1. Horgas, Ann L. PhD, RN, FGSA, FAAN
  2. Bruckenthal, Patricia PhD, APRN-BC, FAAN
  3. Chen, Shaoshuai MS, BSN, RN
  4. Herr, Keela A. PhD, RN, AGSF, FGSA, FAAN
  5. Young, Heather M. PhD, RN, FAAN
  6. Fishman, Scott MD


This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.


This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Horgas, A.L., et al. Assessing Pain in Older Adults. Am J Nurs 2022; 122 (12): 42-48.


Article Content

Pain in older adults is common and affects their quality of life. Pain is more than a physical experience; it contributes to psychological distress, sleep disturbances, loneliness, and poor appetite.1 Family caregivers often engage in managing their care recipient's pain, and 80% find this stressful.2

Figure. A nurse advi... - Click to enlarge in new windowFigure. A nurse advises a family caregiver on assessing pain. Photo courtesy of the AARP Public Policy Institute.

Accurately assessing pain and sharing pain information with health care providers are essential to establishing patient-centered treatment plans and effective ongoing pain management. To that end, this article discusses how nurses can teach family caregivers to recognize and document pain at home in order to optimize pain treatment and outcomes. We outline key elements of the pain assessment process; strategies, tools, and considerations for assessing pain in older adults, including those with cognitive impairment; and challenges faced by caregivers of people living with pain.



The components of a comprehensive pain assessment for older adults are similar to those for younger people but may be complicated by unique circumstances associated with aging, including sensory and cognitive impairment, lifelong patterns of pain coping (ranging from heightened attention to pain to suppression or denial of pain), and fear of consequences of reporting pain or loss of independence. Pain assessment requires self-report, when possible, and ongoing observation. Both are subjective and may be filtered through individual and cultural influences. Family caregivers play an important role in helping older adults reflect on their pain, observing behaviors that may suggest pain and discomfort, and recording these findings to share with health care providers when needed.


Steps in comprehensive pain assessment include: 1) determining the presence, source, characteristics, and impact of pain; 2) identifying exacerbating and relieving factors associated with pain; 3) recognizing the presence of coexisting illness or health conditions that might affect pain; 4) reviewing attitudes, beliefs, and expectations regarding pain; and 5) gathering information that may affect the treatment plan, including details about sociocultural factors, the person's quality of life, and their functional goals. The following sections highlight key aspects of pain assessment in older adults.



Self-report. With older adults who are cognitively intact and can communicate, the best approach to assessing pain is to directly ask about it. Nurses can coach caregivers to conduct a "one-minute pain assessment," asking three questions3:


* "Do you have any aches or pains today?"


* "Can you tell me about your pain, aches, soreness, or discomfort?"


* "Would you say your pain is mild, moderate, or severe?"



Physical assessment. Conducting a physical assessment and determining the impact of pain on the person's functioning can help identify the potential cause of the pain. Caregivers may engage in varying degrees of physical assessment, from observing how the person performs typical daily activities to physical examination. Physical assessment may include inspection for skin discoloration (redness, paleness, bruising, mottling) or obvious deformity. Observation of pain behaviors (facial expressions, vocalizations, body movements like limping or bracing) can also indicate the presence of pain.


Gathering and sharing information with providers. Details about medical history, including surgeries, accidents or injuries, psychological conditions, and past and present medication use, are important in guiding treatment decisions; caregivers should keep a written record on hand and communicate these details to providers. Additionally, it is valuable for caregivers and providers to discuss psychosocial factors pertaining to the older adult, such as their level of social support; participation in recreational activities; and financial resources; as well as attitudes, beliefs, and cultural factors that influence how the older adult perceives and expresses pain.


Substance use. It is also important to assess and share with providers the care recipient's use of substances, such as tobacco, cannabis, alcohol, or illicit drugs, as well as herbal supplements. Ongoing assessment of the amount and frequency consumed, the effects on pain and function, and any side effects (both positive and negative) is needed, and this information is critical in developing successful patient-centered care plans.


Recent literature has highlighted the benefits of cannabis in the treatment of various types of pain.4, 5 Because cannabis use in older adults is increasingly common, obtaining information on whether and how the person uses it, and how it affects them, is essential.


