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Observational study
Even with regular use of an observational scale to assess pain among nursing home residents with dementia, pain-relieving interventions are not frequently used
  1. Jiska Cohen-Mansfield
  1. Herczeg Institute on Aging, and Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Israel
  1. Correspondence to: Professor Jiska Cohen-Mansfield
    Herczeg Institute on Aging, Tel Aviv University, P.O.B. 39040, Ramat Aviv, Tel-Aviv, 69978, Israel; jiska{at}

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Commentary on: Zwakhalen SM, Van’t Hof CE, Hamers JP. Systematic pain assessment using an observational scale in nursing home residents with dementia: exploring feasibility and applied interventions. J Clin Nurs 2012;21:3009–17.

Implications for practice and research

  • Observational behavioural tools often fail to identify pain among people with dementia, rendering their utility to clinical practice questionable.

  • Caregivers used strategies such as redirecting rather than analgesic medication.

  • Further research is needed to explore the most effective strategies for decreasing pain in this context. This likely includes using different assessment strategies, different treatment protocols and staff mentoring.


The underdetection of pain in people with dementia is commonplace1 resulting in reduced quality of life and increased behaviour problems. Research has shown that pain can be detected and effectively treated in nursing home residents with dementia,2 ,3 reducing behaviour problems3 ,4 and pain.4 However, adequate pain detection and treatment has not been integrated into practice. This study aimed to examine the implementation of a systematic pain observations protocol by nursing staff and its impact on analgesic medication use in people with dementia.


Six nursing staff members were asked to observe pain, twice a week, in 22 nursing home residents on one unit. Observations were recorded on the Dutch version of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) for 6 weeks. Staff were asked to record the interventions that were implemented following the assessment on a datasheet that included a range of possible interventions. Staff were interviewed for their feedback on the protocol.


The nursing staff members demonstrated high compliance (90%) with the observation protocol. Only 23% of the observations resulted in a score indicating pain. Compliance with completing the intervention datasheet was lower (65%). About half of those who completed this datasheet indicated that no intervention was undertaken, and the rest described non-pharmacological interventions such as distraction and comforting. Staff members provided mixed reports on the protocol, on the one hand describing it as user-friendly and feasible, and on the other hand finding pain cues interpretation difficult and unclear and opting for less frequent observations.


This study tackles the important clinical problem of undertreatment of pain in people with dementia as well as the problem of translating research findings into practice and promoting behavioural change in frontline staff members. The study4 demonstrated success in changing staff behaviours so as to perform and record the behavioural observations. However, as data were only collected over a 6-week period, longer term changes need to be examined.

The use of an observational assessment tool in this study may have impacted on the results. Other research of pain detection in people with advanced dementia found that observational assessments consistently underdetected pain in comparison to direct care nursing staff ratings and self-report.4 In Cohen-Mansfield and Lipson's study informant assessments by direct-care staff provided the most complete picture since persons with advanced dementia often cannot provide reliable self-report. While staff in this study reported the tool to be clinically useful, it resulted in low detection of pain, and even when detected, did not result in analgesic use. Furthermore, in line with recent research,5 staff members reported difficulty in interpreting pain cues, suggesting that assessments should focus on observable symptoms and minimise the need for interpretation and judgement by the staff.

Nurses reported using redirection and comforting interventions. The current intervention protocol included a sheet with various pharmacological and non-pharmacological interventions. Other studies that demonstrated significant pain decreases in this population3 ,4 used clinical protocols based solely on analgesic use. It is possible that when nurses are given a choice they prefer using non-pharmacological interventions in this population. It is also possible that, as demonstrated in other studies,6 nurses did not appreciate the pain sufficiently to request analgesic drugs, or that they lacked knowledge concerning appropriate analgesic medication. Future studies need to combine other assessments, use of clinical guidelines for analgesic use, and may also require systemic changes, such as staff mentoring, and using a palliative care specialist or a dementia specialist.

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  • Competing interests None.

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