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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

Symp­tom
Desc­rip­tion
Rating
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.
[___]
Frown
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.
[___]
Fidgeting
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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