Chronic Non-Cancer Pain

The Problem

  • Chronic non-cancer pain becomes more prevalent as patients grow older.
  • Pain is a subjective experience that is best reported by the individual patient.
  • Persons with dementia and other related neurocognitive deficits may be unable to clearly articulate pain symptoms or experiences.
  • Typical pain assessment tools are unlikely to yield useful information for clinicians in the noncommunicative patient.
  • Behavioral changes in patients with dementia may be multifactorial, with undertreated pain as a possible etiology.
  • Medical treatment of pain in older adults is frequently complicated by complex medical histories and medication regimens.

The Solution

  • Inter-professional planning of care for the patient with inclusion of family members or caregivers will provide a clearer understanding of behavioral changes.
  • Each health professional must understand and respect the roles and input of the entire care planning team.
  • Providers, caregivers, and staff must be aware of pain as an etiology for behavioral changes and comfortable with its assessment using a validated tool.
  • Treatment must be individualized, evidence-based when feasible, and balance benefits and risks to the patient.

A recent Institute of Medicine report suggests that as many as 60% of those over the age of 65 experience ongoing musculoskeletal pain.  Over half of these older adults experienced the indicated pain for more than one year.  Similar studies lead us to believe that pain becomes more prevalent with corresponding age.

There are currently no labs, tests, imaging, or physical examination techniques that clinically identify pain or the predicted severity for the patient.

Unfortunately not long ago, it was a widely held belief that persons with dementia did not experience pain.  This was based on faulty studies tracking how often these patients asked for “as needed” pain relievers.  We now know that patients with dementia and cognitive impairment DO experience pain, but are a vulnerable population as they may not be able to articulate the severity, quality, or disability associated with their pain syndrome.

Pain assessment tools may be validated for use in many populations, languages, and clinical situations.  The most frequently used tools are the simplest, and request the patient either rate their pain on a scale, mark their rating on a line, or even point to a face that best describes how they feel.  Unfortunately, it becomes harder for patients to communicate their pain, regardless of the tool, as their dementia worsens.  Tools exist to help family, caregivers, and you assess their behaviors to help in identifying pain.

Certain behaviors may be more predictive of untreated or undertreated pain in a patient with dementia.  Before assuming the patient has pain, however, other potential etiologies must be considered and ruled out.

Treating pain in older patients can be difficult.  Lack of mobility, patient understanding, and other medical problems may cause confusion among the healthcare team when trying to balance the risks versus the benefits of any given treatment.

Because assessing pain in cognitively impaired adults in difficult, and older patients frequently have numerous additional issues, a team approach is always the best medicine.  In fact, numerous studies prove that pain is better treated by an interdisciplinary healthcare team compared to any one profession alone.

Part of being an effective healthcare team is understanding and respecting the roles, responsibilities, and skills that each profession has to offer. 

Too frequently patients with dementia or other types of cognitive impairment are treated inappropriately when problematic behaviors arise.  Be aware of behaviors, and the assessment tools available, to rule out untreated pain for problematic behaviors prior to moving to other non-pain focused treatments.

The American Geriatrics Society has published treatment guidelines for the management of persistent pain in older adults.  While sound clinical studies are typically lacking in the elderly population, consider the pros and cons of the non-pharmacologic and pharmacotherapy when considering instituting in this fragile population.

What is dementia?

  • Dementia is impairment of memory and learning combined with either:
  • Difficulty in handling or completing complex tasks
  • Lack of reasoning ability
  • Problems with spatial orientation
  • Impaired language
  • Slow (insidious) onset and progressive nature

Dementia is somewhat like a diagnosis of exclusion.  While an exhaustive list of possibilities is beyond the scope of this case, the following should be ruled out:

  • Delirium
  • Stroke
  • Infectious process
  • Other neurodegenerative diseases
  • Malignancy

Many options exist for the diagnosis of dementia.  Many health professionals will use the Mini Mental Status Examination (MMSE) to screen for potential cognitive impairment.

Mini Mental Status Examination (MMSE)


Possible points

Patient’s Response


Orientation to time


Unable to say the month, date, or day of the week.

From broadest to most narrow. Orientation to time has been correlated with future decline.

Orientation to place


States she is in the hospital and wants to go home. Can’t name the LTC facility.

From broadest to most narrow. This is sometimes narrowed down to streets, and sometimes to floor.



Able to repeat when prompted

Repeating named prompts

Attention and calculation



When asked to count by sevens, can say 7, 14 and then refuses to participate.

Serial sevens or spelling "world" backwards It has been suggested that serial sevens may be more appropriate in a population where English is not the first language.



Unable to recall

Registration recall



Able to name objects

Naming a pencil and a watch



Able to repeat a phrase


Speaking back a phrase

Complex commands


(see drawing)

Varies. Can involve drawing figure shown.

Scoring for the Mini-Mental Status Exam

  • 25-30 normal cognition
  • 21-24 mild dementia
  • 10-20 moderate dementia
  • < 9 severe dementia

Kovatch Serial Trial Intervention

Oftentimes patients with dementia cannot communicate problems they might be experiencing.  This includes pain.  The Kovach Serial Trial Intervention is a valuable, step-wise approach to a patient with dementia that cannot verbalize his or her needs.

