The PAINAD tool is very useful and well validated tool for assessing pain in patients with dementia. I am not sure if this has ever been studied in post-operative hip patients specifically, however, this population would likely have underlying dementia making it a validated tool. There are several good documents which provide a systematic review of all the various tools and this tool always ranked in the top 3. It is the easiest to use (scores 0-10) like the NRS making it my favourite for clinical utility.

I would also encourage the use of a delirium screening tool, as quite often it may be due to opioid neruotoxicity from the drug or dehydration and they may require rotation to another drug or look for other causes for the delirium.

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I also use the PAINAD to look at acute pain responses in severely demented patients. I wouldn't utilize the consolability or breathing domains within it, though. They are by far the most subjective in terms of ratings. Breathing especially hasn't really stood up to scrutiny in cross-validation studies.

My understanding is the the PACSLAC is also good, but more so for assessing chronic pain. It's also much longer than the PAINAD, though I was told by the developer that they are working on a much shorter version.

I think the key here is inability to self report so although there may or may not be dementia evident tools developed for this purpose are appropriate. I agree with PAINAD or Abbey Pain Scale.

Thanks, Paul and Sarah. That is really helpful. PAINAD looks interesting with reasonable validity. The issue of the acutely confused (30-60%) hip frature patient isn't completely clear from the papers, but I'll keep looking.

I agree with those in favour of PAINAD. And Sarah makes a VERY important point about dehydration and neurotoxicity. Some aged patients at a disadvantage from the start unfortunately then bear the brunt of poor quality care. This leads to a vicious cycle and more neglect and desperation, leading to conclusion readily of 'dementia' and no analgesia. May be a more attentive and caring attitude may be priceless in the long term.

You might find recently published guidelines on the management of pain in older people helpful http://ageing.oxfordjournals.org/content/42/suppl_1.toc

You might consider looking at the Defense and Veterans Pain Rating Scale (Pain Medicine Volume 14, Issue 1, pages 110–123, January 2013) located at http://www.dvcipm.org/clinical-resources/pain-rating-scale. The scale is open source and will be a standard in the DoD. It has not been validated in dementia although it has elements that might be useful for assessments in this population due to the visual cues embedded in the scale.

I d' not Know specific tools for the pain assessment in these patients , but I think that a simple instrument as VAS 0-10 administered ( behaviorally ) by nurses very skilled in orthopedic patients and in confused subjects are reliable. Actually these patients comprise two domains of interest for the assessment : hip fracture and confusion. A behavioral scale (a cluster of items defining related body postures, positions ... ) measuring the first may disclose analgesia efficacy but also orthopedic surgery efficay ( and possible complications). The second may be a main bias , but at last pain is a private, subjective , experience.

Valeria Bachiocco

Hi; I recommend that you look at the Verbal Ranking (rating) Scale (0-4 points). We used it in a number of studies in patients with hip fracture. 0=no pain, 1=light pain, 2=moderate pain, 3=severe pain, and 4=intolerable pain. Points are only used for classification of the pain level, as you ask patients about categories if they indicate pain. It has proven superior to other pain scales in patients with cognitive impairment.

Morten Tange Kristensen

We use the Abbey pain tool, which seems to work well, although we are still in the validation period locally.

Hi there,

I'm pretty certain that either the Wong-Baker or the Bieri has been validated with confused/demented elders. These avoid the use of numbers that can be confusing conceptually for older patients with confusion.

Hi, all. Thanks for all the answers. I've found a nice summary here: http://www.health.vic.gov.au/qualitycouncil/downloads/apmm_toolkit.pdf

It's a bit old but thorough and goes through many of the pros and cons of each. For the mildly confused most things seem to work. PAINAD looks really interesting. Not sure how well Wong-Baker will work, especially in the more confused and those with low mood. Will keep looking, so thanks for all the pointers.

The facial pain scales - Wong-Baker and Bieri - are poor reliability with elderly people, as they don't look like pain faces but more general emotion, and patients choose the face they like, usually the smiley zero pain one. Better to use behavioural scales, particularly those which incorporate facial expression properly, as that is somewhat preserved in mild to moderate demential.

Many of the reviews I've read suggest that the Faces-Pain Scale-Revised is reliable in mild dementia patients. I always test to make sure they understand at least the extremes of the scale (point to the face that means the most pain/no pain at all - point to a face that means a little pain, things like that). The FPS has faces that look a bit more anatomical, though (not round faces, for example), so that is perhaps why it does a bit better.