, week 1), Embase
Classic & Embase (1947 to 2016, week24),
Cochrane Central Register of Controlled Trials
(May 2016) and PsycINFO (1806 to June 2016,
week 2). Keywords such as dementia, pain
management and managing pain were used to
retrieve relevant studies. The searches were lim-
ited to English language and human subjects only
(Supplementary Material).
The title and abstract of search results
were screened independently by three authors
(SChow, R Chow and M Lam). Articles were
subjected to full-text screening if the title and/or
abstract mentioned dementia patients, pain and
assessment tools. Articles were included in this
systematic review if there was any mention of a
standardized assessment tool, such as a devel-
oped questionnaire, used in an LTC facility
for older adults with dementia. Studies were
excluded if they were a review article or used
nonstandardized tools (i.e.,interview questions
developed by the author that varied from per-
son to person). The entire screening process
was in adherence to Preferred Reporting Items
for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines.
978 records excluded
32 full-text papers excluded,
with reasons
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 Pain assessment tools for older adults with dementia in long-term care facilities
The primary information of interest was the
assessment tool used in the study. Secondary
information included sample size, assessor, assess-
ment period, study conclusion, constituents of
each assessment tool and reliability/validity tests.
Results
The database search yielded 1033 references, of
which a total of 55 articles were identified for
full-text screening, and ultimately 23[6,13,2545]
were included in this review (Figure 1) .
Studies ranged from six participants [43]
to 71,227 participants[25] , and the mean age
across all studies was over 80years. All studies
reported that the majority of patients (>50%)
were women. Eight studies[13,25,29,31,32,35,38,41]
employed multiple tools, while other 15 stud-
ies [6,2628,30,33,34,36,37,39,40,4245] used only one
assessment tool. Pain Assessment Checklist for
Seniors with Limited Ability to Communicate
(PACSLAC) and the Verbal Descriptor Scale
(VDS) were employed in four studies, while
the Pain Assessment in Advanced Dementia
(PAINAD) and MobilizationObservation
BehaviourIntensityDementia-2 (MOBID-2)
tools were cited thrice. The Non-Communicative
Patients Pain A ssessment Instrument
(NOPPAIN), Checklist for Nonverbal Pain
Indicators (CNPI), Functional Pain Scale
(FPS), Pain Assessment for the Dementing
Elderly (PADE), Present Pain Intensity (PPI)
and Pain Assessment Checklist for Seniors
with Limited Ability to Communicate Dutch
(PACSLAC-D) were studied twice, and the
remaining 14 tools were used once (Table 1) .
Self-reported tools were completed either
through an interview[26,35,38] or using a pre-
specified scale such as the Numeric Rating
Scale (NRS)[25] . Observational tools were typi-
cally completed by either a researcher[30,32,37,39]
or a caregiver[6,25,26,28,31,3337,4045] , such as a
nurse, a nursing assistant or a nursing student.
The assessment period varied with some stud-
ies only assessing participants once and oth-
ers assessing multiple times. The majority of
the single-assessment studies only took into
account current pain[2627,2930,35,4243] , while
other studies assessed pain over an extended
period of time 1 day[34] , 5 days[25] , over
2 weeks[36] or spanning five exercises [44] .
Multiple time-assessment studies ranged from
twice within 2h[41] , to two- to three-times
per week[28] , to daily observations for 10 days
(Table 1)[45] .
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Systematic Review
Six of the documented tools (Faces Pain
Scale Revised [FPS-R], FPS, Global Pain
Assessment [GPA], PPI, Short-Form McGill
Pain Questionnaire [SF-MPQ] and VDS)
were self-report scales, while the other 18
(Abbey Pain Scale, Certified Nursing Assistant
Pain Assessment Tool [CPAT], CNPI,
Chinese Pain Assessment in Advanced
Dementia [C -PA INA D], Doloplus-II,
Minimum Data Set Pain Behavior Scale
[MDS-PBS], MOBID-2, Mahoney Pain
Scale [MPS], NOPPAIN, Observational
Pain Behavior Assessment Instrument,
PACSL AC, PACSL AC-II, PACSL AC-D,
PADE, PAINAD, Pain Assessment in the
Communicatively Impaired [PACI], Pain
Assessment in Non-communicative Elderly and
Resident Assessment Instrument [RAI]) were
observer-rated.
Self-report assessment tools typically feature
the fewest items FPS-R, GPA, PPI have two
items each, while VDS and FPS have two and
four items, respectively, when completed in its
entirety with the exception of SF-MPQ, which
had 15 items. Observer-rated tools feature more
components, with PACSLAC notably consist-
ing of 60 prompts. The shortened versions of
PACSLAC, PACSLAC-II and PACSLAC-D
have 31 and 24 components, respectively, but
are still longer than most of the other tools. The
components of self-report tools often manifest
themselves in the form of questions, probing at
presence of pain, severity of pain and occasion-
ally effect on well-being. Observational tools
heavily rely on observations of vocalization,
nonverbal expressions (such as facial expres-
sion), and physical behavior for pain assessment.
Components of observational tools were scored
on severity scales, categorical scales or simply
evaluated dichotomously (present or absent)
(Table 2) .
Of the 23 studies included, 13 evaluated the
reliability/validity of their scales. PACSLAC
was tested thrice[30,33,38] , while PAINAD[31,32] ,
CNPI [31,32] and NOPPAIN[35,43] were tested
twice. PACSLAC-II, PACSLAC-D, OPBAI,
MOBID-2, PACI, PPI, VDS, C-PAINAD,
MPS and PADE each were tested once, and
Abbey Pain Scale, CPAT, Doloplus-II, FPS-R,
FPS, GPA, Minimum Data Set Pain Behavior
Scale, Pain Assessment in Non-communicative
Elderly, RAI and SF-MPQ were not tested in the
26 studies. MPS had poor to acceptable inter-
rater reliability[40] ; PAINAD had poor internal
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Systematic Review Chow, Chow, Lam et al.

