It is often difficult to determine the amount of pain an elderly person is experiencing.This is complicated by dementia and verbal impairment. This presentation describes helpful methods to assess pain in the elderly.

1. Measure of Pain in Elderly People with Dementia
Ross Finesmith M.D.
www.linkedin.com/pub/ross-finesmith-m-d/20/407/894
Abstract
The care of the elderly patient suffering from dementia is complex, particularly when
the nurse employs patient-centred, individualised approaches to care. Pain assessment
in such cognitively impaired individuals is made much more difficult by their
condition. Pain is frequently experienced by elderly patients, with reported prevalence
rates as high as 45–84% among patients in healthcare settings. Cognitive impairment
is also common in the elderly, with studies showing that approximately half of
patients in nursing homes or palliative care settings are affected to some degree
The Doloplus-2 method of clinical evaluation has been used to assess pain in elderly
and those with dementia for 15 years. This paper will examine the published literature
on the Doloplus-2 scale, evaluate the clinical utility and psychometric properties of
this instrument through critical appraisal, and discuss how Doloplus-2 may be used in
pain management for elderly patients with dementia.
Perspective
This article presents a critical review of a behavioural pain assessment scale, the
Doloplus-2. The Doloplus-2 is a rating scale completed by nursing staff to categorize
patient’s behavioral responses to acute pain. This measure could potentially help
clinicians more effectively identify the extent of pain in elderly who are unable to
verbalize their painful symptoms.
Page 1

2. Key words: Pain scales, Doloplus, Alzheimer’s, Pain assessment. Elderly pain scale
Index
Introduction ………………………………………………………………………4-5
Critical Appraisal …………………..…………………………………………………5
- The Doloplus-2 scale ……………………………..………………………………..6
- Clinical Utility …………………………………………...………………………6-8
- Psychometric Properties …………………………..…………………...…………..8
- Validity…………………. …………………………………………………….8-9
- Reliability………..………………………………...…………………………9-10
- Responsiveness………………………………………………...……………10-11
2

3. - Other factors to consider …………………………………………………………..11
Conclusion ……………………………………………………………………….12-13
Appendices ……………………………………………………………………….14-16
References………………………………………………………………………...17-20
3

4. Introduction
Evidence based practice is an essential aspect for all health care professionals because
it is becoming fundamental for practice clinical decision making. Macnee and
McCabe18
stress the importance of the evidence base in delivering care quality
improvement. Although the nature of evidence based practice continues to be debated,
especially from the differing ideological positions of nurses, medical staff and other
professions, the use of evidence to inform and change practice is an important
function of any nurse and requires the ability to apply critical evaluation to key areas
of care as Melnyk and Fineout-Overholt 21
emphasise.
The care of the elderly patient suffering from dementia (any one of the spectrum of
disorders which produce dementia) is complex, particularly when the nurse employs
patient-centred, individualised approaches to care. Elderly patients often present with
complex healthcare needs, yet from some evidence available it is suggested that the
elderly nursing care standards continue to be less than optimal.14
Over 50% of
nursing home residents, and a similar number of elderly patients admitted to acute
care hospitals, have dementia.11
Pain assessment in such cognitively impaired
individuals is made much more difficult by their condition3
. Pain can result in
behavioral changes in any person and should always be considered as a potential
cause in patients with dementia, especially in those that are non-verbal. Failure to
recognize pain in older adults can have serious effects on cognitive performance,
quality of life; increase symptoms of depression and functional ability29
.
An evaluation of pain measurement would serve many purposes, including identifying
how consistently measurement tools or instruments are used by nursing staff (or other
staff), identifying how effective the tools are in actually identifying pain, or how
effective they are in reduced negative outcomes or behaviours in patients such as
those with dementia whose cognitive impairments limit their ability to communicate
pain levels. Davies et al6
identify that altered cognitive patients are unable to inform
others of their pain.
This essay examines one method of clinical evaluation applied to the clinical setting;
the clinical evaluation method chosen is outcome measurement Pain assessment is the
4

