Purpose: This pain behavior tool is used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably communicate their pain. It can be used by a nurse or by a CNA to screen for pain-related behaviors.  PAINAD Tool.

When to use: It should be used at the following time points:

  • At initial intake/admission to services
  • For an older adult with behavioral symptoms suggestive of pain, assess at least every 8 hours
  • Any time a change in pain status is reported
  • One hour following a pain intervention to assess effectiveness
  • For older adults residing in long term health care settings, assessments should be completed at each quarterly review

How to use:


Observe the older adult for 3-5 minutes during activity/with movement (such as bathing, turning, transferring).

For each item included in the PAINAD, select the score (0, 1, 2) that reflects the current state of the behavior.

Add the score for each item to achieve a total score. Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items).

After each use, compare the total score to the previous score received. An increased score suggests an increase in pain, while a lower score suggests pain is decreased.

CNA should report any changes or scores to the nurse for follow-up assessment.

See “How To Try This Video: Pain Assessment in Older Adults” for training staff.

Documentation: Document/record all scores in a location that is readily accessible to others on the health care team. 

Note: Behavior observation scores should be considered alongside knowledge of existing painful conditions and reports from someone who knows the older adult (like a family member or nursing assistant) and their pain behaviors. Remember some older adults may not demonstrate obvious pain behaviors or cues.

Reference: Warden, V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc, 4:9-15. Developed at the New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA.

PDF iconPAINAD Instructions - PDF Version