Table 1. Employed pain measurement tools for patients with dementia.

Study (year) Population Patient Pain Assessor Study conclusion Ref.
size characteristics measurement
(participants) tools
Ahnetal. (2015) 71,227 Nursing home NRS 36,880 participants self-reported Assessing pain [25]
residents VDS pain using NRS or VDS can improve pain
Mean age:85years MDS-PBS 34,347 cases evaluated by management and reduce
73.6% women nurses for participants who risk for aggressive
52.5% severely could not articulate pain using behavior
cognitively impaired MDS-PBS
Barryetal. (2015) 42 Dementia care home VDS Self-reported during interview There exists conflicting [26]
residents Missing information was pain reports assessment
Mean age:82.1years collected from nurse/care of pain continues to
57.1% women assistant interview remain a challenging area
85.7% moderate or
severe dementia
Brown (2010) 189 Continuing care Resident Observational assessor Resident assessment [27]
facility residents assessment instrument is useful to
33.9% over 90years instrument identify patterns but
of age insufficient for pain
70.1% women management purposes;
76.3% non- other tools must be
Alzheimer dementia employed
Cervoetal. (2012) 215 Long-term care CNPI Certified nursing assistant Certified nursing assistant [28]
facility residents pain assessment tool may
Mean age:84.9years be useful for evaluating
47.9% women effects of pain treatment,
49.8% severe as well as reduce falls
dementia and decrease use of
antipsychotic medication
Chanetal. (2014) 124 Long-term care PACSLAC Trained research assistant and The revised PACSLAC-II [29]
facility residents PACSLAC-II second staff differentiates between
Mean age: pain and nonpain states
83.94years
71% women
Cheung and Choi 50 Dementia care PACSLAC Researcher and caregiver PACSLAC has good inter- [30]
(2008) facility residents rater reliability when it is
Mean age:82.9years used by caregivers
72% women

Cohen-Mansfield 153 Nursing home FPS FPS, PPI, VDS and GPA are self- Each tool is consistent [31]
(2008) residents PPI reported in pain assessment, with
Mean age:88years VDS PADE, PAINE, CNPI and higher correlation
82% women GPA Observational Pain Behavior
PADE Assessment Instrument reported
PAINE by nursing staff members
PAINAD
CNPI
Observational
Pain Behavior
Assessment
Instrument
CNPI:Checklist for Nonverbal Pain Indicators; C-PAINAD:Chinese Pain Assessment in Advanced Dementia; FPS:Functional Pain Scale; FPS-R:Faces Pain Scale Revised;
GPA:Global Pain Assessment; MDS-PBS:Minimum Data Set Pain Behavior Scale; MOBID-2:MobilizationObservationBehaviourIntensityDementia-2; NOPPAIN:Non-
Communicative Patients Pain Assessment Instrument; NRS:Numeric Rating Scale; PACI:Pain Assessment in the Communicatively Impaired; PACSLAC:Pain Assessment Checklist
for Seniors with Limited Ability to Communicate; PACSLAC-II:Pain Assessment Checklist for Seniors with Limited Ability to Communicate II; PACSLAC-D:Pain Assessment
Checklist for Seniors with Limited Ability to Communicate Dutch; PADE:Pain Assessment for the Dementing Elderly; PAINAD:Pain Assessment in Advanced Dementia;
PAINE:Pain Assessment in Non-communicative Elderly; PPI:Present Pain Intensity; SF-MPQ:Short-Form McGill Pain Questionnaire; VAS:Visual Analog Scale; VDS:Verbal
DescriptorScale.

