Binder 1

State of the Art Review of Tools for Assessment of Pain
in Nonverbal Older Adults.

Project Overview
Updated by: Keela Herr, RN, PHD, FAAN; Heide Bursch, RN, MSN; Brianne Black,
RN, The University of Iowa.
Specific Aims of the Project
Assessment of pain is a critical component of a comprehensive approach to pain
management in all populations. Such information guides the selection of interventions
and is necessary to monitor the effectiveness of treatment and to communicate care
planning across health providers and care settings. Assessing pain in older adults who are
unable to verbally report pain, however, is a significant challenge to health care
providers.
Clinicians continue to search for a clinically usable tool to adopt in their organizations.
Whereas in general, self-report of pain is the gold standard for pain assessment, in this
population other approaches, such as observational and surrogate report, are necessary.
With increasing attention to finding an effective means for recognition and evaluation of
pain in this vulnerable population, a number of researchers and clinicians have developed
tools in an attempt to address this concern. As more precise and accurate methods for
interpreting the expression of pain in persons with cognitive impairment are being
developed, there is a need for critical evaluation of the existing tools in order to provide
readily available information for best practice to those responsible for the quality of life
of this vulnerable population and to provide a framework for ongoing research.
The specific aims of this project were to 1) identify and evaluate existing tools for
assessment of pain in nonverbal elders, 2) to prepare and make readily available
evaluations of each tool which include evaluation of conceptualization, subject/setting,
reliability and validity, and administration/scoring, along with a summary of strengths
and weaknesses. The update was aimed at a review of research conducted after an earlier
tool critique completed in 2004 by Herr, Decker and Bjoro, both in adding evidence to
existing tools as well as in reviewing new tools to assess pain in non-verbal older adults.
Tools evaluated in the initial review included:
The Abbey Pain Scale (Abbey) (Abbey, J., et al., 2004)
The Assessment of Discomfort in Dementia (ADD) Protocol, (Kovach, C.R., et al.,
(1999)
Checklist of Nonverbal Pain Indicators (CNPI), (Feldt, K., 1996)
The Discomfort Scale-Dementia of the Alzheimers Type (DS-DAT), (Hurley, A., et
al., 1992)
The Doloplus 2, (Wary, B. and the Doloplus Group, 2001)
The Face, Legs, Activity, Cry and Consolability Pain Assessment Tool (the FLACC),
(Merkel, S.I., et al., 1997)
Nursing Assistant-Administered Instrument to Assess Pain in Demented Individuals
(NOPPAIN), (Snow, A.L., et al., 2001)
The Pain Assessment Checklist for Seniors with Limited Ability to Communicate
(PACSLAC), (Fuchs-Lacelle, S.K., et al., 2004)
Pain Assessment for the Dementing Elderly (PADE), (Villaneuva, M.R., et al., 2003)
The Pain Assessment in Advanced Dementia (PAINAD) Scale, (Warden, V., et al.,
2003)
New tools added in the updated review in 2008 include:
Certified Nurse Assistant Pain Assessment Tool (CPAT), (Cervo, F., Raggi, R., BrightLong, L., Wright, W., Rows, et al., 2007)
Discomfort Behavior Scale (DBS), (Stevenson, K., 2006)
Disability Distress Assessment Tool(Dis DAT), (Regnard, C., Mathews, D., Gibson, L.,
Clarke, C., 2007)
Elderly Pain Caring Assessment 2 (EPCA-2), (Morello, R., Jean, A., Alix, M., SellinPeres, D., Fermanian, J., 2007)
Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (MOBID),
(Husebo, B.S., Strand, I., Moe-Nilssen, R., Husebo, S.B., Snow, A,L., Ljunggren, A.E.,
2007)
Pain Assessment in Noncommunicative Elderly Persons (PAINE), (Cohen-Mansfield,
J., 2006)
Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders
(PBOICIE), (Tsai, P., Beck, C., Richards, K., Phillips, L., Roberson, P., Evans, J.,
2008).
Two of the initially reviewed tools were not followed up with further application or
research in non-verbal older adults: ADD and FLACC. In addition to tools strictly
directed at assessing pain in non-verbal adults, the update continues to include discomfort
and distress tools: DBS and Dis DAT . Clinicians are interested in distinguishing these
different constructs and, while presenting behaviors may be similar, clearly treatment and
interventions may differ.
The documents included in this website are:
General Information folder including:
0. Project overview
1. Criteria for Evaluation of Pain Assessment Tools
2. Comparison Grid of Pain Assessment Tools Rated on Evaluation Criteria
3. Comparison of Tool Items with the AGS 2002 Persistent Pain Guidelines
4. Review References
Individual Folder for each tool containing
5. In-depth evaluation of each tool, including contact information of tool
developers
6. Brief summary evaluation of each tool
7. Copy of each tool for which permission was obtained to post
Because the science is continually evolving in the evaluation of existing tools and in
response to the development of new tools, this site was updated July 2008 to provide the
most current data on existing tools available for clinicians and researchers to consider for
use in their settings. It is hoped that there will be further updates in the future as research
and practice developments bring us closer to recommendations for best tools in clinical
and research settings.
Comparison Grid of Pain Assessment Tools for Non-verbal Older Adults Rated on Evaluation Criteria
Abbey
*ADD Protocol
CNPI
CPAT
DBS/MDS
Dis DAT
DS-DAT
Doloplus 2
EPCA-2
FLACC
MOBID
NOPPAIN
PACSLAC
PADE
PAINAD
PAINE
PBOICIE
Conceptualization
Subjects &
Setting
1
2
2
1
2
1
2
2
2
0
2
2
2
1
2
2
1
1
2
2
1
2
1
2
2
2
1
1
2
2
2
3
2
1
Administration,
Scoring,
Feasibility
1
2
2
1
0
1
1
2
1
0
1
2
2
2
3
1
0
Reliability
Validity
Sum of Scores
1
1
2
0
1
0
2
2
2
1
1
2
2
1
3
2
1
1
2
2
1
2
1
2
2
2
1
1
2
2
2
2
1
1
5
9
10
4
7
4
9
10
9
3
6
10
10
8
13
8
4
*ADD Protocol is not included as an assessment tool, but as a protocol for validating presence of pain.
Key to categories for evaluation

Conceptualization is a composite score based on purpose, conceptual basis, item generation and content validity.
Reliability: a composite score including internal consistency reliability, interrater reliability and test-retest reliability.
Validity: a composite score including criterion related and/or construct validity.
Key to rating
3= Available evidence is strong
2= Available evidence supports need for further testing
1= Available evidence is insufficient and/or tool revisions are needed
0= Evidence is absent
Full name of tools
Abbey: The Abbey Pain Scale (Abbey, J., et al., 2004)
ADD: The Assessment of Discomfort in Dementia Protocol, (Kovach, C.R., et al., 1999)
CNPI: Checklist of Nonverbal Pain Indicators, (Feldt, K., 1996)
CPAT: Certified Nurse Assistant Pain Assessment Tool, (Cervo, F. A. et al., 2007)
DBS/MDS: Discomfort Behavior Scale, (Stevenson, K. M. et al., 2006).
Dis DAT: Disability Distress Assessment Tool, (Regnard, C. et al., 2007).
Doloplus 2: The Doloplus 2, (Wary, B. and the Doloplus Group, 2001)
DS-DAT: The Discomfort Scale-Dementia of the Alzheimers Type, (Hurley, A., et al., 1992)
FLACC: The Face, Legs, Activity, Cry and Consolability Pain Assessment Tool, (Merkel, S.I., et al., 1997)
EPCA-2: Elderly Pain Caring Assessment 2 (Morello, R. et al., 2007)
MOBID: Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (Husebo, B. S. et al., 2007).
NOPPAIN: Nursing Assistant-Administered Instrument to Assess Pain in Demented Individuals, (Snow, A.L., et al., 2001)
PACSLAC: The Pain Assessment Checklist for Seniors with Limited Ability to Communicate, (Fuchs-Lacelle, S.K., et al., 2004)
PADE: Pain Assessment for the Dementing Elderly, (Villaneuva, M.R., et al., 2003)
PAINAD: The Pain Assessment in Advanced Dementia Scale, (Warden, V., et al., 2003)
PAINE: Pain Assessment in Noncommunicative Elderly Persons (Cohen-Mansfield, J., 2006).
PBOICIE: Pain Behaviors for Osteoarthritis Instrument for Cognitively Impaired Elders (Tsai, P. F. et al., 2008).
The Abbey Pain Scale (The Abbey) Brief

The Abbey Pain Scale (The Abbey) is an Australian tool developed to measure
severity of pain in people with late-stage dementia that was efficient, effective and able to
be used by a variety of care staff. Although there is no presentation of the conceptual
basis for the tool, it is apparent that this informant-based tool attempts to measure acute
pain, chronic pain and acute on chronic, in the same tool.
The tool includes six items: vocalization, facial expression, change in body
language, behavioral change, physiological change, and physical change. Each item is
leveled on a four point scale for severity of the behavior (Absent: 0; Mild: 1; Moderate:
2; Severe: 3) with total score ranging from 0 to 18. The total score is then interpreted as
severity of pain: No pain: 0-2; Mild: 3-7; Moderate: 8-13; Severe: 14+. The rater is asked
to indicate which type of pain the older adult has: chronic, acute or acute on chronic.
Preliminary studies give no evidence that informants can reliably rate these levels
of pain using this tool.
There are a few limited instructions on the tool schema. Instructions for using the
Abbey Pain Scale are presented on a poster. Nurses are asked to use the tool when pain is
suspected. It is not specifically designed to be a part or routine daily assessment. The tool
apparently takes one minute to score, although there are no data to support this. A followup study does not provide any further supportive information on the feasibility,
administration or clinical utility of the Abbey. With only 50% of care providers reporting
that the scale was good to judge or observe pain indicators, little additional support is
provided.
In study 1, the tool was evaluated in 24 Australian long term care facilities with a
sample of 61 older adults with late-stage for a total of 236 pain episodes. Assessment of
presence and degree of cognitive impairment and pain in study subjects was not
standardized. Age and gender distribution are appropriate but there is no mention of
ethnic/racial diversity in either study. Study 2 was conducted in 17 Belgian nursing
homes with 185 caregivers and 157 residents. The tool has not been tested in the United
States.
Using 5 subjects per tool item as a minimum requirement for this review, a minimum
sample size of 60 subjects (12 items x 5 subjects) and 30 subjects (6 items x 5 subjects) in
stage 1 and stage II respectively would be needed. Thus, with 52 subjects in stage I this
sample is not sufficient for regression analysis; however, with 61 subjects in stage II the
sample is sufficient for tool evaluation. No additional tool item evaluation study was
conducted in Study 2.
Reliability
Internal consistency reliabilities for pre- and post intervention are acceptable but it is
unclear what data were used in the analysis (e.g. pain episode, resident or mean
score).
Interrater reliability between two staff members pre and post intervention was low
particularly for post intervention evaluation.
No test-retest reliability is available.
Study 2 did not add further information on reliability of the tool. Reliability, therefore,
has not been adequately established based on available information.
Completed 04/04
Revised 06/08
Validity
Concurrent validity of the scale was evaluated against the holistic impression of pain
as assessed by the nurse: Gamma: 0.586 (p<.001).
Predictive validity was assessed by change in mean pain score pre-intervention: 9.02
( .48), post intervention: 4.21 ( .41). A paired t-test was statistically significant
(p<0.001). However, it is unclear what unit of analysis was used for examining prepost score changes (e.g. pain episode, resident or mean score).
Summary
Clinicians considering this tool need to be aware of conceptual issues. There is
conceptual blurring between acute and chronic pain with no discussion in the paper on
distinguishing characteristics of the pain types. Moreover, there is blurring between pain
behaviors and pain etiology. Although the tool does include at least one cue from each of
the 6 categories of non-verbal pain behavior indicators from the AGS Guideline on
Persistent Pain in Older Adults, the inclusion of physiological indicators is not supported
in the literature on chronic pain. Thus, an individual with chronic pain being scored on
this tool may lose 3 points towards the overall severity score. Moreover, the ability of
health care providers to determine severity of pain from behavioral indicators has not
been established. Tool reliability is equivocal with current data available. Validity testing
based on nurse judgment of pain severity is not substantiated in the literature,
particularly, as in this case, without evidence supporting the expertise of the raters. Thus
tool revision and additional testing in controlled circumstances are recommended before
using this tool in clinical practice.
Source of evidence
Abbey, J.A., Piller, N., DeBellis, A, Esterman, A., Parker, D., Giles, L. & Lowcay, B.
(2004). The Abbey Pain Scale. A 1-minute numerical indicator for people with
late-stage dementia. International Journal of Palliative Nursing, 10(1), 6-13.
Van Iersel, T., Timmerman, D. & Mullie, A. (2006). Introduction of a pain scale for
palliative care patients with cognitive impairment. International Journal of
Palliative Nursing, 12(2), 54-59.
Contact information:
Jennifer Abbey, RN, PhD, FRCNA
P.O. Box 703, Bribie Island
Queensland 4507
Australia
E-mail: jabbey@optusnet.com.au
Summary completed by:
K. Herr, S. Decker, K. Bjoro, University of Iowa (2004)
Updated by K. Herr, H. Bursch and B. Black, University of Iowa (2008)
Contact information: keela-herr@uiowa.edu
Completed 04/04
Revised 06/08
Tool:
Tool developer:
The Abbey Pain Scale

Abbey, J.A., DeBellis, A, Piller, N., Esterman, A., Parker, D.,
Giles, L. & Lowcay, B.
Country of origin: Australia
Reviewed:
04/04
Revised:
06/08
Conceptualization
Panel rating: 1
Revised: 1
Purpose
Conceptual basis
Item Generation
The stated purpose was to develop a pain scale for people with late-stage
dementia that was efficient, effective and able to be used by a variety of care
staff. The Abbey Pain Scale is an informant-based tool.
There is no discussion or presentation of the conceptual basis for the tool.
The tool attempts to measure severity of acute pain, chronic pain and
acute on chronic. Yet a clear discussion of the conceptual basis for the tool
is absent.
Tool items
Vocalization
Facial expression
Change in body language
Behavioral change
Physiological change
Physical change
Each item is leveled on a four point scale for severity (Absent: 0; Mild: 1;
Moderate: 2; Severe 3). Individual item scores are summed to arrive at a total
score ranging from 0-18. The total score is interpreted as follows: No pain: 02; Mild: 3-7; Moderate: 8-13; Severe: 14+.
Item generation process
Phase I: A draft of the scale was based on:
Literature review
A Delphi study by geriatric and pain experts
Focus group of practitioners.
Phase II: A prototype of the tool consisting of 12 items was generated in
which each of the 6 items listed above was measured on both a dichotomous
scale and an ordinal scale.
Content Validity
-Panel Commentary
Completed 04/04
Revised 06/08
Regression analysis was used to determine which of the twelve items were
most predictive of the de facto gold standard (nurses holistic impression of
pain severity). Twelve items predicted 42% of the variability on the holistic
pain question. Items measuring pain severity were more powerful predictors
of holistic pain than presence/absence of pain. Thus, items rated as
present/absent were deleted. Six severity items were retained accounting for
41% of the variability in the scores.
The draft scale was reviewed by gerontological and pain experts through a
Delphi study before being tested clinically and also by discussion with
practitioners using focus group debate.
There is conceptual blurring between acute and chronic pain. There is no
discussion in the paper on characteristics of the one type of pain in
relationship to the other or the overlap (e.g. physiologic changes vs.

behavioral change).
There is conceptual blurring between pain behaviors and pain etiology, (e.g.
presence of skin tears or arthritis), both elements of the rating scale.
Development of the tool is based on the assumption that caregivers can
reliably rate the intensity of pain in elders, although the interpretation of pain
severity has not been substantiated in the research on pain in elders with
dementia. Nurses holistic impression of pain severity was used as the gold
standard. However, this assumption is not supported by current literature,
which indicates that caregivers can detect presence of pain, but not severity or
intensity.
Therefore, using the gold standard of caregivers report of pain intensity in
regression analysis to derive tool items is a limitation.
Little information is available on the Delphi study: who the experts were,
what items were presented in the Delphi and the results. Also, almost no
information is available on the focus group: who were the participants, and
their expertise (educational and clinical background and relevance to elders
with dementia and pain).
Comprehensiveness and clarity of items
The tool includes at least one cue from each of the 6 categories of non-verbal
pain behaviors in the AGS Persistent Pain Guidelines. Facial expression,
Verbalizations/vocalizations, Body language and to some extent Changes in
activity patterns or routines, Mental status changes and Changes in
interpersonal interactions.
However, inclusion of physiological indicators may compromise the overall
tool scoring of chronic pain.
The rationale for including pain etiology items in a tool for assessing pain that
totals overall severity of behaviors in non-verbal elders is not clear.
The tool is intended to measure acute pain, chronic pain and acute on chronic
pain. However, it is unclear how the tool could differentiate pain types.
Moreover, the tool has not been formally evaluated for content validity.
Subjects
Panel rating: 1
Revised: 1
Subjects
Study 1 (Abbey et al., 2004)

The tool development and testing took place in 24 aged care residential
facilities in four Australian states: South Australia, New South Wales,
Queensland and Victoria.
Inclusion criteria:
Residents with late-stage dementia as confirmed by a senior registered nurse
and who were perceived by facility staff as experiencing pain during the
project.
Staff observations were made by 61 staff who completed the pain scale: 45
registered nurses and 7 enrolled nurses.
In the initial stage of tool testing, data were available for 52 residents for a
Completed 04/04
Revised 06/08
total of 770 pain episodes (non-independent scores).

