Delaine Ammaturo, BA (Hons) and Thomas Hadjistavropoulos, Ph.D., FCAHS



Older adults with dementia frequently present with musculoskeletal pain problems and mobility concerns (1). As such, physiotherapists often provide care for this population aimed at preventing further functional decline, promoting mobility, and generally improving quality of life. Despite the important role of physiotherapy with patients who have dementia and pain, physiotherapists are challenged by the communication impairments that characterize dementia. This is especially true when trying to assess pain in these patients. In order to effectively provide treatment of pain to this population, valid pain assessment is essential. This short article is intended to provide information on effective provision of pain assessment among older adults with dementia using scales developed and validated by our group.

Undertreatment of Pain in Patients with Dementia

Pain in older adults, especially residents of long-term care (LTC) facilities (i.e., nursing homes), is an important public health issue.  There is a very high prevalence of chronic pain in this population – as high as 80% according to recent reports (2, 3, 4).  The impact of pain on older adults with dementia can be devastating to their overall quality of life, mental health, and is often associated with a quicker progression of cognitive and functional decline (5, 6, 7). Pain is a complex subjective experience that does not affect everyone in the same way (8). In circumstances involving dementia patients, caregivers may disregard behavioural pain cues (9). As such, pain needs to be assessed carefully. Dementia can create a barrier to the effective communication between caregivers and the individual in pain and, in the more severe stages of cognitive decline, limits ability to provide reliable self-report.  Given the subjectivity of the pain experience, the absence of valid self-report presents challenges for pain assessment. 

The PACSLAC Scales

The American Geriatrics Society (AGS) has outlined a list of domains that are important to assess when evaluating pain in seniors with dementia (i.e., vocalizations/verbalizations, facial expressions, body movements, changes in interpersonal interactions, changes in activity patterns/routines, and mental status changes). These domains are important to consider in the evaluation of behavioural observational pain scales (BOPS) (10).  To address the challenges of pain assessment in this population with cognitive impairments, several BOPS have been developed.  Please refer to Hadjistavropoulos et al., (11) for a recent review of these tools.  Of the many tools that have been developed, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) (12) is among the most researched ones (e.g., 13, 14) and represents the focus of this brief article.  Clinicians are encouraged to read recent reviews of the literature (e.g., 11) to learn about other measures that are well regarded.

The PACSLAC was found to differentiate between pain and non-pain states in older individuals with dementia (15).  Moreover, research has suggested that regular use of the PACSLAC leads to improved pain management practices (16, 17).  Lastly, the PACSLAC’s comprehensive content has the advantage that it encompasses every aspect of nonverbal behaviours considered significant by the AGS for the assessment of pain in persons with dementia (10).

Recently the PACSLAC was revised in an effort to improve its specificity and reduce its length without compromising psychometric properties.  The resulting PACSLAC-II is a valid and reliable 31-item tool designed to assess the presence or absence of pain based on observation of pain behaviours (refer to description of psychometric properties below).  It normally takes less than 5 minutes to complete and is organized into conceptually based, internally consistent subscales (i.e., Social Personality/Mood Indicators, Facial Expressions, Activity/Body Movement, and Physiological Indicators/Eating/Sleeping Changes/Vocal Behaviors), although only the total score should be used clinically.  Psychometric investigations of the PACSLAC-II indicated satisfactory internal consistency, strong convergent validity (the PACSLAC-II was significantly correlated with other observational pain tools), and ability to discriminate between pain and baseline conditions using vaccination  and movement-exacerbated pain  and to account for more variance than other tools (18). 

Access to valid observational methods of pain assessment for use by physiotherapists will facilitate earlier detection of symptoms and better treatment of pain for this vulnerable population. We suggest the regular use of evidence-based pain assessment of older persons with dementia, using a standardized approach.  Without regular and systematic assessment, pain problems will often go undetected in this population. Given the need for systematic pain assessment and intervention for older adults with dementia, mobility concerns, and musculoskeletal pain problems, we suggest greater use of the PACSLAC-II by physiotherapists.  The PACSLAC-II does not have a cut off score. We are of the opinion that observational pain assessment tools for dementia cannot have generalizable cut off scores because scores are dependent on a variety of factors (e.g., type of dementia, duration of observation, and whether or not a patient is ambulatory can all affect the number of pain behaviours displayed). Instead, we have recommended an individualized approach to assessment, which we have detailed in a knowledge translation article that we published in Physiotherapy Canada in 2010 (19; see volume 62, issue 2, pages 104-113).  The Physiotherapy Canada article talks about the PACSLAC (as opposed to the PACSLAC-II) but the approach to assessment would be the same irrespective of observational tool used.  We encourage clinicians interested in using the PACSLAC scales or other tools of this kind of this kind to consult this article:

Declaration of Conflict of Interest:  Thomas Hadjistavropoulos is one of the developers and copyright holders of the PACSLAC scales.  He has no commercial interest on the scales.

Additional Information

Instructions for the use of the PACSLAC-II can be found at this link:

A copy of the PACSLAC-II can be found at this link:

For permission to reproduce the PACSLAC-II, please contact the copyright holders:

The authors work for the Centre on Aging and Health, University of Regina



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