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Alzheimer’s Discomfort Scale for Dementia Cheat Sheet by

Alzheimer’s Discomfort Scale for Dementia
assessment     medical     healthcare     dementia     pain     alzheimer-s     discomfort

Discomfort Scale

Noisy Breathing
Negative sounding noise on inspir­ation or expira­tion: breathing looks strenuous, labored, or wearing: respir­ations sound loud, harsh, or gasping: difficulty breathing or trying hard at attempting to achieve a good gas exchange; episodic bursts of rapid breaths or hyperv­ent­ila­tion.
Negative Vocali­zation
Noise or speech with a negative or disapp­roving quality: hushed low sounds such as constant muttering with a guttural tone: monotone, subdued, or varying pitched noise with a definite unpleasant sound: faster rate than a conver­sation or drawn out as in a moan or groan: repeating the same words with a mournful tone: expressing hurt or pain.
Content Facial Expression
Pleasant, calm looking face, tranquil, at ease, or serene: relaxed facial expression with a slack unclenched jaw: overall look is one of peace.
Sad Facial Expression
Troubl­ed-­looking face, looking hurt, worried, lost, or lonesome: distressed appear­ance: sunken “hang dog” look with lackluster eyes: tears: crying.
Frightened Facial Expression
Scared, concer­ned­-lo­oking face: looking bothered, fearful, or troubled: alarmed appearance with open eyes and pleading face.
Face looks strained: or scowling looks: displeased expression with a wrinkled brow and creases in the forehead: corners of mouth turned down.
Relaxed Body Language
Easy openhanded position: look of being in a restful position: may be cuddled up or stretched out: muscles look of normal firmness and joints are without stress: look of being idle/lazy or “laid back”: appearance of “ just killing the day” casual.
Tense Body Language
Extrem­ities show tension: wringing of hands: clenched fists, or knees pulled up tightly: look of being in a strained and inflexible position.
Restless inpatient motion, acting squirmy or jittery appearance of trying to get away from hurt area, forceful touching, tugging or rubbing of body parts.
Total Score
Rating Scale: 0=None, 1=Low, 2=Mode­rate, 3=High

Adapted from Hurley AC, Volicer BJ, Hanrahan PA, et al. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health 1992; 15:369-377

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