In stage II of tool testing, data were available for 61 residents for a total of
236 pain episodes.
Age: 83 years (median), Range: 60-97 years.
Gender: Female: 66%, Male 34%.
-Panel Commentary
Study 2 (van Iersel, et al., 2006)

17 nursing homes in Belgium
185 care providers
157 patients unable to express pain verbally (no measure of cognitive
impairment)
Gender: 78% female; 22% male
Age: mean 85 years (range 22-100)
Focus on long term care setting is clearly identified. However, the initial
study was carried out at 24 sites with 61 staff members with varied skill level
completing observations. This allows for wide variation and consequently
potential for measurement error.
A standard assessment approach to document presence of dementia or level of
cognitive impairment is not included in either study. Relying on senior
nurses confirmation of dementia allows inconsistent assessment across study
sites.
The study subjects in Study 1 are limited to those who were identified by the
staff as having pain. It is not known whether pain assessment was carried out
on a regular basis. Patients with atypical presentation of pain may not have
been identified for participation in the study. Study 2 did not provide any
information on how patients were determined to have pain or not.
Age and gender distribution are appropriate but there is no mention of
ethnic/racial diversity in either study. Study 1 represents Australian residents
and Study 2 represents Belgian residents. The tool has not been evaluated in
the United States.
Using 5 subjects per tool item as a minimum requirement for this review, a
minimum sample size of 60 subjects (12 items x 5 subjects) and 30 subjects
(6 items x 5 subjects) in stage 1 and stage II respectively would be needed.
Thus, with 52 subjects in stage I this sample is not sufficient for regression
analysis; however, with 61 subjects in stage II the sample is sufficient for tool
evaluation. No additional tool item evaluation study was conducted in Study
2.
Administration, Scoring, Feasibility

Panel rating: 1
Revised: 1
Administration,
Scoring,
Feasibility
Instructions for using the Abbey Pain Scale are presented on a poster. Nurses
are asked to use the tool when pain is suspected. Prompts depicted on the
poster include These people have dementia. Are they in pain? If they
cant tell you, use the one-minute Abbey Pain Scale.
There are a few limited instructions on the tool schema. Scoring prodecure is
described above.
The rater is asked to indicate what type of pain the subject has: acute, chronic
or acute on chronic.
Completed 04/04
Revised 06/08
There are qualitative reports that the tool took less than one minute to
complete.
-Panel Commentary
Study 2 (van Iersel et al., 2006)

No specific information on clinical utility or feasibility is provided, but it
appears that the tool was readily used by the care providers in these nursing
homes. 56% of care providers judged indicators on the Abbey as good
indicators of pain, while 21% disagreed and 24% felt it was not easy to
administer.
Method of administration and scoring is not adequately described.
Nurses are asked to use the tool when pain is suspected. It is unclear what
triggers the pain assessment. A lack of systematic pain assessment may
result in non-detection of pain. Systematic pain assessment may have
been more appropriate in a tool development study. This gives rise to the
issue of scheduled pain assessment vs. prn assessment.
Scoring procedures are unclear. There are no instructions on what
constitutes the different severity levels for each item.
There is no justification for the total severity scoring system or its
interpretation.
There is no indication as to how the rater arrives at type of pain or how
this impacts treatment decisions.
Clinical utility
Time: The tool developers report the tool takes less than one minute to
score. However, no data are provided.
Skill needed: The tool developers do not specify skill level needed. All
nursing personnel are referred to as staff. It is unclear if there are any
limitations to the scope of practice of those using the tool.
Clinical utility has not been formally studied. Tool developers report the tool
takes less than one minute to score. However, no data are provided. The tool
developers do not specify skill level needed. All nursing personnel are
referred to as staff. It is unclear if there are any limitations to the scope of
practice of those using the tool.
Study 2 does not provide any further supportive information on the feasibility,
administration or clinical utility of the Abbey. With only 50% of care
providers reporting that the scale was good to judge or observe pain
indicators, little additional support is provided.
Reliability
Panel rating: 1
Revised: 1
Internal consistency

Internal consistency was assessed in stage II of tool testing. Data were
available for 61 residents for a total of 236 pain episodes (see sample
characteristics above).
Internal consistency reliability reported:
Pre-intervention: =.74 and post-intervention: =.74.
Interrater reliability
Completed 04/04
Revised 06/08

No reliability information provided.
Interrater reliability was assessed in stage II of the testing. Residents (n=18)
were assessed by two staff members. Characteristics of the wider sample of
subjects are provided above.
Assessed by intra-class correlation coefficient:

Pre intervention: ICC=0.63 (p=0.02)
Post-intervention: ICC=0.44 (p=0.12).
Test-retest reliability
-Panel commentary

No reliability information provided.
No test retest or intrarater reliability is reported in either Study 1 or 2.
Although the tool has an acceptable level of internal consistency, it is unclear
what data were used for analysis, eg. patients, mean pain score, pain episodes.
Staff qualifications are not specified.
Intraclass correlation is an appropriate test for interrater reliability. However,
the reliabilities are low, particularly for post intervention evaluation.
No test-retest or intrarater reliability is available.
Thus, tool reliability has not been adequately established based on available
information.
Validity: Criterion or construct

Panel rating: 1
Revised: 1
Construct validity/
Criterion related validity

Validity testing was conducted in stage II of testing.
Sample included 61 residents (see sample characteristics above) with a total
of 236 pain episodes.
The number and types of intervention varied from patient to patient.
However, the most common intervention was analgesics, followed by
repositioning.
Staff (n=61) completed the pain scale: 45 (74%) were registered nurses and 7
(12%) were enrolled nurses.
Concurrent validity
The pre-intervention pain score was associated with the holistic impression of
pain as assessed by the nurse.
The holistic impression was rated on a scale of 1=no pain, 2=mild,
3=discomforting, 4=distressing or 5=severe.
Results: Gamma: 0.586 (p<.001).
Predictive validity
Change in pain score before and after intervention: Average pain score
(n=61):
Pre-intervention (n=61): 9.02 ( 3.75)
Post-intervention (n=61): 4.21 ( 3.20)
Paired t-test: showed the reduction to be highly statistically significant
(p<0.001).
The purpose of this study was to determine provider feedback on the items in
the Abbey and their usefulness in detecting pain. Outcomes represent only
provider perceptions of the scale.
Completed 04/04
Revised 06/08
-Panel commentary
On average, 56% of care providers considered the observed categories of the

Abbey good, and 52% considered them to be easy to observe indicators of
pain. Best indicators for which over 80-% agreed were facial expression,
vocalization and body language. Physiological changes in Abbey were not
considered a good indicator (80%).
Concurrent validity
The holistic impression of pain as assessed by the nurse was used as a gold
standard. However, the expertise or competence to assess pain in persons with
dementia is not reported.
There is no indication as to whether the Abbey Pain Scale scores and the
holistic impression of pain are independent measures or assessed by the same
nurse, which would impact data validity.
Validity data is based on 61 different staff using the tool which presents bias
for evaluation and interpretation.
Gamma is an appropriate measure of association for measures at ordinal level
or higher. Gamma varies between -1 and 1. The results in this study indicate
that the two measures are moderately positively associated.
Predictive validity
Variability in interventions and their effectiveness limits ability to make
conclusions regarding change in pain. However, because data reported are in
the expected direction regarding change in pain score, future testing in
controlled circumstances is warranted.
Study 2 provides care provider perceptions of indicator usefulness but does
not provide any method of judging validity of those assessments and does not
contribute to psychometric evaluation of the Abbey.
Summary of panel evaluation of pain assessment tool

The Abbey Pain Scale includes key behaviors representative of the scope of behavioral pain indicators in
persons with dementia. However, the tool also includes items such as physiological changes and pain
etiologies, which are not behavioral pain indicators and are not conceptually congruent with the intent of the
tool. Moreover, the ability of health care providers to determine severity of pain from behavioral indicators
has not been established. The subject sample is appropriate, however validation in minority samples and use
of a standard assessment of cognitive impairment are needed. Scoring procedures and training to use the tool
are not clear, nor is qualification of those individuals providing the gold standard. Tool reliability is not
supported with current data available. Validity testing based on nurse judgment of pain severity is not
substantiated in the literature, particularly without evidence supporting the expertise of the raters. Tool
revision and additional testing in controlled circumstances are recommended.
Source of evidence
Abbey, J.A., Piller, N., DeBellis, A, Esterman, A., Parker, D., Giles, L. & Lowcay, B. (2004). The Abbey
Pain Scale. A 1-minute numerical indicator for people with late-stage dementia. International Journal
of Palliative Nursing, 10(1), 6-13.
Van Iersel, T., Timmerman, D. & Mullie, A. (2006). Introduction of a pain scale for palliative care patients
with cognitive impairment. International Journal of Palliative Nursing, 12(2), 54-59.
Key to panel rating

Completed 04/04
Revised 06/08
Contact address for tool developer:

Jennifer Abbey, RN, PhD, FRCNA
P.O. Box 703, Bribie Island
Queensland 4507
Australia
E-mail: jabbey@optusnet.com.au
Evaluation completed by:

K. Herr, S. Decker, K. Bjoro, University of Iowa.
Revision 6/08 by:

K. Herr, B. Black, H. Bursch, The University of Iowa
Completed 04/04
Revised 06/08
Doloplus 2 Brief
The Doloplus 2 is a French tool developed for the multidimensional assessment of
pain in non-verbal elders. The tool consists of three subscales and a total of 10 items:
Somatic reactions (5 items), Psychomotor reactions (2 items) and Psychosocial reactions
(3 items). Each item is leveled with four behavioral descriptions representing increasing
severity of pain rated from 0 to 3. Individual item scores are summed to arrive at a total
score ranging from 0 to 30 points. Five points is the threshold indicating pain. However,
as the tool developers point out, pain can not be ruled out if the older adult has less than
five points.
The Doloplus 2 is based on sound assumptions of multidimensionality of pain in
elders with pain that are supported in the literature on pain in elders with dementia. The
tool is comprehensive covering 5 of 6 pain behavior categories in the AGS Persistent
Pain Guideline. While there is emerging evidence that observation or informant-based
pain assessment tools can track change in degrees of pain for individual residents,
current literature does not support the hypothesis that such tools can reliably
differentiate between mild, moderate, and severe pain, or rate pain severity on a scale
from 0-10. As with any observational tool, a small number of behaviors observed
increases its specificity, but limits sensitivity in that it may not detect pain in persons
presenting with less obvious behaviors.
Method of administration and scoring procedures are clearly described. Follow-up
studies indicated that it took an average of 10 (6 to 12) minutes to administer the
Doloplus-2. The tool is intended for use by health and social care providers as well as
family of the elder. However, training requirements for reliable use of the tool by these
different groups are not reported. It must be noted that in one study nurses in the clinical
setting identified the tool as the least preferred method of pain assessment when
compared to other similar observational tools. There is preliminary work with a
shortened version of the Doloplus 2.
Nurses in clinical practice wishing to use this tool may find several items in the
the English translation unclear. Several items seem foreign when compared to the words
and expressions most commonly used in English literature on pain in dementia. The
English version appears to need refinement.
Although the French version of the Doloplus 2 has been tested in diverse
populations and settings including long term care, geriatric clinics and palliative care in
France and Switzerland (see report of reliability and validity below), dementia sessment
was not standardized and there are currently no reports of testing of the English version
of the Doloplus 2.
Reliability
Internal consistency was tested in a pooled sample of 501 elders from centers
participating in the Doloplus Group. Average age of subjects was 82.5 (8) range 5596; 173 males and 337 females. Cronbach alpha was 0.82. Zwakhalen reported
internal consistency of 0.58-0.80. Pautex found that internal consistency was lower in
residents with dementia (r=0.67) than in residents who were cognitively intact
(r=0.84). Internal consistency scores were lowest for the items expression (r=0.82)
and mobility (r=0.82). Internal consistency was slightly lower for the shortened
Completed 04/04
Revised 06/08
version or the Doloplus-2 (Cronbach alpha=0.71) than the complete version

(Cronbach alpha 0.85).
Interrater reliability was reported but may not have been statistically significant in
two samples at palliative care hospitals in France.
Test-retest reliability was evaluated in a pooled sample of 83 patients from divergent
settings and was found to be good but not statistically significant. Pautex found
strong test-retest reliability on subsamples of 20 residents from the same hospital
units who had the same characteristics and stable chronic pain.
Validity
Convergent validity was established between the Doloplus 2 and a VAS in a mixed
sample of 143 elders from various geriatric or palliative care units in France and
Switzerland (p< 0.001).
Sensitivity was tested at 11 centers in a pooled sample of 183 elders, 73 males and
110 females, average age 80.7 years (8.6), range 65-101 years. D0: 10.6 (5.3);
D1: 7.5 (4.4); D7: 4.9 (4.2) (information from web site).
Following testing, Pautex shortened the Doloplus 2 to include only the items which
were significantly associated with VAS scores. This version was also compared with
the VAS. The revised version contained 3-items of the somatic dimension and two of
the psychosocial dimension.
There has been a considerable amount of evidence supporting the validity of the
Doloplus-2 in subsequent studies. However, all of the studies have been in foreign
populations and further validation needs to be done in English. The surprisingly high
correlation between the Doloplus-2 and self report rating scales as reported in Study
3 are inconsistent with the finding in the literature. Most studies report correlations
of approximately .30 between observational tools and self-report assessments.
Summary
The Doloplus 2 is a comprehensive tool for assessing pain in nonverbal elders.
The tool addresses many key indicators noted in the literature and AGS Guidelines. Via
their website information the tool developers report extensive testing in Europe.
However, information in English is limited and available reports do not provide sufficient
detail on which to base sound judgment of the tool evaluation. Translation issues are
evident and further study or description regarding the use of Doloplus 2 in Englishspeaking populations is needed.
Sources of evidence
Doloplus-2 website: http://www.Doloplus-2.com
Holen, J., Saltvedt, I., Fayers, P., Bjornnes, M., Stenseth, G., Hval, B., et al (2005). The
Norwegian Doloplus-2, a tool for behavioral pain assessment: translation and pilot
validation in nursing home residents with cognitive impairment. Palliative Medicine,
19, 411-7.
Lefebvre-Chapiro, S. & the Doloplus-2 group. (2001). The Doloplus-2 scale evaluating
pain in the elderly. European Journal of Palliative Care, 8(5), 191-194.
Completed 04/04
Revised 06/08
Pautex, S. Michon, A., Guedira, M. Emond, H., Le Lous, P., Samaras, D. et al (2006).
Pain in severe dementia: Self-assessment or observational scale? JAGS, 54, 10401045.
Pautex, S., Herrmann, F., Michon, A., Giannakopoulos, P., Gold, G. (2007).
Psychometric properties of the doloplus-2 observational pain scale and comparison to
self-assessment in hospitalized elderly. Clinical Journal of Pain, 23(9), 774-9.
Zwakhalen, S., Hamers, J., & Berger, M. (2006). The psychometric quality and clinical
usefulness of three pain assessment tools for elderly people with dementia. Pain, 126,
210-220.
Dr. Bernard Wary
Service Regional de Soins Palliatifs
CHR Meta-Thionville-BP 60327
57126 Thionville Cedex
France
E-mail cspbelair@free.fr
The tool is available free of charge from the official Doloplus 2 website:
http://www.doloplus.com/versiongb/rubautres/intro.htm
Contact e-mail address found at official Doloplus-2 website: zidetzen@club-internet.fr
(Dr. Bernard Wary, personal communication, July 2008)
This summary was completed by:
K. Herr, S. Decker, K. Bjoro, University of Iowa (2004).
Updated by:
K. Herr, H. Bursch and B. Black, The University of Iowa (2008).
Completed 04/04
Revised 06/08
Tool:
Tool developer:
Country of origin:
Reviewed:
Revised:
Doloplus-2
Wary, B. and The Doloplus-2 Group
France
04/04
06/08
Conceptualization
Panel rating: 1
Revised: 2
Purpose
Conceptual basis
The Doloplus-2 is an observational pain assessment tool developed for the

multidimensional assessment of pain in non-verbal elders who experience
chronic pain.
Doloplus-2 was based on Doloplus developed by Wary et al (1993).
Pain is multidimensional with somatic, psychomotor and psychosocial
dimensions. Within these domains observations are made of patient behaviors
that could potentially reveal pain.
This tool bases evaluation on changes in the elders behavior. The individual
trajectory of the elder is emphasized.
Item Generation
The tool attempts to measure pain severity.

Study 1(Lefebvre-Chapiro, 2001)
There are three subscales with a total of 10 items:
Somatic reactions (5 items)
Somatic complaints
Protective body postures adopted at rest
Protection of sore areas
Expression
Sleep pattern
Psychomotor reactions (2 items)
Washing and/or dressing
Mobility
Psychosocial reactions (3 items)
Communication
Social life
Behavioral problems
Each of the ten behavioral items is leveled with four descriptions of behaviors
rated on a four point scale from 0 to 3 representing increasing severity of
pain. Individual item scores are summed to arrive at a total score, which
ranges from 0 to 30 points. Five points is the threshold stated as indicating
pain.
Item generation process
Doloplus-2 was developed by Wary et al., (1993) based on The Douleur
Enfant (Gustave Roussy), a scale for young children and was adapted for use
in older adults. Doloplus-2 was developed by the Doloplus-2 Group.
Study 5 ( Pautex 2007)
Following testing, the Doloplus-2 was shortened to include only the items
which were significantly associated with VAS scores. This version was also
compared with the VAS. The revised version contained 3-items of the somatic
dimension and two of the psychosocial dimension.
Completed 06/08
Content Validity
-Panel Commentary
Somatic Dimensions:
Somatic complaints
Protective body posture adopted at rest
Psychosocial Dimensions
Social Interactions
Behavior
Very little information on the tool development is available in English. It is
not known if the tool was reviewed by an external panel of content experts in
the field of pain in elders with dementia.
The purpose of the tool is clearly expressed and appropriate.
The tool is based on sound assumptions of multidimensionality of pain in
elders with pain that are supported in the literature on pain in elders with
dementia.
While there is emerging evidence that observation or informant-based pain
assessment tools can track change in degrees of pain for individual residents,
current literature does not support the hypothesis that such tools can reliably
differentiate between mild, moderate, and severe pain, or rate pain severity
on a scale from 0-10. As with any observational tool, a small number of
behaviors observed increases its specificity, but limits sensitivity in that it
may not detect pain in persons presenting with less obvious behaviors.
The tool covers 5 of 6 pain behavior categories in the AGS Persistent Pain
Guidelines: Facial expression, verbalizations/ vocalizations, body language,
changes in activity patterns or routines, changes in interpersonal interactions.
However, the category mental status change is not addressed.
Several items are unclear in the English translation of the Doloplus-2 and
seem foreign when compared to the words and expressions most commonly
used in English literature on pain in dementia (eg repetitive reactive
behavior vs agitation or aggression; resists all persuasion vs. resistance
to care. Protection of sore areas is commonly referred to as guarding
in English and expression is more commonly referred to as facial
expression. This indicates that the English translation needs further
refinement. Although the French version may have face validity, this has not
been established for the English translation. It is unclear whether the lack of
clarity in items is solely due to the translation or whether this lack of clarity is
also present in the original French version.
No description of the item generation process is available in English for the
original Doloplus or for Doloplus-2.
Subjects
Panel rating: 2
Revised: 2
Subjects
Study 1(Lefebvre-Chapiro, 2001)

Many tests have been conducted at various sites in France and Switzerland.
Internal consistency was tested in a pooled sample of 510 elders from all
centers participating in the Doloplus-2 Group. Average age of subjects was
82.5 ( 8.0), range 66-96 years, with 173 males and 337 females.
Inter-observer reliability was tested in two separate samples at palliative care
hospitals at Metz-Thionville and Marseille respectively. The Metz-Thionville
Completed 06/08
study included 43 residents with an average age of 73.5 ( 7.21) with 28

males and 15 females. The Marseille study included 41 residents with average
age 82 (8.3) with 9 males and 32 females.
Testretest reliability was evaluated in a mixed sample of 83 residents with
16 males and 67 females. Average age was 82.5 ( 8.0), range 66-96 years
with short, medium and long stay hospitalization as well as palliative care.
Data from these divergent settings were pooled.
Convergent validity was evaluated in various geriatric centers or palliative
care units in France and Switzerland in a mixed sample of 143 elders, 44
males and 99 females with an average age of 80.7 years ( 8.8), range 65101.
Sensitivity was tested at 11 centers. The sample included 183 elders with an
average age of 80.7 ( 8.6), range of 65-101, 73 males and 110 females.
Study 2 ( Holen et al, 2005)
Location: a nursing home in Trondheim, Norway
Subjects: 59 nursing home residents with a ICD-10 diagnosis of dementia
Age: The authors states that there was a median age of 82 with a range of
39
Dementia: MMSE median of 9 (Q1=3, Q3=18) and 88% of the residents had
a score < 24. Three residents did not complete the MMSE because they
were aggressive and/or refused to answer.
Diversity: unspecified minorities (14%)
Pain:. The presence of pain was based on information in the medical record,
information from the nurse responsible for the patient or the patients
primary contact, information from the patient when possible, and a
clinical examination. Patients pain was scored using the NRS-11 (0-10
likert scale). Four residents received a score of 4 or greater, 28
residents received a score from 1-3, and 25 residents did not show signs
of pain.
Staff: The Doloplus-2 was completed by the patients nurse who collaborated
with the research assistant.
Study 3 (Pautex et al 2006 )
Location: in departments of geriatrics or psychiatry
Subjects: 129 French speaking hospitalized residents who met the DSM-FIV
criteria for dementia with a MMSE less than 11 and a Clinical Dementia
Rating of 3 or greater.
Age: 83.76.8
Gender: 40 men, 89 women
Cognitive Status:
Dementia
- Alzheimers disease 50 (39%)
- Mixed Dementia 44 (34%)
- Vascular Dementia 21 (16%)
- Other causes 14 (11%)
MMSE 6.83.0
Pain: 57 (44%) reported experiencing pain
Staff: Nursing staff in charge of the patient completed the Doloplus-2
Study 4 (Zwakhalen 2006)
Location: nursing home and psycho-geriatric wards in the Netherlands
Completed 06/08
Subjects: 144 nursing home residents including 128 demented residents and
16 somatically ill nursing home residents
Gender: demented residents (28 )21.9% men, (100) 78.1% women;
somatically ill residents 5 men, 11 women
Age: mean age dementia residents 82.4 (6.8), somatically ill 78.1(10.6)
Dementia: MDS Cognitive Performance Scale
Severe : 61(47.7%)
Moderate: 36(28.1%)
Mild: 28(21.9%)
Unknown: 3 (2.3%)
Pain: Based on information derived from the MDS. 25% of the psychogeriatric patient experienced pain on a daily basis and 17.2%
experience pain less frequently than daily. Of these residents that
experienced pain, 14.1% had mild pain, 22.7% had moderate pain, and
5.5% experienced unbearable pain at times.
Staff: 12 nurses from three nursing homes in the Netherlands.
-Panel Commentary
Study 5 (Pautex 2007)