10.2217/nmt-2016-0033 Neurodegener. Dis. Manag. (Epub ahead of print) future science group
 Pain assessment tools for older adults with dementia in long-term care facilities Systematic Review

Table 1. Employed pain measurement tools for patients with dementia (cont.).
Study (year) Population Patient Pain Assessor Study conclusion Ref.
size characteristics measurement
(participants) tools
Ersek et al. (2010) 60 Nursing home CNPI Research assistant The tools should be [32]
residents PAINAD only one part of a
Mean age:89years multidimensional pain
88.1% women assessment program
that includes multiple
comprehensive screening
tools
Fuchs-Lacelle et al. 173 Long-term care unit PACSLAC Nursing staff PACSLAC improves [33]
(2008) residents pain management and
Mean age: decreases nursing staff
85.13years stress
79% women
Hadjistavropoulos 152 Long-term care Doloplus-II Research nurse Doloplus-II is predictive [34]
et al. (2008) home residents of depression, dementia
Mean age: severity and delirium
86.31years
70.6% women
Horgas et al. 40 Long-term care NOPPAIN NOPPAIN completed by nursing NOPPAIN shows promise [35]
(2007) facility residents NRS students to evaluate pain in those
Mean age:83years VDS NRS and VDS verbally self- with mild-to-moderate
78% women reported dementia
Husebo et al. 352 Nursing home MOBID-2 Primary caregivers usually Patients receive better [36]
(2014) residents licensed practical nurse care regarding pain
Mean age: treatment
85.89years
41.5% women
Jordan et al. (2011) 79 Nursing home PAINAD Researcher or nurse PAINAD is a sensitive [37]
residents tool for pain detection
Mean age:82years in people with advanced
72% women dementia, but has a high
100% advanced false-positive rate
dementia
Kaasalainen et al. 338 Long-term care PACSLAC PACSLAC and PACI completed by PACSLAC and PACI vary as [38]
(2013) home residents (PACI) observational raters a function of participants
Mean age:82.8years PPI PPI and NRS verbally self-rated ability to verbally report
64% women NRS by demented participants pain (i.e.,PPI and NRS)
Liu and Lai (2014) 30 Long-term care C-PAINAD Research assistant PAINAD and other similar [39]
home residents tools are important
for pain management
strategies
Mahoney and 112 Nursing home Mahoney Pain Nurses Mahoney Pain Scale may [40]
Peters (2008) residents Scale be useful for assessing
Mean age:85.4years pain in dementia,
78% women documented as accurate
100% advanced and easy to use
dementia
CNPI:Checklist for Nonverbal Pain Indicators; C-PAINAD:Chinese Pain Assessment in Advanced Dementia; FPS:Functional Pain Scale; FPS-R:Faces Pain Scale Revised;
GPA:Global Pain Assessment; MDS-PBS:Minimum Data Set Pain Behavior Scale; MOBID-2:MobilizationObservationBehaviourIntensityDementia-2; NOPPAIN:Non-
Communicative Patients Pain Assessment Instrument; NRS:Numeric Rating Scale; PACI:Pain Assessment in the Communicatively Impaired; PACSLAC:Pain Assessment Checklist
for Seniors with Limited Ability to Communicate; PACSLAC-II:Pain Assessment Checklist for Seniors with Limited Ability to Communicate II; PACSLAC-D:Pain Assessment
Checklist for Seniors with Limited Ability to Communicate Dutch; PADE:Pain Assessment for the Dementing Elderly; PAINAD:Pain Assessment in Advanced Dementia;
PAINE:Pain Assessment in Non-communicative Elderly; PPI:Present Pain Intensity; SF-MPQ:Short-Form McGill Pain Questionnaire; VAS:Visual Analog Scale; VDS:Verbal
DescriptorScale.

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Systematic Review Chow, Chow, Lam et al.

