NURSING
44 Pain assessment and management are necessary for the control and/or alleviation of pain (for information
PR ACTICE
& SKILL
Pain
Assessment in
Older Adults
Authors
Nathalie Smith, RN, MSN, CNP
Sara Grose, MSN, RN, PHN, CNL, CLE
Reviewers
Darlene A. Strayer, RN, MBA
Cinahl Information Systems
Glendale, California
Nursing Practice Council
Glendale Adventist Medical Center
Glendale, California
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems
August 20, 2010
Published by Cinahl Information Systems. Copyright2010, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any
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from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a
general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
What is Pain Assessment in Older Adults?
on pain management in older adults, see Nursing Practice & SkillPain Management in Older Adults)
Where: Any clinical or home care setting
What and How: Older adults should receive regular pain assessment and appropriate pain
management to improve comfort and quality of life. Patients should therefore be monitored routinely
for pain, and reassessed at frequent intervals
Who: Pain assessment can be performed by any properly trained health clinician or family member
44 Patients experiencing acute pain usually show obvious physical signs of distress. Those experiencing
chronic pain, however, often show few or no outward signs
44 Pain assessment may be complicated in older adults who have cognitive impairment because they may
not be able to communicate with caretakers
44 Pain can be experienced differently by patients of various cultural backgrounds. Research efforts are
underway to develop culturally sensitive pain assessment tools
Why Pain Assessment was Ordered in Older Adults
44 Pain assessment is necessary to determine whether a patient is experiencing pain. If so, assessment
should be repeated at regular intervals as part of an ongoing pain management plan
Why Pain Assessment is Important in Older Adults
44 Pain assessment is an essential first step in planning for and providing pain management
Pain management is critical because unrelieved pain may lead to
Sleep disturbances and fatigue
Decreased mobility, chronic pain, and depression
Stress responses due to unrelieved pain may generate increases in cardiac output, impair insulin
response, increased cortisol production, and increase fluid retention. Patient may become at
increased risk for myocardial infarction, pulmonary infection, venous thromboembolism, and
prolonged paralytic ileus
Facts and Figures
44 Persistent pain occurs in up to 50% of community-dwelling older persons and is highly prevalent among
residents of skilled nursing facilities (SNFs) (Pautex et al., 2007)
44 Older patients are most likely of all age groups to receive inadequate pain assessment. The risk for inadequate
pain assessment is especially high among older patients who have dementia (McAuliffe et al., 2009)
44 People of all ages who have chronic pain often experience concurrent depression (Poole et al., 2009)
What You Need to Know Before Assessing Pain in an Older Adult
44 Follow facility protocols for identifying the patient and obtaining completed facility informed
consent documents
44 Verify facility protocols and/or clinician orders regarding pain assessment for older patients
44 Assess the patient and family members for knowledge deficits regarding how pain is prevented, assessed,
and treated
44 Assess the patients and family members expectations about pain management (if and when it will be
experienced), and their level of anxiety and coping ability regarding pain
44 Explain about the use of pharmacologic and nonpharmacologic measures for pain control
44 Older adults may require a longer period of time for you to explain how the pain assessment tool is to be used
44 Older adults may underreport pain
44 Lighting and environmental noise may increase an older adults pain
44 Supplies necessary for pain assessment include a clinically-validated pain assessment tool appropriate to
the patients cognitive and linguistic abilities
44 Clinically validated pain assessment tools appropriate to older adults may include
The Assessment of Discomfort in Dementia Protocol (ADD), which has been tested in long-term care
 settings for chronic and acute pain
Nursing Assistant-Administered Instrument to Assess Pain in Demented Individuals (NOPPAIN), which has been tested in long-term care
settings for chronic and acute pain
Checklist of Nonverbal Pain Indicators (CNPI), which has been tested in hospital and long-term care settings for chronic and acute pain
The Pain Assessment in Advanced Dementia Scale (PAINAD), which has been tested in hospital and long-term care settings for chronic and
acute pain
The Pain Assessment Scale for Seniors with Severe Dementia (PACSLAC), which has been tested in long-term care facilities for chronic pain
The Visual Analogue Scale (VAS), a vertical or horizontal line, 10 cm in length, with end points labeled "no pain" and the "worst pain," or
similar words
The Faces Pain Scale generates a numerical pain score (05) which is later recorded. This scale is published in over 20 languages, and is helpful
if the clinician and patient speak different languages and translation is not available
44 Physical therapists should participate in standardized, ongoing, regular pain assessment of older adults with dementia in long-term care facilities

