Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale

Sep 17, 2026

Instrument development and psychometric evaluation of the PAINAD pain assessment tool for individuals with advanced dementia who cannot reliably self-report. The study used expert clinician input and behavioral observation to create a five-item observational scale (0–10). PAINAD was compared with the Discomfort Scale and two visual analog scales during development, and then applied to assess analgesic efficacy in a quality improvement activity. Results supported interrater reliability, internal consistency, and construct validity, with PAINAD detecting pre/post medication score differences.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Objectives

Design

Setting and Participants

Measurements

Results

Conclusions

Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale Victoria Warden, RN, Ann C. Hurley, RN, DNSc, FAAN, and Ladislav Volicer, MD, PhD, FAAN | Objectives: To develop a clinically relevant and easy to use pain assessment tool for individuals with advanced dementia that has adequate psychometric properties.
Design: Instrument development study using expert clinicians and behavioral observation methods. Measurement of sensitivity of the instrument to detect the effects of analgesic medications in a quality improvement activity.
Setting: Inpatient dementia special care units in a Veterans Administration Medical Center.
Participants: Nineteen residents with advanced dementia who were aphasic or lacked the ability to report their degree of pain and six professional staff members. Additionally, data from medical records of 25 residents who were receiving pain medications as required (PRN) were collected.
Measurements: Based on the literature review, related assessment tools and consultation with expert clinicians, a ﬁve-item observational tool with a range of 0 to 10 was developed. The tool, Pain Assessment in Advanced Dementia (PAINAD), was compared with the Discomfort Scale and two visual analog scales (discom- | fort and pain) by trained raters/expert clinicians in the development study, and used for detection of analgesic efﬁcacy in a quality improvement activity.
Results: Adequate levels of interrater reliability were achieved between dyads of the principal investigator with each clinical research rater and between two raters. PAINAD had satisfactory reliability by internal consistency with a one factor solution. PAINAD and the Discomfort Scale–Dementia of Alzheimer Type (DSDAT) were signiﬁcantly correlated, providing evidence of construct validity. PAINAD detected statistically signiﬁcant difference between scores obtained before and after receiving a pain medication.
Conclusions: The PAINAD is a simple, valid, and reliable instrument for measurement of pain in noncommunicative patients. Since the patient population used for its development and testing was limited to a relatively small number of males, further research is needed before it can be universally recommended.
(J Am Med Dir Assoc 2003; 4: 9–15)
Keywords: Alzheimer’s disease; pain; assessment; dementia. | | --- | --- | Pain in elderly nursing home residents is a prevalent problem, estimated to occur in 26 to 83% of residents.1–5 Many residents have several diagnoses that may be directly related to pain, such as degenerative arthritis and diabetic neuropathy.6,7 The cognitively intact elderly often underreport pain, believing that pain goes along with aging. Reported pain is often dismissed with statements such as “What do you expect at your age?”8 Because pain is underreported, it is frequently Geriatric Research Education Clinical Center, Edith Nourse Rogers Memorial Veterans Medical Center, Bedford, Massachusetts (V.W., A.C.H., L.V.), The School of Nursing, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts (A.C.H.), and Departments of Pharmacology and Psychiatry, Boston University School of Medicine (L.V.), Boston, Massachusetts. Address correspondence to Victoria Warden, GRECC (182B), E. N. Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730 . E-mail: [Victoria.Warden@med.va.gov](Victoria.Warden@med.va.gov). Copyright ©2003 American Medical Directors Association DOI: 10.1097/01.JAM.0000043422.31640.F7 undertreated in the elderly.9 This attitude and acceptance of pain as a consequence of aging may lead to less pain assessment in general8 and even less treatment of pain in those cognitively impaired elders who cannot self-report pain.10 The importance of pain detection and treatment was recognized in several reports and practice guidelines. 11,12 Untreated pain can cause secondary symptoms of sleep disturbance, weight loss, and depres

FAQs

What is the main objective of the PAINAD instrument development study?

To develop a clinically relevant, easy-to-use pain assessment tool for people with advanced dementia that has adequate psychometric properties.

How is the PAINAD scale structured and scored?

PAINAD is a five-item observational tool with a total range of 0 to 10.

What evidence supports PAINAD’s validity and reliability?

The study reports adequate interrater reliability, satisfactory internal consistency with a one-factor solution, significant correlations with the Discomfort Scale–DSDAT for construct validity, and statistically significant score differences before versus after analgesic medication.

Sep 17, 2026

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