Smoking cessation has been associated with improved pain outcomes in geriatric populations, although the initial phase of cessation may be associated with increased pain, which can precipitate relapse.6



People with Alzheimer disease and related dementias have a decreased ability to self-report pain due to progressive cognitive decline.7 Pathological brain changes affect language, memory, and the cognitive processing needed to communicate pain.8 Despite their diminished ability to self-report pain, there is no evidence that people with dementia experience less pain.9 In people with Alzheimer dementia or vascular dementia, the two most common types of dementia, pain intensity is similar to that experienced by cognitively intact older adults but the emotional response to pain is more pronounced.9 Further, there is evidence that people with dementia display more pronounced facial indicators of pain than those without dementia.10 This is an important point for caregivers, as the evidence indicates a need for focused attention on pain assessment in this population.


In patients unable to provide self-report, nurses should take a hierarchical approach to pain assessment that includes the following steps: 1) be aware of potential causes of pain, 2) attempt to obtain a self-report of pain, 3) observe behaviors, 4) seek input from family and caregivers on their observations of the person's pain, and 5) attempt an analgesic trial.8 Self-report may be possible in people with mild to moderate dementia using simple numeric or verbal descriptor scales.10, 11 For those with moderate to severe dementia, observation of behavioral or nonverbal indicators of pain is recommended, including facial expressions (grimacing), body movements (guarding, bracing, or rubbing), and vocalizations (groaning, verbal expressions).10 Changes in behavior may also indicate pain in people with dementia.12 Nurses and other health care providers can educate caregivers on how to use this stepwise approach to guide pain assessment at home, including nonverbal indicators to look out for.



Use of a standardized pain assessment tool enables caregivers and health care providers to track the older adult's pain experience over time. Nurses can help caregivers select an appropriate pain assessment tool and encourage them to use it consistently. Among people who can provide self-report, commonly used tools to measure pain intensity include verbal descriptor scales or numerical rating scales.13 Other tools, such as the PEG (pain, enjoyment, general activity) scale, assess the impact of pain on emotional and physical function.14 For older adults who cannot self-report, observational tools are recommended. The Pain Assessment in Advanced Dementia scale is easy to use and can be completed in less than five minutes.15 Caregivers should be encouraged to use this tool to assess pain at different times of the day, such as when the older adult is at rest, during activities or movement, and before and after pain interventions.



Nurses and other clinicians should educate family caregivers on the importance of consistently monitoring and documenting the older adult's pain. Caregivers can use a pain diary to record pain information and share it with providers (see The information collected in a pain diary can help to identify changes and patterns in pain over time, which is crucial for recognizing exacerbations and evaluating treatment effectiveness.


How often pain should be assessed depends on the type and severity of the pain. For people with persistent musculoskeletal pain, recording pain daily or several times per week may be sufficient. For people with severe or fluctuating pain, more frequent pain assessment and recording is warranted to detect patterns, triggers, and treatment effectiveness. If multiple caregivers care for the older adult, they should all use the same assessment tool, assessment timing, and pain diary.


Some caregivers and older adults may prefer to use mobile apps to assess and record pain.16, 17 The Keele Pain Recorder is an evidence-based, validated pain monitoring app available for download.18 The app helps patients track pain intensity, its impact on daily life, and medication effectiveness, and the recorded data can be easily shared with health care providers.



Being a caregiver of someone experiencing pain can be challenging. In married couples, adults with chronic pain and their spouses have high rates of depression and marital discord.19 The impact on family caregivers of an older adult's pain can be influenced by the type and closeness of the relationship, accuracy of pain perceptions, coping styles, and communication patterns.20 Having accurate perceptions of the care recipient's pain is associated with more positive family outcomes.20


Assessing caregivers' self-efficacy-their confidence or certainty that they can perform a task21-may identify the need for further education. Nurses can assess pain-related self-efficacy by asking the caregiver questions like, "How certain are you that you can help the patient control her or his pain?" Questions can also focus on specific aspects of pain management, such as communicating about pain or assessing pain. Coaching older adults and caregivers to enhance their self-efficacy to manage pain has been shown to increase caregiver satisfaction and improve patients' pain severity.22 In addition, higher levels of self-efficacy for pain communication were associated with better outcomes in people with pain and their partners.23


It is important to acknowledge and remind caregivers of the effect the care recipient's pain can have on the caregiver's well-being. Seeing someone in pain can trigger fear about disease progression or worry about how long the pain will last or how severe it will become. Nurses can encourage caregivers to seek resources as needed, whether in the form of knowledge, assistance, or respite. It may be helpful for caregivers to discuss their feelings at a support group or with friends or family members. Caregivers should be encouraged to engage in self-care to support their emotional and physical health.



