How to Use the Pain Assessment in Advanced Dementia Scale (PAINAD) to Determine Discomfort in Your Loved One with Dementia

Published on October 13, 2023

Updated on November 18, 2023

If you have a loved one with dementia, it can be difficult to know if they are in pain or . The Pain Assessment in Advanced Dementia Scale (PAINAD) is a tool that can help you determine if your loved one is uncomfortable. The Pain Assessment in Advanced Dementia Scale (PAINAD) is different from other pain assessment tools for people with dementia in several ways:

  1. Observation-Based Tool: The PAINAD doesn't rely on self-reporting by the patient, making it reliable even for non-verbal individuals.
  2. Simplicity: It's a short and straightforward tool that can be used by non-healthcare professionals, reducing barriers to use.
  3. Five Behavior Areas: The PAINAD assesses five key areas of behavior: breathing, vocalization, facial expression, body language, and consolability.
  4. Versatility: It can be used for both verbal and nonverbal patients, making it widely applicable.
  5. Reliability: Studies have shown it to be reliable for assessing pain in advanced dementia patients.

Other pain assessment tools may rely on self-reporting, which is often challenging for those with advanced dementia. Additionally, they might be complex and time-consuming. The PAINAD's focus on observable behaviors and ease of use makes it a valuable tool for assessing pain in patients with advanced dementia.

The Pain Assessment in Advanced Dementia Scale (PAINAD) assesses five areas, which are:
  • Breathing: Independent of vocalization.
  • Negative vocalization: Such as moaning or groaning.
  • Facial expression: Including frowning or grimacing.
  • Body language: Indicating tension or .
  • Consolability: How easily the patient can be comforted.

Each area is scored from 0 to 2, resulting in a total score ranging from 0 to 10. A higher score suggests more severe or pain, while a score between 0 and 2 indicates comfort.

Using the PAINAD Scale

Step 1: Observe Your Loved One

Before you can use the PAINAD scale, you need to observe your loved one for five minutes. During this time, look for any behaviors that might indicate discomfort or pain. These behaviors include:

  • Facial expressions: Look for frowning, grimacing, or other signs of distress on your loved one's face.
  • Vocalizations: Listen for moaning, groaning, or other sounds that might indicate discomfort.
  • Body language: Look for tense muscles, , or other signs of discomfort in your loved one's body language.
  • Breathing: Observe your loved one's breathing for any signs of distress, such as rapid or shallow breathing.
  • Consolability: Try to console your loved one by holding their hand or speaking to them in a soothing voice. Observe how they respond.

Step 2: Score Your Loved One’s Behaviors

After observing your loved one for five minutes, you can use the PAINAD scale to score their behaviors. The scale uses a score of 0-2 for each behavior, with a total score ranging from 0-10. Here's how to score each behavior:

  • Facial expressions: Look for furrowing of the brow, narrowing of the eyes, or deepening of the nasolabial furrow (lines on your face around your nose and mouth). Score 0 for no expression, 1 for a mild expression, and 2 for a moderate to severe expression.
  • Vocalizations: Listen for moaning, groaning, or other sounds that might indicate discomfort. Score 0 for no vocalization, 1 for occasional moaning or groaning, and 2 for frequent or loud vocalization.
  • Body language: Look for tense muscles, restlessness, or other signs of discomfort in your loved one's body language. Score 0 for relaxed muscles, 1 for tense muscles or restlessness, and 2 for rigid muscles or constant restlessness.
  • Breathing: Observe your loved one's breathing for any signs of distress, such as rapid or shallow breathing. Score 0 for normal breathing, 1 for occasional labored breathing or short periods of hyperventilation, and 2 for noisy labored breathing, long periods of hyperventilation, or Cheyne-Stokes respirations.
  • Consolability: Try to console your loved one by holding their hand or speaking to them in a soothing voice. Observe how they respond. Score 0 for easily consoled, 1 for difficult to console, and 2 for unable to console.