Location: Geneva University Geriatric Hospital and Department of
Psychiatry
Subjects: 289 French speaking residents with a DSMIV diagnosis of dementia
and 49 French speaking residents without a DSMIV diagnosis of dementia,
but a MMSE of > 25.
Gender: 133 women, 47 men
Age: 83.7 6.5
Cognitive Status:
Diagnoses of Dementia (n=52, 39%)
- Mixed Dementia (n=45, 34%)
- VascularDementia (n=26, 20%), other causes (n=7, 5%)
MMSE 18.0 7.7
Pain: For those residents who reported experiencing pain its intensity as
measured by the VAS (10 point scale) was 4.0 (3.0) and by the 30-point
observational rating scale was 4.0 (7.0). 49% of the residents reported
that they experienced pain in response to a direct pain question.
Staff: Doloplus-2 was completed by the nurse in charge of the patient, after
discussing the patient with 1 or 2 team members who had contact with
the patient as well.
The French version of the tool has been tested in diverse populations and
settings including long term care, geriatric clinics and palliative care in
France and Switzerland. There is no mention of possible cross cultural
issues. Only one of the five studies presented above included ethnic groups in
the sample for tool evaluation. It is not mentioned how the tool developers
controlled for variability between sites. Age distribution is appropriate.
There is gender imbalance, but this is expected for the population.
Using 5 subjects per tool item as the minimum requirement for this review, a
minimum sample size of 50 subjects (10 items x 5 subjects) would be needed.
Thus, with the exception of the sample that was used in study one for
evaluation of inter-observer reliability the sample sizes listed above are
sufficient for tool evaluation. In study 2 it is noted that only 4 residents in the
sample actually presented with a pain score greater than 4 on a 10-point
likert scale.
Currently there is available literature written in English on the Doloplus-2;
however the tool has only been tested in non-English populations. Although
the evaluation of the tool in European samples is strong, there is a need to
Completed 06/08
complete more work with the Doloplus-2 in North American populations.

Panel rating: 2
Revised: 2
Administration,
Scoring,
Feasibility
Study 1(Lefebvre-Chapiro, 2001):

Scoring of items (see under item generation above).
Individual trajectory of pain is emphasized.
The score is viewed as individual and is not intended for comparison between
residents. Change in the score over time is important.
If there is doubt about the presence of pain, a therapeutic test is
recommended.
Instructions for administration of the tool have been developed.
According to tool developers the tool takes at most a few minutes to
administer.
The tool is recommended for health-care, social care or home use.
Scoring by several caregivers is recommended. Also family and other persons
are encouraged to contribute.
Study 4 ( Zwakhalen 2006)
To assess the clinical usefulness of three scales (Doloplus-2, PACSLAC, and
PAINAD) nurses were asked which scale they considered most useful and
which scale they preferred after having used all of the scales for all of the
participants. The nurses rated the tools using a 0-10 scale.
75% of the nurses preferred the PACSLAC to measure pain in elderly
residents with dementia. The lowest usefulness scores were reported for
Doloplus-2 (mean 5.6; SD 2.2). Nursing comments regarding Doloplus-2
include: the scale provides a more general view, a clear manual is provided,
and the scale is difficult to score and interpret.
-Panel Commentary

One nurse from each unit was trained to use the Doloplus-2 and had the
responsibility to train and supervise the other nurses for at least 1 hour.
Administration of the Doloplus-2 took an average of 10 (6 to 12) minutes.
In this study, it was possible to complete the Doloplus-2 for 180 residents, but
the item for sleep pattern was not completed in three residents.
Method of administration is clearly described and scoring procedures are
clearly described.
Interpretation of tool score is unclear. It is not clear how the score of 5 to
indicate pain was determined. The instructions indicate that if an item is
inappropriate it is not scored. However, it is not noted how the overall score
of the tool is affected when some items are not scored.
Follow-up studies indicated that it took an average of 10 (6 to 12) minutes to
administer the Doloplus-2. The tool developers have intended that the tool
may be used by health care providers, personnel in social care as well as
family of the elder, but training requirements to assure reliable results are not
reported .It is important to note nurse comments identifying the Doloplus-2 as
the least preferred tool for clinical use.
Reliability
Completed 06/08
Panel rating: 2
Revised: 2

(See sample description under subjects above.)
Cronbach alpha coefficient = 0.82
If any one of 10 items is eliminated, Cronbach alpha falls below 0.82.
Study 4 ( Zwakhalen 2006)

Internal consistency Cronbach alpha scores ranged from .58 to .80
Internal Consistency (Cronbachs alpha) of the Pain Assessment Scales
Doloplus-2
Somatic Dimension
Psychomotor Dimension
Psychosocial Dimension
At Rest
0.75(89)
0.7
0.8
0.63
During Movement
0.74(26)
0.63
0.77
0.58
The pool of nurses that offered verbal critiques for the tools commented that
it is questionable whether all items of the Doloplus-2 are relevant to detect
pain.

Internal consistency was lower in residents with dementia (r=0.67) than in
residents who were cognitively intact (r=0.84). Internal consistency scores
were lowest for the items expression (r=0.82) and mobility (r=0.82).
Internal consistency was slightly lower for the shortened version or the
Doloplus-2 (Cronbach alpha=0.71) than the complete version (Cronbach
alpha 0.85).
Interobserver reliability was tested in two separate studies at palliative care
hospitals at Thionville and Marseille respectively:
For both studies the paired sample t-test was used to analyze the data.
Thionville
Scorer A: Total average score 11.4/30 ( 5)
Scorer B: Total average score 10.9/30 ( 4.8)
Marseille
Scorer A: Total average score 17.3/30 ( 4.9)
Scorer B: Total average score 17.1/30 ( 4.6).
Test-retest reliability is reported.
Pain scores were measured at 2 times at 4 hour intervals.
T-test was conducted:
T1: average score: 9.33/30 (5.17)
T2 (+ 4h): average score: 9.36/30 (5.47)
Students t-test was not statistically significant.
Completed 06/08
-Panel commentary

Test-retest evaluation was completed on subsamples of 20 residents from the
same hospital units who had the same characteristics and stable chronic
pain. The first Doloplus-2 was completed on a given day and then the second
Doloplus-2 was completed one day after the first one. The interclass
correlation coefficient between the first and second assessment was 0.96.
For study 1, little information is available about the sample that was used to
arrive at the results for internal consistency, especially as relates to cognitive
status of residents. There is also no information provided regarding raters of
the residents for this study. However, the Cronbach alpha coefficient is
appropriate for the data and the correlation coefficient is strong. Subsequent
studies provide support of internal consistency with good correlations.
In the sample used to test inter-rater reliability, no information on the
cognitive status of the residents or a description for the raters is provided.
Here, the data do not appear to be analyzed by subject. Average scores and ttests do not adequately assess interrater reliability of the tool. Data from two
raters independently and simultaneously assessing one subject would be
considered appropriate. No correlation coefficient is provided. Subsequent
studies do no contribute to inter-rater reliability.
In study 1, scores from the same subject measured at two different times were
measured. The interval of 4 hours was appropriate if no intervention occurred.
Average scores were calculated and Students t-test was conducted. However,
data on the t-test were not reported. Moreover, correlation would have been
more appropriate. Information on how the test-retest was conducted is
limited. No information is provided as to whether subjects received any pain
treatment between measurements. There is also no information on the
qualifications of the raters. Data were pooled from various settings. There is
no report on how the tool developers controlled for variability across settings.
The subsequent study that contributed to test-retest shows a strong interclass
correlation coefficient of .96. The repeat test for test-retest evaluation was
completed on the following day, which is a fairly short time frame for
retesting. However, there is also a concern for receiving stable pain measures
if test-retest is completed following a longer time frame. There is still a need
for data from English speaking populations.

Panel rating: 1
Revised: 2
Construct validity/
Convergent validity
Doloplus-2 and VAS scores were compared.
VAS scores varied from 0 to 10 with an average score of 5.46 ( 2.27).
The convergent validity of the VAS and Doloplus-2 scale was significant
(p<0.001).
Sensitivity: (See sample description under subjects above.)
D0: 10.6 ( 5.3); D1: 7.5 ( 4.4); D7: 4.9 ( 4.2).
Study 3 (Pautex et al 2006)

Each patient was given the Verbal Rating Scale (VRS), the Faces Pain Scale
Completed 06/08
(FPS), and the Horizontal Visual Analog Scale (HVAS). Residents were
asked to position a sliding marker to indicate the level of pain they were
currently experiencing. Residents were considered to have demonstrated
comprehension of the scale if on both occasions they were able to explain its
use and could correctly indicate which position corresponded to no pain at
all and which position corresponded to the most severe pain. On each
occasion the explanations were repeated up to three times before subjects
were considered unable to comprehend a scale. On the same day the nursing
staff in charge of the patient completed the Doloplus-2.
The Doloplus-2 correlated only moderately with self-assessment ratings
(r=0.26 to 0.63, P<.001) in residents reporting pain. For residents reporting
pain using the VRS, HVAS, and FPS, the median pain intensity scores
(interquartile range) were 3.0(2.0), 3.0(3.0), and 2.0(2.0) respectively. Using
the Doloplus-2 to measure pain the median pain intensity (interquartile
range) was 9.0(5.0). The observational rating scale tended to underestimate
severity when compared with all three self-assessment scales.
Correlation between Different Scales:
Spearman rho
First Assessment
Second Assessment
VRS
HVAS FPS
VRS HVAS FPS
Doloplus-2
0.47
0.25
0.36
0.63
0.24
0.48
Study 4 (Zwakhalen 2006)

To examine construct validity of the Doloplus-2, pain vs. non-pain groups
were created based on information about no pain versus daily pain
derived from the MDS scale. The mean total scores for the daily pain
group were 9.8(6.0) and the no pain group had a mean of 5.1(3.9).
The Doloplus-2 was then compared to the following pain assessment tools:
VAS, VRS, PACSLAC, and PAINAD. Low scores were found for the
Doloplus-2 as compared to the other pain assessment tools which had
correlations scores ranging from 0.69 to 0.89.
Pearson Correlation Between Scales
DOLOPLUS-2
0.29
0.36
0.33
0.29
0.34
VAS rater 1
VRS
VAS nurse
PACSLAC
PAINAD
Study 5( Pautex 2007)

Convergent Validity was evaluated between the VAS and the Doloplus-2.
Residents were considered to have understood the VAS if on two occasions
they were able to explain its use and could clearly explain which position on
a sliding vertical marker represented no pain and the most severe pain.
Following the self assessments the nurse that was in charge of the patient
completed the Doloplus-2.
The Spearmans coefficient was equal to 0.46 for the correlation between the
Doloplus-2 and the VAS. The correlation was higher for residents without
Completed 06/08
dementia, 0.68 vs. 0.38 in residents with dementia. Half of the included
residents reported no pain so a sub- analysis that included only residents who
reported pain was performed. The results showed a significant correlation
between Doloplus-2 and VAS (Spearman coefficient=0.36, p=0.000).
In a multiple linear regression model Doloplus-2 predicted 41% of the
variability of pain intensity measured by the VAS. Doloplus-2 predicted 69%
of the VAS score in residents without dementia and 36% in residents with
dementia. The somatic dimension explained 36% of the variability and the
psychosocial dimension explained 5% of the variability, but psychomotor
dimension barely contributed.
The intensity of pain measured by the VAS was mainly associated with the
somatic dimension of Doloplus-2 in particular the items: somatic complaints,
protective body postures, and protection of sore areas. Two items of the
psychosocial reaction were also statistically significant (p < 0.05): social
interaction and behavior. These items were then used to develop a shortened
version of the Doloplus-2 to compare with the VAS. The correlation between
the intensity of pain measured by the VAS and the score of the shortened
version of the Doloplus-2 was 0.48. Here the correlation was also better in
residents without dementia (0.71 vs. 0.39 in residents with dementia).
Criterion Validity
Study 2 (Holen et al, 2005)
Pain ratings by experts using the NRS-11 were set as the standard for
criterion validity. A regression analysis was performed to evaluate how well
the Doloplus-2 could predict the experts scores using two methods:
regression analyses of each items isolated explanation value of the expert
score and step wise regression analysis to explore the consecutive
contribution of the different Doloplus-2 items.
The experts rated 25 residents as pain free. Among these 6 had a Doloplus-2
score of 0 and 19 had <5 leaving five false positives with scores of 5 and 6.
(Of the 59 cases the Doloplus-2 made false positives on 10 occasions).
-Panel commentary
A regression analysis was performed to explore how well the Doloplus-2

could explain the experts pain scores. The unstandardized residuals had a
SD=1.02. The Doloplus-2 explained 62% of the variance of the pain
distribution in this population. Stepwise regression analysis demonstrated
that facial expressions explained 48% of the variance of the expert score
alone. Facial expressions, protective body postures adopted at rest, somatic
complaints, and communication explained 68% of the total variability in the
experts scores in the study population.
For 85% of the assessments, the Doloplus-2 score multiplied by 0.25 beta
corresponded to the expert score 1 unit on the NRS scale.
There has been a considerable amount of evidence supporting the validity of
the Doloplus-2 in subsequent studies. However, all of the studies have been in
foreign populations and further validation needs to be done in English. The
surprisingly high correlation between the Doloplus-2 and self report rating
scales as reported in Study 3 are inconsistent with the finding in the
literature. Most studies report correlations of approximately .30 between
observational tools and self-report assessments.
Use of the VAS by elders with dementia as a gold standard for comparison is
questionable. If the VAS is used by the caregiver, question also remains
Completed 06/08
regarding ability/accuracy of health care provider judgments of severity in

this population.

The Doloplus-2 is a comprehensive tool for assessing pain in nonverbal elders. The tool addresses many key
indicators noted in the literature and AGS Guidelines. The tool is conceptually supported. Via their website
information the tool developers report extensive testing in Europe. High correlations are reported between
the Doloplus-2 and self-report assessment tools and the correlations that are reported are significantly
higher than typically shown in the literature. Internal consistency has been adequate with good correlation
values. The validity of the tool is supported in subsequent studies. It must be noted that in one study nurses
in the clinical setting identified the tool as the least preferred method of pain assessment when compared to
other similar observational tools. However, information in English is limited and available reports do not
provide sufficient detail on which to base sound judgment of the tool evaluation. Translation issues are
evident and further study or description regarding the use of Doloplus-2 in English-speaking populations is
needed.
Sources of evidence
Doloplus-2 website: http://www.Doloplus-2.com
Holen, J., Saltvedt, I., Fayers, P., Bjornnes, M., Stenseth, G., Hval, B., et al (2005). The Norwegian
Doloplus-2, a tool for behavioral pain assessment: translation and pilot validation in nursing home
residents with cognitive impairment. Palliative Medicine, 19, 411-7.
Lefebvre-Chapiro, S. & the Doloplus-2 group. (2001). The Doloplus-2 scale evaluating pain in the
elderly. European Journal of Palliative Care, 8(5), 191-194.
Pautex, S. Michon, A., Guedira, M. Emond, H., Le Lous, P., Samaras, D. et al (2006). Pain in severe
dementia: Self-assessment or observational scale? JAGS, 54, 1040- 1045.
Pautex, S., Herrmann, F., Michon, A., Giannakopoulos, P., Gold, G. (2007). Psychometric properties of
the doloplus-2 observational pain scale and comparison to self-assessment in hospitalized elderly.
Clinical Journal of Pain, 23(9), 774-9.
Zwakhalen, S., Hamers, J., & Berger, M. (2006). The psychometric quality and clinical usefulness of three
pain assessment tools for elderly people with dementia. Pain, 126, 210-220.
Key to panel rating

Contact Information for tool developer:

Dr. Bernard Wary
Service Regional de Soins Palliatifs
CHR Meta-Thionville-BP 60327
57126 Thionville Cedex
France
E-mail cspbelair@free.fr
Official Doloplus-2 website: http://www.doloplus.com/versiongb/rubautres/intro.htm
Contact e-mail address found at official Doloplus-2 website: zidetzen@club-internet.fr
Evaluation 04/04 by:

Revision 06/08 by:

K. Herr, B. Black, H. Bursch, The University of Iowa
Completed 06/08
10
Completed 06/08
11
DOLOPLUS-2 SCALE
NAME :
BEHAVIOURAL PAIN ASSESSMENT IN THE ELDERLY

Christian Name :
DATES
Unit :
Behavioural Records
SOMATIC REACTIONS
1 Somatic
complaints
no complaints . . . . . . . . . . . . . . . . .
complaints expressed upon inquiry only
occasionnal involuntary complaints . . .
continuous involontary complaints . . . .
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0
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2 Protective
body postures
adopted at rest
no protective body posture . . . . . . . . . . . . . . . . . . .

the patient occasionally avoids certain positions . . . . .
protective postures continuously and effectively sought .
protective postures continuously sought, without success
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3 Protection of
sore areas
no protective action taken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

protective actions attempted without interfering against any investigation
protective actions against any investigation or nursing . . . . . . . . . . . .
protective actions taken at rest, even when not approached . . . . . . . .
........
or nursing
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4 Expression
usual expression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
expression showing pain when approached . . . . . . . . . . . . . . . . . .
expression showing pain even without being approached . . . . . . . .
permanent and unusually blank look (voiceless,staring, looking blank)
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5 Sleep pattern
normal sleep . . . . . . . . . . . . .
difficult to go to sleep . . . . . . .
frequent waking (restlessness) .
insomnia affecting waking times
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usual abilities unaffected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

usual abilities slightly affected (careful but thorough) . . . . . . . . . . . . . . . . . . . . .
usual abilities highly impaired, washing &/or dressing is laborious and incomplete
washing &/or dressing rendered impossible as the patient resists any attempt . . . .
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usual abilities & activities remain unaffected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

usual activities are reduced (the patient avoids certain movements and reduces his/her walking distance)
usual activities and abilities reduced (even with help, the patient cuts down on his/her movements) . . .
any movement is impossible, the patient resists all persuasion . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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PSYCHOMOTOR REACTIONS
6 washing
&/or
dressing
7 Mobility
PSYCHOSOCIAL REACTIONS
8 Communication
unchanged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
heightened (the patient demands attention in an unusual manner)
lessened (the patient cuts him/herself off) . . . . . . . . . . . . . . . . .
absence or refusal of any form of communication . . . . . . . . . . .
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9 Social life
participates normally in every activity (meals, entertainment, therapy workshop)

participates in activities when asked to do so only . . . . . . . . . . . . . . . . . . .
sometimes refuses to participate in any activity . . . . . . . . . . . . . . . . . . . . . .
refuses to participate in anything . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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10 Problems of
behaviour
normal behaviour . . . . . . . . . . . . . . . . .
problems of repetitive reactive behaviour . .
problems of permanent reactive behaviour .
permanent behaviour problems (without any
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COPYRIGHT
............
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............
external stimulus)
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SCORE
DOLOPLUS-2 SCALE : LEXICON

Somatic complaints
The patients expresses pain by word, gesture, cries, tears or moans.
Protective body postures adopted at rest

Unusual body positions intended to avoid or relieve pain.

