Special Article| Volume 21, ISSUE 2, P149-163, February 2020

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Pain Assessment for Older Persons in Nursing Home Care: An Evidence-Based Practice Guideline

Published:October 23, 2019DOI:


      Up to 80% of nursing home residents are affected by pain. Pain assessment aims to determine pain intensity, quality, and course of pain to underpin diagnostic decision making. In the nursing home population, pain assessment is frequently compromised by cognitive impairment. Characteristics of the nursing home setting, such as resident's age, staff skill mix, and overall aims of the care provided, also need to be taken into account. Therefore, an interdisciplinary evidence-based clinical practice guideline for pain assessment in the nursing home setting was developed.
      A systematic literature search was carried out covering publications between 2003 and 2015. Thirty-nine studies were included in the preparation of this guideline, supplemented by 12 international reference guidelines. Recommendations were subjected to a structured consensus-finding process with representatives from 37 scientific and professional organizations and patient representatives. The guideline underwent independent peer review before finalization.
      It comprises 62 recommendations that are grouped into 4 chapters: (1) context of pain assessment in nursing home care; (2) screening; (3) focused assessment; and (4) reassessment/monitoring of pain. Main recommendations stipulate that clinicians should assess the patient's ability to provide self-report of pain when screening for pain and that each resident should be screened for the presence of pain. A focused assessment of pain, performed during rest and activities, should include pain intensity, changed behaviors, general mobility, pain history, comorbidities, and pain medication. Pain should be re-assessed at regular intervals using the same instruments that were used for the focused assessment. Guideline development demonstrated that many aspects of pain assessment in older persons have not received adequate research attention so far. Available studies predominantly possess only low levels of evidence. Therefore, research into this area needs to be systematically developed to address questions of clinical relevance to support patient care.


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        • Hadjistavropoulos T.
        • Herr K.
        • Turk D.C.
        • et al.
        An interdisciplinary expert consensus statement on assessment of pain in older persons.
        Clin J Pain. 2007; 23: S1-S43
        • Takai Y.
        • Yamamoto-Mitani N.
        • Okamoto Y.
        • et al.
        Literature review of pain prevalence among older residents of nursing homes.
        Pain Manage Nurs. 2010; 11: 209-223
        • Osterbrink J.
        • Hufnagel M.
        • Kutschar P.
        • et al.
        Die Schmerzsituation von Bewohnern in der stationären Altenhilfe.
        Schmerz. 2012; 26: 27-35
        • Lukas A.
        • Mayer B.
        • Onder G.
        • et al.
        Schmerztherapie in deutschen Pflegeeinrichtungen im europaischen Vergleich. Ergebnisse der SHELTER-Studie.
        Schmerz. 2015; 29: 411-421
        • Schreier M.M.
        • Stering U.
        • Pitzer S.
        • et al.
        Schmerz und Schmerzerfassung in Altenpflegeheimen: Ergebnisse der OSiA-Studie.
        Schmerz. 2015; 29: 203-210
        • Hadjistavropoulos T.
        • Herr K.
        • Prkachin K.M.
        • et al.
        Pain assessment in elderly adults with dementia.
        Lancet Neurol. 2014; 13: 1216-1227
        • Chandler R.C.
        • Zwakhalen S.M.G.
        • Docking R.
        • et al.
        Attitudinal and knowledge barriers towards effective pain assessment and management in dementia: A narrative synthesis.
        Curr Alzheimer Res. 2017; 14: 523-537
        • Robinson C.L.
        Relieving pain in the elderly.
        Health Progress. 2007; 88 (70): 48-53
        • Zanocchi M.
        • Maero B.
        • Nicola E.
        • et al.
        Chronic pain in a sample of nursing home residents: Prevalence, characteristics, influence on quality of life (QoL).
        Arch Gerontol Geriatr. 2008; 47: 121-128
        • Torvik K.
        • Kaasa S.
        • Kirkevold O.
        • et al.
        Pain and quality of life among residents of Norwegian nursing homes.
        Pain Manage Nurs. 2010; 11: 35-44
        • McLennon S.M.
        Persistent Pain Management in Older Adults Evidence-based Guideline.
        University of Iowa, 2005
        • Abdulla A.
        • Adams N.
        • Bone M.
        • et al.
        Guidance on the management of pain in older people.
        Age Ageing. 2013; 42: i1-i57
        • Melzack R.
        • Katz J.
        Pain Measurement in Adult Patients.
        in: McMahon S. Koltzenburg M. Tracey I. Wall and Melzack's Textbook of Pain. Elsevier, Philadelphia2013: 301-314
        • British Pain Society
        British Geriatrics Society. Guidance on the Assessment of Pain in Older People.
