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Pain Assessment in Advanced Dementia Cheat Sheet by

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Introd­uction

This pain behavior tool is used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably commun­icate their pain. It can be used by a nurse or by a CNA to screen for pain-r­elated behaviors
Source: Warden V, Hurley AC, Volicer L. Develo­pment and psycho­metric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale.
J Am Med Dir Assoc. 2003;4­(1)­:9-15

Instru­ctions

When to Use:
It should be used at the following time points:

1. At initial intake­/ad­mission to services
2. For an older adult with behavioral symptoms suggestive of pain, assess at least every 8 hours
3. Any time a change in pain status is reported
4. One hour following a pain interv­ention to assess effect­iveness
5. For older adults residing in long term health care settings, assess­ments should be completed at each quarterly review

How to Use:
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).

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.

CNA should report any changes or scores to the nurse for follow-up assess­ment.

Docu­men­tat­ion:
Docume­nt/­record all scores in a location that is readily accessible to others on the health care team.
Note: Behavior observ­ation scores should be considered alongside knowledge of existing painful conditions and reports from someone who knows the older adult (like a family member or nursing assistant) and their pain behaviors. Remember some older adults may not demons­trate obvious pain behaviors or cues.
 

PAINAD Scoring

Assessment

Items
0 point
1 point
2 point
Breathing Indepe­ndent of vocali­zation
Normal
Occasional labored breathing. Short period of hyperv­ent­ilation
Noisy labored breathing. Long period of hyperv­ent­ila­tion. Cheyne­-stokes respir­ations.
Negative vocali­zation
None
Occasional moan or groan. Low- level of speech with a negative or disapp­roving quality
Repeated troubled calling out. Loud moaning or groaning. Crying
Facial expression
Smiling or inexpr­essive
Sad, fright­ened, frown
Facial grimacing
Body language
Relaxed
console Distracted or reassured by voice or touch
Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out
Consol­ability
No need to console
Distracted or reassured by voice or touch
Unable to console, distract or reassure
Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), Obtained scores are not to be used to inter absolute pain intensity. For example, a score of 10 on the PAINAD is not necess­arily equal to a Numerical Pain Scale rate of 10 (severe pain). Instead, 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.

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