The patient protects one or several areas of his/her body by a defensive attitude or gestures.
Expression
The facial expression appears to express pain (grimaces, drawn, atonic) as does the gaze (fixed
gaze, empty gaze, absent, tears).
Investigation
Any investigation whatsoever (approach of a caregiver, mobilization, care procedure, etc.).
Washing/dressing
Pain assessment during washing and/or dressing, alone or with assistance.
Mobility
Evaluation of pain in movement: change of position, transfer, walking alone or with assistance.
Communication
Verbal or non-verbal.
Social life
Meals, events, activities, therapeutic workshops, visits, etc.
Problems of behaviour
Aggressiveness, agitation, confusion, indifference, lapsing, regression, asking for euthanasia, etc.
DOLOPLUS-2 SCALE : INSTRUCTIONS FOR USE

1 Scale use requires learning
As is the case with any new instrument, it is judicious to test it before circulating it. Scale scoring time
decreases with experience (at most a few minutes). Where possible, it is of value to appoint a reference
person in a given care structure.
2 Pluridisciplinary team scoring

Irrespective of the health-care, social-care or home structure, scoring by several caregivers is preferable
(physician, nurse, nursing assistant, etc.). At home, the family and other persons can contribute using
a liaison notebook, telephone or even a bedside meeting. The scale should be included in the 'care'
or 'liaison notebook' file.
3 Do not score if the item is inappropriate

It is not necessary to have a response for all the items on the scale, particularly given an unknown patient
on whom one does not yet have all the data, particularly at psychosocial level. Similarly, in the event of
coma, scoring will be mainly based on the somatic items.
4 Compile score kinetics

Re-assessment should be twice daily until the pain is sedated, then at longer intervals, depending on the
situation. Compile score kinetics and show the kinetics on the care chart (like temperature or blood pressure).
The scale will thus become an essential argument in the management of the symptom and in treatment
initiation.
5 Do not compare scores on different patients

Pain is a subjective and personal sensation and emotion. It is therefore of no value to compare scores
between patients. Only the time course of the scores in a given patient is of interest.
6 If in doubt, do not hesitate to conduct a test treatment with an appropriate analgesic

It is now accepted that a score greater than or equal to 5/30 is a sign of pain. However, for borderline
scores, the patient should be given the benefit of the doubt. If the patient's behavior changes following
analgesic administration, pain is indeed involved.
7 The scale scores pain and not depression, dependence or cognitive functions
Numerous instruments are available for each situation. It is of primary importance to understand that the
scale is used to detect changes in behavior related to potential pain.
Thus, for items 6 and 7, we are not evaluating dependence or independence but pain.
8 Do not use the DOLOPLUS 2 scale systematically

When the elderly patient is communicative and cooperative, it is logical to use the self-assessment instruments.
When pain is patent, it is more urgent to relieve it than to assess it ... However, if there is the slightest
doubt, hetero-assessment will avoid underestimation.
The Non-Communicative Patients Pain Assessment Instrument (NOPPAIN) Brief

The Non-Communicative Patients Pain Assessment Instrument (NOPPAIN) is a
nursing assistant-administered instrument for assessing pain behaviors in patients with
dementia. This tool focuses on observation of specific pain behaviors while doing
common care tasks. Pain is assessed at rest and with movement. The tool has four main
sections: 1) care conditions under which pain behaviors are observed such as bathing,
dressing, transfers; 2) six items about presence/absence of pain behaviors (pain words,
pain noises, pain faces, bracing, rubbing and restlessness), 3) pain behavior intensity
ratings using a six point Likert scale; 4) a pain thermometer for rating overall pain
intensity.
The method of administration for using the NOPPAIN is described; however,
scoring procedures are unclear. Moreover, no criteria are provided for establishing lowhigh intensity of pain behavior. Interpretation of tool score is unclear and there is no
indication on how to proceed once rating of individual items is completed.
The tool requires little time to complete following a period of observation
consistent with time to complete care activities. NOPPAIN derives a level of pain
intensity from the presence and intensity of behaviors observed. The tool developers
called it a pain screening tool because diagnosis or analysis of observation is not within
the scope of NA practice. NAs are asked to perform behavioral observation and rate
intensity of behaviors prior to formulation of a global pain score in each patient. The
basis for assessment of intensity of behaviors is not reported neither is the process of how
NAs translate the NSR of behavior intensity into a VDS of pain intensity.
The tool was clearly developed for use by nursing assistants. Thus, scope of
practice for nursing assistants in screening for pain must be considered. It is unclear what
investment in training of nursing assistants is needed to assure accuracy in tool
completion. Horgas (2007) tested the reliability and validity of the NOPPAIN when used
as assessment instrument by nurses; she demonstrated that accuracy of administration
might be improved with training.
The NOPPAIN has been evaluated in two studies:
Study 1 involved research NAs who viewed videos of an actress portraying an
individual with severe dementia receiving care from a NA. The NAs were mainly
African-American, female, on average 37 years of age with high school diploma/GED
and nearly 10 years of experience.
In study 2 The NOPPAIN was evaluated in 4 Houston nursing homes and a VA
nursing home unit and involved severely demented residents; the sample was
predominantly female and culturally diverse. The nursing assistants were mainly female
African-American, average age 37 years with 50% holding a high school education.
The tool is complex and large sample sizes would be needed to establish internal
consistency for all items. Using 5 subjects per tool item as a minimum requirement for
this review, a minimum sample size of 35 subjects (7 items x 5 subjects) would be needed
to test the six pain behaviors, their intensities and the global pain score on the pain
thermometer. Study 2 (unpublished) and study 3 involving real patients met the minimum
sample size requirement. More studies are needed beyond the laboratory setting and
involving more diverse patient populations.
Completed 04/04
Revised 06/08
Reliability
Internal consistency. No report of internal consistency is currently available.
Interrrater reliability was evaluated in study 2 (see above) using videotapes of NAs
performing morning care tasks with residents with dementia. Twenty six videos were
shown to 6 untrained NAs and to 6 NAs who received one hour of training on use of
the NOPPAIN. IRRs were moderate to strong for all tool items and improved with
one hour of training. Horgas found interrater reliability for presence of the 6
behaviors to be good. Average interrater reliability for pain intensity was very good.
Test-retest reliability was evaluated in study 2 with a subset of untrained NAs.
Results indicate low to moderate test retest reliability at both 2 and 24 hours. Only the
Pain thermometer was stronger at 2 hours than 24 hours. In the Horgas study, each
student rater re-scored 10% of the videos 1 week later: average of 0.7 and 0.86 for
presence of pain. ICC >0.67 for pain intensity ratings (missing intra-rater
consistency for pain words and rubbing).
Validity
Construct validity was evaluated in study 1 using standard videotaped patient
scenarios representing a continuum of pain intensity levels using an actor to portray a
bed-bound patient with severe dementia receiving care from a NA. NAs watched and
rated videos using the NOPPAIN assessment process and completed global pain
rating for each video. NAs global pain rating on the NOPPAIN and pain levels
portrayed in the videos resulted in weighted Kappa=0.87. NAs identified videos
showing the most pain from each of 15 pairs. The parameter estimates conformed to
expected responses, although borderline. The lowest intensity pain condition had the
smallest parameter, with parameter size increasing with each subsequent level of the
pain response scale. All pain level comparisons were 82-10% correct.
Construct validity was evaluated in study 2 comparing NOPPAIN ratings by
untrained NAs to physician NOPPAIN ratings and physician pain classification
(pain/no pain) using sensitivity/specificity. For the Pain Activity Summary Score
sensitivity and specificity was moderate to strong. For the Pain Behaviors Summary
Score sensitivity was strong, however specificity scores were low suggesting the tool
may classify patients as having pain when they are not. Moreover caution is
warranted due to low levels of pain in the sample that limits evaluation of tool ability
to detect pain in those with higher pain levels.
Horgas compared nurse-ratings of pain intensity with videotaped behaviors of real
patients believed to be in pain. Videos were coded extensively using the Keefe and
Block Pain Behavior Measurement System. This additional standard for comparison
adds to claims for convergent validity of the NOPPAIN even outside the laboratory
setting.
Horgas found strong correlations between NOPPAIN and self-reported VDS and NRS
in the cognitively intact population only. This underscores the need for behavioral
assessment in this population.
The concern remains that the tool only captures typical pain behaviors and while
raters consistently identify intensity as portrayed in an enacted sequence there is no
validation that patients will present with this sequence as expression of intensity. A
Completed 04/04
Revised 06/08
final concern is that, while caregivers can identify pain in video, they may actually
under-detect pain within the caregiving context itself.
Summary
The NOPPAIN was developed for the purpose of nursing assistants screening for
pain in older adults with dementia. The tool has limited comprehensiveness with
behaviors addressing only obvious and not subtle cues or changes indicated in the
literature. However, preliminary testing has established that the screening tool is reliable
and has preliminary validity, thus may be useful when combined with a more
comprehensive screen for other indicators. Use of proxy report for pain severity in a
nonverbal population has not been supported in the literature and this aspect of the tool
should be evaluated in clinical samples. The tool has been tested in a racially/ethnically
diverse sample, although further study is warranted. The tool appears to be clinically
useful given the ability of nursing assistants to use and the limited time required for
completion. Further psychometric testing is encouraged, including consideration of items
to tap nursing assistants knowledge of baseline behavior and recognition of subtle
changes that might reflect presence of pain. Because assessment activities are outside the
scope of nursing assistant practice, it will be important to determine if the expectations of
the tool for NAs are actually screening activity. The tool was used successfully by senior
nursing students in the laboratory setting rating real patient videos.
Sources of evidence
Snow , A.L., Hovanec, L., Passano, J., Brandt, J. (2001). Development of a pain assessment
instrument for use with severely demented patients. Poster session presented at the Annual
Meeting of the American Psychological Association. Washington, DC.
Snow, A. L., Weber, J. B., O'Malley, K. J., Cody, M., Beck, C., Bruera, E., et al. (2004).
NOPPAIN: A nursing assistant-administered pain assessment instrument for use in dementia.
Dementia and Geriatric Cognitive Disorders, 17(3), 240-246.
Snow, A.L.,Cody, M., Beck, C., Bruera, E., OMalley, K.J. Aston, C., El-Issa, L., Kunik, M.E.
Nursing assistants as pain screeners for nursing home residents with severe dementia: In vivo
validation of the NOPPAIN. (draft article, 2004).
Horgas, A. L., Nichols, A. L., Schapson, C. A., & Vietes, K. (2007). Assessing pain in persons
with dementia: Relationships among the non-communicative patient's pain assessment
instrument, self-report, and behavioral observations. Pain Management Nursing: Official
Journal of the American Society of Pain Management Nurses, 8(2), 77-85.
Contact information for tool developer:
Lynn Snow, PhD
E-mail: lsnow@bama.ua.edu
Critique completed by:
Updated by :
Completed 04/04
Revised 06/08
Tool:
Nursing Assistant-Administered Instrument to Assess Pain in

Demented Individuals (NOPPAIN)
Tool developer:
Snow, A.L., Weber, J.B., OMalley, Cody, M., Beck, C., Bruera,
E., Ashton, C., Kunik, M.E.
Country of origin: USA
Reviewed:
04/04
Revised:
06/08
Conceptualization
Panel rating: 2
Revised: 2
Purpose
Conceptual basis
Item Generation
The Non-Communicative Patients Pain Assessment Instrument (NOPPAIN)

is a nursing assistant-administered instrument for observing and rating pain
behaviors in patients with dementia.
No definition of pain or identification of the conceptual basis for the tool is
provided.
There is recognition that verbal assessment of pain in patients with dementia
Alzheimer type (DAT) is problematic. This tool focuses on observation of
specific pain behaviors while doing common care tasks, such as bathing,
dressing and transfers. Pain is assessed at rest and with movement.
NOPPAIN derives a level of pain intensity from the presence and intensity of
behaviors observed. The tool developers called it a pain screening tool
because diagnosis or analysis of observation is not within the scope of NA
practice. NAs are asked to perform behavioral observation and rate intensity
of behaviors prior to formulation of a global pain score in each patient.
Horgas (2007) tested the reliability and validity of the NOPPAIN when used
as assessment instrument by nurses.
The tool was developed by consultation with a panel of 10 clinical and
research experts in pain assessment in dementia, nursing home research and
psychometrics that advised about item and instrument format issues.
Little information is provided about the actual items that were generated in
this process. However, the resulting items appear to reflect those on the
Checklist of Nonverbal Pain Indicators (Feldt, 1998).
The basis for assessment of intensity of behaviors is not reported neither is
the process of how NAs translate the NSR of behavior intensity into a VDS of
pain intensity.
Nursing assistants global assessment of pain is based on the tool developers
assumption that caregivers can reliably rate the intensity of pain in elders.
Tool items
The tool has four main sections:
In the first section questions are asked about the caregiving situation (what
tasks were performed and whether pain was observed). Two simple questions
allow the patient to self-report about pain and hurt.
In the second section the nursing assistant is presented with 6 pain behaviors
with graphic illustrations:
Pain words
Pain noises
Pain faces
Rubbing
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Bracing
Restlessness
For each of these items the nursing assistant is asked 1) if the behavior was
observed (yes/no) and 2) to rate the intensity of the particular behavior on a 5
point numeric rating scale (NSR) with anchors 0=lowest possible intensity,
5=highest possible intensity.
Section three allows the NA to mark the location of pain on a body schematic.
Content Validity
-Panel Commentary
In section four the nursing assistant is asked to rate the patients global pain
intensity on that day on a verbal descriptor scale (VDS) in the shape of a pain
thermometer with 6 verbal pain descriptors from no pain to pain is almost
unbearable.
The NOPPAIN is based on review of the literature and was developed in
consultation with a multidisciplinary panel of experts not involved in the
study. Content validity was established in study 1 (Snow, 2004) where
nursing assistants identified NOPPAIN behaviors in a standardized actorpatient video and were able to distinguish levels of pain based on enacted
behaviors by comparing 2 different videos/pain levels at a time.
Study 3 (Horgas, 2007)
This study compares nurse-ratings of pain intensity with videotaped
behaviors of real patients believed to be in pain. Videos were coded
extensively using the Keefe and Block Pain Behavior Measurement System.
This additional standard for comparison adds to claims for convergent
validity of the NOPPAIN.
The tool covers 3 of 6 pain behavior categories in the AGS Persistent Pain
Guidelines: Facial expression, Verbalizations/ vocalizations and Body
language. More subtle pain behaviors in the AGS Guidelines are not
addressed: Changes in activity patterns or routines, Mental status changes,
Changes in interpersonal interactions. Thus, the tool has limited
comprehensiveness which may limit the likelihood of detecting pain,
particularly in patients who do not present with obvious pain behaviors.
One justification for involving nursing assistants in pain screening is that they
may observe subtle behaviors. However, the NOPPAIN only addresses
typical pain behaviors. While the unique knowledge that the nursing
assistant may contribute to pain screening is not specifically incorporated
into the tool it is unknown how such unique knowledge influences formulation
of the final global pain score assigned by the NA in each patient.
The nursing assistant is expected to rate the intensity of a particular behavior
on a 6 point scale. However, there is little indication as to what will be
observed to differentiate levels of intensity.
Beyond recognizing presence/absence of pain-related behaviors by
caregivers, the current literature presents conflicting information about
reliability and validity of caregivers proxy assessment of pain severity in
elders with dementia who are experiencing pain. There is a conceptual leap
in inferring not only the presence but also the intensity of pain from pain
behaviors. While there is emerging evidence that observation or informantbased pain assessment tools can track change in degrees of pain for
individual patients, current literature does not support the hypothesis that
such tools can reliably differentiate between arbitrary categories on a VDS or
even escalating levels on an NSR. More testing is needed to support any
population-based normed correlation between intensity of pain behaviors and
Completed 04/04
Revised 06/08
intensity of pain.
Use of standardized patient behavior for pain assessment and rating in
cognitively impaired older patients is debatable. The addition of behavior
coded real patient videos as gold standard in study 2 adds strength to the
contention that nurses recognize pain behaviors and can identify levels of
pain in individual patients.
Subjects
Panel rating: 3
Revised: 2
Subjects
Study 1 (Snow, 2004)

Characteristics of nursing assistants (N=21):
Gender: Female: 86%, Male: 14%
Average age: 37 years (11.50), Range: 21-60 years.
Racial/ethnic composition: Caucasian: 5%, African-American: 76%,
Hispanic: 10%, Asian: 7%.
Education background: High school diploma/GED: 71%
Experience: average 9.8 years, range 3 mos. 30 years
All NAs were hired from the same temporary employment agency.
Study 2 (Snow 2004, unpublished)
Setting: Four Houston nursing homes and a VA nursing home unit
Characteristics of residents (n=83):
Age of subjects: Average 83.17 years (8.79) Range 50-100 years
Average MDS-Cognition Subscale: 5.46 (2.86)
Racial/ethnic diversity: Caucasian: 68%, African-American: 12%,
Hispanic: 11%, Other: 9%
Most common pain related diagnoses were arthritis (41%), pain (39%),
osteoporosis (28%) and fractures (28%).
Characteristics of nursing assistants (N=20):
Average age: 37 years (10.50), Range: 21-60 years.
Racial/ethnic composition: Caucasian: 4%, African-American: 81%,
Hispanic: 7%, Asian: 7%.
Education background: High school diploma/GED: 59%
All NAs were hired from the same temporary employment agency.
40 Subjects were randomly selected from a volunteer sample of 128
participants from a variety of institutional and community settings.
Mean age: 83
Gender: predominantly female
Diversity: not stated
Cognitive impairment: 20 subjects were cognitively intact (MMSE 24-30)
and 20 were impaired (MMSE 10-23).
Subjects were English-speaking, able to stand up from a chair, with Dx of
osteoarthritis in lower body and not visually or hearing impaired. All had
previously completed pain interviews and videotaped activity protocol
data from the parent study (parent study is not cited).
-Panel Commentary
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Revised 06/08
Characteristics of raters: 2 senior honors nursing students

There is a clearly identified focus on the longterm care setting.
Gender balance in the NA samples of the first two studies reflects general
distribution in this population. Both NA samples are racially/ ethnically
diverse. Patient subjects in the unpublished study 2 are severely cognitively

impaired as measured with standard dementia assessment tool (MMSE).
Study 3 sample is only 50% cognitively impaired and less diverse. Sample
size (N=40) is adequate but has some missing observations.
The tool is complex and large sample sizes would be needed to establish
internal consistency for all items. Using 5 subjects per tool item as a
minimum requirement for this review, a minimum sample size of 35 subjects
(7 items x 5 subjects) would be needed to test the six pain behaviors, their
intensities and the global pain score on the pain thermometer. Study 2
(unpublished) and study 3 involving real patients meet the minimum sample
size requirement. More studies are needed beyond the laboratory setting and
involving more diverse patient populations.