Table 1. Employed pain measurement tools for patients with dementia (cont.).
Study (year) Population Patient Pain Assessor Study conclusion Ref.
size characteristics measurement
(participants) tools
Manias et al. (2011) 192 Geriatric evaluation VAS VAS, FPS-R, VDS and FPS VAS and FPS-R affords [41]
and management FPS-R completed by participant better pain relief
unit residents SF-MPQ SF-MPQ, PAINAD and Abbey Observed-rated tools
Mean age:80years PAINAD Pain Scale completed by a nurse can be helpful for self-
Abbey Pain reported pain, to confirm
Scale assessment
VDS
FPS
Sandvik et al. 327 Nursing home unit MOBID-2 Caregiver MOBID-2 shows excellent [42]
(2014) residents reliability and sensitivity
Mean age:
85.80years
80% women
Snow et al. (2004) 6 Data not available NOPPAIN Nursing assistant NOPPAIN is an instrument [43]
to detect pain in nursing
home patients with
dementia
Tang et al. (2016) 12 Nursing home MOBID-2 Nursing home staff assistants MOBID-2 in combination [44]
residents with medication reviews
Mean age:87years can be used as a tool
58% women for optimization of
medication use
Villanueva et al. 65 Long-term care PADE Certified nursing assistants or PADE is a good tool to [45]
(2003) facility residents similarly trained caregivers assess pain
Mean age:82years
74% women
Zwakhalen et al. 128 Dementia care ward PACSLAC-D Observer Availability of clinically [13]
(2007) residents VAS useful tools has major
Mean age:82.4years implications for nursing
78.1% women practice and patient care
47.7% severely
cognitively impaired
Zwakhalen et al. 22 Nursing home PACSLAC-D Nurses PACSLAC-D was easy to [6]
(2012) residents use
Mean age:80 years
68% women
CNPI:Checklist for Nonverbal Pain Indicators; C-PAINAD:Chinese Pain Assessment in Advanced Dementia; FPS:Functional Pain Scale; FPS-R:Faces Pain Scale Revised;
GPA:Global Pain Assessment; MDS-PBS:Minimum Data Set Pain Behavior Scale; MOBID-2:MobilizationObservationBehaviourIntensityDementia-2; NOPPAIN:Non-
Communicative Patients Pain Assessment Instrument; NRS:Numeric Rating Scale; PACI:Pain Assessment in the Communicatively Impaired; PACSLAC:Pain Assessment Checklist
for Seniors with Limited Ability to Communicate; PACSLAC-II:Pain Assessment Checklist for Seniors with Limited Ability to Communicate II; PACSLAC-D:Pain Assessment
Checklist for Seniors with Limited Ability to Communicate Dutch; PADE:Pain Assessment for the Dementing Elderly; PAINAD:Pain Assessment in Advanced Dementia;
PAINE:Pain Assessment in Non-communicative Elderly; PPI:Present Pain Intensity; SF-MPQ:Short-Form McGill Pain Questionnaire; VAS:Visual Analog Scale; VDS:Verbal
DescriptorScale.

consistency when rating patients at rest[32] ; and
PACI was reported to have the lowest correlation
(concurrent validity) with PPI during rest[38] .
The remaining tools were each reported to have
acceptable to good consistency (Table 3) .
Four studies[29,31,35,38] directly compared dif-
ferent tools in an effort to determine which one
had better reliability. Chan et al. reported that
PACSLAC-II had better reliability when com-
pared with other tools CNPU, NOPPAIN,
PACSLAC, PADE and PAINAD[29] . Cohen-
Mansfield concluded that PAINAD and CNPI
both had high inter-rater agreement 94%[31] .
Kaasalainen et al. determined that PACSLAC
had higher inter-rater reliability than PACI
during periods of activity, while PACI had bet-
ter reliability than PACSLAC during periods
of rest[38] . Kaasalainenetal. also found high
correlation between two self-report tools PPI
and VDS[38] . Horgas et al. noted that there

