Pain Assessment in Advanced Dementia
Pain Assessment in Advanced Dementia is a pain scale developed by Victoria Warden, Ann C. Hurley, and Ladislav Volicer to provide a universal method of analysing the pain experienced by people in late stage dementia.
| Behavior | 0 | 1 | 2 | Score |
| Breathing independent of vocalization | Normal | Occasional laboured breathing, short period of hyperventilation | Noisy laboured breathing, long period of hyperventilation, Cheyne-Stokes respirations | |
| Negative vocalization | - | Occasional moans or groans, low-level speech with a negative or disapproving quality | Repeated troubled calling out, loud moaning or groaning, crying | |
| Facial expression | Smiling or inexpressive | Sad, frightened, frown | Facial grimacing | |
| Body language | Relaxed | Tense, distresses pacing, fidgeting | Rigid, fists clenched, knees pulled up, pulling or pushing away, striking out | |
| Consolability | No need to console | Distracted or reassured by voice or touch | Unable to console, distract, or reassure |
"The total score ranges from 0-10 points. A possible interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain;
7-10=severe pain."