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Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools

Sandra MG Zwakhalen1*, Jan PH Hamers1, Huda Huijer Abu-Saad2 and Martijn PF Berger3

Author affiliations

1 Department of Health Care Studies, Section of Nursing Science, Universiteit Maastricht, P.O. Box 616, 6200 MD Maastricht, The Netherlands

2 School of nursing, Faculty of Medicine, American University of Beirut, P.O.Box 11-0236, Riad El-Solh / Beirut 1107 2020, Lebanon

3 Department of Methodology and Statistics, Universiteit Maastricht, The Netherlands

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Citation and License

BMC Geriatrics 2006, 6:3  doi:10.1186/1471-2318-6-3

Published: 27 January 2006



Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.


This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.


Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.


Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.