10.2217/nmt-2016-0033 Neurodegener. Dis. Manag. (Epub ahead of print) future science group
 Pain assessment tools for older adults with dementia in long-term care facilities
Table 2. Components of standardized pain measurement tools.
Instrument
Abbey Pain Scale
Certified Nursing Assistant Pain
Assessment Tool
Checklist for Nonverbal Pain Indicators 06
Chinese Pain Assessment in
Advanced Dementia
Doloplus-II
Faces Pain Scale Revised
Functional Pain Scale
Global Pain Assessment
Minimum Data Set Pain Behavior
Scale
MobilizationObservation
BehaviourIntensityDementia-2
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Scoring scale
018
Components assessed from 0
to 3
05
Each category scored using
binary system
Components rated absent (0) or
present (1)
04 for each category
03 for each item
05 per item, corresponding to
six faces
Requires certain responses to
proceed to next question
Items rated 1 to 5
4-point scale
04
Components rated
dichotomously
010 for each component Observer Pain behavior and intensity during guided behavior
Systematic Review
Rater Components
Observer Vocalization
Facial expression
Change in body language
Behavioral change
Physiological change
Physical change
Observer Facial expression
Behavior
Mood
Body language
Activity level
Observer Verbal vocal complaints
Nonverbal vocalizations
Facial grimaces/winces
Bracing
Restlessness
Rubbing
Observer Breathing
Negative vocalizations
Facial expression
Body language
Consolability
Observer Somatic complaints
Protective body postures
Adapted at rest
Self-protection of sore areas
Expression
Sleep pattern
Washing and/or dressing
Mobility
Communication
Social life
Behavior problems
Self-rated Severity of pain currently experienced at rest
Severity of pain experienced on movement
Self-rated Are you in pain?
Is your pain tolerable?
Does it prevent you from doing activities?
Can you use the telephone, watch television or read?
Self-rated How much pain are you in?
How much pain were you in, in the past week?
Observer Nonverbal sounds crying, whining, gasping,
moaning or groaning
Vocal complains of pain that hurts, ouch or stop
Facial expressions grimaces, winces, wrinkled
foreheads, furrowed brows, clenched teeth or jaws
Protective body movements or postures
opening hands, stretching arms toward head,
stretching and bending knees and hips, turning in bed
or sitting at bedside
Pain behavior and intensity related to anatomy head,
mouth, neck, heart, lung, chest wall, abdomen, pelvis,
genital organs and skin
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Systematic Review Chow, Chow, Lam et al.
Table 2. Components of standardized pain measurement tools (cont.).
Instrument
Mahoney Pain Scale
Non-Communicative Patients Pain
Assessment Instrument
Observational Pain Behavior
Assessment Instrument
Pain Assessment in the
Communicatively Impaired
Pain Assessment Checklist for Seniors
with Limited Ability to Communicate
Pain Assessment Checklist for
Seniors with Limited Ability to
CommunicateII 0 or 1
Pain Assessment Checklist for Seniors
with Limited Ability to Communicate
Dutch
Pain Assessment for the Dementing
Elderly
Pain Assessment in Advanced
Dementia
10.2217/nmt-2016-0033
Scoring scale Rater Components
024 Observer Facial expression
Components rated 0 to 3 Breathing
Vocalization
Body language
Normal/agitated behavior
Sleep pattern and behavior
Physical state
Painful situations
Presence of pain during Observer Activities lying down resident, turning resident in
activities bed, transferring resident, sitting resident, dressing
05 for pain response resident, feeding resident, standing resident, walking
resident or bathing resident
Pain response pain words, pain faces, bracing, pain
noises, rubbing or restlessness
06 for each category Observer Five categories restlessness, muscle tenseness, body
movement, facial expressions and sounds
12 behaviors
07 Observer Brow lower
Dichotomous response (yes/no) Lid tighten
for each item Cheek raise
Sounds
Words
Guarding
Rub/touch
060 Observer Facial expressions 13 items
Items are scored as 0 or 1 Verbalizations and vocalizations 7 items
Body movement 19 items
Change in interpersonal interactions 4 items
Changes in activity patterns or routines 4 items
Mental status changes 7 items
Other 6 items
031 Observer Facial expressions 11 items
Items are similarly scored either Verbalizations and vocalizations 5 items
Body movements 12 items
Changes in interpersonal interactions 2 items
Changes in activity patterns or routines 1 item
Mental status changes 1 item
024 Observer Facial expressions 7 items
Items are scored 0 or 1 Verbalizations and vocalizations 3 items
Body movements 6 items
Changes in interpersonal interactions 4 items
Mental status changes 3 items
Other 1 item
14 for each item Observer Physical (13 items) observable, facial expression,
breathing pattern, posture
Global assessment (1 item)
Functional (10 items) dressing, feeding oneself,
transfers from wheelchair to bed
010 Observer Breathing
Each item is scored 0 to 2 Negative vocalizations
Facial expression
Body language
Consolability
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 Pain assessment tools for older adults with dementia in long-term care facilities Systematic Review

Table 2. Components of standardized pain measurement tools (cont.).

