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Assessing pain when a person cannot tell you

Aged care staff GPs & clinicians Residents & families 7 min read

By Dr Josh Hatch, FRACGP

The Quality Standards require providers to assess each person’s pain, including where the person has difficulty communicating it 1. The Australian Pain Society’s guidance for residential care has separate assessment procedures for residents who can communicate and residents who cannot 10.

Numbers in the text link to the 6 sources listed at the foot of this page.

Asking first

Where a resident can answer, their own report is the starting point. Simple questions work: is anything sore or aching, where, and does it stop you doing anything? It helps to ask at the times pain is likely, such as getting up or during care, as well as at rest.

A diagnosis of dementia does not mean a person can no longer rate their own pain. In trials of pain management for nursing home residents with dementia, some residents rated their own pain and others were rated by staff 44.

The tools in common use

  • PAINAD. Pain Assessment in Advanced Dementia: a five-item observational tool scored from 0 to 10, developed in a US veterans’ dementia unit. The original study included 19 residents, a small number of men, and its authors said more research was needed before it could be universally recommended 7.

  • Abbey Pain Scale. Developed in Australian residential aged care homes for people with late- or end-stage dementia who could not say what they needed. Users said it could be completed in about a minute, and average scores fell by more than half after pain relief was given 8.

  • Other tools. A review of eight systematic reviews covering 28 observational tools found limited evidence for the reliability, validity and clinical usefulness of any of them, and concluded that no single tool could be recommended over the others 6.

What the tools can and cannot do

The tools score behaviour, and there is no gold standard to check them against 6. A high score is a reason to look for a cause, including pain. A low score in a resident who seems unwell does not rule pain out.

What a tool does well is make assessment routine and comparable: the same tool, used the same way, before and after a change in treatment. Both the PAINAD and Abbey development studies used their tool this way and found lower scores after pain relief 78.

Action 5.5.8 of the Quality Standards also requires processes for planning for, monitoring and responding to each person’s need for pain relief, and for pain management to be available 24 hours a day 1. An assessment that is recorded but not acted on does not meet that requirement.

Questions families can ask

  • “Which pain tool is used for my relative, and how often?”

  • “What were the recent scores, and what was done about them?”

  • “Is pain checked before and after showering, dressing or moving?”

  • “If pain relief is charted as needed, how do staff decide when to give it?”

Related pages on this site

Sources cited on this page

  1. 1 Australian Government Department of Health, Disability and Ageing. Strengthened Aged Care Quality Standards (November 2025; implemented 1 November 2025). Outcome 5.5, Action 5.5.8; Outcome 5.7, Actions 5.7.3 and 5.7.4. View source
  2. 6 Lichtner V, Dowding D, Esterhuizen P, et al. Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC Geriatr. 2014;14:138. View source
  3. 7 Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9–15. (Instrument development study, 19 residents.) View source
  4. 8 Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004;10(1):6–13. (Validation study in Australian residential aged care.) View source
  5. 10 The Australian Pain Society. Pain in Residential Aged Care Facilities: Management Strategies, 2nd edition, and supporting resources (resource page, copyright 2019). View source
  6. 44 Manietta C, Labonté V, Thiesemann R, et al. Algorithm-based pain management for people with dementia in nursing homes. Cochrane Database Syst Rev. 2022;4:CD013339. View source

See every source cited across the pain section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at November 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. It gives no doses, and it does not recommend any procedure, clinic or practitioner. Evidence and Australian regulatory and PBS arrangements change — always confirm current advice with the treating GP, pharmacist or specialist.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

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