PAINAD Scale Can Help Caregivers Identify Pain in Loved Ones with Advanced Dementia

Patient Expert

After watching Mom's last days at the nursing home when she was uncommunicative, I often have wondered how caregivers would realize that a loved one who is at the end stages of Alzheimer's was in pain.  That's where the Pain Assessment in Advanced Dementia (PAINAD) scale can be of use.

According to Lippincott's Nursing, this scale is a behavior-observation tool for use with people who have advanced dementia to the point that they can no longer communicate verbally. This scale was adapted from the Discomfort Scale for Dementia of the Alzheimer Type and the a scale used to assess pain levels in babies called the Face, Legs, Activity, Cry , Consolability Scale.

The PAINAD scale is a rubric that lets a medical professional rate the severity of an item that may be indicative of pain. Lippincott's Nursing stated, "The PAINAD scale's value is twofold. First, in combination with other assessments (for example, monitoring known sources of pain such as acute or chronic conditions), the PAINAD scale can assure the clinician that behaviors are (or are not) pain related. Second, because behaviors that might indicate pain are not the same in all people with dementia, it's useful to evaluate a patient's actions in a consistent manner using a single tool. This helps the provider to recognize the patient's unique behavioral patterns and thereby detect changes."

The site notes that pain profiles will differ based on the individual; in fact, some people who are in pain will not show any of the behaviors that are included on the PAINAD scale. "Some behaviors not included are changes in interpersonal interactions (becoming withdrawn, decreasing social interactions), changes in activity patterns (such as in sleeping or eating), and changes in mental status (increased confusion). It's therefore important for clinicians to recognize a patient's pain profile, which will aid in the timely treatment of underlying conditions," the website reported.

Here's what PAINAD looks like:

Breathing independent of vocalization:

  • 0: the person has normal breathing
  • 1: the person is displaying occasional labored breathing and short periods of hyperventilation.
  • 2: the person is displaying noisy labored breathing, long periods of hyperventilation, and Cheyne-Stokes respirations, which, according to, is "cyclic breathing marked by a gradual increase in the rapidity of respiration followed by a gradual decrease and total cessation for from 5 to 50 seconds."

Negative vocalization:

  • 0: the person is not displaying negative vocalization.
  • 1: the person is displaying an occasional moan or groan, as well as low-level speech with a negative or disapproving quality.
  • 2: the person displays repeated troubled calling out, loud moaning or groaning, and crying.

Facial expression:

  • 0: the person is smiling or inexpressive.
  • 1: the person is sad, frightened or frowning.
  • 2: the person displays facial grimacing.

Body language:

  • 0: the person is relaxed.
  • 1: the person is tense, distressed, pacing or fidgeting.
  • 2: the person displays rigid posture, clenched fists, knees pulled up. The person also may be pulling or pushing away, or striking out.


  • 0: the person does not need to be consoled.
  • 1: the person can be distracted or reassured by voice or touch.

2: the caregiver is unable to console, distract or reassure the person.

Geriatric recommends that this scale be used in the following time period:

  • Observe the older adult for 3-5 minutes during activity/with movement (such as bathing, turning, transferring).
  • For each item included in the PAINAD, select the score (0, 1, 2) that reflects the current state of the behavior.
  • Add the score for each item to achieve a total score. Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score suggesting more severe pain (0= "no pain" to 10= "severe pain").
  • After each use, compare the total score to the previous score received. An increased score suggests an increase in pain, while a lower score suggests pain is decreased.

Geriatric also suggests that if you are placing a loved one in a nursing home, make sure that the staff does an initial baseline of behaviors related to pain. This scale should be rechecked regularly. Special emphasis should be placed on it when a change in pain status is reported as well as 1-2 hours after a pain intervention has been administered.

Helping a loved one who has advanced dementia live a comfortable life is an important goal, but it can be difficult to attain since the person often is unable to communicate about their physical status. The PAINAD scale is one tool that can help caregivers turn this goal into a reality.