Pain Assessment in Advanced Dementia Scale (PAINAD)


Observe the patient for five minutes before scoring his or her behaviours. Score the behaviours according to the following table. Definitions of each item are provided below. The patient can be observed under different conditions (e.g., at rest, during a pleasant activity, during caregiving, after the administration of pain medication)







independent of vocalisation

- Normal - Occasional laboured breathing
- Short period of hyperventilation
- Noisy laboured breathing
- Long period of hyperventilation
- Cheyne-Stokes respirations

Negative vocalisation

- None - Occasional moan or groan
- Low-level speech with a negative or disapproving quality
- Repeated troubled calling out
- Loud moaning or groaning
- Crying

Facial expression

- Smiling or inexpressive - Sad
- Frightened
- Frown
- Facial grimacing

Body language

- Relaxed - Tense
- Distressed pacing
- Fidgeting
- Rigid
- Fists clenched
- Knees pulled up
- Pulling or pushing away
- Striking out


- No need to console - Distracted or reassured by voice or touch - Unable to console, distract, or reassure


The total score ranges from 0-10 points. A possible interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain. These ranges are based on a standard 0-10 scale of pain, but have not been substantiated in the literature for this tool.


  • Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15
  • copy of the above PAINAD print version

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 12/08/22.