Abbey Pain Scale

Original Editor - Lauren Lopez Top Contributors - Lauren Lopez and Kim Jackson


For caregivers to assess the pain experience of people with end-stage dementia who are non-verbal. 


Pain assessment can be extremely complex in individuals with dementia, particularly toward the end stages of dementia when an individual may become nonverbal. Pain is a significant experience for those with dementia and it is widely believed to be under reported in the dementia population. In the absence of self-reported pain, caregivers and clinicians must rely on their observation and the knowledge they have of the person in questions usual behaviours. 

As a result, the Abbey Pain Scale (APS) was designed to assist in the assessment of pain in the nonverbal individual suffering from end-stage dementia[1].

Like many pain scales for use with people with dementia, there is not a lot of evidence regarding the APS. This is probably because of the nature of the group the scale is designed for. However, the APS has been incorporated into Australian pain guidelines and is recommended by researchers[2][3] 

It is easy to use and no training is required[2]. It is easily accessible online and provides some sort of formalised pain assessment for this complex group of dementia sufferers. 

Intended Population

Individuals with progressed dementia where they are unable to verbalise pain, and their caregivers.

Methods of Use

The APS requires the caregiver or clinician to observe the individual with dementia for signs of pain. 

The Australian Pain Society recommends using this as a movement-based assessment[4], i.e. that observations are made when the individual is moving for daily cares e.g. dressing or pressure area care. Pain may become more obvious on movement, compared to at rest. 

The Australian Pain Society also recommends that the scale is completed again one hour post any intervention[4]. If pain appears to persist then a comprehensive assessment of the person’s care must be done to identify causes of pain and any corresponding treatments to ease pain. If pain appears to persist beyond 24 hours medical help should be sought. 

Each item is rated and rate the following six items on a scale of absent=0, mild=1, moderate=2 or severe=3. 

The six items to be observed are: 

  1. Vocalisation
  2. Facial expression
  3. Change in body language 
  4. Behavioural change 
  5. Physiological change 
  6. Physical changes 

Scores are then added to create a total score which can then be compared to the following to give an overall description of the person’s perceived pain experience. 

0-2  = No pain 

3-7 = Mild pain 

8-13 = Moderate pain 

>14 = Severe pain 







The original authors[1] reported satisfactory reliability of the APS. The Danish version showed good inter-rater reliability[6] and the Japanese version reported good reliability[7].


Discriminant validity: significant differences observed pre/post treatment[2][6].  

The Australian Pain Society notes that the APS does not discriminate between pain and distress so careful observation after pain relief is also needed[4]


  1. 1.0 1.1 Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L, Lowcay B. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliate Nurs. 2004; 10: 1: 6-13. Accessed 11 January 2019.
  2. 2.0 2.1 2.2 Lichtner V, Dowding D, Esterhuizen P, Closs SJ, Long AF, Corbett A, Briggs M. Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC Geriatr. 2014; 14: 138. Accessed 10 January 2019.
  3. Schofield P. The Assessment of Pain in Older People: UK National Guidelines. Age Ageing. 2018; 47(Suppl 1): i1–i22. Accessed 10 January 2019.
  4. 4.0 4.1 4.2 The Australian Pain Society. Abbey Pain Scale. Available from Accessed 10 January 2019.
  5. Karlson C. Reliability and utility of the Abbey Pain Scale-SWE for pain assessment among people with dementia (in progress). Available from Accessed 10 January 2019.
  6. 6.0 6.1 6.2 Gregersen M, Melin AS, Nygaard IS, Nielsen CH, Beedholm-Ebsen M. Reliability of the Danish Abbey Pain Scale in severely demented and non-communicative older patients. Int J Palliat Nurs. 2016. 22;10:482-488.
  7. 7.0 7.1 Takai Y, Yamamoto-Mitani N, Chiba Y, Nishikawa Y, Hayashi K, Sugai Y. Abbey Pain Scale: development and validation of the Japanese version. Geriatr Gerontol Int. 2010.10;2:145-53.
  8. Takai Y, Yamamoto-Mitani N, Chiba Y, Kato A. Feasibility and clinical utility of the Japanese version of the Abbey pain scale in Japanese aged care. Pain Manag Nurs. 2014;15: 2:439-48.