Pain Assessment for People Who Have Dementia

Original Editor - Rania Nasr Top Contributors - Rania Nasr, Kim Jackson and Lauren Lopez

Introduction[edit | edit source]

Improper pain assessment in people with impaired cognition, such as those with dementia, whose ability to report or verbalize pain is compromised, results in under-detected and untreated pain, which then contributes to worsening cognition (eg, delirium) and behavior (eg, agitation and aggression), inappropriate prescribing (eg, antipsychotics), and adverse drug effects (eg, death)[1]. Accurate and objective pain assessment is a foundation stone of optimal pain management. This is particularly relevant for patients with impaired cognition, such as those with dementia, whose ability to report or verbalize pain is compromised. it is important to choose and use a suitable pain assessment tool in order to provide proper treatment for people with dementia[2].  Two recognised assessment tools are, PAINAD which is based on observation, and ePAT that is an electronic application developed to assess pain for people with dementia.

Pain Assessment in Advanced Dementia (PAINAD) Scale[edit | edit source]

PAINAD[3] is a commonly suggested tool to assess people with dementia or any cognitive impairment that prevents them from communicating their pain. roper use of the PAINAD scale as part of a comprehensive pain management plan can help reduce the likelihood of a patient experiencing unrecognized and untreated pain[4]. This is an easy to use, simple, reliable and valid tool to assess pain in non-communicative people[3]. Studies confirm that using a self-report tool such as Numeric Rating Scare (NRS) is insufficient and inaccurate when used to assess people with dementia. Hence, an observational tool like PAINAD is more reliable[5]. This tool that consists of 5 behaviors which need to be observed; breathing, negative vocalization, facial expression, body language and consolability. The total score ranges from 0-10 and it is interpreted as follows:

  • 1-3=mild pain
  • 4-6=moderate pain
  • 7-10=severe pain

Below is a simple video that demonstrates using of PAINAD scale:


The Electronic Pain Assessment Tool (ePAT)[edit | edit source]

ePAT is a point-of-care smart device App, it utilizes automated facial recognition technology (video) to detect facial micro-expressions indicative of pain. It also records the presence of pain-related behaviors under five additional clinical indicators domains (Voice, Movement, Behavior, Activity, and Body). This App was developed to produce an objective and accurate assessment of pain in patients with dementia, which ult\imately leads to effective pain management[7].

Purpose[edit | edit source]

The ePAT is a multimodal pain scale designed to assist clinicians and health care workers assess pain in people with moderate to severe dementia at the point of care.

Developer[edit | edit source]

The ePAT has been developed by a research team at Curtin University, Western Australia, in collaboration with the Swiss company, nViso SA which is located at the Swiss Federal Institute of Technology in Lausanne (EPFL).

Content[edit | edit source]

Using a 10 second video of the subject’s face, the ePAT maps the face and automatically identifies in real-time the presence of pain related facial micro-expressions. This is combined with a range of behavioral and physical features based on the other five domains; [Domain 1: The Face (9 items), Domain 2: The Voice (9 items), Domain 3: The Movement (7 items), Domain 4: The Behavior (7 items), Domain 5: The Activity (4 items) and Domain 6: The Body (6 items)]. Each domain represents a subclass that evaluates a certain dimension of pain.

Method of Administration and Platform Used[edit | edit source]

The technology is packaged in a software app that can be used across a range of mobile smart devices. 


References[edit | edit source]

  1. Hoti K, Atee M, Hughes JD. Clinimetric properties of the electronic Pain Assessment Tool (ePAT) for aged-care residents with moderate to severe dementia. Journal of pain research. 2018;11:1037.
  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 geriatrics. 2014 Dec;14(1):138.
  3. 3.0 3.1 Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. Journal of the American Medical Directors Association. 2003 Jan 1;4(1):9-15.
  4. Paulson CM, Monroe T, Mion LC. Pain assessment in hospitalized older adults with dementia and delirium. Journal of gerontological nursing. 2014 May 2;40(6):10-5.
  5. Malara A, De Biase GA, Bettarini F, Ceravolo F, Di Cello S, Garo M, Praino F, Settembrini V, Sgro G, Spadea F, Rispoli V. Pain assessment in elderly with behavioral and psychological symptoms of dementia. Journal of Alzheimer's Disease. 2016 Jan 1;50(4):1217-25.
  6. Tara Dorenkamp. PAINAD Video. Available from: [last accessed 6/16/2019]
  7. Atee M, Hoti K, Parsons R, Hughes JD. Pain assessment in dementia: evaluation of a point-of-care technological solution. Journal of Alzheimer's disease. 2017 Jan 1;60(1):137-50.
  8. New Industries WA. WA Innovator of the year 2016-Travel Award Winner. Available from: [last accessed 6/17/2019]