Step 3: Interpret Your Loved One’s Score

Once you have scored your loved one's behaviors, you can interpret their score. A score of zero (0) means no pain. A score of 1-3 indicates mild discomfort. A score of 4-7 indicates moderate discomfort. A score of 8-10 indicates severe discomfort. Providers should be notified for severe discomfort.

Hospice PAINAD Score to Rating and Recommendations

PAINAD ScorePain SeverityRecommendations
0NoneNone
1-3MildNothing to Acetaminophen (Tylenol)
4-7ModerateOpioid / Breakthrough Pain Medication
8-10SevereCall your provider! Opioid / Breakthrough Pain Medication
Please always consult your hospice provider or doctor in terms of the recommendations or changes to the table that they would apply and follow their instructions!

Examples of using the PAINAD Scale

Example 1: PAINAD score of 0

You are visiting your grandmother who has dementia at her nursing home. You notice that she is smiling and relaxed. She breathes normally and does not make any noises. She does not seem to have any pain on her face or body. She is happy to see you and responds to your voice and touch. You use the PAINAD scale to score her pain as follows:

  • Breathing: 0 (normal)
  • Negative vocalization: 0 (none)
  • Facial expression: 0 (smiling)
  • Body language: 0 (relaxed)
  • Consolability: 0 (no need to console)

The total score is 0, which means she has no pain. You are glad that she is comfortable and enjoy spending time with her.

Example 2: PAINAD score of 3

You are helping your father who has dementia with his morning routine. He has arthritis and sometimes has pain in his joints. You notice that he is breathing a little harder than usual and occasionally moans. He looks sad and frowns when you touch his arms or legs. He is tense and fidgets with his hands. He is distracted by your voice and touch, but still seems unhappy. You use the PAINAD scale to score his pain as follows:

  • Breathing: 1 (occasional labored breathing)
  • Negative vocalization: 1 (occasional moan or groan)
  • Facial expression: 1 (sad)
  • Body language: 1 (tense)
  • Consolability: 1 (distracted or reassured by voice or touch)

The total score is 3, which means he has mild pain. You decide to give him his pain medication and massage his joints gently. You hope that his pain will improve soon.

Example 3: PAINAD score of 4

You are taking your mother who has dementia to the dentist. She has a toothache and needs a filling. You notice that she is breathing rapidly and deeply. She makes low-level speech with a negative or disapproving quality. She looks frightened and grimaces when the dentist examines her mouth. She is rigid and pulls away from the dentist. She is unable to console, distract or reassure. You use the PAINAD scale to score her pain as follows:

  • Breathing: 2 (short period of hyperventilation)
  • Negative vocalization: 1 (low level speech with a negative or disapproving quality)
  • Facial expression: 2 (frightened)
  • Body language: 2 (rigid)
  • Consolability: 0 (unable to console, distract or reassure)

The total score is 4, which means she has moderate pain. You ask the dentist to give her some local anesthesia and explain what he is going to do. You hold her hand and talk to her calmly. You hope that the procedure will be over soon and that her pain will go away.

Example 4: PAINAD score of 7

You are watching your husband who has dementia at home. He has a urinary tract infection and needs . You notice that he is breathing noisily and laboriously. He cries out loud and repeats troubled phrases. He looks angry and facially grimaces. He is rigid and strikes out at you when you try to help him. He is unable to console, distract or reassure. You use the PAINAD scale to score his pain as follows:

  • Breathing: 2 (noisy labored breathing)
  • Negative vocalization: 2 (repeated troubled calling out)
  • Facial expression: 2 (facial grimacing)
  • Body language: 2 (striking out)
  • Consolability: 0 (unable to console, distract or reassure)

The total score is 7, which means he has severe pain. You call his doctor and ask for advice. You give him his pain medication and try to keep him comfortable. You hope that the infection will clear up soon and that his pain will subside.