        • World Health Organisation (WHO)
        Definition of an older or elderly person. Proposed working definition of an older person in Africa for the MDS Project.
        (Available at:)
        • Scottish Intercollegiate Guidelines Network (SIGN)
        SIGN 50, A guideline developer's handbook.
        (Available at:)
        • Mokkink L.B.
        • Terwee C.B.
        • Knol D.L.
        • et al.
        The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: A clarification of its content.
        BMC Med Res Methodol. 2010; 10: 22
        • National Institute for Health and Clinical Excellence (NICE)
        The guidelines manual (appendices), Appendix H Methodology checklist: Qualitative studies.
        (Available at:)
        • Guyatt G.
        • Oxman A.D.
        • Akl E.A.
        • et al.
        GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.
        J Clin Epidemiol. 2011; 64: 383-394
        • Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF)
        Deutsches Instrument zur methodischen Leitlinien Bewertung (DELBI).
        (Available at:)
        • Sirsch E.
        • Laekeman M.
        • Gnass I.
        • Fischer T.
        • Schmerzassessment bei älteren Menschen in der vollstationären Altenhilfe. Leitlinienreport der multiprofessionellen S3-Leitlinie
        Deutsche Schmerzgesellschaft, Deutsches Zentrum für Neurodegenerative Erkrankungen.
        (Available at:)
        • Sirsch E.
        • Schuler M.
        • Fischer T.
        • Gnass I.
        • Laekeman M.A.
        • Leonhardt C.
        • Berkemer E.
        • Drebenstedt C.
        • Löseke E.
        • Schwarzmann G.
        • Kopke K.
        • Lukas A.
        Der Schmerz. 2012; 26: 410-418
        • American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons (AGS)
        The Management of Persistent Pain in Older Persons.
        JAGS. 2002; 50: S206-S224
        • American Medical Directors Association (AMDA)
        Pain management in the long-term-care Setting Clinical Practice Guideline.
        (Columbia (MD))2012
        • Lichtner V.
        • Dowding D.
        • Esterhuizen P.
        • et al.
        Pain assessment for people with dementia: A systematic review of systematic reviews of pain assessment tools.
        BMC Geriatr. 2014; 14: 138
        • Vereniging van en voor Specialisten Ouderengeneeskunde (Verenso)
        Multidisciplinaire Richtlijn Pijn. Deel 1.
        Verenso, Utrecht2011
      1. Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (DNQP): Expertenstandard Schmerzmanagement in der Pflege bei chronischen Schmerzen. Deutsches Netzwerk für Qualitätsentwicklung in der Pflege, Osnabrück2015
        • Cleeland C.S.
        • Ryan K.M.
        Pain assessment: Global use of the Brief Pain Inventory.
        Ann Acad Med Singapore. 1994; 23: 129-138
        • Melzack R.
        The McGill Pain Questionnaire: Major properties and scoring methods.
        Pain. 1975; 1: 277-299
      2. Health Care Association of New Jersey (HCANJ): Pain management guideline. Health Care Association of New Jersey (HCANJ), Hamilton (NJ)2006
      3. American Medical Directors Association (AMDA): Pain management in the long-term care setting. 2009 (American Medical Directors Association (AMDA), Columbia, MD)
        • Hadjistavropoulos T.
        • Fitzgerald T.D.
        • Marchildon G.P.
        Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities.
        Physiother Canada. 2010; 62: 104-113
      4. Australian Pain Society (APS): Pain in Residential Aged Care Facilities. Management Strategies, Sydney2005
        • Registered Nurses Association of Ontario (RNAO)
        Assessment and management of pain.
        Registered Nurses Association of Ontario (RNAO), Toronto (ON)2002
        • Registered Nurses Association of Ontario (RNAO)
        Assessment and management of pain supplement.
        Registered Nurses Association of Ontario (RNAO), Toronto (ON)2007
        • Schofield P.
        The assessment of pain in older people.
        UK National Guidelines. Age and Ageing, 2018: 47.i1-47.i22
      5. Goucke R. Pain in Residential Aged Care Facilities: Management Strategies. 2nd ed. The Australian Pain Society, North Sydney, NSW2018
        • Vereniging van en voor Specialisten Ouderengeneeskunde (Verenso)
        Herkenning en behandeling van pijn bij kwetsbare ouderen Deel 2.
        Verenso, Utrecht2016
        • Royal College of Nursing (RCN)
        RCN Pain Knowledge and Skills Framework for the Nursing Team.
        (Available at:)
        • Gnass I.
        • Löwe S.
        • Ralic N.
        • et al.
        Kompetenzentwicklung entlang des RCN pain knowledge and skills framework for nursing teams.
        Schmerznachrichten. 2018; : 53-57
        • Abbey J.
        • Piller N.
        • De Bellis A.
