presence of pa<strong>in</strong>.Scor<strong>in</strong>g of the breath<strong>in</strong>g <strong>in</strong>dicator seems unrelated to pa<strong>in</strong> severity.Breath<strong>in</strong>g does not seem to be a key <strong>in</strong>dicator of pa<strong>in</strong>. However, the tooldevelopers argue that one of the known areas believed to cause negativefeel<strong>in</strong>gs for persons with dementia is the aversive symptoms associated with<strong>in</strong>tercurrent respiratory <strong>in</strong>fections and that pneumonia is a the proximal causeof death for many demented persons. Thus, they <strong>in</strong>cluded the breath<strong>in</strong>g item.We perceive consolablity as a response to an <strong>in</strong>tervention, not a behavioralmanifestation of pa<strong>in</strong>. However, the relationship between consolability andpa<strong>in</strong> may be an area for future research <strong>in</strong> this population.The validity for the scor<strong>in</strong>g of items accord<strong>in</strong>g to pa<strong>in</strong> severity or separationof behaviors with<strong>in</strong> each major category is not established, (eg. Breath<strong>in</strong>g isscored: Normal=0, Occasional labored breath<strong>in</strong>g/Short period ofhyperventilation =1, Noisy labored breath<strong>in</strong>g/Long period ofhyperventilation/Cheyne-Stokes respirations=2). However the tool appears toidentify higher and lower levels of pa<strong>in</strong> <strong>in</strong> an <strong>in</strong>dividual.Although the PAINAD does not adequately sample the content area ofbehavioral <strong>in</strong>dicators for pa<strong>in</strong> <strong>in</strong> elders with dementia who are unable tocommunicate, studies have demonstrated that the tool measures pa<strong>in</strong>. It maynot detect pa<strong>in</strong> <strong>in</strong> patients that demonstrate pa<strong>in</strong> with behaviors other thanthose <strong>in</strong>cluded <strong>in</strong> the tool.SubjectsPanel rat<strong>in</strong>g: 1Revised: 3Subjects Study 1 (Warden et al., 2003)Long term care VA <strong>Dementia</strong> Special Care Unit (96 patient unit).Subjects: 19 veterans, all CaucasianAverage age: 78.1 years (±5), Range 66-85 yearsGender: Female: 0, Male: 100%The subjects had dementia for 8.7 years on average (±4.7), Range 1-20.Length of time <strong>in</strong> residence: 16.5 months average (±13.5), Range 1-50months.MMSE: 2.8 ±4.5, Range 0-16.Bedford Alzheimer Nurs<strong>in</strong>g Severity Subscale: average 16.4 ±4.4, Range 9-23.Study 2 Lane et al., 2003)QI study – charts of 25 patients were used.No demographic data or disease characteristics are available for thesesubjects.Study 3 (Costardi et al., 2006)Geriatric Evaluation and Rehabilitation Unit, Northern Italy (n=1)Subjects: 20 with chronic pa<strong>in</strong> and dementiaAverage age: 82 (SD=5.9) years; Range: 73-93 yearsGender: Female 80% Male: 20%MMSE: 16.4 + 3.8, range 10-22Study 4 (Hutchison et al., 2006)Acute care hospital, US (n=1)Subjects: 53 control and 27 PAINAD with acute postop pa<strong>in</strong>Reviewed 04/04Revised 06/082
Average Age: 85.2 control and 88 PAINADGender: 85% female <strong>in</strong> control and 78% female <strong>in</strong> PAINADMMSE: control: 0% with less than 25 <strong>in</strong> control and 100% diagnoseddementiaPAINAD group: 23.6% with MMSE less than 25 and 76.4% diagnoseddementiaStudy 5 (Leong et al., 2006)Nurs<strong>in</strong>g Home <strong>in</strong> S<strong>in</strong>gapore (n=1)Subjects: 88 with moderate and severe dementiaAverage Age: 79.6 (SD=8.3)Gender: 61.4% female; 38.6% maleMMSE: Not reportedStudy 6 (van Iersel et al., 2006)Palliative care patients <strong>in</strong> NH sett<strong>in</strong>g (n=17)Patients who could not express pa<strong>in</strong>Subjects: 157 patientsAverage Age: 85 years; range 22-100Gender: 78% female; 22% maleMMSE: Not reportedStudy 7 (Zwakhalen et al., 2006)Nurs<strong>in</strong>g Homes <strong>in</strong> Netherlands (n=3)Subjects: 128 patients with dementia; both acute and chronic pa<strong>in</strong>Average Age: 82.4 (SD=6.8) years; range 60-96Gender: 78.1% female; 21.9% maleMMSE: Not reported; Cognitive Performance Scale: 21.9% mild, 28.1%moderate, 47.7% severeStudy 8 (Schuler et al., 2007)Nurs<strong>in</strong>g Homes <strong>in</strong> Germany (n=8)Subjects: 99 residents with dementiaAverage Age: 84.9 (SD=7.5)Gender: 80% female; 20% maleMMSE: Mean 12.1 (SD=9.7)Study 9 (Cohen-Mansfield & Lipson, 2008)Nurs<strong>in</strong>g homes <strong>in</strong> US (n=4)Subjects: 121 with dementiaAverage Age: 88 (range 59-101)Gender: 81.8% femaleMMSE: Mean 6.3 (range 0-20)Study 10 (DeWaters et al., 2008)Orthopedic unit <strong>in</strong> US hospital (n=1)Subjects: 25 verbal older persons, <strong>in</strong>cludes 13 cognitively <strong>in</strong>tact and 12cognitively impaired personsAverage age: 81.24 (range 65-95)Gender: 84% femaleMMSE: 20.52 (range 9-30) plus diagnosis of dementia or confusion-Panel Commentary The PAINAD has received considerable attention <strong>in</strong>ternationally and 7additional studies have been conducted that provide additional psychometricdata on this tool. The PAINAD was translated and tested <strong>in</strong> S<strong>in</strong>gapore,Belgium, Italy, Netherlands, and Germany, as well as two studies <strong>in</strong> the US.The majority of additional study has been conducted <strong>in</strong> NHs, however test<strong>in</strong>gReviewed 04/04Revised 06/083