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Abbey Pain Scale for Dementia Patients
Observational pain assessment for patients with advanced dementia who cannot self-report pain.
Abbey Pain Scale for Dementia Patients
Vocalisation (whimpering, groaning, crying)
Facial expression (tense, frowning, grimacing, frightened)
Change in body language (fidgeting, rocking, guarding, withdrawn)
Behavioural change (increased confusion, refusing food, altered usual patterns)
Physiological change (temperature, pulse or blood pressure change, sweating, flushing, pallor)
Physical changes (skin tears, pressure areas, arthritis, contractures, prior injury)
Result0 points
No pain (range 0-18). Reassess after any analgesic intervention.
- Pain category
- No pain
When to use
- Assessing pain in patients with advanced dementia or others unable to verbalise their pain experience.
Formula
Sum of 6 domains (vocalisation, facial expression, body language, behavioural change, physiological change, physical change), each scored 0 (absent) to 3 (severe). Range 0-18: 0-2 no pain, 3-7 mild, 8-13 moderate, 14-18 severe.
Pearls and pitfalls
- A screening/monitoring tool, not diagnostic of pain type - clinical judgement about cause (acute, chronic, or acute-on-chronic) is still required.
- Best used to track response to analgesia over repeated observations rather than as a single snapshot.