PAINAD Scale: Breathing and Vocalization

• The Pain Assessment in Advanced Dementia (PAINAD) Scale is used to assess pain in individuals with advanced dementia.

Breathing Assessment

• 0: Normal breathing is effortless, quiet, and rhythmic.
• 1: Occasional labored breathing includes episodic bursts of harsh, difficult, or wearing respirations. Short periods of hyperventilation have intervals of rapid, deep breaths.
• 2: Noisy labored breathing involves negative sounds on inspiration or expiration, like loud gurgling or wheezing. Long periods of hyperventilation mean excessive rate and depth of respirations for a considerable time. Cheyne-Stokes respirations include rhythmic waxing and waning of breathing, from very deep to shallow, with periods of apnea.

Negative Vocalization Assessment

• 0: None. Speech or vocalization with a neutral or pleasant quality.
• 1: Occasional moans or groans are mournful sounds, wails or laments, louder than usual inarticulate involuntary sounds. Low level speech with a negative quality includes muttering, mumbling, whining, grumbling, or swearing in a complaining tone.
• 2: Repeated troubled calling out involves phrases used repeatedly in a tone suggesting anxiety or distress. Loud moaning or groaning includes mournful sounds, louder than usual volume. Crying involves an utterance of emotion accompanied by tears, possibly sobbing.

Facial Expression Assessment

• 0: Smiling or inexpressive includes upturned corners of the mouth and a look of pleasure or contentment; inexpressive means neutral and relaxed.
• 1: Sad involves an unhappy, lonesome, sorrowful, or dejected look. Frightened involves a look of fear, alarm or heightened anxiety with wide open eyes. Frowning includes a downward turn of the corners of the mouth with increased facial wrinkling.
• 2: Facial grimacing involves a distorted, distressed look with wrinkled brow and mouth; eyes may be squeezed shut.

Body Language Assessment

• 0: Relaxed appearance means calm, restful, mellow.
• 1: Tense appearance means strained, apprehensive, or worried; the jaw may be clenched (excluding contractures). Distressed pacing is unsettled, possibly fearful or worried; the rate may be faster or slower. Fidgeting is restless movement like squirming or wiggling in a chair; repetitive touching or rubbing may also be observed.
• 2: Rigid body means stiffening; arms and/or legs are tight and inflexible; the trunk may appear straight and unyielding (excluding contractures). Fists clenched mean tightly closed hands, opened/closed repeatedly or held tightly shut. Knees pulled up means flexing the legs toward the chest (excluding contractures). Pulling or pushing away happens with resistiveness upon approach or care. Striking out involves hitting, kicking, grabbing, punching, biting, or other assault.

Consolability Assessment:

• 0: No need to console means a sense of well-being and contentment.
• 1: Distracted/reassured by voice or touch happens with a disruption stopping behavior during interaction, without indication of distress.
• 2: Unable to console, distract, or reassure involves the inability to soothe, with no amount of comforting alleviating the behavior.

Pain Scoring

• 1-3 indicates mild pain, managed by non-pharmacologic approaches such as repositioning or acetaminophen.
• 4-6 indicates moderate pain.
• 7-10 indicates moderate to severe pain, potentially requiring stronger analgesia like an opioid.