Monthly Archives: July 2014

Living With Alzheimer’s: Assessing Patients’ Pain

The following is a restructuring of information that may help caregivers living with loved ones with Alzheimer’s recognize the symptoms of pain in an Alzheimer’s patient who is suffering from pain but can no longer describe it, and help them. A link to the online site the information is taken from is provided at the end of this post.


Pain in older adults is very often undertreated, and it may be especially so in older adults with severe dementia.

While Alzheimer’s disease itself does not cause pain, patients may suffer pain from other sources. These sources may include improperly fitting clothes, stomach cramps, constipation, undiscovered sprains or broken bones, arthritis, pressure sores and bruises. Poor hygiene may also lead to pain; for example, sore gums may result from improper oral (teeth/mouth) care.

Changes in a patient’s ability to communicate verbally present special challenges in treating pain, and unrelieved pain can have serious consequences, including declines in physical function and diminished appetite. The Pain Assessment in Advanced Dementia (PAINAD) scale has been designed to assess pain in this population by looking at five specific indicators: breathing, vocalization, facial expression, body language, and consolability. A trained nurse or other health care worker can use the scale in less than five minutes of observation. For an online video showing nurses using the PAINAD scale and other pain-assessment tools, go to

The PAINAD scale is a behavior-observation tool developed for use in patients whose dementia is so advanced that they can’t verbally communicate the fact that they’re in pain. Designed for easy use, it requires a brief training-and-observation period.

* breathing: labored breathing or hyperventilating

* vocalization: moaning or crying

* facial expression: frowning or grimacing

* body language: clenching fists or pushing away caregivers

* consolability: an inability to be comforted

Each item is scored on a scale of 0 to 2. When scores from the five indicators are totaled, the patient’s score can range from 0 (no pain) to 10 (severe pain). The intention was to create a 0-to-10 pain-rating scale for people with advanced dementia that relies on observation and is similar to the commonly used 0-to-10 pain-rating scale that relies on the patient’s own report of pain.


If pain is present: caregivers are advised to evaluate and modify their approach to care. All caregivers are asked to consider the following questions.

* Is the patient handled gently?

* Is s/he given warnings before s/he’s touched or moved?

* Is s/he kept covered and warm while care is given?

* Are you attending to behavioral cues and not rushing through activities?

* Do you stop care activities when s/he resists them?

The creators of the PAINAD scale have given no specific guidance on the treatment of pain according to each score. The soundness of using a 0-to-10 behavioral scale to rate the severity of pain has not been established.5 At the most general level, a score of 1 would indicate mild pain and a score of 10 would indicate severe pain. Mild pain (a total score of 1 or 2) warrants comfort measures (such nonpharmacologic approaches as repositioning or distraction, or a mild analgesic such as acetaminophen); moderate-to-severe pain (a total score of 5 to 10) warrants stronger analgesia, such as an opioid, as well as comfort measures.

CHALLENGES that may arise

It may be difficult to determine whether a particular behavior is related to pain or to something else, such as anxiety or being too cold. Some behaviors may be inconsistent or very subtle; detecting subtle changes may require observing the patient at different times over the course of several days. Often, more pain-related behaviors are seen during movements involved in bathing, getting out of bed, or dressing.

When working with people with advanced dementia, caregivers should remember that it’s impossible to determine whether a person is in pain through behavior alone.9 Thus, the pain indicators in the PAINAD scale (or any other behavioral pain measure) should not be considered definitive. Rather, such a scale should be used within a broader, more comprehensive pain-assessment protocol. This would include trying to obtain the patient’s report of pain, investigating possible causes of pain (such as injury or illness), and possibly starting an analgesic trial.4 It’s also important to talk with family members to ascertain behaviors, or changes in behaviors, that indicated pain when the patient was younger or more cognitively intact.

ONLINE RESOURCES: For more information on the Pain Assessment in Advanced Dementia scale and other geriatric assessment tools and best practices, go to clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program. The site presents authoritative clinical products, resources, and continuing education opportunities that support individual nurses and practice settings.