5. chosen intervention for elderly people who suffer dementia. The outcome measure
tool is the Doloplus-2 (see appendix 1). This paper will examine published literature
on the Doloplus-2 scale, evaluate the clinical utility and psychometric properties of
this instrument through critical appraisal, and discuss how Doloplus-2 may be used in
pain management for elderly patients with dementia (see appendix 2).
The critical appraisal checklist as Jerosch-Herold16
guide is followed in this paper
because it is rigorous and comprehensive. It is hoped that the evidence gathered will
allow informed decision-making on the acceptability of this scale for use by nurses
and other care providers in everyday clinical practice.
Critical appraisal
Pain is frequently experienced by elderly patients, with reported prevalence rates as
high as 45–84% among patients in healthcare settings.12,19
Cognitive impairment is
also common in the elderly, with studies showing that approximately half of patients
in nursing homes or palliative care settings are affected to some degree. 8,20,22
Regular
assessment is vital in order to manage pain effectively. Elderly patients who had mild
cognitive impairment might be able to communicate well enough to understand and
use simple self-report tools for pain assessment such as the (VAS) tool, which is
Visual Analogue Scale, (VRS) Verbal Rating Scale, (NRS) Numeric Rating Scale or
(FPS) Facial Pain Scale. However, patients with moderate or severe impairment are
frequently unable to understand or answer even simple questions.8
These patients present a challenge for nurses and other care providers and evidence
shows that their pain management is frequently suboptimal, often as a result of
inadequate assessment and diagnosis.22,37
Behavioural pain assessment instruments must be used with this group for their pain
assessment. It is important to note that the behavioural pain assessment tools do not
measure pain directly, but are based on observations of behaviour related to sleep
patterns, level of appetite, patterns of physical activity and mobility, and expression of
body language .37
Assessment of physiological indicators for example: the heart rate
(Pulse) or blood pressure (BP) may also be included.37
There are many scales of
behavioural pain assessment that have been developed for use including Doloplus-2,
5

6. Pain Assessment in Advanced Dementia (PAINAD), Pain Assessment in Dementing
Elderly (PADE), Pain Assessment Checklist for Seniors with Limited Ability to
Communicate (PACSLAC) and Abbey Pain Scale.9,1,34,33,35
Glendinning 10
defines the outcomes as “Outcomes refer to the impact or the end
results of services on the person’s life”. Therefore it is important to evaluate and
appraise the tools used to measure them as Melnyk and Fineout-Overholt21
define the
“outcomes measurement is a generic term used to describe the collection and
reporting of information about an observed effect in relation to some care delivery
process or health promotion action. It requires the careful identification of reliable and
valid outcome indicators, the selection of appropriate measurement methods, and the
assurance of timeliness of data collection and reporting”.
Using these tools is intended to improve the elderly people quality of life and
monitoring the effectiveness of the intervention as well as for the professional
development by discovering who needs training as Corr and Siddons 5
say. Those
tools which form part of models of care planning and management of pain, underline
and reinforce continuous reassessment of pain in the light of changes in the patient’s
condition due to medical procedures, movement, activities of daily living, and the
administration of methods of pain relief. This kind of approach reflects the essence of
nursing care. As such, pain assessment must also be considered an essential
component of the nursing care of these individuals, because with the cognitive
impairments that are caused by dementia, they are some of the most vulnerable
patients that nurses will have in their care.
The Doloplus-2 scale
Clinical utility
The clinical utility of an instrument is an important factor in determining if the
instrument will be acceptable in clinical practice.28
To date, there are a lack of
published data on all of the available behavioural pain assessment tools demonstrating
their clinical utility, but the Doloplus-2 scale is the most widely tested scale.37
6