Table 1 summarizes the key steps of the pain assessment process. Additionally, nurses can refer caregivers to the tear sheet, Information for Family Caregivers, which offers tips on assessing the care recipient's pain, gathering pain information, and communicating effectively with the health care provider. It also includes links to pain assessment tools, a pain diary template, and other pain-related resources.

Table 1 - Click to enlarge in new windowTable 1. Key Elements of Pain Assessment for Caregivers

Information for Family Caregivers

Assessing Pain


As a caregiver, you play an important role in recognizing when the person you care for is in pain, gathering information needed to help the health care provider treat and manage pain, and communicating with the provider.


How to Know When Pain Is Present


* If the person can communicate, ask questions such as:


* Are you having pain, aching, hurting, discomfort, or soreness?


* Where does it hurt? (Have them point to the area.)


* Is this a new pain or pain you have had before?


* How severe is the pain? (Have them rate it as mild, moderate, or severe, or on a scale from 0 to 10.)


* What does the pain feel like? Is it sharp, dull, or burning? Are there other words to describe it?


* When do you feel the pain? Does it come and go? Is it there all the time?


* What makes it better? What makes it worse? (For example, does changing positions help? Does a heating pad help?)


* Listen for words the person may use to describe pain, like ache, hurt, and discomfort.


* Observe the person. They may express pain by


* grimacing, bracing, limping, moaning, or groaning.


* sleeping less or walking less.


* appearing detached, sad, or irritable.


* no longer engaging in activities they used to enjoy.


* being agitated, lashing out, or yelling.


* Be aware that some people prefer not to say they are in pain. Reasons may include


* believing they should be brave or stoic and not complain when hurting.


* believing that pain is part of aging, and nothing can help.


* fear of the pain's cause, hospitalization, or pain treatment.



When to Seek Professional Help


* If pain is mild to moderate and comes and goes, you may be able to manage it by using over-the-counter pain medications and/or heat or cold treatment, helping the person move into a different position, or distracting them with music or activities they enjoy.


* Contact a health care provider if pain is moderate to severe, persistent, not relieved by the above approaches, worsens suddenly, or prevents the person from engaging in activities that are important to them.



How to Gather Information to Share with the Provider


* Keep a written record of the person's medical, surgical, and accident history; current diagnoses; and current and past pain medications. Have this available when communicating with health care providers.


* Use a pain assessment tool to evaluate the severity of the person's pain, any changes over time, and how pain affects daily activities and mood. Several tools are available at


* Choose a tool that you can use easily and consistently. Ask your provider for guidance, if needed.


* If the person has dementia or cognitive impairment, use a behavioral pain tool ( to observe and record behaviors that may indicate pain.


* Pick a regular time to monitor and evaluate pain, such as daily in the morning, weekly, or any time pain is new or worsening. Use the same tool each time.


* Use a pain diary ( to record information about pain, possible pain triggers, treatments used, and response to treatment. Sharing the diary with the provider at appointments will help guide treatment decisions by showing patterns of pain and how treatment affects the pain.



Tips for Communicating with the Health Care Provider


* Help the person you care for communicate about pain directly with the provider, but be prepared to step in if they are not giving an accurate or complete picture.


* If the person has hearing or visual impairment, make sure they have access to items like hearing aids, glasses, and communication devices at the appointment.


* Be prepared to discuss


* how pain affects the person's quality of life.


- Can they sleep? Eat? Walk?


- Can they spend meaningful time with family and friends?


* any pain treatments that were tried and how they worked.


* the person's goals for pain relief.


* Be sure to ask any questions you may have.



Resources to Explore




* One Minute Pain Assessment (


* Using a Pain Diary (


* Assessing Pain in Your Family Member with Dementia: A Toolkit to Support Caregivers (


* Caregiver Guide: Pain (


* National Institute on Aging: Pain: You Can Get Help (


* American Chronic Pain Association: Daily Activity Checklist (



Family caregiver instructional videos about pain can be found on AARP's website:


* How to Assess Pain


* Self-Care, Resources, and Techniques



For additional information, the AARP Public Policy Institute's Home Alone Alliance website offers publications, training webinars, blog posts, and videos for family caregivers:


Resources for Nurses


* How to Assess Pain


* Self-Care, Resources, and Techniques


Note: Family caregivers can access these videos, as well as additional information and resources, on AARP's Home Alone Alliance web page:


INSTRUCTIONS Assessing Pain in Older Adults: Caregivers play a key role in recognizing and documenting pain at home.



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