Panel rating: 2
Revised: 2
Administration, Scoring,
Feasibility
The tool has four main sections (for specification see Item Generation
section above). It was designed to require minimal training for proper use.
Instructions on the form indicate that the NA should complete the form
following at least 5 minutes of daily care activities while observing for pain
behaviors. The form is to be completed immediately following care activities.
In a feasibility study, administration of the NOPPAIN took nursing assistants
less than 30 seconds after an average of 8.71 minutes (3.70, range 3-15
minutes) involved in care activity and observing the patient prior to
completion.
-Panel Commentary
Study 3 concluded that nurse raters were able to easily, reliably and validly
rate pain behavior presence and intensity after a short training session
using CD-ROM.
The method of administration is described but scoring procedures are unclear.
No criteria are provided for establishing low-high intensity of pain behavior.
NAs only rate behaviors associated with activities performed. There are no
directions as to how missing activities influence the global pain score.
There is concern about NA rating of severity of the residents pain (on the
pain thermometer) given inaccuracies of surrogate reporting. Study 3
(Horgas, 2007) demonstrated that accuracy of administration might be
improved with training.
Interpretation of the tool score is unclear. There is no indication on how to
proceed once rating of individual items is completed.
Findings for clinical utility are promising: The tool requires little time to
complete following a period of observation consistent with time to complete
care activities.
The tool was clearly developed for use by nursing assistants. Scope of
practice for nursing assistants in screening for pain must be considered.
Reliability
Panel rating: 2
Revised: 2
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Revised 06/08
Internal consistency of the tool has not been established.
Study 2 (Snow, 2004 unpublished)

Interrater reliability was conducted in a subsample of NAs (See
characteristics of nursing assistants under subjects above).
Interrater reliability was evaluated using 78 videotapes of NAs performing
morning care tasks (e.g. cleaning, dressing, transferring, and toileting) with
residents with dementia. Twenty-six videos were randomly chosen and shown
in random order to a group of 6 NAs who had not participated in either the
video development or training session on use of the NOPPAIN.
To evaluate the effect of brief training on interrater reliability, a group of 6
NAs, independent from those who participated in the above activities,
received one hour of training on how to complete the NOPPAIN.
Interrater reliabilities (mean percent agreement) for each main item on the
NOPPAIN for untrained and trained raters ranged as follows:
Was the activity done?*

Pain during activity?
Was Pain Behavior Present?
Pain Behavior Intensity
Pain Thermometer
Untrained raters
.79 - .94
.66 - .87
.59 - .87
.68 - .92
.85
Trained raters
.78 - .94
.66 - .92
.69 - .99
.77 - .99
.97
(* Activities include: lying down, turned, transferred, sitting, dressing,

eating, standing, walking, bathing)

The PI and 2 undergraduate honors nursing students reviewed a brief
standardized CD-based training program, i.e. they viewed enacted levels of
pain as developed by the authors of NOPPAIN (see construct validity for
study 1). Raters also practiced NOPPAIN scoring until they reached 90%
agreement with the author. Nursing students then independently scored forty
10-minute videotapes which depicted the standardized activity protocol to
elicit pain behaviors based on the work of Keefe and colleagues (see pain
behaviors listed in item generation). Behaviors were presented in random
sequence to minimize order effects.
Across the 6 behaviors, Kappa coefficients ranged from 0.72-1.0 for
presence of the behavior (M=0.88). Raters agreed in a range of 0.721.0 on pain intensity (M=0.91).
Study 2 (Snow 2004, unpublished)
This study was conducted with a subset of untrained nursing assistants (see
under subjects above) with no previous contact with residents while providing
morning care to residents. The procedure was repeated 2 hours later (n=42)
and 24 hours later (n=34). Reliabilities reported were:
Was Pain Behavior Present?

Pain Behavior Intensity
Pain Thermometer
2 hours
.22 - .68a
.25 - .68s
.60 s
24 hours
.27 - .67a
.14 - .66s
.39 s
a = phi correlations
s=spearman correlation

Each student rater re-scored 10% of the videos 1 week later:
average of 0.7 and 0.86 for presence of pain
Completed 04/04
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ICC =>0.67 for pain intensity ratings (missing intra-rater consistency for
pain words and rubbing).
-Panel commentary
Internal consistency needs to be established yet.

Interrater reliabilities were moderate to strong for all tool items. The
reliabilities for observing presence of pain behaviors and pain behavior
intensity improved with one hour of training.
Test-retest reliability was low to moderate at both 2 and 24 hours. Only the
Pain Thermometer was stronger at 2 hours than 24 hours (study 2).
Test-retest/intrarater consistency over time in study 3 (Horgas, 2007) was
good to very good.

Panel rating: 2
Revised: 2
Construct validity/
Construct validity (study 1, Snow 2004)

Standard videotaped patient scenarios representing a continuum of pain
intensity levels were developed using an actor to portray a bed-bound patient
with severe dementia receiving personal care from a nursing assistant.
NAs watched and rated each video using the NOPPAIN assessment process.
NAs completed the global pain rating for each video and were asked to
identify the video showing the most pain from each of 15 pairs.
NAs global pain rating on the NOPPAIN and pain levels portrayed in the
videos resulted in weighted Kappa=0.87 (SE: 0.2, 95% CI: 0.82-0.91).
For paired comparisons (Bradley-Terry model of paired comparisons), the
parameter estimates conformed to expected responses, although borderline
(Deviance GFI=18.14(10), p=0.0527, non-significance indicates a good fit).
The lowest intensity pain condition had the smallest parameter, with
parameter size increasing with each subsequent level of the pain response
scale. Lack of agreement was mainly due to confusion between mild pain
and moderate pain, which was shown by 65% of the raters. All pain level
comparisons were 82-100% correct.
Construct validity (study 2, Snow 2004, unpublished)
Construct validity was evaluated by comparing nursing assistant NOPPAIN
ratings to a physician gold standard. The gold standard for pain presence was
consensus of two palliative care physicians on NOPPAIN scores and
dichotomous pain classification.
According to physician consensus classifications, 15 of 75 (20%) of patients
were in pain. All 15 were classified by physician consensus as having mild
pain on the pain thermometer; on the 0-10 pain scale, 8 (11%) were classified
as having pain of level 1, 6 (8%) had pain at level 2 and 1 (1%) had pain at
level 3.
Pain behaviors were observed most often during transferring, turning,
dressing. Of the pain behaviors: bracing, pain faces and pain noises were
observed most often (in 67-73% of those classified as in pain), pain words
(33%) and restlessness (13%) less often, while rubbing was not observed.
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NOPPAIN Validity Indices using sensitivity/specificity were as follows:

Untrained rater validity:
Physician ratings and NA ratings
NA NOPPAIN
NA NOPPAIN and
and Physician
Physician Pain
NOPPAIN
Classification
(Pain/No pain)
Pain Activity Summary Score
.73/.86
.67/.88
Pain Behaviors Summary Score
.90/.45
.93/.43
-Panel commentary

Convergent validity: Correlation analyses were conducted to examine the
relationship between self-reported pain and NOPPAIN scores.
Correlation of NOPPAIN NRS and self-report NRS r = 0.39 (p<0.01)
Correlation of NOPPAIN VDS and self-report VDS r = 0.31(p<0.05)
These correlations were twice as strong when figured separately for
cognitively intact patients and not significant for the cognitively impaired
sample.
NOPPAIN scores were also compared to behavioral rating scores from
detailed observational coding available for videos from the parent study. In
the cognitively impaired sample correlations were very strong for all pain
behaviors except bracing which was not observed In the cognitively intact
sample, pain words and rubbing were not observed and there was no
correlation with pain noises.
Total number of pain behaviors observed: r =/> 0.63 in the total group
as well as in cognitively intact and impaired groups (p< 0.001).
Preliminary evidence of tool validity is presented; however, additional study
in clinical settings with larger samples and actual non-research caregivers is
needed. The judgment of pain severity in persons with dementia by
caregivers has not been substantiated in prior literature; however preliminary
work on this tool using a standardized video approach suggests additional
study in this area is warranted with clinical samples.
The low specificity scores on the pain behavior items suggest the tool may
classify patients as having pain when they are not.
A caution is warranted regarding the low levels of pain in the sample that
limits evaluation of tool ability to detect pain in those with higher pain levels.
The poor correlation between NOPPAIN and self- report among cognitively
impaired patients underscores the need for behavioral assessment in this
population.
The high correlation between detailed behavior coding and NOPPAIN scores
strongly supports construct and criterion validity of the test outside the
laboratory setting.
The concern remains that the tool only captures typical pain behaviors and
while raters consistently identify intensity as portrayed in an enacted
sequence there is no validation that patients will present with this sequence
as expression of intensity. A final concern is that, while caregivers can
identify pain in video, they may actually under-detect pain within the
caregiving context itself.

The NOPPAIN was developed for the purpose of nursing assistants screening for pain in older adults with
dementia. The tool has limited comprehensiveness with behaviors addressing only obvious and not subtle
cues or changes indicated in the literature. However, preliminary testing has established that the screening
Completed 04/04
Revised 06/08
tool is reliable and has preliminary validity, thus may be useful when combined with a more comprehensive
screen for other indicators. One follow-up study supplied support for convergent validity of proxy report
with detailed behavioral coding in patient video and this aspect of the tool should be evaluated further in
clinical samples. The tool has been tested in a racially/ethnically diverse sample, although further study is
warranted. The tool appears to be clinically useful given the ability of nursing assistants to use and the
limited time required for completion. Because assessment activities are outside the scope of nursing
assistant practice, it will be important to determine if the expectations of the tool for NAs are actually
screening activity. The tool was used successfully by senior nursing students in the laboratory setting rating
real patient videos.
Sources of evidence
Snow , A.L., Hovanec, L., Passano, J., Brandt, J. (2001). Development of a pain assessment instrument for
use with severely demented patients. Poster session presented at the Annual Meeting of the American
Psychological Association. Washington, DC.
Snow, A. L., Weber, J. B., O'Malley, K. J., Cody, M., Beck, C., Bruera, E., et al. (2004). NOPPAIN: A
nursing assistant-administered pain assessment instrument for use in dementia. Dementia and Geriatric
Cognitive Disorders, 17(3), 240-246.
Snow, A.L.,Cody, M., Beck, C., Bruera, E., OMalley, K.J. Aston, C., El-Issa, L., Kunik, M.E. Nursing
assistants as pain screeners for nursing home residents with severe dementia: In vivo validation of the
NOPPAIN. (draft article, 2004).
Horgas, A. L., Nichols, A. L., Schapson, C. A., & Vietes, K. (2007). Assessing pain in persons with
dementia: Relationships among the non-communicative patient's pain assessment instrument, selfreport, and behavioral observations. Pain Management Nursing : Official Journal of the American
Society of Pain Management Nurses, 8(2), 77-85.
Key to panel rating

Contact address for tool developer

Lynn Snow, PhD
Houston Center for Quality of Care and Utilizations Studies
Veterans Affairs Medical Center
2002 Holcombe Boulevard 142
Houston, Texas 77030
E-mail: lsnow@bama.ua.edu

Revision 06/08 by::

K. Herr, H. Bursch, B. Black
Completed 04/04
Revised 06/08
The Pain Assessment Checklist for Seniors with Limited Ability to Communicate
(PACSLAC) Brief
The Pain Assessment Scale for Seniors with Severe Dementia (PACSLAC)
developed by a Canadian team, is a tool for the familiar caregiver to observe and assess
both common and subtle pain behaviors. The tool is a checklist with four subscales and a
total of 60 items: Facial expressions (13 items), Activity/body movements (20 items),
Social/personality/mood (12 items) and Physiological indicators/eating and sleeping
changes/vocal behaviors (15 items). Each item is scored on a present/absent dichotomous
scale. Subscale scores are summed to arrive at a total score ranging from 0 to 60.
However, no interpretation of the total score is currently available.
Simple instructions on how to administer and score the tool are clearly described
on the tool form. Preliminary cut-offs for determining pain presence are determined for
the PACSLAC. Although the original PACSLAC includes 60 items, the tool requires a
limited amount of time to administer, indicating that the tool is potentially useful in
everyday clinical practice. Testing of the PACSLAC-D (Dutch Language), the shorter 24
item scale, suggests the tool is user friendly requiring a short time for training (30
minutes), has an established cut-off to facilitate score interpretation, and can be
completed in a few minutes. Preliminary evidence of clinical utility and normative data
for scoring is provided, although further validation with larger and more diverse is
needed.
The PACSLAC was tested in a sample of 40 RN/resident dyads in which the
nurse recalled a resident that had been under his/her care for at least six months and who
experienced pain. Nurses were 44 years on average with an average of 19 years
experience. The 40 corresponding residents were 85 years on average, 30 females/10
males, 33 had a diagnosis of dementia and 34 had a diagnosis associated with pain.
Follow-up studies evaluated the PACSLAC and PACSLAC D (Dutch language)
prospectively in NH settings with samples of patients with dementia. Methods for
evaluating cognitive status are appropriate and indicate severe impairment in most
studies. Age and gender representation is appropriate. There is no information in any of
the studies regarding racial/ethnic diversity, except testing in Canadians and Dutch.
Using a minimum requirement of 5 subjects per item for the purposes of this review, the
sample sizes for testing the PACSLAC and the PACSLAC-D (Dutch Language) are small.
Additionally, few subjects in the existing studies had moderate or severe pain impacting
evaluation of the tool usefulness across the full range of scoring. Additional evaluation
in larger English-speaking samples with increased diversity are needed.
Reliability
Internal consistency was good based on four remembered events: two painful events,
one distressing (but not pain-related) and one calm event. The methodology of using
remembered events is appropriate in preliminary stages of tool development, but is
subject to recall bias. Follow-up studies 3 and 4 were able to duplicate good internal
consistencies for both total PACSLAC and PACSLAC D scales.
Studies 3, 5 and 6 found generally high interrater reliabilities for both versions, total
scales and sub scales.
Completed 04/04
Revised 06/08
Study 3 had strong intrarater reliability between bedside and video scorings but the
time interval is not specified.
Additional testing in diverse samples, including those with greater range of pain
severity, is recommended.
Validity
Discriminant validity was evaluated based on retrospective recall of painful events by
the nurse for four events as indicated above. The total PACSLAC score was able to
discriminate among painful, calm, and non-pain related distress events (p<.001).
Subscales: Facial expressions, Activity/rocking movement and Physiological
indicators/eating and sleeping changes/vocal behaviors discriminated among painful,
distressing and calm events (p<.001) and subscale Social/personality/mood
discriminated between pain and calm events but not between pain and the distress
events.
Criterion related validity was moderate using Global Pain Intensity Ratings of the
nurses perception of the patients pain as the gold standard.
Zwakhalen translated the PACSLAC into Dutch and used principal component
analysis with Oblimin rotation to reduce the 60-item tool into a shortened version
with only 24 items. The reduced version of the scale strongly correlated with the long
60-item version of the scale with Pearsons r of 0.945. It is important to note that the
PACSLAC-D (Dutch Language) does not contain items that require prior knowledge
of the patient and thus is a direct observation tool only. Both the PACSLAC and
PACSLAC-D (Dutch Language) have been validated in Dutch. Further study of the
PACSLAC is warranted to determine if frequency of item use and a similar factor
structure and reduction holds up in English and other languages and populations.
Further evaluation in studies 2, 3 and 5 provide support for congruent and
discriminant validity of the PACSLAC, as well as preliminary support for cut-off
points and sensitivity and specificity of the shorter PACSLAC-D (Dutch Language).
Additional study in larger samples, with samples experiencing greater pain severity,
and to evaluate tool sensitivity are needed.
Summary
The PACSLAC is a potentially clinically useful behavior checklist that appears
simple to use for assessing and monitoring changes in persons with dementia and diverse
presentations of pain-related behavior. The tool is comprehensive and addresses pertinent
indicators noted in the literature and AGS Guideline. Prospective evaluation has added to
the tools reliability and validity, as well as factor analysis to determine the most efficient
and useful indicator set for clinical use. However, the revised PACSLAC-D (Dutch
Language) no longer contains items that are based on knowledge of the patient and this
may under-recognize pain in patients who demonstrate less obvious indicators such as
changes in activity or behavior. Because of this major revision in the tool, the PACSLAC
and PACSLAC-D (Dutch Language) psychometric evaluations should be considered
independently. Preliminary normative data and cut-offs are provided but require further
validation in larger, more diverse samples. Additional factor analysis in Englishspeaking samples, other diverse samples, and in patients with increased levels of pain
severity is needed, as is determination of tool sensitivity in detecting treatment effects.
Completed 04/04
Revised 06/08
Source of Evidence
Fuchs-Lacelle, S. & Hadjistavropoulos, T. (2004). Development and preliminary validation of the
Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC).
Pain Management Nursing, 5(2).
Fuchs-Lacelle, S.& Hadjistavropoulos, T. (2005). A checklist for pain assessment in LTC.
PACSLAC: Pain Assessment Checklist for Seniors with Limited Ability to Communicate.
Canadian Nursing Home, 16(4), 4-7.
Zwakhalen, S., Hamers, J. & Berger, M. (2006). The psychometric quality and clinical
usefulness of three pain assessment tools for elderly people dementia. Pain, 126(1-3), 210220.
Zwakhalen, S., Hamers, J. & Berger, M. (2007). Improving the clinical usefulness of a behavioral
pain scale for older people with dementia. Journal of Advanced Nursing, 58(5), 493-502.
Zwakhalen, S., Koopmans, R., Geels, P., Berger, M. & Hamers, J. (2008) The prevalence of pain
in nursing home residents with dementia measured using an observational pain scale.
European Journal of Pain, xx, xxxx. (in press).
Fuchs-Lacelle, S., Hadjistavropolous, T. & Lix, L. (in press). Pain assessment as intervention: A
study of older adults with severe dementia. Clinical Journal of Pain, xx ,xxx. (in press)
The authors recommend additional articles pertaining to a French language version of the
PACSLAC (Dr. Thomas Hadjistavropoulos, personal communication, July 2008):
Aubin, M., Verreault, R., Savoie, M., LeMay, S., Hadjistavropoulos, T., Fillion, L., Beaulieu, M.,
Viens, C., Bergeron, R., Vzina, L., Misson, L. & Fuchs-Lacelle, S. (2008). Validit et utilit
clinique d'une grille d'observation (PACSLAC-F) pour valuer la douleur chez des ans
atteints de dmence vivant en milieu de soins de longue dure. Canadian Journal on
Aging/La revue canadienne du vieillissement, 27, 45-55. [DISCUSSION OF PACLAC-F)
Aubin, M., Gigure, A., Hadjistavropoulos, T. & Verreault, R. (2007). Evaluation systmatique
des instruments pour mesurer la douleur chez les personnes ges ayant des capacits rduites
communiquer. Pain Research and Management, 12, 195-203. [Systematic review, using a
grid of the PACSLAC in comparison to all other tools that we could find]
Contact information for PACSLAC:
Thomas Hadjistavropoulos, PhD
Email: Thomas.Hadjistavropoulos@uregina.ca
Contact information for PACSLAC-D (Dutch language version):
Sandra Zwakhalen, PhD
Email: S.Zwakhalen@zw.unimaas.nl
Updated by:
Completed 04/04
Revised 06/08
Tool:
The Pain Assessment Checklist for Seniors with Limited Ability

to Communicate(PACSLAC)
Tool developer:
Fuchs-Lacelle, S.K. & Hadjistavropoulos, T.
Country of origin: Canada
Reviewed:
04/04
Revised:
06/08
Conceptualization
Panel rating: 2
Revised: 2
Purpose
Conceptual basis
Item Generation
The PACSLAC is a caregiver-administered pain assessment checklist using

direct observation and familiar caregiver information for the assessment of
pain in elders with limited ability to communicate.
A unified conceptual basis for the tool is not evident; However, the tool does
tap pain behaviors from all 6 domains of the AGS Persistent Pain Guidelines.
The authors acknowledge the limitations of rating behaviors as to pain
intensity in a population with diverse presentations and thus pain indicators
are measured on a dichotomous present/absent scale.
Tool items
There are four subscales with a total of 60 items:
Facial expressions (13 items)
Activity/body movements (20 items)
Social/personality/mood (12 items)
Physiological indicators/Eating and sleeping changes/Vocal behaviors
(15 items).
Each item is scored on a dichotomous scale by checking off those pain
behaviors that are observed. The number of checks on each subscale are
added together and recorded and then these sums are added together for a
total score.
Phase I: Item generation
Items were generated through serial interviews with experienced professional
caregivers of seniors with severe dementia (see sample characteristics below).
Interviews were recorded, transcribed. Transcribed material was then
reviewed by two researchers who each independently developed an initial set
of non-overlapping behaviors. The original total of 71 behaviors was
collapsed to 65, which was used to develop the PACSLAC. A second coder
independently used the list of 71 pain behaviors to review a random sample of
15 transcribed interviews. Agreement between the two coders on total number
of instances each coder endorsed each behavior on the list resulted in
correlation of 0.94 (p<.01). The behaviors were then grouped conceptually
by the authors.
Phase II: Item analysis and assessment of internal consistency
A preliminary tool with 7 subscales with a total of 65 pain behaviors was
used by a separate sample of 40 professional caregivers (see sample
characteristics below) who reported on pain experiences of remembered
patients with severe dementia. The number of subscale was reduced to four in
order to improve internal consistency: Facial expressions, Activity/body
movements, Social/personality/mood and Physiological indicators/Eating and
sleeping changes/Vocal behaviors. Moreover, two items of the 65 items were
deleted.
Reviewed: 04/04
Revised: 06/08
Content Validity
Phase III: Preliminary validation of the PACSLAC