7. The Doloplus scale was originally developed as a 15-item scale in 1992 as a tool to
assess pain in elderly patients with cognitive failure, then refined to the present
Doloplus-2 scale in 1999.36
The scale comprises 10 items across 3 domains: somatic
(5 items), psychomotor (2 items) and psychosocial (3 items), and records observations
of various aspects of patient behaviour that may be indicative of pain. Items assess
pain-related behaviours such as facial expressions, disturbed sleep, verbal reaction,
protective body postures and functional impairment in daily activities, as well as
psychosocial reactions and changes in patterns of communication (see appendix 1).
Items are scored at one of four different levels which correspond to pain intensity
levels rising (where 0 = normal behaviour and 3 = high level of pain-related
behaviour).14,17
A final score ≥ 5 out of thirty (where 30 = maximum score of pain)
confirms that the patient is suffering pain.37
The final score obtained is not a measure
of the pain experienced by the patient at a particular point in time, rather a reflection
of the progression of pain experienced.37
Research has shown that scales, which can be used effectively not including an in-
depth knowledge of the patient, are of greater value than those which require the user
to be familiar with the patient which they are assessing.30
A possible limitation of this
scale is that it appears that the nurse or other care provider needs to know the patient
well in order to attain the most accurate results. A further limitation is that although
instructions for use are provided, certain items may be difficult to understand or
interpret.37
Therefore, additional training may be required to ensure competency in
those nurses wishing to use this scale with their patients, which will incur additional
cost, thus making the scale less cost-effective. There is no available information about
how long the scale takes to complete.
There is limited evidence to date on the portability of the Doloplus-2 scale. The
published literature that is available documents the findings of studies involving pain
assessment in elderly patients in hospitals and nursing homes, which was the patient
population for which this instrument was developed.14
Psychometric properties of the Doloplus-2 scale
7

8. Three psychometric properties are of particular importance when assessing a given
outcome measure, namely validity, reliability and responsiveness. Holen and
colleagues assessed the validity and reliability of the Doloplus-2 scale in a study in
2007. Their paper clearly defines the purpose of the study – to test the Doloplus-2
scale criterion validity and inter-rater reliability in elderly patients recruited from
nursing homes.14
The study was conducted in a total of 73 patients with a mean age
of 84 years. Within this sample, 50% of patients were reported to have severe
cognitive impairment and 36% were classed as moderately impaired (Mini Mental
State Examination [MMSE] scores of 0–10 and 11–20, respectively). It must be noted
that this is a small sample size and no power calculation was reported in the paper.
The study sample was representative of the patient population in whom the instrument
would be used (i.e. elderly patients with cognitive impairment). The scale description
is briefly included in the methods section of the paper, with full referencing of earlier
studies. User competency is demonstrated by the inclusion of a statement indicating
that the nurses who would be administering the instrument were either trained or
familiar with the patient.14
Although this study was conducted in a small number of patients, it can be considered
suitable for inclusion in this evidence-based investigation of the Doloplus-2 scale.
Validity
Validity relates to two factors: whether an instrument measures what it is intended for,
and how much confidence users can have in the results obtained when using the
instrument.5
Three different types of validity must be considered: face, content and
criterion validity. The Doloplus-2 scale is meaningful to both the patient and the nurse
as a behavioural pain assessment tool, thus demonstrating the face validity of this
instrument. Furthermore, this scale provides a comprehensive assessment of changes
in pain-related behaviour across three different domains, confirming content
validity.37
Criterion validity examines the extent to which a particular scale corresponds with
another well-established measure, typically considered the ‘gold standard’. However,
in the case of behavioural pain assessment, no gold standard currently exists and other
pain measures must therefore be used for comparison. In an observational study of a
8

9. convenience sample of 73 patients by Holen and colleagues,14
a pain specialist nurse
evaluated patients’ pain levels using a Numerical Rating Scale (a widely used pain
measure with favourable psychometric properties).
Results of univariate regression analyses showed no correlation between results
obtained using the Doloplus-2 scale and the expert’s pain ratings (R2
= 0.02).
Interestingly, when results obtained with Doloplus-2 were compared with pain ratings
on a subset of patients (n = 16) assessed by a geriatric expert nurse, a considerable
higher rating of R2
= 0.54 was obtained. It must therefore be debated whether pain
ratings determined by a pain expert who was unfamiliar with the patients provides an
acceptable means of comparison.
A prospective observational study by Pautex and colleagues25
in 2007 conducted in
180 hospitalised patients (mean age = 83.7 years; mean MMSE = 18.0) also
investigated the criterion validity of the Doloplus-2 scale. It improved on the previous
study with a larger sample size and by comparing observed pain to patient-reported
pain. The self-report VAS was employed as the gold standard in this study.27,15
Findings showed moderate correlation of Doloplus-2 with the VAS (Spearman
coefficient=0.46).25
Results of a small-scale study (n = 16 participants) conducted
using a French language version of the scale reported a correlation between Doloplus-
2 and both the VAS and L’Echelle Comportementa le Pour Personne Agées (ECPA)
(r = 0.67 using Pearson correlation coefficients).37
Torvik et al32
designed a study to assess the reliability (internal consistency) of
Doloplus-2 and compare registered nurses’ estimations of pain to the findings on the
Doloplus-2 assessment. A total of 77 non-verbal patients with a mean age of 86 were
included from 7 nursing homes in Norway. The patient’s primary registered nurse
administered the Doloplus-2 following an instructional session.
Concordance (90%) was found between proxy rating and Doloplus-2 scores with
respect to estimating ‘pain’ with the two different assessment methods, suggesting
that the two measures are addressing the same pain construct. The Cronbach’s alpha
score for the total questionnaire was 0.71
9