Instrument
Pain Assessment in Non-
communicative Elderly
Present Pain Intensity
Resident Assessment Instrument
Short-Form McGill Pain Questionnaire 03 for each item
Verbal Descriptor Scale
Scoring scale
7-point frequency scale for first
15 items
Binary response for remaining 7
6-point scale
Categorical answers
Self-rated Sensory subscale (11 items) throbbing, shooting,
Requires certain response to
proceed to next question
6-point scale for follow-up
question
Rater Components
Observer Moaning
Rigidity
Facial grimaces
Restlessness/repetitive movements
Rubbing self
Gasping/sighing
Crying/whimpering/whining
Screaming/yelling
Pushing others toward self
Guarding/abnormally stiff
Bracing/leaning on a wall or chair
Moodiness/irritation/depressed mood
Apathetic/low energy
Strange posture
Involvement in activities
Falls
Trembling/shaking
Swollen joints
Tight/swollen belly
Blood stains
Changes in vital signs
Broken bones/dislocated limbs
Self-rated How much pain do you feel?
How bad is your pain or discomfort?
Observer Frequency of complaints/evidence of pain
Intensity of pain
Location of pain
stabbing, sharp, cramping, gnawing, hot/burning,
achieving, heavy, tender, splitting
Affective subscale (4 items) tiring/exhausting,
sickening, fearful, punishing/cruel
Self-rated Are you in pain or discomfort?
How bad is your pain or discomfort?

was correlation between self-report tools and
NOPPAIN in worst pain score for cognitively
intact participants, and also some degree of cor-
relation in pain indicators for all participants
(Table 3)[35] .
Ahn et al. concluded that assessing pain
can improve pain management, and Barry et
al. noted that assessment remains a challeng-
ing area[25,26] . Brown recognized that the RAI
pain section is useful to identify patterns but
must be commissioned together with other
tools for effective pain assessment[27] . Ersek
et al. similarly concluded that tools should be
only one part of a multidimensional pain assess-
ment regiment[32] . Manias et al. identified that
self-rated pain assessment, where applicable,
offers better pain relief, and Kaasalainen et al.
concluded that their observed-rater tools, the
PACSLAC and PACI, vary as a function of
the participants ability to articulate their pain
via PPI andNRS[38,41] . The other studies all
reported that their respective pain measurement
tools showed promise for better pain treatment
in demented elderly (Table 1)[6,13,28,31,37,39,40,42,45] .
Discussion
Pain is highly prevalent in institutionalized
older adults and requires reliable and valid
measures in order for optimal symptom con-
trol to be implemented. A variety of assessment
tools, both self-report and observational, allow
certain inferences to be drawn about pain-
related processes. Two studies[46,47] , although
not specifically dealing with participants in

future science group www.futuremedicine.com 10.2217/nmt-2016-0033

Systematic Review Chow, Chow, Lam et al.

Table 3. Reliability/validity testing of tools.

