Pain Assessment in Late-Stage Alzheimer's Disease

Health Professional

As Alzheimer's disease progresses towards the later stages, the ability of the affected person to communicate becomes increasingly compromised. Caregivers can no longer ask "are you comfortable?" or, "are you in pain?" and get a reliable answer. A caregiver has to interpret what behavior means. Are shouts, screams, severe withdrawal, aggression, due to confusion, something else, or are they signs of pain?

The way in which we experience pain differs. Pain is a subjective experience. People who have problems communicating are disadvantaged. Research into the prevalence of pain in elders in nursing homes is estimated at between 40 and 80 percent. There is evidence that people with cognitive disabilities may have an even higher risk of being under-medicated for pain. Painful conditions such as arthritis, cancer, urine infections are sometimes not treated with painkilling medications. Even when people can communicate effectively research suggests that observers tend to assume that people over-report pain either verbally or in their facials expressions.

Effective pain management for people with dementia is a complex issue. Families and health professionals caring for people with dementia have to acquire new skills and it can be a rather hit and miss situation.

All caregivers have to use their observational skills and be sensitive to non-verbal forms of communication to assess the presence and level of pain in someone with Alzheimer's disease. There are indicators to help:

Facial Expressions that may indicate pain include:

  • Facial grimacing
  • Frowning
  • Sad look
  • Tighter facial expression
  • Screwing up the nose
  • Wincing
  • Clenching teeth

Body Movements/Activity indicators of pain include:

  • Flinching
  • Pulling away
  • Restlessness
  • Fidgeting
  • Thrashing
  • Stiffness or rigidity
  • Signs of physical discomfort in areas of the body. So, limping, guarding against someone touching or feeling a particular area are examples.
  • Going into a fetal position.

Social, Mood and Personality indicators of pain include:

  • Physical aggression-throwing things, hitting, scratching,
  • Throwing things
  • Verbal aggression
  • Not allowing people near
  • Increased irritability, frustration, anxiety
  • Upset

Physical indicators of pain include:

  • Pale
  • Sweating, or cold and clammy
  • Shaking
  • Changes in appetite including increased or decreased appetite
  • Screaming, yelling
  • Crying
  • Moaning, groaning
  • Changes of sleep


The more pain symptoms someone with Alzheimer's has and the more intense the symptoms are, the easier it will be to assess pain and the level of pain. Keeping a record can help assess pain levels and response to analgesic medications. If pain is suspected there is really no harm in assuming it exists. In such circumstances analgesics should be given and the patient observed for signs of becoming more settled.

Contact a doctor about more effective pain relief