Pain Assessment for Older Adults

By: Ellen Flaherty, PhD, APRN, AGSF, Dartmouth Centers for Health & Aging  

WHY: There is significant evidence demonstrating that pain is a common problem in older adults (persons 65 years of age and older). In one study, 50% of adults 65 years of age and older said they experienced pain in the previous 30 days. Up to 80% of nursing residents experience pain regularly (National Center for Health Statistics, 2006). Although many older adults suffer from pain there is widespread undertreatment of pain. Reasons for this include concerns related to opioid dependence, the belief that pain is a normal part of aging, and a lack of routine pain assessment. Persistent pain has been associated with functional impairment, falls, slow rehabilitation, depression, anxiety, decreased socialization, sleep disturbance, as well as increased healthcare utilization and costs. In 2009, the Joint Commission removed the requirement that pain be assessed as “the fifth vital sign” due to, in part, concerns of overtreatment of pain with opioids. However, in 2016, The Joint Commission began a project to both revise its pain assessment and management standards and identified the assessment and management of both acute and chronic pain a priority. 

BEST TOOL: Identifying and measuring pain begins with a person’s self-report. This can be challenging in a population with disparities in cognition, literacy, and language. Simply worded questions and tools, that are easily understood, continue to be the most effective. The best choice for assessing pain intensity include: the Iowa Pain Thermometer (IPT), the Numeric Rating Scale (NRS), and the Faces Pain Scale-Revised (FPS-R). The most widely used tool, the NRS, asks a person to rate their pain by assigning a numerical value with zero indicating no pain and 10 representing the worst pain imaginable. The IPT is a modified Verbal Descriptor Scale (VDS) with seven pain descriptors describing different levels of pain intensity. The FPS-R asks people to describe their pain according to a facial expression corresponding with their pain. 

TARGET POPULATION: All three scales are used with older adults in acute and long term care settings and in the community. While there are specific tools designed to capture pain in non-verbal cognitively impaired older adults, studies have shown that the FPS-R and the IPT may be used effectively with cognitively impaired older adults. The choice of a scale may depend on institutional preference or the presence of a particular language or sensory impairment. The most important consideration is the consistent use of the same scale with each individual. 

VALIDITY AND RELIABILITY: All three scales have demonstrated good internal consistency with Cronbach’s α coefficients of 0.85 to 0.89. Test-retest reliability for each ranged from 0.57 to 0.83 for the NRS, from 0.52 to 0.83 for the verbal descriptor scale and from 0.44 to 0.94 for the FPS-R. A factor analysis found that all three scales were valid, although the FPS-R was the weakest (Herr, Spratt, Mobily, & Richardson, 2004). 

STRENGTHS AND LIMITATIONS: The overall strengths of these scales are their ability to quickly and reliably screen for pain. These scales are intended to assess pain intensity and should not be substituted for a more comprehensive pain assessment that would include obtaining a pain history and a physical exam leading to the etiology of pain. For cognitively intact older adults all three scales are effective screening tools, with the NRS being the most widely used tool. In one study, the IPT showed the lowest failure rates with little appreciable affects associated with cognitively impaired older adults (Herr, Spratt, Garand, & Li, 2007).  While the research is limited there has been some evidence that these tools are effective when used with a variety of ethnic populations.


Best practice information on care of older adults:
Baker, D. The Joint Commission’s Pain Standards: Origins and Evolution. Oakbrook Terrace, IL. The Joint Commission 2017.
Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2006. With chartbook on trends in the health of Americans. Special features: Pain. Hyattsville, MD. Available at:
Cornelius, R.,Herr, K., Gordon, D., Kretzer, K., & Butcher, H. (2017). Acute Pain Management in Older Adults. Journal of Gerontological Nursing, 43(2), 18-27.
Herr, K., Bjoro, K., & Decker, S. (2006). Tools for assessment of pain in nonverbal older adults with dementia: A state-of-the-science review. Journal of Pain and Symptom Management, 31(2), 170-192.
Herr, K., Spratt, K., Garand, L., & Li, L. (2007) Evaluation of the Iowa Pain Thermometer and other selected pain intensity scales in younger and older adult cohorts using controlled clinical pain: A preliminary study. Pain Medicine, 8(7), 585-600.
Herr, K., Spratt, K., Mobily, P., & Richardson, G. (2004). Pain intensity assessment in older adults: Use of Experimental Pain to Compare Psychometric Properties and Usability of Selected Scales in Adult and Older Populations. Clinical Journal of Pain, 20(4), 207-219.
Taylor, L., & Herr, K. (2003). Pain intensity assessment: A comparison of selected pain intensity scales for use in cognitively intact and cognitively impaired African American older adults. Pain Management Nursing, 4(2), 87-95.
Taylor, L.J., Harris, J., Epps, C., & Herr, K. (2005). Psychometric evaluation of selected pain intensity scales for use in cognitively impaired and cognitively intact older adults. Rehabilitation Nursing, 30(2), 55-61.
Ware, J. Epps, C., Herr, K., & Packard, A. (2006). Evaluation of the revised faces pain scale, verbal descriptor scale, numeric rating scale, and Iowa pain thermometer in older minority adults. Pain Management Nursing, 7(3), 117-125.