Pain Assessment Guidelines and Frameworks

Consistent, reliable pain assessment and management is crucial to ensuring quality of life for the elderly population. It is estimated up to 93% of older people experience chronic pain1, which, if untreated or inadequately treated, can exacerbate the underlying condition and severely reduce daily function.

To that end, pain should be routinely assessed and investigated as a possible cause if there are any significant changes in an elderly person’s behaviour or function. In this article, we explore the key components in assessing pain, both for those who can and those who cannot reliably self-report their pain levels.

Questioning about the presence of pain

For those who are able to verbalise their levels of pain, self-reporting on a scale of 0-10 is considered the gold standard of pain assessment. Carers or clinicians should ask whether the person is experiencing pain at rest or while moving. Some best practices include:

  • Use a quiet area with minimal distractions
  • Ask at least two different questions phrased differently to assess pain
  • Use a variety of words to describe pain such as ‘sore’, ‘hurt’, ‘discomfort’ or ‘aching’
  • Allow plenty of time for the person to process the question and respond

Observation for signs of pain

Observation is an important tool in assessing pain in all elderly people, but particularly those who are not able to reliably self-report their pain, such as cognitively impaired older adults. Potential indicators of pain include:

Facial expressions

  • Frowning, sad or frightened face
  • Grimacing, wrinkled forehead
  • Closed or tightened eyes
  • Any distorted expression
  • Rapid blinking


  • Sighing, groaning, moaning
  • Grunting, chanting, calling out
  • Verbally abusive
  • Noisy breathing
  • Asking for assistance

Body movements

  • Tense posture, guarding, rigid, fidgeting
  • Pacing, rocking or repetitive movements
  • Reduced or restricted movement
  • Gait or mobility changes

Changes in behaviours

  • Aggressive, combative, resisting care
  • Socially inappropriate behaviour
  • Decreased social interactions
  • Withdrawn

Changes in activity patterns or routines

  • Appetite change, refusing food
  • Increase in rest periods
  • Sudden cessation of common routines
  • Increased wandering
  • Sleep or rest pattern changes

Mental status changes

  • Increased confusion
  • Crying
  • Irritability or distress

Physiological signs

  • Pallor
  • Sweating
  • Rapid breathing (tachypnoea)
  • Altered breathing
  • Rapid heart rate (tachycardia)
  • Hypertension

Note that physiological signs of pain may only be observable during a severe acute pain episode2.

Descriptions of pain

A comprehensive description of the person’s pain can assist in measuring its impact on their ability to take part in daily activities and their overall quality of life. The PQRST mnemonic can be used to form a description of the person’s pain:

  • Provoking factors (P): What provokes the pain? What makes it better and what makes it worse?
  • Quality (Q): What is the pain like? Is it aching, sharp, dull, burning, pounding?
  • Region and Radiation (R): Where is the pain located and does it go anywhere else?
  • Severity (S): Ask the person to rate their pain on a scale of 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable. Numerical rating scales (NRS) can also be used to monitor increases or decreases in pain levels over time.
  • Timing (T): When did the pain start? Is it constant or does it come and go?

Measurement using pain assessment tools

Using a multidimensional pain assessment tool ensures consistency and objectivity when assessing pain, and allows for ongoing monitoring of pain levels over time. This not only enables better care outcomes for the elderly population, but also improves clinical workflow for carers and helps facilities demonstrate compliance with national and global standards of care.

PainChek®, for example, is a clinically validated pain assessment tool that supports accurate and rapid pain assessment at the point of care. The digital pain assessment solution combines PainChek®’s AI pain assessment tool, which intelligently automates the multidimensional pain assessment process, with the Numerical Rating Scale (NRS) – one of the most widely used pain assessment scales for elderly people.

The PainChek® pain scale is composed of 42 items distributed across six domains3:

  • The Face: Utilising video-based facial recognition technology, or via manual analysis
  • The Voice
  • The Movement
  • The Behaviour
  • The Activity
  • The Body

The app also facilitates the recording of additional notes, such as PQRST descriptors.

PainChek®’s functionality allows reliable, accurate pain assessment in those who can reliably self-report their experience of pain, as well as those who cannot, such as older people living with dementia or other forms of cognitive impairment.

Reliable, ongoing pain assessment using a dedicated pain assessment tool can lead to improved pain management outcomes for older people. For example, a 12-month case study conducted by Orchard Care Homes in the UK found that implementing PainChek® resulted in:

  • 50% reduction in use of PRN benzodiazepines on average per month
  • 46% reduction in prescription of benzodiazepines
  • 25% reduction in prescription of antipsychotics, and 33% of residents with prescribed doses reduced
  • 92% reduction in the quantity of safeguardings reported relating to behaviour

These outcomes demonstrate the real-world impact pain assessment tools can have on pain management strategies for older people.

To find out more about how PainChek® supports effective pain assessment and management for older people, book a one-on-one session with a PainChek expert.


1Guidance on the management of pain in older people, Age and Ageing, Volume 42, Issue suppl_1, March 2013, Pages i1–i57,
2Pat Schofield, The Assessment of Pain in Older People: UK National Guidelines, Age and Ageing, Volume 47, Issue suppl_1, March 2018, Pages i1–i22,
3Atee, M., Hoti, K., Parsons, R., and Hughes, J. D. (2017a). Pain assessment in dementia: evaluation of a point-of-care technological solution. J. Alzheimers Dis. 60, 137–150. doi: 10.3233/JAD-170375

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