Instructions:
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)
Behaviour |
0 |
1 |
2 |
Score |
Breathing |
- 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 |
|
Consolability |
- No need to console | - Distracted or reassured by voice or touch | - Unable to console, distract, or reassure |
Scoring:
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.
Links/References
- 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
- dementiapathways.ie copy of the above PAINAD print version