Background     The inability of cognitively impaired patients to communicate information about pain places them at high risk for inadequate pain control.  Two common risk groups in palliative care include:

• Patients with underlying brain pathology such as dementia, Parkinson’s disease, stroke, or developmental abnormalities (see Fast Fact #192).
• Patients receiving sedating medications such as ICU patients receiving sedative/hypnotics to control anxiety/agitation from mechanical ventilation.

General Strategies     Recommended strategies to assess pain in these patients include the following:

• Ask the patient:  many patients who appear cognitively impaired may still be able to provide useful information concerning pain.
• Interview the caregivers and family:  patterns of particular behaviors may have developed that indicate pain (e.g. placing a hand on the forehead for headache).
• Review the medical record for known pain-inducing pathology:  for instance a diabetic patient with painful neuropathy that was manifest when the patient was cognitively intact. 
• Complete a physical examination and directed laboratory studies to assess for common pain-inducing problems (e.g. fracture, urinary tract infection).

Pain Scales     In addition to these measures, clinicians should use a validated pain rating system for the cognitively impaired.  Such rating systems focus on the following observational items:

• Facial expression
• Body posture
• Vocalizations
• Appetite
• Interactivity 

Representative examples of pain rating scales for the cognitively impaired, along with background information concerning validation studies and clinical experience can be found at: http://www.healthcare.uiowa.edu/igec/tools/categoryMenu.asp?categoryID=7. 

• Doloplus-2 scale  www.doloplus.com (1997)
• Assessment of Discomfort in Dementia Protocol (1999)
• Pain Assessment in Advanced Dementia (PAINAD) (2003)
• Checklist of Nonverbal Pain Indicators (2000)
• Pain Assessment for the Demented Elderly (2003)
• Pain Assessment for Seniors with Limited Ability to Communicate (2004)
• Abbey Pain Scale (2004)

To date, there are no trials showing clear superiority of one of these scales. Thus, clinicians should choose one tool and use it consistently to ensure uniformity among health care providers and across shifts. 

References

1. Closs SJ, Barr B, Briggs M, et al. A comparison of five pain assessment scales for nursing home residents with varying degrees of Cognitive impairment. J Pain and Symptom Manage. 2004; 27(3):196-205.
2. Feldt K. The Checklist of Nonverbal Pain Indicators (CNPI). Pain Manage Nursing. 2000; 1(1):13-21.
3. Frampton M. Experience assessment and management of pain in people with dementia. Age and Ageing. 2003; 32(3):248-251.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in November 2004. Version re-copy-edited in April 2009; revised again July 2015.