Managing pain in dementia: lower dependency and fewer hospital transfers

Many individuals living with dementia often experience pain but find themselves unable to self-report this pain, causing it to go undetected.

Pain can drive functional decline in activities of daily living (ADLs), distressed behaviours, sleep disruption and falls – each contributing to increased care needs and the higher likelihood of hospital transfer. Longitudinal evidence shows that changes in pain predict ADL decline independent of dementia severity, meaning better pain management is a direct lever for maintaining independence and reducing dependency scores.

Reduced mobility, accumulating long-term conditions, poor discharge communication and care home resource constraints are all major determinants of hospital readmission and will increase the number of avoidable hospital transfers. Pain identification is key to reducing factors that lead to increased dependency and hospital visits. Here is why:

1. Pain increases baseline dependency– Residents experiencing pain tend to score lower on the Katz Index of ADLs than those without pain. When pain levels rise over a three-month period, this often predicts further decline at six months, particularly in areas such as transferring and feeding.
2. Pain limits completion of ADLs in line with severity– Functional pain scales show a clear pattern: moderate pain restricts the ability to carry out daily activities, while severe pain can make most ADLs impossible without assistance. These limitations directly contribute to higher dependency scores.
3. Pain is often mistaken for dementia-related behaviours– Agitation, resistance to care, and social withdrawal frequently indicate untreated pain. Indeed, pain is a frequently overlooked cause of Behavioural and Psychological Symptoms of Dementia (BPSD). However, pain remains significantly underassessed in people with advanced dementia, especially in care home settings.
4. Movement-related pain accelerates ADL decline– Pain levels are typically higher during movement – the very moments when ADLs must be performed. This increases difficulty and reduces independence over time.
5. Growing dependency increases hospital transfer risk– As care needs intensify, residents become more prone to falls, pressure ulcers, infections, and behavioural crises, all of which commonly lead to hospital admissions.
6. Dependence on caregivers strongly predicts readmissions– Research by the NIHR shows that people with dementia who rely on caregivers for mobility have a 59% higher risk of 30‑day hospital readmission, and those dependent for self‑care face a 73% higher readmission risk.

People living with dementia often experience rising dependency due to cognitive decline, mobility issues, behavioural symptoms and unmet care needs. As dependency increases, so does the likelihood of hospital transfer, either in the form of acute admissions, avoidable readmissions or nursing home-to-hospital transfers.

How PainChek^® transforms pain assessment

It is important that people living with dementia are given routine, structured pain assessments using validated observational tools. Ad-hoc or inappropriate tools can often miss pain and further inflate dependency. It is also necessary to treat pain early and review it regularly to preserve mobility, sleep, mood and participation. Assessing at rest and in movement is vital as movement-provoked pain is a key driver of ADL difficulty and associated behaviours.

PainChek^® is a CE‑marked medical device for pain assessment. Now FDA De Novo cleared, it analyses micro-facial expressions plus observable pain indicators (voice, movement, behaviour, activity, body) to generate objective pain scores for people who cannot reliably self‑report. It drives frequent, reliable pain assessments, enabling timely treatment that improves ADL performance and reduces avoidable hospital transfers.

Making a difference

PainChek has been found to have higher interrater reliability than the Abbey Pain Scale, with strong rater agreement at both rest and post-movement. This helps to reduce subjectivity so more staff can assess pain consistently and confidently.

• Scottish Care Inspectorate: PainChek was trialled in the Scottish care system across the country in a government-funded pilot through the Scottish Care Inspectorate. This pilot demonstrated substantial clinical and economic benefits for aged care providers using PainChek, including a 27% reduction in dependency scores on a national level.
• Randolph Hill Nursing Homes: saw a 73% reduced/maintained dependency score over six months, coinciding with a 70% reduction in altered sleep cycles, a 23% reduction in stress and distress and a 50% reduction in altered and random movement.
• Greenock Medical Aid Society: during a six-month evaluation using PainChek, a 68% reduced/maintained dependency score was achieved. This improvement made it easier to care for residents as they were less resistive to care and able to engage much better with personal care and ADLs.

Driving better dependency scores and fewer transfers

By improving the accuracy, frequency, and quality of pain assessments, PainChek helps prevent pain‑related functional decline, behavioural incidents, and medical deterioration that often leads to hospitalisation. PainChek generates an objective pain score that accurately identifies pain, ensuring it is treated early and helping to prevent the functional decline, which increases dependency scores.

In a recent whitepaper, use of PainChek was linked to several positive clinical outcomes including:

• An increase in accurate pain assessment and residents receiving appropriate pain relief because of this newly identified pain
• A reduction in distressed behaviours linked to untreated pain
• A reduction in the number of falls and hospital admissions

Accurate pain identification ensures that pain is treated early, preventing functional decline that increases dependency scores. Untreated pain can lead to immobility, lower ADL functioning, reduced appetite, disturbed sleep and behavioural expressions of discomfort – all of which increase dependency. By systematically detecting pain, PainChek enables targeted treatment that supports mobility, daily functioning, and independence.

Early treatment can help to prevent complications such as falls, infections, and dehydration which commonly result in hospital admissions for people living with dementia. Preventing these can reduce hospital admissions and the likelihood of emergency interventions for residents.

A practical blueprint

To help improve pain management for dementia patients and reduce dependency and hospital visits, NHS ICBs and care providers should look to:

1. Commission a standardised pain pathway for dementia – mandate validated pain assessments on admission, daily and before/after care is delivered.
2. Deploy digital assessments (e.g. PainChek) at scale – integrate these with current platforms and enable role-based access so all staff members have access.
3. Link pain scores to ADL goals and care plans – for rising pain scores, it is important that analgesia review, physio input, hydration/nutrition check, sleep hygiene and constipation checks are automatically triggered.
4. Target behavioural incidents via pain-first approaches – require pain assessment before psychotropics or 1:1 supervision.
5. Train and support the workforce – continuous training on recognising pain presentations in dementia is key. Including carers in this where appropriate can help to extend monitoring coverage.

Supporting independence and reducing hospital transfers

Pain management plays a crucial role in helping people with dementia maintain mobility, cognition, sleep, and overall engagement. By providing consistent, objective assessments at scale, PainChek supports early identification of pain, helping to prevent avoidable hospital transfers linked to untreated pain, falls, behavioural crises, and general health deterioration.

Learn more about the importance of identifying and addressing pain early and the positive effect this can have in our latest free resource.