MDCalc

Abbey Pain Scale for Dementia Patients

Assesses pain in patients with advanced dementia.

Vocalization

E.g., whimpering, groaning, crying

Facial expression

E.g., looking tense, frowning, grimacing, frightened

Changes in body language

E.g., fidgeting, rocking, guarding part of body, withdrawn

Behavioral changes

E.g., increased confusion, refusing to eat, alteration in usual patterns

Physiological changes

E.g., temperature, pulse or blood pressure outside normal limits, perspiring, flushing or pallor

Physical changes

E.g., skin tears, pressure areas, arthritis, contractures, previous injuries

Result:

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Advice
  • Use this tool to support, not replace, clinical judgment and a full clinical assessment.
  • Interpret results in context, including the patient’s baseline behavior, recent procedures or injuries, vital signs, medications, and possible non-pain causes of distress.
  • When pain is suspected, evaluate for reversible causes and consider appropriate analgesic and nonpharmacologic interventions.
  • Rescore after pain interventions to assess response.
  • See local institutional guidance for protocols on initial and ongoing assessment timing and appropriate documentation.
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