Challenging: Pain Assessment in Patients with Dementia

Pain can stimulate dementia-like symptoms, and may therefore not be recognized as such, and consequently be misinterpreted as dementia.1

These misconceptions and barriers mean that pain is often under-reported, underdiagnosed and undertreated in the elderly population.2-4

Patients with dementia are at a particularly high risk for under-treatment of pain, and the severity of dementia is directly correlated to an increased risk of under-treatment of pain.2

Elderly patients are under-represented in multidisciplinary pain clinics – an indication that this patient population is being undertreated, compared with their non-elderly counterparts. Studies have shown that there is under-treatment of pain in elderly patients with hip fracture and dementia, in contrast to those without dementia.3, 4

The diagnosis of chronic pain in cognitively impaired patients imposes major challenges. Self-report, however, should be attempted and can be attained in the majority of patients with mild-to-moderate dementia or cognitive impairment. Complaints of pain expressed in a clear way tend to decrease over the course of dementia, while non-verbal expressions and behaviour changes become more frequent. As dementia progresses, behaviour observations and caregiver interviews become increasingly important for pain assessment.

Common pain behaviours in cognitively impaired elderly persons include certain facial expressions, verbalizations, body movements, changes in personal interactions, changes in activity patterns or routines and mental status changes. Avoidance behaviour – i.e. what the patient is not doing – is also an important behaviour to note.

It is vital that nurses, caregivers and family members monitor behaviour in order to detect changes in pain. Such monitoring is difficult for physicians to do, as they are only in contact with the patient for a short time.



1Tosato M, et al. Pain. 2012;153:305-10.
2 Herr K. Pain assessment strategies in older patients. J Pain. 2011; 12:3-13.
3 Morrison RS, Siu AL. Pain Symptom Manage. 2000;19:240-8.
4 Titler M, et al. Appl Nurs Res. 2003;16:211-27.