Study (year) Purpose Study conclusion Ref.
Chan et al. (2014) Validation of PACSLAC-II PACSLAC-II showed strongest correlation with PACSLAC and NOPPAIN [29]
PACSLAC-II demonstrated highest effect sizes in influenza vaccination and
movement-exacerbated pain conditions (compared with CNPI), NOPPAIN,
(PACSLAC), (PADE) and (PAINAD)
No significant inter-rater variability
Cheung and Choi (2008) Evaluation of inter-rater Strongly significant inter-rater reliability of PACSLAC [30]
reliability for PACSLAC
Cohen-Mansfield (2008) Inter-rater reliability for 94% agreement for PAINAD items [31]
PAINAD, CNPI and OPBAI 94% agreement for CNPI
OPBAI showed 93% agreement
Ersek et al. (2010) Internal consistency of CNPI Good internal consistency for CNPI at rest and during movement [32]
and PAINAD Poor internal consistency for PAINAD at rest, and acceptable consistency
with movement
Fuchs-Lacelle et al. Reliability of independent Substantial agreement for use of PACSLAC [33]
(2008) coders use of PACSLAC
Horgas et al. (2007) Inter-rater reliability of High reliability between observers ratings for NOPPAIN [35]
NOPPAIN, correlation analysis Correlation of worst-pain score between self-report tools and NOPPAIN in
between NOPPAIN and self- cognitively intact participants
report tools Five of six pain indicators for cognitively impaired and three of six for
cognitively intact correlated with NOPPAIN scores
Husebo et al. (2014) Testretest reliability of Testretest reliability was high for items and the total score [36]
MOBID-2
Kaasalainen et al. (2013) Inter-rater reliability for Higher inter-rater reliability for PACSLAC than PACI during periods of activity [38]
PACSLAC and PACI, and Higher inter-rater reliability for PACI than PACSLAC during rest
concurrent validity between Strongest correlation (concurrent validity) between two verbal report tools
all tools during an activity period
Lowest correlation (concurrent validity) between PPI and PACI during rest
Liu and Lai (2014) Correlation of C-PAINAD with C-PAINAD had similar correlation to PAINAD [39]
Pain Visual Analog Scale
Mahoney and Peters Interrater reliability ofMPS MPS had poor-to-acceptable inter-rater reliability for each item [40]
(2008)
Snow et al. (2004) Analysis of agreement Exemplary agreement between raters for NOPPAIN [43]
between NOPPAIN ratings
Villanueva et al. (2003) Reliability and construct Inter-rater reliability between different raters was high [45]
validity of PADE Internal consistency was acceptable for parts I and III of PADE
Zwakhalen et al. (2007) Internal consistency of High levels of internal consistency for complete scale and all subscales [13]
PACSLAC-D Good correlation with PACSLAC
CNPI:Checklist for Nonverbal Pain Indicators; C-PAINAD:Chinese Pain Assessment in Advanced Dementia; MOBID-2:Mobilization-Observation-Behaviour-Intensity-Dementia-2;
MPS:Mahoney Pain Scale; NOPPAIN:Non-Communicative Patients Pain Assessment Instrument; OPBAI:Observational Pain Behavior Assessment Instrument; PACI:Pain
Assessment in the Communicatively Impaired; PACSLAC:Pain Assessment Checklist for Seniors with Limited Ability to Communicate; PACSLAC-II:Pain Assessment Checklist for
Seniors with Limited Ability to Communicate II; PACSLAC-D:Pain Assessment Checklist for Seniors with Limited Ability to Communicate Dutch; PADE:Pain Assessment for the
Dementing Elderly; PAINAD:Pain Assessment in Advanced Dementia; PPI:Present Pain Intensity.

LTCs, might also shed light on additional
aspects involved in pain assessment.
Multiple self-report pain assessment tools
exist, which should be the gold standard for
measuring pain in cognitively intact individu-
als. However, older adults with dementia may
not be able to participate in these types of
assessments due to communication difficulties,
which may lead to underdetection of pain[31] .
In response, observational tools may be concur-
rently used to provide a more holistic pain assess-
ment[38] . As this review revealed, some degree of
correlation was found between self-report tools
and observer-rated tools; there still exists items,
however, that can only be captured by self-report
tools. Patient involvement is an essential compo-
nent of pain assessment, and when possible, tools
and modifications should be employed to fur-
ther characterize patients subjective experience
of pain and pain severity.
Although past research has proven that the
elderly with mild-to-moderate dementia have
the capacity to handle self-report tools, clini-
cians should be aware of deteriorating cognitive