An additional three items were deleted following phase III. The final tool has
60 items on 4 subscales (see sample characteristics and results of validation
study below).
Phase II Assessment of Usefulness
The professional caregivers also rated PACSLAC items for usefulness on a
numeric rating scale (Usefulness Scale) anchored by 0 (not useful) and 10
(very useful) to indicate how useful that specific behavior was for deciding
whether pain was present. All items except one were rated as being useful in
identifying pain as indicated by a score of at least 5.
Study 3 (Zwakhalen, Hamers & Berger, 2006)
The study evaluated the validity of a Dutch-translated version of the
PACSLAC and demonstrated reliability and validity in this language.
Study 4 (Zwakhalen, Hamers, & Berger, 2007)
Because 28 of 60 PACSLAC items were not used for over 90% of study
participants in Study 3, item reduction was attempted. Using observation of
patients for two minutes while receiving an influenza vaccination (T2) and
during a patient-specific pain moment (e.g. care activities, washing or
mobilization) (T3), item reduction techniques were used to refine the
PACSLAC. This study used a translated (Dutch) version of the PACSLAC
and the observer had no prior knowledge of the patient. Pain intensity was
rated on a VAS. VAS and PACSLAC scoring were performed in random
order within a time interval of less than three weeks.
Principal components analysis with Oblimin rotation used to determine factor
structure with re-examination of matrix following any item deletions to
validate final scale and subscales.
-Panel Commentary
35 items were discarded based on low IC and MSA values. Additional items
were deleted based on low factor loadings. The final revised tool represented
three components explaining 45.7% of variance with 24 items called
PACSLAC-D (Dutch Language).
Alpha for total scale with 24 items=0.86 at T2 and 0.82 at T3.
Cronbachs alpha for three subscales were high, ranging from 0.72 to 0.82.
The reduced version of the scale was correlated with the long 60-item version
of the scale with Pearsons r of 0.945.
It is important to note that the PACSLAC-D (Dutch Language) dos not
contain items that require prior knowledge of the patient and thus is a direct
observation tool only.
The tool covers all 6 pain behavior categories in the AGS Persistent Pain
Guidelines. However, the subscales appear to be conceptually based (derived
by the authors), rather than based on factor analysis. A strength of the
PACSLAC is the broad nature of indicators that allows for recognition of
pain in those with idiosyncratic or less obvious pain behaviors. The subscale
includes seven indicators that conceptually represent
vocalization/verbalization; two represent change in activity pattern and three
may represent change in mental status. Because of the large number of
diverse indicators on this subscale, refinement may be needed.
Because the PACSLAC is a broad list with potential pain indicators for acute
and/or persistent pain and is not scored to represent severity of persistent
pain, inclusion of physiological indicators appears appropriate.
The items are dichotomous and scored as present/absent. The tool does not
Reviewed: 04/04
Revised: 06/08
attempt to measure pain severity, which is appropriate for older adults with
dementia who are not able to communicate their pain verbally.
The PACSLAC was assessed for content validity by an independent review
process involving professional caregivers as experts and was assessed as
being clinically useful for assessing pain in elders with severe dementia.
A shortened version has been developed in Dutch called PACSLAC-D (Dutch
Language) with 24 items derived through factor analytic procedures based
on a small sample and based on an acute pain episode (with small sample
experiencing situation-based pain). This shortened tool has preliminary
reliability and validity, although additional testing with other types of more
chronic pain and larger samples is needed. Both the PACSLAC and
PACSLAC-D (Dutch Language) have been validated in Dutch. Further study
of the PACSLAC is warranted to determine if frequency of item use and a
similar factor structure and reduction holds up in English and other
languages and populations.
It should be noted that the PACSLAC is an informant-based tool requiring
knowledge of the patients baseline behaviors as opposed to the PACSLAC-D
(Dutch Language) which is strictly an observation-based tool. Given the fact
that there are 60 items in the PACSLAC it has been suggested that the very
few items requiring prior knowledge of the patient could be left blank. More
testing is needed to see how this would affect reliability of the PACSLAC.
Subjects
Panel rating: 1
Revised: 2
Subjects
Study 1 (Fuchs-Lacelle & Hadjistavropoulos, 2004)

Stage I
28 primary caregivers of elders 65 years of age or older living in long term
care due to serious limitations in their ability to communicate.
The primary caregivers were registered nurses, licensed practical nurses and
special care aides
Stage II
40 RN/Resident Dyads
40 Registered nurses and registered psychiatric nurses who worked in long
term care facilities with older adults with cognitive impairments that limited
their ability to communicate. None of these caregivers had participated in
phase I. Nurse characteristics:
Average age: 49 years (10.2)
Experience as a nurse: 21.4 years (13.0)
Experience with patients reported on: 3.6 years (2.8)
40 patients
Average age: 83.2 years (7.8)
Gender: 11 males, 29 females
Dementia severity: Present Functioning Questionnaire (PFQ): Average
score: 44.6, (5.3), indicating severe dementia.
The subjects were remembered patients under the care of the nurse.
Stage III
40 RN/Resident Dyads
40 nurses:
Average age: 44 years
Average years experience as a nurse: 19 years
40 patients:
Reviewed: 04/04
Revised: 06/08
Average age: 85 years

Gender: 10 males, 30 females
33 patients with a diagnosis of dementia.
34 patients had a diagnosis associated with pain.
Present Functioning Questionnaire (PFQ): Average score: 41, (3.3).
The subjects were remembered patients under the care of the nurse for
at least six months and who experienced pain.
50 nurses
Age: No information
Gender: 70% female, 30% male
Patients (no information on number of patients assessed)
Cognitive status: Present Functioning Questionnaire (PFQ) average score 37
(5.7) indicating serious cognitive impairment.
144 nursing home residents, with 128 dementia, 12 psychogeriatric patients.
Age: mean 82.4 (SD-6.8), range 60-98 years
Gender:78.1% female, 21.9% male
Cognitive Status for dementia patients: MDS-CPS 47.7% severely impaired
(n-61), 28.1% moderately impaired (n-36), 21.9% mildly impaired (n=28)
Diagnosis: 32% Alzheimers Disease; 18.8% vascular dementia, 9.4%
other and 39.8% unknown.
Pain: based on MDS, 25% of psycho-geriatric patients experienced pain on
daily basis; 42.2% of residents reported frequent pain (14.1% mild, 22.7%
moderate, 5.5% unbearable).
16 somatically ill (control group for pain intensity scores)
Age: 78.1 (SD 10.6) years
Gender: 11 female, 5 male
Nurses (n=12)
Age: mean 34.3 (SD-9.6) years
Gender: 10 female, 2 male
128 nursing home residents with dementia
Age: mean 82.4 (SD-6.8), range 60-98 years
Gender: 78.1% female; 21.9% male
Cognitive status: same sample of dementia patients as in study 3.
Study 5 (Zwakhalen,, Koopmans, Geels, Berger & Hamers, 2008)
117 residents from 3 Dutch nursing homes
Age: mean 82.8 (SD=6.1), range 60-97
Gender:80% female, 20% male
Cognitive status: MMSE mean score 5.7 (SD=6.8) suggesting severe
impairment
Study 6 (Fuchs-Lacelle, Hadjistavropoulos, & Lix, in press)
21 units within 12 long-term care facilities
181 patients randomly assigned to experimental (E) or control group (C)
Age: mean 84.89 (SD=6.54) experimental and 8/39 (SD=7.00) control group
Gender: E: 70.8% female; 29.2% male
C: 88.1% female; 11.9% male
Reviewed: 04/04
Revised: 06/08
-Panel Commentary
Cognitive Status: PFQ E=38.99 (SD=7.8)

C=38.86 (SD=7.2)
Caregivers/Nurses
61 RNs, LPNs and NAs
Age: E= mean 44.1 (SD=11.4)
C= mean 46.0 (SD=9.88)
Gender: E: 100% female; 0 male
C: 96.5% female; 3.5% male
The use of remembered patients may be appropriate for preliminary
instrument testing. However, recall bias on the part of the nurses represents a
threat to the validity of this study.
The PACSLAC has been evaluated prospectively in NH settings with sample
of patients with dementia. Methods for evaluating cognitive status are
appropriate and indicate severe impairment in most studies. Age and gender
representation is appropriate. There is no information in any of the studies
regarding racial/ethnic diversity, except testing in Canadians and Dutch.
Using a minimum requirement of 5 subjects per item for the purposes of this
review, the sample sizes for testing the PACSLAC and the PACSLAC-D
(Dutch Language) are small. Additionally, few subjects in the existing studies
had moderate or severe pain impacting evaluation of the tool usefulness
across the full range of scoring. Additional evaluation in larger Englishspeaking samples with increased diversity are needed.

Panel rating: 2
Revised: 2
Administration,
Scoring,
Feasibility
There are four subscales with a total of 60 items.

Each item is scored on a dichotomous scale with one check for each item
identified. Subscale scores are summed to arrive at a total score.
It took most nurses less than five minutes to complete the PACSLAC.
Nurses completed the PACSLAC prospectively while working with the patient
over an 8-hour shift, observing intermittently. No information on time to
complete, perceptions of use, or feasibility reported.
Nurses rated clinical usefulness(on a 10-point scale) showing 75%
preferring the PACSLAC to measure pain in elderly patients with dementia.
Mean usefulness score for PACSLAC (7.0; SD 0.5) compared to the PAINAD
5.89 (SD 1.7).
PACSLAC was reported to be user-friendly and not time-consuming by the
participating nurses. Once used to the scale, they could assess patients
within a few minutes.
Study 5 (Zwakhalen., Koopmans, Geels, Berger & Hamers, 2008)
10 raters from 3 NHs received a short instruction session on use of the
PACSLAC-D (Dutch Language) (30 minutes) and observed residents once for
five randomly selected minutes during personal morning care (e.g. washing,
showering). No raters had prior in-depth knowledge of the NH residents.
Validity and reliability established suggest the tool is readily used with
minimal training.
Cut-offs for pain were established for the PACSLAC-D (Dutch Language)
with 4 out of 24 considered to indicate presence of pain. With this cut-off, the
scale sensitivity was 0.96 and specificity was 0.90. Procedure to establish
cut-off included linear transformation using other observational scales with
Reviewed: 04/04
Revised: 06/08
known cut-offs, verification of cut-off with empirical data and determining

sensitivity and specificity with sample of the study.
-Panel Commentary
Study 6 (Fuchs-Lacelle, Hadjistavropoulos & Lix, in press)

The study provides data regarding the impact of PACSLAC use on patient
outcomes. Regular use of the PACSLAC improved pain management
practices over time as reflected in increased usage of PRN analgesic
medications and a decrease in observable behaviors as pain interventions
increased. Nurses who used the PACSLAC reported decreased distress and
burnout over time. Also preliminary normative data suggest that scores
greater than 12 (out of 60) represent high levels of pain for patients in LTCF.
Scores between 0-5 are indicative of usual pain.
Simple instructions on how to administer and score the tool are provided on
the tool form. Scoring procedures are clear, and preliminary cut-offs for
determining pain presence are determined for the PACSLAC. Although the
original PACSLAC includes 60 items, the tool requires a limited amount of
time to administer, indicating that the tool is potentially useful in everyday
clinical practice. Testing of the PACSLAC-D (Dutch Language), the shorter
24 item scale, suggests the tool is user friendly requiring a short time for
training (30 minutes), has an established cut-off to facilitate score
interpretation, and can be completed in a few minutes. Preliminary evidence
of clinical utility and normative data for scoring is provided, although further
validation with larger and more diverse is needed.
Reliability
Panel rating: 1
Revised: 2

Stage II
In phase II of tool development the PACSLAC observations were made by
professional caregivers (see sample characteristics above). Following deletion
of two items phase II and subscale revisions the following subscale internal
consistency reliabilities were reported:
Total tool (63 items):
=.92
Subscales:
Facial Reactions:
=.80
Social/Personality/Mood:
=.82
Activity/Body Movement:
=.84
Physiological indicators/
Eating and sleeping changes/
Vocal behaviors
=.74
Stage III
Internal consistency was conducted in a sample of 40 RN/Resident dyads (see
sample specifications above). The 40 RNs rated 40 residents on the
PACSLAC retrospectively based on four remembered events: two painful
events, one distressing (but not pain-related) and one calm event. Internal
consistency based on average for the two pain events was =.85.
Internal consistency for subscales:
Facial Reactions:
Social/Personality/Mood:
Activity/Body Movement:
Physiological indicators/
Eating and sleeping changes/
Vocal behaviors
Reviewed: 04/04
Revised: 06/08
=.56
=.85
=.55
=.59

Internal consistencies reported for Dutch PACSLAC across rating by nurses
and rater at T and, T3.
Ranges for Cronbachs alphas were as follows:
Total scale: 0.80-0.84
Facial Expressions subscale: 0.57-0.73
Activity/Body Movement subscale: 0.40-0.57
Social/Personality subscale: 0.65-0.76
Physiological/Eating/Sleeping changes/Vocal behaviors: 0.20-0.43

Internal consistency evaluated for the revised 24-item PACSLAC-D (Dutch
Language).
Alpha for total scale with 24 items=0.86 at T2 and 0.82 at T3.
Cronbachs alpha for three subscales were high, ranging from 0.72 to 0.82.
ICCs between rater 1 and the nurses for the PACSLAC
Total scale rs 0.93-0.96; subscales 0.77 to 0.95. The correlations could be
lower depending on the pair of raters compared.
No interrater reliability reported for the PACSLAC-D (Dutch Language) (24
item scale)
Fifteen residents were assessed by two raters simultaneously during morning
care. ICC for total scale= 0.89; Facial expressions= -.89,
Resistance/Defense=0.76, Social-Emotional aspects/mood= 0.56
-Panel commentary
Study 6 (Fuchs-Lacelle, Hadjistavropoulos & Lix, in press)

Interrater reliability established between two independent, trained RA
observers. Kappa coefficient=0.61, degree of agreement=0.97
Intrarater reliability assessed by comparing scores on PACSLAC allocated
by rater 1 at bedside with those rescored for the same time based on video
recordings (n=29, no time interval given between testing points).
Cronbachs alpha=0.86 overall with subscale rs from 0.72 to 0.92
The PACSLAC has good internal consistency, interrater reliability and
intrarater reliability. The PACSLAC-D (Dutch Language) also has good
reliability estimates established in preliminary testing. Additional testing in
diverse samples, including those with greater range of pain severity, is
recommended.

Panel rating: 2
Revised: 2
Construct validity/
Reviewed: 04/04
Revised: 06/08

Discriminant validity
Discriminant validity was based on retrospective recall of painful events by
the nurse, two pain events with very clear cause, one distressing (but not painrelated) event, one calm event (no signs of distress).
Results:
Pain Event I > Distress Event (p< .001)
Pain Event I > Calm Event (p<.001)
Pain Event II > Distress Event (p<.001)
Pain Event II > Calm Event (p<.001)

Distress Event > Calm Event (p<.001).
Conclusion: The total PACSLAC score is able to discriminate among painful,
calm, and non-pain related distress events F (3,117) = 108.1 (p<.001).
Subscales: Facial Expressions, Activity/Rocking Movement and
discriminated as follows: Pain > Distress > Calm (p<.001).
Subscale Social/Personality/Mood discriminated between
pain and calm events but not between pain and the distress events.
Three additional items were deleted during this phase because they occurred
with greater frequency during calm events.
In Study 1, Global Pain Intensity Ratings of the nurses perception of the
patients pain and PACSLAC total scores were moderately correlated:
PE1: r=.39 (p<.05)
PE2: r=.54 (p<.001).
This report compared nursing observations of patients without known pain to
earlier retrospective ratings of pain events and distress event.
MANOVA used to compare four subscale scores from observations after a
nursing shift with the two Pain Events and the Distress Event.
Total scores for both the Pain Events were significantly higher than
for the total scores based on observation (of patients with no known
pain problems) during a nursing work shift (t(80) > 4.0, p. < 0.001).
All subscales were significantly higher for Pain Event I than for the
subscale scores obtained after a nursing shift (F(80) > 9.46, p <
0.05).
Subscale scores for Activity/Body Movements,
Social/Personality/Mood and Other were higher for Pain Event II
than for nursing shift (F(80) > 9.43, p > .05).
Total scores and the Activity/Body Movements and other subscale
scores did not differ between the pain assessment completed after a
nursing shift and the assessment based on the Distress Event.
Pain and non-pain groups (based on self-report on VRS) were identified and
PACSLAC ability to detect increasing pain with increased behaviors was
evaluated.
Construct validity confirmed with upward trend in scores comparing mean
PACSLAC scores at rest (2.6), at injection, T1 (5.5) and at pain inducing
moment T2 (9.6).
Congruent validity also established between the PACSLAC and PAINAD
(r=0.85). Low correlations noted between the PACLSLAC and
DOLOPLUS-2 (r=0.29 ) suggesting these two tools are not measuring the
same construct.
Using data from Study 4, cut-offs for determining pain presence were
identified and used in a prospective evaluation of pain prevalence in nursing
Reviewed: 04/04
Revised: 06/08
-Panel commentary
homes. The findings are consistent with other studies but use an
observational tool for determining pain presence. The cut-off was verified
using data from Study 3 to establish sensitivity and specificity of the tool.
PACSLAC-D (Dutch Language) sensitivity is 0.96 and specificity is 0.90
based on a > 4 score.
Retrospective recall of patients and their pain-related conditions in initial
testing carries potential for bias but further testing supports tool validity.
Further evaluation provides support for congruent and discriminant validity
of the PACSLAC, as well as preliminary support for sensitivity and specificity
of the shorter PACSLAC-D (Dutch Language). Additional study in larger
samples, with samples experiencing greater pain severity, and to evaluate
tool sensitivity are needed.