Go to and click on the How to Try This link to access all articles and videos in this series.

Living With Alzheimer’s: The Question of Appropriate Therapies

Professionals agree there is currently no treatment that will cure Alzheimer’s because its cause is not known. During the course of our journey, doctors have given us the option of prescription drugs to “possibly help” treat the disease. Many others have suggested remedies, and various testimonials and ads promoting alternative treatments have popped up. It can be overwhelming, and we’ve spent our fair share of time doing what I call, chasing rainbows. Coconut oil, vitamins, and other such things did nothing for Bill.

When he was diagnosed, our question to doctors was: are there any drugs that can slow it down? There are some that, “Might, or might not, have any effect,” the gerontologist said. We chose to try them.

“Aricept,” I was told, “won’t slow it down, but it will let him use everything that he has left.” It did seem to help Bill focus on tasks better than he had been able to after the disease hit. However, it also caused him to have nightmares, terrible muscle cramps, a continually runny nose, and other side effects. When we reported these, his prescription was changed to Ebixa (Memantine).

As his condition continued its downhill course, I couldn’t know whether the drug was really doing anything to help, but he continued to take it because we wouldn’t be able to tell if it was helping unless he stopped taking it. After almost 8 years, I decided to stop it (without his knowledge so the results would be in the realm of ‘placebo’ trials), to try and determine what, if any, effect it was having. Within a few weeks, I noticed Bill was more confused when he woke up. He needed directions to the ensuite bathroom, more help with dressing. Other things he had done himself, or with minimal supervision, now required more involvement from me. He also followed me around the house more closely, as if he was afraid I would disappear if he didn’t keep me in sight. His search for words to describe his needs, or an event, also became more pronounced. So, after three months off it, I put Ebixa back on his daily menu. And after a week or so noticed his descriptive powers improve, his thoughts become clearer than they were, and he could do more things independently again. That said, I don’t know whether it’s the drug that made the difference.

Alzheimer’s is an up and down, winding path, not a straight line, and at various stages in the disease patients do have periods of more confusion, followed by or interspersed with periods of greater cohesion. No one knows why. Added to that are expectations. It’s possible my interactions with him changed in ways I didn’t realize during his time off the drug, and that could have affected him in ways I don’t understand. Or it could have affected my perceptions of what was actually going on. When it comes to ‘scientific testing’, tests like the one I conducted are highly flawed, and I don’t recommend it.

What is known is that everyone’s experience with taking prescription drugs to help cope with the disease is different, and what does seem to work for everyone when it comes to maintaining, or increasing, health are the things we’ve all heard about most of our lives—good food, regular exercise, and social involvement. Laughter also helps. In other words, the same things every human requires to establish and maintain a full and healthy life will also help Alzheimer’s patients (and caregivers).

Fortunately, Bill always was, and still is, a social guy who enjoys a range of activities. And when he loses the ability to do something he likes to do, we work together to find another activity he can do. It does get harder as the disease progresses, but he’s always game to try, and often things work out better than I expect they will. Such as, deciding to take advantage of the Adult Daycare Program, which he now attends one day a week.

I was nervous about signing him up for this, believing that he still had significantly more function than many who attend the program, and that he would not enjoy the activities there. My concerns were immediately dispelled. He fully appreciates the warm and friendly staff, finds people there he can talk to, and though every activity isn’t his cup of tea, he enjoys many others. He often comes home with a tale about something or other they’ve done that he got a special kick out of.

In addition, I am mindful every human needs to feel they are making a valuable contribution to life in order to feel they are living a full life. So, I keep giving Bill tasks to do, even if I have to later finish or redo them. (More often, I find it more beneficial for both of us to just accept the job he does, whatever the level of competence he does it with). As well, I try to recognize changes that are occurring, and create new, helpful strategies for dealing with them.