Pain Assessments for Older Adults

 Purpose 

The purpose of this page is to provide physical therapists with information about different pain assessments available to use with older adults.

 Objectives 

1.      Provide therapists with pain assessments to use with cognitively intact older adults.

2.      Provide therapists with pain assessments to use with cognitively impaired older adults.

3.      Provide therapists with pain assessment to use with older adults with advanced dementia.

4.      Provide additional resources to pain assessments and pain management strategies for older adults.

 Why is Assessing Pain in Older Adults Important 

At least 25% of older adults have persistent pain. However, the prevalence of pain in older adults varies, depending on if they are in a nursing facility or community dwelling. Up to 80% of older adults in nursing facilities and 50% of community dwelling adults have pain.1 Pain has been shown to have a positive relationship to depression.2 With such high prevalence pain in older adult and the association between pain and depression, it is imperative that we assess and treat pain in this population to help improve their independence and quality of life.

 Pain Assessments to Use in Cognitively Intact Older Adults 

Older adults who are cognitively intact can communicate their pain to others, and so the pain assessments used for this population are self-reported measures.3

Numeric Rating Scale (NRS)

Instructions: Ask the patient to rate their pain on a scale of 0 to 10 at that moment. The NRS can also be used to assess how severe the pain can get, or how severe the pain is at its lowest.

Scoring: 0 indicating no pain, and 10 being the worst pain imaginable.

Pros: Simple to use, does not require a form.

Cons: Very subjective since everyone’s perception of pain is different.

Verbal Descriptor Scale (VDS)

Instructions: Ask the patient to rate their pain from “no pain”, to “mild”, “moderate”, “severe”, or “pain as bad as it could be.”

Scoring: No numbers are used in this assessment.

Pros: Simple to use, does not require a form. Patients do not have to quantify their pain.

Cons: Very subjective since everyone’s perception of pain is different.

 Pain Assessments to Use on Cognitively Impaired Older Adults 

Older adults who have cognitive impairments may have difficulty describing or quantifying their pain, and so assessments used for this population are self-reported measures that do not involve words or numbers.

Faces Pain Scale – Revised FPS-R)

Instructions: Show the patient the images of the different faces and ask them to select the face that represents how severe the pain feels at that moment.

Scoring: Each face is rated either 0, 2, 4, 6, 8, or 10.

Pros: Quick and simple to use for both patients and therapists.

Cons: Does not provide detail as to description nor duration of pain.

A copy of the FPS-R can be found here.

 Pain Assessments to Use in Older Adults with Advanced Dementia 

Patients with advanced dementia are unable to communicate their pain to others, and so the pain assessments used for this population are based on observations of their behavior.

Discomfort Scale – Dementia of the Alzheimer’s Type (DS-DAT)

Instructions: Observe your patient for 5 minutes and score them based on: noisy breathing, negative vocalization, lack of content facial expression, sad facial expression, frightened facial expression, lack of relaxed body language, tense body language, and fidgeting. For each behavior, you assess the number of episodes, the intensity of the behavior (low versus high), and duration ( 1 minute). The frequency, intensity, and duration of the behavior are combined to give the patient a score of 0-3 for each behavior. A 0 indicates absence of the behavior, and 3 indicates high frequency, duration, and intensity of the behavior.

Scoring: A patient can score between 0 and 27. The higher the score, the higher the level of discomfort.

Pros: Gives you a detailed assessment of each behavior.

Cons: May be difficult to administer due to number of behaviors that are assessed.

A copy of the DS-DAT and additional scoring information can be found here.

'''Pain Assessment in Advanced Dementia Scale (PAINAD)'''

Instructions: Observe your patient for 5 minutes and score them based on: breathing (disregarding vocalization), negative vocalization, facial expressions, body language, and consolability. The patient can score anywhere from 0-2 for each behavior, with 0 indicating normal or absence of the behavior, and 2 indicating extreme presence of the behavior.4

Scoring: A patient can score between 0-10. Evidence shows that a score of 2 or higher indicates that the patient has pain that should be treated.5

1-3 = mild pain

4-6 = moderate pain

7-10 = severe pain

Pros: Quick and simple to use. Comparable in construct validity compared to the DS-DAT.2

Cons: May be more subjective due to the decrease in amount of detail with scoring criteria.

A copy of the PAINAD and additional scoring information can be found here.

 Additional Resources 

For more information on additional pain assessments and pain management, you can visit the following websites:

Assessing Pain

www.geriatricpain.org

www.iasp-pain.org

https://www.medscape.com/viewarticle/556382_4

Managing Pain

https://www.webmd.com/pain-management/treating-pain-elderly

http://www.healthinaging.org/aging-and-health-a-to-z/topic:pain-management/

References

1.      Bruckenthal P. Assessment of Pain in Older Adults. In: Current Therapy in Pain. 1st ed.; 2008:14-24.

2.      Geerlings SW, Twisk JWR, Beekman ATF, Deeg DJH, Tilburg WV. Longitudinal relationship between pain and depression in older adults: sex, age and physical disability. Social Psychiatry and Psychiatric Epidemiology. 2002;37(1):23-30. doi:10.1007/s127-002-8210-2.

3.      Flaherty E. Pain Assessment for Older Adults. ''Insight - The Journal of The American Society of Ophthalmic Registered Nurses''. 2007;(7).

4.      Warden V, Hurley AC, Volicer L. Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia Scale. Journal of American Medical Directors Association. 2003;4(1):9-15. doi:10.1097/01.JAM.0000043422.31640.F7.

5.       Zwakhalen SM, Steen JTVD, Najim M. Which Score Most Likely Represents Pain on the Observational PAINAD Pain Scale for Patients with Dementia? Journal of the American Medical Directors Association. 2012;13(4):384-389. doi:10.1016/j.jamda.2011.04.002.