The PACSLAC is a potentially clinically useful behavior checklist that appears simple to use for assessing
and monitoring changes in persons with dementia and diverse presentations of pain-related behavior. The
tool is comprehensive and addresses pertinent indicators noted in the literature and AGS Guideline.
Prospective evaluation has added to the tools reliability and validity, as well as factor analysis to
determine the most efficient and useful indicator set for clinical use (PACSLAC-D (Dutch Language)).
However, the revised PACSLAC-D (Dutch Language) no longer contains items that are based on knowledge
of the patient and this may under-recognize pain in patients who demonstrate less obvious indicators such
as changes in activity or behavior. Because of this major revision in the tool, the PACSLAC and PACSLACD (Dutch Language) psychometric evaluations should be considered independently. Preliminary normative
data and cut-offs are provided but require further validation in larger, more diverse samples. Additional
factor analysis in English-speaking samples, other diverse samples, and in patients with increased levels of
pain severity is needed, as is determination of tool sensitivity in detecting treatment effects.
Source of evidence
Fuchs-Lacelle, S. & Hadjistavropoulos, T. (2004). Development and preliminary validation of the Pain
Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). Pain
Management Nursing, 5(2).
Fuchs-Lacelle, S.& Hadjistavropoulos, T. (2005). A checklist for pain assessment in LTC. PACSLAC:
Pain Assessment Checklist for Seniors with Limited Ability to Communicate. Canadian Nursing
Home, 16(4), 4-7.
Zwakhalen, S., Hamers, J. & Berger, M. (2006). The psychometric quality and clinical usefulness of three
pain assessment tools for elderly people dementia. Pain, 126(1-3), 210-220.
Zwakhalen, S., Hamers, J. & Berger, M. (2007). Improving the clinical usefulness of a behavioral pain
scale for older people with dementia. Journal of Advanced Nursing, 58(5), 493-502.
Zwakhalen, S., Koopmans, R., Geels, P., Berger, M. & Hamers, J. (2008) The prevalence of pain in
nursing home residents with dementia measured using an observational pain scale. European Journal
of Pain, xx, xxxx. (in press).
Fuchs-Lacelle, S., Hadjistavropolous, T. & Lix, L. (in press). Pain assessment as intervention: A study of
older adults with severe dementia. Clinical Journal of Pain, xx ,xxx. (in press)
Key to panel rating

Reviewed: 04/04
Revised: 06/08
Contact address for PACSLAC:

The PACSLAC is copyrighted by Shannon Fuchs-Lacelle and Thomas Hadjistavropoulos and may not be
reproduced without permission. For permission to reproduce the PACSLAC please contact
Thomas Hadjistavropoulos, PhD
Thomas.Hadjistavropoulos@uregina.ca
Contact address for PACSLAC-D (Dutch Language):

Sandra Zwakhalen, PhD
Email: S.Zwakhalen@zw.unimaas.nl

K. Herr, S. Decker, K. Bjoro, The University of Iowa.
Revision 06/08 by:

K. Herr, H. Bursch, B. Black, The University of Iowa
Reviewed: 04/04
Revised: 06/08
10
Pain Assessment Checklist for Seniors with Limited Ability to Communicate

(PACSLAC)
Indicate with a checkmark, which of the items on the
PACSLAC occurred during the period of interest.
Scoring the sub-scales is derived by counting the
checkmarks in each column. To generate a total pain
sum all sub-scale totals.
Facial Expression
Present
Grimacing
Sad look
Tighter Face
Dirty Look
Change in Eyes
(Squinting, dull, bright, increased eye
movements)
Frowning
Pain Expression
Grim Face
Clenching Teeth
Wincing
Open Mouth
Creasing Forehead
Screwing Up Nose
Activity/Body Movement
Fidgeting
Pulling Away
Flinching
Restless
Pacing
Wandering
Trying to Leave
Refusing to Move
Thrashing
Decreased Activity
Refusing Medications
Moving Slow
Impulsive Behaviours
(Repeat Movements)
Uncooperative/Resistance to care
Guarding Sore Area
Touching/Holding Sore Area
Limping
Clenching Fist
Going into Fetal Position
Stiff/Rigid
Social/Personality/Mood
Present
Physical Aggression
(e.g. pushing people and/or objects,
scratching others, hitting others, striking,
kicking).
Verbal Aggression
Not Wanting to be Touched
Not Allowing People Near
Angry/Mad
Throwing Things
Increased Confusion
Anxious
Upset
Agitated
Cranky/Irritable
Frustrated
Other
(Physiological changes/Eating
Sleeping Changes/Vocal Behaviors)
Present
Pale Face
Flushed, Red Face
Teary Eyed
Sweating
Shaking/Trembling
Cold Clammy
Changes in Sleep Routine (Please circle 1
or 2)
1) Decreased Sleep
-----------------------------------2) Increased Sleep During
the Day
Changes in Appetite (Please circle 1 or 2)
1) Decreased Appetite
----------------------------------2) Increased Appetite
Screaming/Yelling
Calling Out (i.e. for help)
Crying
A Specific Sound of Vocalization
For pain ow, ouch
Moaning and groaning
Mumbling
Grunting
Total Checklist Score
Present
The PACSLAC may not be reproduced or translated without permission. For permission to reproduce
the PACSLAC contact the copyright holders (Thomas.hadjistavropoulos@uregina.ca).
THE DEVELOPERS OF THE PACSLAC SPECIFICALLY DISCLAIM ANY AND ALL LIABILITY
ARISING DIRECTLY OR INDIRECTLY FOR USE OR APPLICATION OF THE PACSLAC. USE OF
THE PACSLAC MAY NOT BE APPROPRIATE FOR SOME PATIENTS AND THE PACSLAC IS NOT
A SUBSTITUTE FOR A THOROUGH ASSESSMENT OF THE PATIENT BY A QUALIFIED HEALTH
PROFESSIONAL.
References
Fuchs-Lacelle, S. & Hadjistavropoulos, T. (2004). Development and preliminary validation of the pain
assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management
Nursing, 5(1), 37-49.
The Pain Assessment in Advanced Dementia Scale (PAINAD) Brief

The Pain Assessment in Advanced Dementia (PAINAD) Scale was developed to
provide a clinically relevant and easy to use pain assessment tool for individuals with
advanced dementia. The tool is an adaptation of the DS-DAT and the FLACC and
includes five items: Breathing, Negative vocalization, Facial expression, Body language,
and Consolability. Each item is leveled on a three point scale (0-2) for severity.
The tool covers only 3 of 6 categories of non-verbal pain behaviors in the AGS
Persistent Pain Guidelines: facial expression, verbalizations/vocalizations and body
language. Although these are the most common pain indicators, the more subtle pain
indicators such as changes in activity patterns or routines, mental status changes and
changes in interpersonal interactions are not included. The tool is based on the
assumption that caregivers can reliably rate the intensity of elders pain, an assumption
for which there is conflicting evidence in current literature. Subsequent studies have
demonstrated that the tool can detect presence of pain and appears to identify higher and
lower levels of pain in an individual. It may not detect pain in patients that demonstrate
pain with behaviors other than those included in the tool.
Method of administration is described and a guide with definitions of items is
provided. Scoring procedures are clearly described, although no guide to interpretation of
the tool score is provided. Subjects in the pilot study were observed for 5 minutes, but a
clear recommendation for length of observation is not provided. The tool appears simple
to understand and appears to be easy to use with limited training. Subsequent studies have
demonstrated strong clinical utility with administration possible within 1-3 minutes,
limited training required (minimum of 15 minutes to 2 hours), and reported ease of use
by raters.
Initial testing of the PAINAD was conducted in two studies both conducted in
long term care VA Dementia special care units. Study 1 sample involved 19 severely
demented veterans, all male Caucasians, with an average age of 78.1 years (5), range
66-85 years. Study 2 was a QI study which involved charts of 25 patients. However, no
demographic data or disease characteristics were available. Thus, limited sample size and
demographic details of subjects limit generalizability of study results.
The PAINAD has received considerable attention internationally and 7 additional
studies have been conducted that provide additional psychometric data on this tool. The
PAINAD was translated and tested in Singapore, Belgium, Italy, Netherlands, and
Germany, as well as two studies in the US. The majority of additional study has been
conducted in NHs, however testing has also occurred in an acute care hospital and
geriatric rehabilitation center. These studies have added data with female subjects, a
gap in the development studies. There is still limited data on individuals from different
races, although cultural variation has been tested across countries. All studies have
included individuals with dementia. Age of subjects across studies is appropriate with
mean age of samples ranging from 78 to 88 years.
Reliability.
Internal consistency was evaluated based on a pooled sample of study 1 and study 2.
Cronbachs alpha from three situations ranged from .50 to .65, which is moderate
Completed 04/04
Revised 06/08
given a new tool with only 5 items. Moreover, the approach of combining research
and QI data to establish reliability is not methodologically sound. Follow-up studies
have demonstrated good internal consistency with correlations ranging from 0.69 to
0.85. However, the item of breathing is low.
Interrater reliability is reported for 19 subjects with pairs of simultaneous
observations by two independent raters. Pearsons correlation coefficient: during
pleasant activity: r=.97 and during unpleasant activity: r=.82. Interrater reliability
reports across 5 studies indicate strong reliability. Pearsons r ranges from 0.75 to
0.97 with most reports over 0.80.
Test-retest reliability in three follow-up studies is strong with rs ranging from 0.88
to 0.90.
Validity
Factor structure analysis for combined PAINAD data: 1 factor=50.1% variance
(eigenvalue 2.51), 1 minor factor explained 20.6% (eigenvalue 1.03). Further study of
the PAINAD provides support for construct validity. A single factor was again
isolated with greater distribution of pain. However, the number of patients with
behaviors reflecting the high end of the scale scoring is still small.
PAINAD was compared to the Pain VAS, DS-DAT, Discomfort VAS. Correlation
coefficients at rest were r=.75, r=.76, r=.76, respectively. PAINAD was compared to
the Pain-VAS during presumed pleasant conditions: r=.87-.95 and during presumed
unpleasant conditions: r=.82-.91. Further study of the PAINAD provides support for
good concurrent validity with across tool correlations ranging from 0.65 to 095 with
the exception of comparison of the PAINAD to self report of pain (0.30).
Discriminant validity of the PAINAD was established in study 1 with subjects
(n=19) observed during a pleasant activity, during rest or time of no activity, during
caregiving that might be unpleasant with mean scores: 1.01.3, 1.31.3 and 3.11.7
respectively.
Using QI data it was demonstrated that the PAINAD was able to capture pain and
change in pain. Average PAINAD scores prior to prn medication (6.71.8) and 30
minutes after pain medication (1.82.2) were significant (t24=9.6, p<.001).
Further study of the PAINAD provides some support for construct, predictive,
concurrent and discriminant validity. The most recent study that examines tool
sensitivity in detecting change from treatment raises questions regarding the tools
ability to do so with persons with severe dementia. Further study is needed.
Although studies have raised concern regarding the items of breathing and
consolability, authors urge maintaining the current items structure to allow
international comparisons. Because removal of items did not demonstrate improved
internal consistency, this recommendation seems supportable.
Summary
The PAINAD was developed as a shorter, easier observation tool for assessing
pain in nonverbal elders. The tool items included are not comprehensive, but subsequent
studies have provided data suggesting the tool does detect pain and changing levels of
behavior (not pain) intensity. Because of the small number of items that are used to
detect pain, the ability of the PAINAD to detect pain in those with less obvious changes
Completed 04/04
Revised 06/08
in behavior (e.g. mental status changes, aggressive behavior, changes in activities) may
still be compromised.
Although clinicians desire to have a tool that provides a 1-10 score similar to the
1-10 NRS commonly used as the gold standard in verbal patients, the soundness of
establishing a rating scale with pain severity scoring of behaviors has not been
substantiated in the literature. Completed studies suggest the tool could be used to show
higher and lower levels of pain, but there is no data to attach level of pain severity to the
number obtained with the tool.
Tool reliability is good for interrater reliability, but internal consistency is only
moderate and stability has not been demonstrated. Tool has good reliability in all areas.
Some conceptual and methodological issues have been identified with the
development and testing of the PAINAD. However, the positive findings in detection of
changes in pain behavior following intervention in the QI study reported suggests
additional study in controlled circumstances is warranted. Follow-up studies have
continued to document ability to detect pain and differentiate pain and no pain groups.
However, further study of tool sensitivity to detect change in behavior in response to
treatment is needed.
Source of evidence
Warden, V., Hurley, A.C., Volicer, L. (2003). Development and psychometric evaluation
of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of the
American Medical Directors, Jan/Feb, 9-15.
Lane, P., Kuntupis, M., MacDonald, S., McCarthy, P., Panke, J., Warden, V., Volicer, L.
(2003). A pain assessment tool for people with advanced Alzheimers and other
progressive dementias. Home Healthcare Nurse, 21(1), 32-37.
Costardi, D., Rozzini, L., Costanzi, C., Ghianda, D., Franzoni, S., Padovani, A. &
Trabucchi, M. (2006). The Italian version of the pain assessment in advanced
dementia (PAINAD) scale. Archives of Gerontology and Geriatrics, 44(2), 175-180.
DeWaters, T., Faut-Callahan, M., McCann, J. J., Paice, J. A., Fogg, L., Hollinger-Smith,
L., et al. (2008). Comparison of self-reported pain and the PAINAD scale in
hospitalized cognitively impaired and intact older adults after hip fracture surgery.
Orthopaedic Nursing / National Association of Orthopaedic Nurses, 27(1), 21-28.
Hutchison, R., Tucker, W., Kim, S. & Gilder, R. (2006). Evaluation of a behavioral
assessment tool for the individual unable to self-report pain. American Journal of
Hospice and Palliative Medicine, 23(4), 328-331.
Leong, I., Chong, M. & Gibson, S. (2006). The use of a self-reported pain measure, a
nurse-reported pain measure and the PAINAD in nursing home residents with
moderate and severe dementia: a validation study. Age and Ageing, 35, 252-256.
Completed 04/04
Revised 06/08
Schuler, M., Becker, S., Kaspar, R., Nikolaus, T., Kruse, A. & Basler, H. (2007).
Psychometric properties of the German Pain Assesssment in Advanced Dementia
(PAINAD-G) in Nursing Home residents. American Medical Directors Association,
July, 388-395.
Van Iersel, T., Timmerman, D. & Mullie, A. (2006). Introduction of a pain scale for
palliative care patients with cognitive impairment. International Study of Palliative
Nursing, 12(2), 54-59.
Zwakhalen, S., Hamers, I. & Berger, M. (2006). The psychometric quality and clinical
usefulness of three pain assessment tools for elderly people with dementia. Pain,
126, 210-220.
Cohen-Mansfield, J. & Lipson, S. (2008). The utility of pain assessment for analgesic
use in persons with dementia. Pain, 134(1-2), 16-23.
Victoria Warden, RN
GRECC (182B)
E. N. Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730.
E-mail: Victoria.Warden@med.va.gov.
Revised by:
Completed 04/04
Revised 06/08
Tool:
Tool developer:
Country of origin:
Reviewed:
Revised:
The Assessment in Advanced Dementia (PAINAD)

Warden V., Hurley, A.C., Volicer, L.
USA
04/04
06/08
Conceptualization
Panel rating: 1
Revised: 2
Purpose
Conceptual basis
Item Generation
Content Validity
-Panel Commentary
The Pain Assessment in Advanced Dementia (PAINAD) Scale was developed

to provide a clinically relevant and easy to use observational pain assessment
tool for individuals with advanced dementia.
The aim of the tool developers was to develop a tool for measuring pain in
non-communicative individuals that would be simple to administer and had a
score from 0 to 10.
Pain is the concept being measured.
The tool attempts to measure pain severity.
Tool items
Breathing
Negative vocalization
Facial expression
Body language
Consolability
Each item is leveled on a three point scale for severity using behavioral
descriptors.
Item generation
PAINAD is based on selected items from the DS-DAT and the FLACC. The
FLACC was developed for measuring postoperative pain in young children.
The article provides a review of literature and existing pain tools. However,
little information on item generation is available.
The content validity of the PAINAD was not established by independent
content experts. However, subsequent evaluation studies have demonstrated
that the tool measures pain behavior.
The measurement of pain severity has not been substantiated in the research
on pain in elders with dementia. Although establishing a 0-10 point scale to
represent pain severity may be clinically desirable, the validity of determining
level of pain severity in a population of non-verbal elders with diverse
presentations of possible pain related behaviors has not been established.
The tool covers 3 of 6 categories of non-verbal pain behaviors in the AGS
Persistent Pain Guidelines: Facial expression, verbalizations/vocalizations
and body language. Three items not addressed are: Changes in activity
patterns or routines, Mental status changes, Changes in interpersonal
interactions.
The FLACC indicators have not been demonstrated appropriate for elders
with dementia and the tool item generation is narrow in focus. With only 5
items used to assess pain, the most salient indicators should be included to
ensure greatest likelihood of detecting pain. Of the five pain-related behavior
categories in the PAINAD, two are not most salient (breathing and
consolability), potentially minimizing the likelihood of detecting pain.
However, subsequent studies have demonstrated that the tool can detect
Reviewed 04/04
Revised 06/08
presence of pain.
Scoring of the breathing indicator seems unrelated to pain severity.
Breathing does not seem to be a key indicator of pain. However, the tool
developers argue that one of the known areas believed to cause negative
feelings for persons with dementia is the aversive symptoms associated with
intercurrent respiratory infections and that pneumonia is a the proximal cause
of death for many demented persons. Thus, they included the breathing item.
We perceive consolablity as a response to an intervention, not a behavioral
manifestation of pain. However, the relationship between consolability and
pain may be an area for future research in this population.
The validity for the scoring of items according to pain severity or separation
of behaviors within each major category is not established, (eg. Breathing is
scored: Normal=0, Occasional labored breathing/Short period of
hyperventilation =1, Noisy labored breathing/Long period of
hyperventilation/Cheyne-Stokes respirations=2). However the tool appears to
identify higher and lower levels of pain in an individual.
Although the PAINAD does not adequately sample the content area of
behavioral indicators for pain in elders with dementia who are unable to
communicate, studies have demonstrated that the tool measures pain. It may
not detect pain in patients that demonstrate pain with behaviors other than
those included in the tool.
Subjects
Panel rating: 1
Revised: 3
Subjects
Study 1 (Warden et al., 2003)

Long term care VA Dementia Special Care Unit (96 patient unit).
Subjects: 19 veterans, all Caucasian
Average age: 78.1 years (5), Range 66-85 years
Gender: Female: 0, Male: 100%
The subjects had dementia for 8.7 years on average (4.7), Range 1-20.
Length of time in residence: 16.5 months average (13.5), Range 1-50
months.
MMSE: 2.8 4.5, Range 0-16.
Bedford Alzheimer Nursing Severity Subscale: average 16.4 4.4, Range 923.
Study 2 Lane et al., 2003)
QI study charts of 25 patients were used.
No demographic data or disease characteristics are available for these
subjects.
Study 3 (Costardi et al., 2006)
Geriatric Evaluation and Rehabilitation Unit, Northern Italy (n=1)
Subjects: 20 with chronic pain and dementia
Average age: 82 (SD=5.9) years; Range: 73-93 years
Gender: Female 80% Male: 20%
MMSE: 16.4 + 3.8, range 10-22
Study 4 (Hutchison et al., 2006)
Acute care hospital, US (n=1)
Subjects: 53 control and 27 PAINAD with acute postop pain
Reviewed 04/04
Revised 06/08
Average Age: 85.2 control and 88 PAINAD

Gender: 85% female in control and 78% female in PAINAD
MMSE: control: 0% with less than 25 in control and 100% diagnosed
dementia
PAINAD group: 23.6% with MMSE less than 25 and 76.4% diagnosed
dementia
Study 5 (Leong et al., 2006)
Nursing Home in Singapore (n=1)
Subjects: 88 with moderate and severe dementia
Average Age: 79.6 (SD=8.3)
MMSE: Not reported
Palliative care patients in NH setting (n=17)
Patients who could not express pain
Subjects: 157 patients
Average Age: 85 years; range 22-100
MMSE: Not reported
Study 7 (Zwakhalen et al., 2006)
Nursing Homes in Netherlands (n=3)
Subjects: 128 patients with dementia; both acute and chronic pain
Average Age: 82.4 (SD=6.8) years; range 60-96
MMSE: Not reported; Cognitive Performance Scale: 21.9% mild, 28.1%
moderate, 47.7% severe
Study 8 (Schuler et al., 2007)
Nursing Homes in Germany (n=8)
Subjects: 99 residents with dementia
Average Age: 84.9 (SD=7.5)
MMSE: Mean 12.1 (SD=9.7)
Study 9 (Cohen-Mansfield & Lipson, 2008)
Nursing homes in US (n=4)
Subjects: 121 with dementia
Average Age: 88 (range 59-101)
Gender: 81.8% female
MMSE: Mean 6.3 (range 0-20)
-Panel Commentary
Reviewed 04/04
Revised 06/08
Study 10 (DeWaters et al., 2008)

Orthopedic unit in US hospital (n=1)
Subjects: 25 verbal older persons, includes 13 cognitively intact and 12
cognitively impaired persons
Average age: 81.24 (range 65-95)
Gender: 84% female
MMSE: 20.52 (range 9-30) plus diagnosis of dementia or confusion
The PAINAD has received considerable attention internationally and 7
additional studies have been conducted that provide additional psychometric
data on this tool. The PAINAD was translated and tested in Singapore,
Belgium, Italy, Netherlands, and Germany, as well as two studies in the US.
The majority of additional study has been conducted in NHs, however testing
has also occurred in acute care hospitals and geriatric rehabilitation center.
These studies have added data with female subjects, a gap in the development
studies. There is still limited data on individuals from different races,
although cultural variation has been tested across countries. All studies have
included individuals with dementia. Age of subjects across studies is
appropriate with mean age of samples ranging from 78 to 88 years.