        • et al.
        The Abbey pain scale: A 1-minute numerical indicator for people with end-stage dementia.
        Int J Palliat Nurs. 2004; 10: 6-13
        • Alexander B.J.
        • Plank P.
        • Carlson M.B.
        • et al.
        Methods of pain assessment in residents of long-term care facilities: A pilot study.
        J Am Med Dir Assoc. 2005; 6: 137-143
        • Alm A.K.
        • Norbergh K.G.
        Nurses' opinions of pain and the assessed need for pain medication for the elderly.
        Pain Manage Nurs. 2013; 14: e31-e38
        • Auret K.A.
        • Toye C.
        • Goucke R.
        • et al.
        Development and testing of a modified version of the brief pain inventory for use in residential aged care facilities.
        J Am Geriatr Soc. 2008; 56: 301-306
        • Baier R.R.
        • Gifford D.R.
        • Patry G.
        • et al.
        Ameliorating pain in nursing homes: A collaborative quality-improvement project.
        J Am Geriatr Soc. 2004; 52: 1988-1995
        • Brown C.A.
        Pain in communication impaired residents with dementia: Analysis of Resident Assessment Instrument (RAI) data.
        Dementia. 2010; 9: 375-389
        • Buffum M.D.
        • Hutt E.
        • Chang V.T.
        • et al.
        Cognitive impairment and pain management: Review of issues and challenges.
        J Rehabil Res Dev. 2007; 44: 315-330
        • Burfield A.H.
        Cohort Study of Pain Behaviors in the Elderly Residing in Skilled Nursing Care, Doctoral Dissertation.
        College of Nursing Orlando University of Central Florida, 2006-2009
        • Cadogan M.P.
        • Schnelle J.F.
        • Al-Sammarrai N.R.
        • et al.
        A standardized quality assessment system to evaluate pain detection and management in the nursing home.
        J Am Med Dir Assoc. 2006; 7: S11-S19
        • Cadogan M.P.
        • Edelen M.O.
        • Lorenz K.A.
        • et al.
        The relationship of reported pain severity to perceived effect on function of nursing home residents.
        J Gerontol A Biol Sci Med Sci. 2008; 63: 969-973
        • Cervo F.A.
        • Bruckenthal P.
        • Fields S.
        • et al.
        The role of the CNA Pain Assessment Tool (CPAT) in the pain management of nursing home residents with dementia.
        Geriatr Nurs. 2012; 33: 430-438
        • Chang S.O.
        • Oh Y.
        • Park E.Y.
        • et al.
        Concept analysis of nurses' identification of pain in demented patients in a nursing home: Development of a hybrid model.
        Pain Manage Nurs. 2011; 12: 61-69
        • Closs S.J.
        • Cash K.
        • Barr B.
        • et al.
        Cues for the identification of pain in nursing home residents.
        Int J Nurs Stud. 2005; 42: 3-12
        • Closs S.J.
        • Barr B.
        • Briggs M.
        Reporting of painful conditions in nursing homes.
        J Clin Nurs. 2006; 15: 1203-1205
        • Edvardsson D.
        • Benny K.
        • Nay R.
        The aged care pain chart: An innovative approach to assessing, managing and documenting pain in older people.
        Australas J Ageing. 2008; 27: 93-96
        • Fuchs-Lacelle S.
        • Hadjistavropoulos T.
        • Lix L.
        Pain assessment as intervention: A study of older adults with severe dementia.
        Clin J Pain. 2008; 24: 697-707
        • Fuchs-Lacelle S.K.
        Pain and Dementia: The Effects of Systematic Assessment on Clinical Practices and Caregiver Stress.
        PhD University of Regina, Regina, Canada2007
        • Fuchs-Lacelle S.
        • Hadjistavropoulos T.
        Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC).
        Pain Manage Nurs. 2004; 5: 37-49
        • Gibson M.C.
        • Woodbury M.G.
        • Hay K.
        • et al.
        Pain reports by older adults in long-term care: A pilot study of changes over time.
        Pain Res Manage. 2005; 10: 159-164
        • Hadjistavropoulos T.
        • Voyer P.
        • Sharpe D.
        • et al.
        Assessing pain in dementia patients with comorbid delirium and/or depression.
        Pain Manage Nurs. 2008; 9: 48-54
        • Halifax E.
        How Certified Nursing Assistants Understand Their Residents' Pain.
        University of California, San Francisco2013
        • Holloway K.
        • McConigley R.
        Understanding nursing assistants' experiences of caring for older people in pain: The Australian experience.
        Pain Manage Nurs. 2009; 10: 99-106
        • Horgas A.L.
        • Nichols A.L.
        • Schapson C.A.
        • et al.
