# 126 Pain Assessment in the Cognitively Impaired


Author(s): L Scott Wilner MD and Robert Arnold MD

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 (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 comparing these different instruments. Thus, clinicians should choose one tool and use it consistently to ensure uniformity among health care providers and across shifts.


  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.

Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: drosiell@mcw.edu. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.

Version History: This Fast Fact was originally edited by David E Weissman MD and published in November 2004. Current version re-copy-edited in April 2009.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Wilner LS, Arnold R. Pain Assessment in the Cognitively Impaired Fast Facts and Concepts. November 2004; 126. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_126.htm.

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

ACGME Competencies: Patient Care, Medical Knowledge

Keyword(s): Pain – Evaluation