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The Pain Assessment in Advanced Dementia (PAINAD) was developed to assess pain in patients who are cognitively impaired, non-communicative, or suffering from dementia and unable to use self report methods to describe pain. Observation of patients during activity records behavioral indicators of pain: breathing, negative vocalization, facial expression, body language, and consolability.

How to use:
PAINAD is a five item observational tool with numerical equivalents for each of the five behavior items listed, with total scores ranging from 0 to 10. Each of the five assessments contains a range from 0 to 2 and the summation of each of the five categories results in the total numerical score. Please refer to the attached item descriptions. To use:
• Assess patient during periods of activity, such as turning, ambulating, transferring
• Assess patient for each of the 5 indicators: breathing, negative vocalization, facial expression, body language, and consolability
• Assign a numerical point value based on each of the 5 assessments observed
• Obtain a total score, by adding scores from the 5 indicators. Total score ranges from a minimum of 0 to a maximum of 10. Populations for use: The primary population for use of the PAINAD is the adult patient with dementia who is unable to self report pain level.

Validity and reliability:
While self-report remains the “gold standard” for pain assessment, several studies have indicated that the PAINAD is an accurate assessment
tool for use in the adult patient population for whom self-report is not a reliable tool due to their altered cognitive abilities.
Herr, K. & Garand, L. (2001). Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine, 17, 457-478.
Leong, I., Chong, M., & Gibson, S. (2006). The use of self-reported pain measure, a nurse-reported pain measure, and the PAINAD in
nursing home residents with moderate and severe dementia: a validation study. Age and aging, 35, 252-256.
Warden, V., Hurley, a., Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia
(PAINAD) scale. American Medical Directors Association, 4, 9-15.


Normal breathing is characterized by effortless, quiet, rhythmic (smooth) respirations
o Occasional labored breathing: episodic bursts of harsh, difficult or wearing respirations.
o Short period of hyperventilation: intervals of rapid, deep breaths lasting a short period of time.
o Noisy labored breathing: sounds on inspiration or expiration. They may be loud, gurgling, wheezing. They appear strenuous or wearing.
o Long period of hyperventilation: an excessive rate and depth of respirations lasting a considerable time.
o Cheyne-Stokes respirations: rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea.

Negative Vocalization:
None is characterized by speech or vocalization that has a neutral or pleasant quality.
o Occasional moan or groan: Moaning is mournful or murmuring sounds, wails or laments. Groaning is louder than usual inarticulate
involuntary sounds, often abruptly beginning and ending.
o Low level speech; negative or disapproving quality: muttering, whining, or swearing in a low volume. Complaining, sarcastic or caustic.
o Repeated troubled calling out : phrases or words being used over and over in a tone that suggests anxiety, uneasiness, or distress.
o Loud moaning or groaning : mournful or murmuring sounds, wails or laments in much louder than usual volume. Loud groaning is
characterized by louder than usual inarticulate involuntary sounds, often abruptly beginning and ending.
o Crying : an utterance of emotion accompanied by tears. There may be sobbing or quiet weeping.

Facial Expression:
Smiling (upturned corners of the mouth with a look of pleasure or contentment) or inexpressive (neutral, at ease, relaxed)
o Sad : an unhappy, lonesome, sorrowful, or dejected look. There may be tears in the eyes.
o Frightened : a look of fear, alarm or heightened anxiety. Eyes appear wide open.
o Frown : a downward turn of the corners of the mouth. Increased facial wrinkling in the forehead and around the mouth may appear.
o Facial grimacing : a distorted, distressed look. The brow is more wrinkled as is the area around the mouth. Eyes may be squeezed shut.

Body Language:
Relaxed: a calm, restful, mellow appearance. The person seems to be taking it easy.
o Tense : a strained, apprehensive or worried appearance. The jaw may be clenched. (exclude any contractures)
o Distressed pacing: activity that seems unsettled. May appear fearful, worried, or disturbed. Pacing may be faster or slower than usual.
o Fidgeting: restless movement. Squirming about or wiggling, may hitch a chair across the room. Repetitive touching, tugging or rubbing.
o Rigid: stiffening of the body. The arms and/or legs are tight and inflexible. The trunk may appear straight and unyielding. (not contractures)
o Fists clenched : tightly closed hands. They may be opened and closed repeatedly or held tightly shut.
o Knees pulled up : flexing the legs and drawing the knees up toward the chest. An overall troubled appearance. (exclude any contractures)
o Pulling or pushing away : Resists attempts of others to help. Tries to escape by yanking or wrenching free or shoving helpers away.
o Striking out : hitting, kicking, grabbing, punching, biting, or other form of personal assault.


No need to console: a sense of well being. The person appears content.
o Distracted or reassured by voice or touch: Behavior suggestive of distress stops when the person is spoken to or touched.
o Unable to console, distract or reassure: the inability to sooth the person or stop a behavior with words or actions. No amount of
comforting, verbal or physical, will alleviate the behavior suggestive of distress.

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