Pain Assessment Tools

Currently there are 17 published pain assessment tools for use in patients who are unable to consistently and reliably communicate.  The City of Hope Pain and Palliative Care Resource Center reviewed all of these tools and graded each of them based on five separate criteria.  The scores for the pain assessment tools are available here.   It’s important that all of us as health professionals can recognize pain, even when the patient can tell us it hurts.

American Geriatrics Society Clinical Practice Guideline: Management of Persistent Pain in Older Persons

Within this guideline, the author panel identified six domains suggestive of pain in cognitively impaired older adults.  The appearance of these behaviors should lead the health professional to include pain in their consideration of the patient.

Facial Expressions

Slight frown; sad, frightened face

Grimacing, wrinkled forehead, closed or tightened eyes

Any distorted expression

Rapid blinking

Verbalizations, Vocalizations

Sighing, moaning, groaning

Grunting, chanting, calling out

Noisy breathing

Asking for help

Verbally abusive

Body Movements

Rigid, tense body posture, guarding


Increased pacing, rocking

Restricted movement

Gait or mobility changes

Changes in Interpersonal Interactions

Aggressive, combative, resisting care

Decreased social interactions

Socially inappropriate, disruptive


Changes in Activity Patterns or Routines

Refusing food, appetite change

Increase in rest periods

Sleep, rest pattern changes

Sudden cessation of common routines

Increased wandering

Mental Status Changes

Crying or tears

Increased confusion

Irritability or distress

City of Hope Pain and Palliative Care Resource Center

The following 5 observational instruments are ranked by the City of Hope as having the most psychometric support for their ability to detect potential pain-related changes in behavior.  While each still is in need of work, they should be given consideration whenever deciding what assessment tool to adopt:

Checklist of nonverbal pain indicators

  • Includes 3/6 AGS categories: facial expressions, verbalization/vocalization, body movements
  • Needs further evaluation to determine usefulness with persistent rest pain

The Doloplus 2

  • Includes 5/6 AGS categories: facial expressions, verbalization/vocalization, body movements, interpersonal interactions, activity patterns/routines
  • English translation not available, nor is training requirement clear
  • Cumbersome - nurses identified the Doloplus-2 as the least preferred tool for clinical use

NOPPAIN: A Nursing Assistant-Administered Pain Assessment Instrument for Use in Dementia

  • Includes 3/6 AGS categories: facial expressions, verbalization/vocalization, body movements
  • Appears clinically useful given the ease of administration for nursing assistants and the short time required for completion.

PAINSLAC: The Pain Assessment Checklist for Seniors with Limited Ability to Communicate

  • Includes 6/6 AGS categories: facial expressions, verbalization/vocalization, body movements, interpersonal interactions, activity patterns/routines, mental status
  • Although the PACSLAC includes 60 items, it requires a limited amount of time to administer

PAINAD: Pain Assessment In Advanced Dementia

  • Includes 3/6 AGS categories: facial expressions, verbalization/vocalization, body movements
  • Studies suggest the tool could be used to identify higher and lower levels of pain, but there are no data to attach level of pain severity to the score obtained with the tool

Free Full Print Publications of Practice Guidelines for Delores' Care

American Geriatrics Society. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57:1331-1346.

Hochberg MC, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.  Arthritis Care & Research 2012;64:465-474.

Chou R, et al. Diagnosis and treatment of low back pain: A joint clinical practice  guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-491.

Herr K, Coyne PJ, Key T et al. Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Manage Nurs 2006;7:44–52.

Web Resources

City of Hope Pain and Palliative Care Clearinghouse.


This curriculum resource was supported with funding from the NIH Pain Consortium, which approves the educational value of the information provided. The authors listed on this resource are responsible for its content, and questions may be directed to their Center of Excellence in Pain Education (url). The NIH Pain Consortium provides these evidence-based curriculum resources on pain management as a service to academic medical, dental, nursing, pharmacy, psychology, social work, and other health professional schools.

This resource is for educational purposes and is not intended as medical practice guidelines. Evidence-based practices may have changed since the publication of the resource.


Southern Illinois University

Chris Herndon, PharmD, BCPS, CPE (co-prinicipal investigator)

Erin Behnen, PharmD, BCPS

McKenzie Ferguson, PharmD, BCPS

Keith Hecht, PharmD, BCOP

Kevin Rowland, PhD

Carol Wesley, PhD, MSW, M.Div

St. Louis University

Raymond Tait, PhD (co-principal investigator)

Mary Ann Lavin, DSc, RN, APRN, FAAN

Patricia E. Freed, MSN, EdD, CNE

Rebecca Lorenz, PhD, RN

Southern Illinois School of Medicine

Michael Neumeister, MD, FRCSC

Margaret Boehler, RN, MS

Cathy Schwind, RN, MS

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Southern Illinois University