Breathing (Independent of Vocalization)

0 — Normal breathing (regular, effortless)+01 — Occasional labored breathing; short period of hyperventilation+12 — Noisy labored breathing; long period of hyperventilation; Cheyne-Stokes respirations+2

Negative Vocalization

0 — None+01 — Occasional moan or groan; low-level speech with a negative or disapproving quality+12 — Repeated troubled calling out; loud moaning or groaning; crying+2

Facial Expression

0 — Smiling or inexpressive (neutral)+01 — Sad; frightened; frown+12 — Facial grimacing+2

Body Language

0 — Relaxed+01 — Tense; distressed pacing; fidgeting+12 — Rigid; fists clenched; knees pulled up; pulling/pushing away; striking out+2

Consolability

0 — No need to console (or easily consoled); distracted or reassured by voice or touch+01 — Consoled with difficulty: distractability or reassurance is inconsistent+12 — Unable to console, distract, or reassure+2

PAINAD — Pain Assessment in Advanced Dementia Scale

PAINAD — Pain Assessment in Advanced Dementia Scale