        Assessing pain in persons with dementia: Relationships among the noncommunicative patient's pain assessment instrument, self-report, and behavioral observations.
        Pain Manage Nurs. 2007; 8: 77-85
        • Jones K.R.
        • Fink R.
        • Hutt E.
        • et al.
        Measuring pain intensity in nursing home residents.
        J Pain Symptom Manage. 2005; 30: 519-527
        • Jordan A.
        • Hughes J.
        • Pakresi M.
        • et al.
        The utility of PAINAD in assessing pain in a UK population with severe dementia.
        Int J Geriatr Psychiatry. 2011; 26: 118-126
        • Kaasalainen S.
        • Brazil K.
        • Akhtar-Danesh N.
        • et al.
        The evaluation of an interdisciplinary pain protocol in long term care.
        J Am Med Dir Assoc. 2012; 13 (664.e1‒664.e8)
        • Kaasalainen S.
        • Coker E.
        • Dolovich L.
        • et al.
        Pain management decision making among long-term care physicians and nurses.
        West J Nurs Res. 2007; 29 (discussion 581‒568): 561-580
        • Keeney C.E.
        • Scharfenberger J.A.
        • O'Brien J.G.
        • et al.
        Initiating and sustaining a standardized pain management program in long-term care facilities.
        J Am Med Dir Assoc. 2008; 9: 347-353
        • Landmark B.T.
        • Gran S.V.
        • Kim H.S.
        Pain and persistent pain in nursing home residents in Norway.
        Res Gerontol Nurs. 2013; 6: 47-56
        • Liu J.Y.
        • Pang P.C.
        • Lo S.K.
        Development and implementation of an observational pain assessment protocol in a nursing home.
        J Clin Nurs. 2012; 21: 1789-1793
        • Lukas A.
        • Barber J.B.
        • Johnson P.
        • et al.
        Observer-rated pain assessment instruments improve both the detection of pain and the evaluation of pain intensity in people with dementia.
        Eur J Pain. 2013; 17: 1558-1568
        • Mahoney A.E.J.
        • Peters L.
        The Mahoney pain scale: Examining pain and agitation in advanced dementia.
        Am J Alzheimer Dis Other Dement. 2008; 23: 250-261
        • Martin R.
        • Williams J.
        • Hadjistavropoulos T.
        • et al.
        A qualitative investigation of seniors' and caregivers' views on pain assessment and management.
        Canadian J Nurs Res. 2005; 37: 143-164
        • Mentes J.C.
        • Teer J.
        • Cadogan M.P.
        The pain experience of cognitively impaired nursing home residents: Perceptions of family members and certified nursing assistants.
        Pain Manage Nurs. 2004; 5: 118-125
        • Mossey J.M.
        • Gallagher R.M.
        The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents.
        Pain Med. 2004; 5: 335-348
        • Sloane P.D.
        • Miller L.L.
        • Mitchell C.M.
        • et al.
        Provision of morning care to nursing home residents with dementia: Opportunity for improvement?.
        Am J Alzheimers Dis Other Demen. 2007; 22: 369-377
        • van Herk R.
        • van Dijk M.
        • Tibboel D.
        • et al.
        The Rotterdam Elderly Pain Observation Scale (REPOS). 1. Nova Science Publishers, Inc, 2009: 367-378
        • Zwakhalen S.M.
        • Van't Hof C.E.
        • Hamers J.P.
        Systematic pain assessment using an observational scale in nursing home residents with dementia: Exploring feasibility and applied interventions.
        J Clin Nurs. 2012; 21: 3009-3017
        • Zwakhalen S.M.
        • van der Steen J.T.
        • Najim M.D.
        Which score most likely represents pain on the observational PAINAD pain scale for patients with dementia?.
        J Am Med Dir Assoc. 2012; 13: 384-389
      6. McCaffery M, Beebe A, Latham J. Schmerz. Ein Handbuch für die Pflegepraxis. 1997; Ullstein Mosby, Berlin.

        • Herr K.
        • Bjoro K.
        • Steffensmeier J.
        • Rakel B.
        Acute pain management in older adults.
        University of Iowa Gerontological Nursing Interventions Research Center, Research Translastion and Dissemination Core, Jul. 113 p. Guideline Summary NGC-5382. Iowa, IA2006
        • Horgas A.L.
        • Yoon S.L.
        Pain management.
        in: Capezuti E. Zwicker D. Mezey M. Fulmer T. Evidence-based geriatric nursing protocols for best practice. 3rd ed. Springer Publishing Company, New York, NY2008: 199-222
        • Lin P.C.
        • Lin L.C.
        • Shyu Y.I.
        • Hua M.S.
        Predictors of pain in nursing homeresidents with dementia: a cross-sectional study.
        J Clin Nurs. 2011; 20: 1849-1857

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