10.2217/nmt-2016-0033 Neurodegener. Dis. Manag. (Epub ahead of print) future science group
 Pain assessment tools for older adults with dementia in long-term care facilities
and linguistic capabilities that could serve as a
potential barrier to administration of self-report
tools[46,4850] . Studies have noted that theVDS
enables accurate assessment, as it consists of
words to express pain intensity (which might be
more stable than diminishing language skills)
up to 90% of people with moderate cognitive
impairment were able to use the VDS due to its
construct of verbal indicators[47,48] . The NRS
and VAS have also been proved to be reliable,
but may be more difficult when compared with
the VDS[47] . For elderly patients with dementia
in the advanced stage, self-report tools are less
reliable and often less applicable[51] . Self-report
tools, however, are typically unidimensional
and only serve as an indicator for pain intensity,
disregarding other pain qualities, location and
functional impact[48] . Self-report tools, admin-
istered alongside observational pain assessment
tools, may be particularly useful in most mild
and moderate dementia patients, and allow for
better pain assessment.
The development of observational pain
assessment tools has afforded clinicians the
opportunity to better assess and manage pain
in all patients with dementia, with PACSLAC
seemingly the most frequently studied.
Although numerous tools like the PAINAD,
Doloplus-II and PACSLAC have been highly
rated by practicing clinicians[5254] , only the
PACSLAC comprehensively covers all six
domains of important nonverbal behaviors rec-
ommended by the American Geriatric Society
(AGS): facial expressions, verbalizations and
vocalizations, body movements, changes in
activity patterns and routines, changes in
interpersonal interactions and mental status
changes [55] . Although the six domains are
derived from expert opinions, no studies have
verified if all the domains are truly relevant and
whether they impact the final decision about
the presence or absence of pain; touching on all
six domains does not show PACSLACs superi-
ority, but rather better adherence to AGS guide-
lines. Studies have also shown PACSLAC to
account for the most variance in ability to dif-
ferentiate between pain-related and nonpain-
related states, along with consistently leading to
improved pain management practices[33,56,57] .
Finally, the PACSLAC has been validated alone
on multiple occasions as a reliable tool[30,33] ,
and proven by Kaasalainen to be a superior
tool in some regards[38] . Nevertheless, the
trade-off of reliability and comprehensive
future science group
Systematic Review
coverage is the length of the tool with 60
items, the PACSLAC may be overburdening
to patients and assessors alike compared with
other assessment tools. The shortened ver-
sions, PACSLAC-II and PACSLAC-D, may
have more utility in the clinical setting while
also retaining coverage of the AGS pain assess-
ment domains. It is also encouraging to note
that PACSLAC-II and PACSLAD-D have been
validated to be equally, if not more reliable than
the original PACSLAC.
Most tools for pain assessment, like
PACSLAC, contain components that overlap
with conditions that may not be pain related,
such as delirium, therefore, making the assess-
ment more challenging to specifically identify
pain symptoms[34] . PAINAD and Abbey Pain
Scale, as other examples, assess pain in addi-
tion to other distressing emotions and behaviors
such as distress and discomfort[41] . Deletion of
certain delirium-correlated items of PACSLAC
in the shortened versions seems to resolve the
issue while also not significantly impacting the
psychometric properties of the tool[56] .
This review was not without limita-
tions. Our eligibility criteria only included
reliability/validity testing for tools and hence
did not examine practicability, which was
included in some other reviews[48,58] .
Conclusion
Self-report assessment tools should always be the
first-line approach for assessing pain when possi-
ble, with observational assessment employed as a
support tool. Although numerous observational
tools have been developed and show promise for
pain assessment, the PACSLAC is one of the first
of its kind to comprehensively inquire about the
domains of important nonverbal behaviors, as
recommended by the AGS. However, its length
may be a hindrance for clinical applicability,
ultimately leading to shortened tools such as the
PACSLAC-II and PACSLAC-D. These short-
ened tools have been proven to have positive
psychometric properties, and feature the abil-
ity to differentiate between pain and nonpain
states while maintaining reliability/validity.
These shortened but comprehensive tools can
hopefully increase the implementation of pain
assessment tools for institutionalized elderly
with dementia, to facilitate the pain manage-
ment process. These tools, however, should
undergo further scrutiny regarding feasibility
and practicability in daily routine use.
www.futuremedicine.com 10.2217/nmt-2016-0033
Systematic Review Chow, Chow, Lam et al.

Future perspective applicability to the LTC setting. Finally, what

This review has focused on the assessment of
pain in LTC residents with dementia. We sup-
port a standardized, structured approach that
utilizes rating scales in order to improve the
detection and treatment of this common and
often underdiagnosed problem. Although we
underscore the limitations of both self-report
and observer-rated instruments because of meth-
odological and practical reasons, because pain is
truly a subjective experience, we have advocated
for the use of self-rated instruments when the
patient is cognitively able. However, for many
patients in LTC with severe dementia, self-rated
instruments will be unreliable and impractical,
and so reliance on observer-rated scales, with
their own limitations, becomes necessary. What
is therefore urgently needed are objective, physi-
ological measures of pain (A.K.A. pain bio-
markers) that can be shown to reliably corre-
late with subjective pain assessments. Research
into serum biomarkers (e.g.,inf lammatory
cytokines), imaging biomarkers (e.g.,fMRI)
and other physiological measures (e.g.,pupi-
lometry, EEG, skin and cardiac measures) is
necessary, paying particular attention to their
is ultimately needed are safer, more effective,
well-tolerated analgesics and nonpharmacologi-
cal treatment techniques (e.g.,neuromulation
with transcanial direct current stimulation)
that will not worsen cognitive function in these
vulnerable people.
Supplementary data
To view the supplementary data that accompany this paper
please visit the journal website at: www.futuremedicine.
com/doi/full/10.2217/nmt-2016-0033.
Financial & competing interests disclosure
N Herrmann is funded by the Alzheimer Society of Canada
and the Alzheimers Drug Discovery Foundation. The
authors have no other relevant affiliations or financial
involvement with any organization or entity with a finan-
cial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or
pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.

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