Panel rating: 2
Revised: 3
Administration, Scoring,
Feasibility
In the pilot test, subjects were observed for 5 minutes prior to scoring.
Definitions for each item are provided.
The scoring system is based on a 3 point scale: 0, 1, 2.
Total scores range from 0 to 10 points, a maximum of 2 points per category.
The tool developers report that because they wanted the 10 point scale, they
determined that there would be a 3 point rating option for each item, and that
in general, 0=none, 1=small or some or occasionally, and 2=large or a more
intense negative behavior making that item operational. Specific definitions
for each behavior are provided.
No interpretation of the score is provided.
A two hour training program was developed including video training tapes.
Comment easily administered with appropriate training
Raters received 15 minute in-service instruction. Clinicians reported easy to
administer, requiring less than 1 minute of time.
No comments provided.
Care providers (n=17): 80% agreed or had no opinion (20% disagreed) that
the PAINAD was a good measure to judge pain and 76% agreed or had no
opinion that PAINAD was easy to use (28% disagreed). Breathing and
consolability indicators were less good indicators (<60%)
On scale of 0-10 for clinical usefulness, nurses (12 nurses in 3 NHs) rated the
PAINAD 5.89 (SD 1.7). 75% preferred the PACSLAC. The PAINAD was
considered user-friendly and not time-consuming by participating nurses
requiring a few minutes to assess.
Used a 2 minute period to observe routine nursing activities and complete
rating. No comments regarding nurse perceptions/rating of usability.
Used a 5 minute observation period. No comments regarding nurse
perceptions/ratings of usability.
-Panel Commentary
Reviewed 04/04
Revised 06/08

No comments re. clinical feasibility
Method of administration is described and a guide with definitions of items is
provided.
Scoring procedures are clearly described.

No guide to interpretation of tool score is provided. The tool developers argue
that clinicians are familiar with a 0-10 scale and that it is assumed that 0
means no observed pain and 10 means a high level of observed pain that
should be treated.
However, this assumes that judging severity of pain represented by behavioral
presentation in non-verbal elders is validwhich has not been substantiated
in the literature.
Subsequent studies have demonstrated strong clinical utility with
administration possible within 1-3 minutes, limited training required
(minimum of 15 minutes to 2 hours), and reported ease of use by raters.
Reliability
Panel rating: 1
Revised: 3
Study 1 & 2 (Warden et al, 2003; Lane et al., 2003)

Internal consistency was evaluated based on data from a sample of 19
veterans and QI data from 25 residents. (For sample characteristics see
subjects above).
Raters were 4 professional nurses with experience on dementia special care
units and a masters level social work intern. Three observations of subjects
for 5 minutes were made under different conditions as indicated below. To
achieve 10 participants per item, the research and QI data were pooled and
examined for internal consistency.
Observation 1: During rest or no activity: Cronbachs alpha=.50
Observation 2: Pleasant activity: movement could lead to pain:
Cronbachs alpha=.59, .63
Observation 3: Potentially unpleasant caregiving activity (eg. Transfers,
bathing, toileting) Cronbachs alpha=.50, .67.
Additional data on internal consistency has been reported by 3 studies.
Internal consistency=0.74
Cronbachs alpha 0.69-0.74; Breathing scored consistently low -.51 to .12
Cronbachs alpha= 0.85

Cronbachs alpha for combined group 0.852
Cronbachs alpha for cognitively intact group =0.846
Cronbachs alpha for cognitively impaired group =0.847
Study 1 (Warden et al., 2003)
Interrater reliability is reported for 19 subjects by pairs of simultaneous
observations by two independent raters.
Pearsons correlation coefficient:
During pleasant activity
r=.97
During unpleasant activity r=.82.
Additional data on inter-rater reliability has been reported by 4 studies
Two raters same day=0.87 (p=.001)
Reviewed 04/04
Revised 06/08

Inter-rater reliabilities reported: 0.75 (rest), 0.85 (after flu vaccine) and 0.81
(patient-specific moment of potential pain). Agreement less strong at rest than
during potential painful activity.
Two nurses morning and evening assessments: reliability= 0.80 (p=.001)
Inter-rater agreement across three RAs: ICC=0.92

Interrater reliability between 2 masters prepared nurse RAs for ten video
vignette ratings: ICC= 0.98
No test-retest reliability is reported.
Data on test-retest and/or intra-rater reliability reported in 3 studies.
One expert rater at baseline and after 15 days=0.88 (p=.045)
Intra-rater reliability=0.89; comparing rating in person with rating on video
-Panel commentary

One nurses morning and evening assessments; r=0.90 (p<.001)
Follow-up studies have demonstrated good internal consistency with
correlations ranging from 0.69 to 0.85. However, the item of breathing is low.
Interrater reliability reports across 5 studies indicate strong reliability.
Pearsons r ranges from 0.75 to 0.97 with most reports over 0.80 and strong
ICCs.
Three studies report strong test-retest reliability with rs ranging from 0.88 to
0.90.

Panel rating: 2
Revised: 2
Construct validity/
Construct validity
Factor structure analysis for combined PAINAD data for study 1 and study 2
1 factor = 50.1% variance (eigenvalue 2.51), 1 minor factor (breathing alone)
explained another 20.6% (eigenvalue 1.03).
QI data: one factor solution: 61% variance (eigenvalue 3.05).
Concurrent validity
The PAINAD was compared to the DS-DAT with VAS components included.
Concurrent validity was reported based on associations from observations of
pain and discomfort at rest.
PAINAD & Pain VAS: r=.75, p<.001
PAINAD & DS-DAT: r=.76, p<.001
PAINAD & DS-VAS: r=.76, p<.001
Reviewed 04/04
Revised 06/08
Concurrent validity was reported based on associations from observations of

pain during 1) presumed pleasant conditions for 18 veterans and 2) presumed
unpleasant conditions for 19 veterans (p=.001 for all correlations).
1) Presumed pleasant conditions (n=18)
PAINAD (1) & Pain-VAS (1) r=.92
Pain-VAS (1) & PAINAD (2) r=.93
2) Presumed unpleasant conditions (n=19)
PAINAD (1) & Pain VAS (1) r=.82
PAINAD (1) & Pain VAS (2) r=.90
Pain-VAS (1) & PAINAD (2) r=.90
Study 1
(For sample characteristics see subjects above.)
Subjects (n=19) were observed 3 times to establish expected pain with
significant outcomes (F1,17 = 10.93, P<0.001)
Mean score
1. During rest or time of no activity:
1.31.3
2. During a pleasant activity:
1.01.3
3. During caregiving that might be unpleasant:
3.11.7
Study 2
(For sample characteristics see subjects above.)
Change in PAINAD before and after administration of prn medications was
reported based on quality improvement data from chart audit of 25 DAT
residents. The PAINAD was administered prior to prn medication and 30
minutes after pain medication with significant results (T(24)=9.6, p<.001):
Prior to prn medication
30 minutes after medication
6.7 1.8
1.8 2.2
Concurrent: PAINAD compared with VDS (0.65, p=0.008)
Predictive: Compared PME in PAINAD assessed group and control group.
Significantly higher PME in PAINAD group (11.25mg) compared to control
group ( 5.75mg) (p<.01). Total of unknown pain intensity lower in PAINAD
group (15%) versus control group (68%) (p<0.01)
Concurrent: PAINAD compared with Nurses Report r=0.842 (p<.001)
PAINAD compared with Patient Self-Report r=0.304 (p<.005)
Discriminant: PAINAD and Cornell Depression r=0.292 (P<.005)
PAINAD and Abbreviated Mental Test r=-0.198
Few residents had severe pain; strongest relationship with nurse reported
pain. Weak relationship between patients report and PAINAD. Demonstrated
ordinal nature of PAINAD categorizing 0-1 as no pain; 2-3 as mild pain; 4 >
as moderate and severe pain. The categorization correlated strongly with
Nurses Rating of Pain (kappa 0.85, p=.001). However, because nurses made
both judgments, potential for bias exists. Good discriminant validity.
Reviewed 04/04
Revised 06/08

Construct: 185 care providers report on perceptions of measure of pain.
80% agreed that three indicators were most valuable in measuring pain:
facial expression, vocalization and body language. Breathing and
consolability less good indicators (<60% agreement).
Predictivet: Pain versus non-pain groups. Evaluated at rest (T1)1, after flu
vaccination (T2) and after potentially painful activity (T3). Consistent
upward trend of mean total score on PAINAD during three times as expected.
Concurrent: PAINAD compared with VAS rater=0.89
PAINAD compared with VAS nurse=0.81
PAINAD compared with VRS (patient)=0.81
PAINAD compared with PACSLAC=0.85
Construct: Demonstrated one factor structure accounting for 63.5%
variance in morning assessment and 62.4% in evening assessment
Predictive: Compared ratings for patients judged to have pain compared to
those judged to be free of pain. All categories of scale (except consolability)
rated higher in residents with pain than without. Pain intensity rated by
nurses did not correlate with the occurrence of pain behaviors. PAINAD-G
did not allow prediction of pain intensity.
Discriminant: No significant correlations between PAINAD-G and
observational measures aimed at nonpain behaviors (apathy,
neuropsychiatric)
Sensitivity: Compared ability of PAINAD (and other tools) to detect pain and
change in pain resulting from treatment intervention. In treatment group of
63, 36 completed treatment to achieve no pain, 27 refused treatment by family
or physician. A comparison group of 58 without pain used
Determination of pain compared across tools noting that this was made by
PAINAD in only 5%. Higher rates found in informant based tools (e.g.
PADE, PAINE). PAINAD was not strong in detecting treatment effects.
-Panel commentary
Reviewed 04/04
Revised 06/08

Concurrent validity/Pearsons r of PAINAD with NRS
For all observations (50): 0.834 (p= .01)
Unlikely pain (at rest) (25): 0.639 (p= .01)
Likely pain (with movement) (25): 0.764 (p=.01)
Cognitively intact (26): 0.735 (p<.001)
Cognitively impaired (24): 0.915 (p<.001)
Discriminant validity/Wilcoxon signed rank test between likely and unlikely
pain events
For all observations: z=4.086
Construct validity
Data from studies 1 and 2 were combined to conduct the factor analysis.
Although a single factor was isolated contributing a moderate amount of
variance, the pain scores were not normally distributed with many scores
clustering around 0, especially during a pleasant condition or 30 minutes after
pain medication.
This limits evaluation of scale effectiveness in those with higher levels of
pain-related behaviors.
Further study of the PAINAD provides support for construct validity. A single
factor was again isolated with greater distribution of pain. However, the
number of patients with behaviors reflecting the high end of the scale scoring
is still small.
Concurrent validity
Correlations among the pain tools are strong. However, lack of independent
raters for scoring of the pain tools and the associated VASs potentially
impacts the level of associations.
Further study of the PAINAD provides support for good concurrent validity
with across tool correlations ranging from 0.65 to 095 with the exception of
comparison of the PAINAD to self report of pain (0.30).
Study 1 results show differences in expected outcome, although scores are
compressed at the lower end of the scale and further study is needed.
The results of study 2 (QI study) appear to capture pain and change in pain.
However, limited information on subjects, variability of raters/assessors,
control over chart audit data limits conclusions that can be reached for initial
tool development and suggest the need for more controlled study.
Further study of the PAINAD provides some support for construct, predictive,
concurrent and discriminant validity. The most recent study that examines
tool sensitivity in detecting change from treatment raises questions regarding
the tools ability to do so with persons with severe dementia. Further study is
needed.
Although studies have raised concern regarding the items of breathing and
consolability, authors urge maintaining the current items structure to allow
international comparisons. Because removal of items did not demonstrate
improved internal consistency, this recommendation seems supportable.

The PAINAD was developed as a shorter, easier observation tool for assessing pain in nonverbal elders. The
tool items included are not comprehensive, but subsequent studies have provided data suggesting the tool
does detect pain and changing levels of behavior (not pain) intensity. Because of the small number of items
that are used to detect pain, the ability of the PAINAD to detect pain in those with less obvious changes in
behavior (e.g. mental status changes, aggressive behavior, changes in activities) may still be compromised.
Although clinicians desire to have a tool that provides a 1-10 score similar to the 1-10 NRS commonly used
as the gold standard in verbal patients, the soundness of establishing a rating scale with pain severity scoring
of behaviors has not been substantiated in the literature. Completed studies suggest the tool could be used to
show higher and lower levels of pain, but there is no data to attach level of pain severity to the number
obtained with the tool.
Tool reliability is good for interrater reliability, but internal consistency is only moderate and stability has
not been demonstrated. Tool has good reliability in all areas.
Some conceptual and methodological issues have been identified with the development and testing of the
PAINAD. However, the positive findings in detection of changes in pain behavior following intervention in
the QI study reported suggests additional study in controlled circumstances is warranted. Follow-up studies
have continued to document ability to detect pain and differentiate pain and no pain groups. Follow-up
studies must be differentiated according to degree of dementia in the sample population, whether they study
acute or chronic pain and the setting of care. Further study of tool sensitivity to detect change in behavior in
response to treatment is needed.
Reviewed 04/04
Revised 06/08
Source of evidence
Warden, V., Hurley, A.C., Volicer, L. (2003). Development and psychometric evaluation of the Pain
Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors,
Jan/Feb, 9-15.
Lane, P., Kuntupis, M., MacDonald, S., McCarthy, P., Panke, J., Warden, V., Volicer, L. (2003). A pain
assessment tool for people with advanced Alzheimers and other progressive dementias. Home
Healthcare Nurse, 21(1), 32-37.
DeWaters, T., Faut-Callahan, M., McCann, J. J., Paice, J. A., Fogg, L., Hollinger-Smith, L., et al. (2008).
Comparison of self-reported pain and the PAINAD scale in hospitalized cognitively impaired and
intact older adults after hip fracture surgery. Orthopaedic Nursing / National Association of
Orthopaedic Nurses, 27(1), 21-28.
Costardi, D., Rozzini, L., Costanzi, C., Ghianda, D., Franzoni, S., Padovani, A. & Trabucchi, M. (2006).
The Italian version of the pain assessment in advanced dementia (PAINAD) scale. Archives of
Gerontology and Geriatrics, 44(2), 175-180.
Hutchison, R., Tucker, W., Kim, S. & Gilder, R. (2006). Evaluation of a behavioral assessment tool for the
individual unable to self-report pain. American Journal of Hospice and Palliative Medicine, 23(4),
328-331.
Leong, I., Chong, M. & Gibson, S. (2006). The use of a self-reported pain measure, a nurse-reported pain
measure and the PAINAD in nursing home residents with moderate and severe dementia: a validation
study. Age and Ageing, 35, 252-256.
Schuler, M., Becker, S., Kaspar, R., Nikolaus, T., Kruse, A. & Basler, H. (2007). Psychometric properties
of the German Pain Assesssment in Advanced Dementia (PAINAD-G) in Nursing Home residents.
American Medical Directors Association, July, 388-395.
Van Iersel, T., Timmerman, D. & Mullie, A. (2006). Introduction of a pain scale for palliative care patients
with cognitive impairment. International Study of Palliative Nursing, 12(2), 54-59.
Zwakhalen, S., Hamers, I. & Berger, M. (2006). The psychometric quality and clinical usefulness of three
pain assessment tools for elderly people with dementia. Pain, 126, 210-220.
Cohen-Mansfield, J. & Lipson, S. (2008). The utility of pain assessment for analgesic use in persons with
dementia. Pain, 134(1-2), 16-23.
Key to panel rating

Contact address for tool developer:

Victoria Warden, RN
GRECC (182B)
E. N. Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730.
E-mail: Victoria.Warden@med.va.gov.

Reviewed 04/04
Revised 06/08
10
Revision completed 06/08 by:

K. Herr, H. Bursch, B. Black, The University of Iowa
Reviewed 04/04
Revised 06/08
11

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State of the Art Review of Tools for Assessment of Pain

in Nonverbal Older Adults.

Key to categories for evaluation

The Abbey Pain Scale (The Abbey) Brief

The Abbey Pain Scale

relationship to the other or the overlap (e.g. physiologic changes vs.

Study 1 (Abbey et al., 2004)

total of 770 pain episodes (non-independent scores).

Study 2 (van Iersel, et al., 2006)

Administration, Scoring, Feasibility

Study 2 (van Iersel et al., 2006)

Study 1 (Abbey et al., 2004)

Study 2 (van Iersel et al., 2006)

Assessed by intra-class correlation coefficient:

Study 2 (van Iersel et al., 2006)

Validity: Criterion or construct

Study 1 (Abbey et al., 2004)

On average, 56% of care providers considered the observed categories of the

Summary of panel evaluation of pain assessment tool

Key to panel rating

Contact address for tool developer:

Evaluation completed by:

Revision 6/08 by:

version or the Doloplus-2 (Cronbach alpha=0.71) than the complete version

The Doloplus-2 is an observational pain assessment tool developed for the

The tool attempts to measure pain severity.

Study 1(Lefebvre-Chapiro, 2001)

study included 43 residents with an average age of 73.5 ( 7.21) with 28

Study 5 (Pautex 2007)

complete more work with the Doloplus-2 in North American populations.

Administration, Scoring, Feasibility

Study 1(Lefebvre-Chapiro, 2001):

Study 5 (Pautex 2007)

Study 1(Lefebvre-Chapiro, 2001):

Study 4 ( Zwakhalen 2006)

Study 5 (Pautex 2007)

Study 5 (Pautex 2007)

Validity: Criterion or construct

Study 3 (Pautex et al 2006)

Study 4 (Zwakhalen 2006)

Study 5( Pautex 2007)

A regression analysis was performed to explore how well the Doloplus-2

regarding ability/accuracy of health care provider judgments of severity in

Summary of panel evaluation of pain assessment tool

Key to panel rating

Contact Information for tool developer:

Evaluation 04/04 by:

Revision 06/08 by:

Contact information: keela-herr@uiowa.edu

BEHAVIOURAL PAIN ASSESSMENT IN THE ELDERLY

no protective body posture . . . . . . . . . . . . . . . . . . .

no protective action taken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

usual abilities unaffected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

usual abilities & activities remain unaffected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

participates normally in every activity (meals, entertainment, therapy workshop)

DOLOPLUS-2 SCALE : LEXICON

Protective body postures adopted at rest

Protection of sore areas

DOLOPLUS-2 SCALE : INSTRUCTIONS FOR USE

2 Pluridisciplinary team scoring

3 Do not score if the item is inappropriate

4 Compile score kinetics

5 Do not compare scores on different patients

6 If in doubt, do not hesitate to conduct a test treatment with an appropriate analgesic