Abbey Pain Scale for Dementia Patients
Abbey Pain Scale
Vocalization
Facial Expression
Body Language
Behavioral Change
Physiological Change
Physical Change
Abbey Pain Score:
0
Assesses pain in patients with advanced dementia.
Why Use
Pain assessment is difficult in the dementia population, a group believed to be under-treated for pain. A standardized tool may help improve management.
When to Use
Patients with severe dementia and potentially in pain.
Formula
Addition of selected points: Criteria Points Vocalization Whimpering, crying Absent 0 Mild 1 Moderate 2 Severe 3 Facial expression Tense, frowning, grimacing, frightened Absent 0 Mild 1 Moderate 2 Severe 3 Body language Fidgeting, rocking, guarding, withdrawn Absent 0 Mild 1 Moderate 2 Severe 3 Physiological changes Temp, pulse or BP elevations, diaphoresis, flushing/pallor Absent 0 Mild 1 Moderate 2 Severe 3 Physical changes Skin tears, pressure sores, arthritis, contractures, previous injuries Absent 0 Mild 1 Moderate 2 Severe 3
Pearls / Pitfalls
The Abbey Pain Scale is a standardized pain assessment tool developed for use in demented nonverbal patients.
Critical Actions
Requires a comprehensive examination to assess for physical injuries, vital signs and sources of potential pain.
More Information
Score interpretation: Scores ≤2 indicate no pain. Scores 3-7 indicate mild pain. Scores 8-13 indicate moderate pain. Scores ≥14 indicate severe pain. Note: all scores can be classified by type of pain: acute, chronic and acute on chronic.