How to Assess for Pain in Older Adults

44 Identify patient per facility protocol
44 Provide privacy
44 Assess patient for ability to communicate
44 For patients who can communicate clearly
Ask patient if s/he is in pain using words like pain, hurt, and discomfort
Ask about the patients ability to sleep and perform ADLs, and how the pain is affecting work, relationships, and enjoyment of life
Ask about previously used interventions and whether they relieved pain
Ask about what triggers pain
Ask what the pain feels like
Ask the patient to show you where the pain is located
Ask if the pain increases or decreases at different times of day
Assess for moaning, crying, reduced activity, grimacing, change in usual behavior, abnormal gait, guarding, diaphoresis, nausea, vomiting,
constipation, muscle tension, sleep disturbances, headache, and increased blood glucose level
Inspect site of pain for discoloration, swelling, drainage
Using your facilitys clinically-validated pain assessment tool, ask the patient about pain intensity
44 For patients who cannot communicate clearly
Assess for potential causes of discomfort (e.g., infection, constipation, or emotional distress)
Attempt to use a clinically-validated pain assessment tool that is easy to use with nonverbal, alert and oriented patients scale such as
the VAS
Ask the patient to indicate where on the line the pain intensity is in relation to the two extremes
The pain score is the number of centimeters between the left end of the scale and the mark the patient has made
the Faces Pain Scale
Instruct the patient to point to the face on the scale that reflects the intensity of the pain the patient is feeling
If self-report is not possible, document in the patients record why this is so, per facility protocol
Assess patients pain by
Observing the patient for changes in behavior that may indicate pain such as restlessness, grimacing, moaning, crying, or rubbing a body part
Asking family members or in-home caregivers who know the patient well whether he or she seems to be in pain. They may identify subtle
changes in behavior that typically indicate pain for this patient
Taking the patients vital signs and monitoring for increased blood pressure, respiration, and heart rate
Assessing for conditions that typically cause pain, such as the following:
recent surgery
physical therapy or other rehabilitation treatment
phlebotomy, wound dressing changes, or other painful procedures
pressure sores or other skin injuries
painful medical conditions including neuropathies and musculoskeletal conditions, including arthritis and low back pain
44 Document pain assessment, per facility protocol

Other Tests, Treatments, or Procedures That May Be Necessary Before or After Pain
Assessment in Older Adults
44 The patient will be reassessed for pain at regular intervals
44 A pain management plan is implemented
44 Based on the patients and/or familys report of the success of the management interventions, pain management strategies will be adjusted as needed

What to Expect After Pain Assessment in Older Adults

44 The patients pain is adequately assessed and treated
Red Flags
44 Persistent pain has been shown to cause or increase depression, anxiety, and sleep disturbance. Older patients who have these problems should be
evaluated routinely for undiagnosed or undertreated chronic pain

What Do I Need to Tell the Patient/Patients Family?

44 Educate the patient/family about what to expect during the pain assessment and management procedures. Encourage questions
44 Explain that the goal of pain management is complete relief of the patients pain, if possible, and the importance of repeated pain assessment is the
revision of the pain management plan to achieve greater or continued pain relief
44 If the pain management is provided to the patient in a home care setting, provide the family with contact information for the treating clinician and
educate regarding the importance of contacting the treating clinician for new, worsening, or unrelieved pain

References
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Flasar, C. (2010). Pain assessment and basic comfort measures. In A. G. Perry, & P. A. Potter (Eds.), Clinical nursing skills & techniques (7th ed., pp. 374-379). St Louis: Mosby Elsevier.
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.
Hadjistavropoulos, T., Fitzgerald, T. D., & Marchildon, G. P. (2010). Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities. Physiotherapy Canada, 62(2), 104-113.
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