Example 5: PAINAD score of 10

You are accompanying your sister who has dementia to the hospital. She has fallen and broken her hip. You notice that she is breathing in a rhythmic pattern of very deep to shallow respirations with periods of no breathing. She screams and cries loudly. She looks in agony and facially grimaces. She is rigid and clenches her fists and knees. She is unable to console, distract or reassure. You use the PAINAD scale to score her pain as follows:

  • Breathing: 2 (Cheyne-Stokes respirations)
  • Negative vocalization: 2 (crying)
  • Facial expression: 2 (facial grimacing)
  • Body language: 2 (rigid)
  • Consolability: 0 (unable to console, distract or reassure)

The total score is 10, which means she has severe pain. You alert the hospital staff and ask for immediate help. You give her your support and sympathy. You hope that she will get the treatment she needs and that her pain will be relieved.

Conclusion

The Pain Assessment in Advanced Dementia Scale (PAINAD) is a useful tool for determining if your loved one with dementia is uncomfortable. By observing your loved one's behaviors and scoring them on the PAINAD scale, you can get a better understanding of their level of discomfort and take steps to address it. Remember, discomfort and pain should be treated similarly when it comes to maintaining the comfort of your loved one.

Resources

Assessing Pain in the Nonverbal Patient

Discomfort is a different type of pain, but pain none the less

Pain Assessment in Hospitalized Older Adults With Dementia and Delirium

Pain Assessment in Dementia – International Association for the Study of Pain (IASP)

Pain Assessment in People with Dementia: AJN The American Journal of Nursing

PAINAD Scale Offers Alternative to Assessing Pain in the Dementia Patient – JEMS: EMS, Emergency Medical Services – Training, Paramedic, EMT News

Pain Assessment in Advanced Dementia Scale (PAINAD) – MDCalc

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia

Chronic Pain & Symptom Tracker: A 90-Day Guided Journal: Detailed Daily Pain Assessment Diary, Mood Tracker & Medication Log for Chronic Illness Management

Pain And Symptom Tracker: Daily Pain Tracking Journal Detailed Pain Assessment Diary, Medication, Supplements Food & Activities Log for Chronic Illness Management

Pain Assessment and Pharmacologic Management

Adult Nonverbal Pain Scale (NVPS) Tool for pain assessment

Assessing pain in patients with cognitive impairment in acute care

FLACC Pain Scale

Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment in Non-Communicative Adult Palliative Care Patients

Pain Assessment in People with Dementia

Tools for Assessment of Pain in Nonverbal Older Adults with Dementia: A State-of-the-Science Review

Understanding the physiological effects of unrelieved pain

Untreated Pain, Narcotics Regulation, and Global Health Ideologies

The Importance of Caregiver Journaling

Reporting Changes of Condition to your Hospice Provider

My Loved One with Dementia

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia) (Video)

How Do I Know Which Dementia I'm Looking At? (Video)

Dementia Training material (Free)

Promoting Meaningful Relationships with Dementia Patients through Validation Therapy

Unlocking the Power of Validation Therapy in Compassionate End-of-Life Care

Validation Therapy: A Valuable Tool for Families and Healthcare Teams

Best Practices for Approaching Combative Dementia Patients

The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer's Disease and Other Dementias

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How Do I Know You? Dementia at the End of Life

The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer's Disease and Other Neurocognitive Disorders (Guides to Caregiving)

Sundown Dementia, Vascular Dementia and Lewy Body Dementia Explained

The Caregiver's Guide to Dementia: Practical Advice for Caring for Yourself and Your Loved One (Caregiver's Guides)

Ahead of Dementia: A Real-World, Upfront, Straightforward, Step-by-Step Guide for Family Caregivers

The Dementia Caregiver's Survival Guide: An 11-Step Plan to Understand the Disease and How To Cope with Financial Challenges, Patient Aggression, and Depression Without Guilt, Overwhelm, or Burnout

Dementia Care Companion: The Complete Handbook of Practical Care from Early to Late Stage

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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