10. In this study, 52% of the patients were rated by nurses to be experiencing pain,
compared with 68% when using Doloplus-2 (p = 0.01). In one-third of the patients the
nurses could not determine whether the patients were in pain while the Doloplus-2
score represented pain. These findings support the use of Doloplus-2 as a supplement
to proxy rating.
Reliability
Reliability relates to the consistency and stability of a particular outcome measure.
There are two types of reliability, which must be considered in any evaluation: test-
retest reliability (i.e. a measure of how consistent the instrument is in producing the
same results at repeated intervals with the same user) and inter-rater reliability (i.e.
how consistent the instrument when used by different people). A systematic review
carried out in 2006 by Holen and colleagues about behavioural pain assessment tools
that reports adequate test – retest and inter - rater reliability of the Doloplus-2 scale.
The study shows, an inter-rater reliability of 0.77 (CI, 0.47–0.92) was obtained using
intra-class correlation coefficients. 14
An observational study conducted in a non-probability sample of 128 residents in
three nursing homes investigated pain during influenza and care situations using a
Dutch translation of the Doloplus-2 scale.38
Test-retest reliability of this scale was
measured using Cronbach’s alpha (where values ≥7.0 are considered high).26
An alpha
coefficient of 0.74 was obtained for the total scale and a range of 0.58–0.80 was
obtained for individual subscales. These findings therefore demonstrate good test-
retest reliability of Doloplus-2 in this population.
In the development and reliability assessment of the Doloplus-2 Japanese version,
non-verbal patients with AD were assessed for pain following surgery for a hip
fracture. In this study, 31 nurses monitored 6 patients during post-surgical
rehabilitation sessions. The intraclass correlation coefficient for inter-rater reliability
for the Version 2 administrators was 0.90 (P < 0.001), with a 95% confidence interval
of 0.88–0.92; the degree of agreement by items (0.67–0.90) was excellent.2
Nurses'
reported that while utilizing the Doloplus-2 there were no difficulties scoring
Japanese expressions and facial expressions. Analysis of individual patient case
10

11. studies indicated that pain scores were high only when the patients clearly were
experiencing pain, such as full weight bearing on the surgical hip. These results were
used to finalize the Japanese Doloplus-2. This was a small sample size and a similar
designed larger cohort still must be studied to confirm these findings.
The reliability, validity and clinical feasibility of Chinese version of the Doloplus-2
scale were supported in a study of institutional older people with moderate and severe
dementia. In this study the internal consistency for the total scale, was alpha 0.74 and
the subscales range was 0.67–0.87. The intra-class correlation coefficient of the scale
was 0.81 and of the subscales ranged from 0.60 to 0.81.4
The mean score of clinical
feasibility assessed by 14 RNs was 4.14 (S.D. 0.77; range 3–5), supporting the clinical
usefulness of Chinese-Doloplus-2 scale. The mean scores of the total C-Doloplus-2
demonstrated that older people with moderate and severe dementia had low levels of
behavioral expressions of pain.
In an eloquently designed study, Pickering et al24
examined the reliability of the
Doloplus-2 scale across 5 different languages. The languages were English, Italian,
Portuguese, Spanish and Dutch.
Nine teams (one for Dutch and two for each of the other languages) were been
developed on the basis of experience and competence in geriatrics and in pain
evaluation of elderly patients with communication disorders. Each team tested the
scale in their native language with at least 40 elderly persons.
There were 40 patients per team and each patient was assessed by two trained
physicians independently. Physician 1 evaluated the patient and physician 2 rated the
patient again 4 hours later without any treatment in between. Each physician assessed
the patients by observing for a few minutes prior to scoring the Doloplus-2®
scale.
The raters were blind to previous ratings.
The aim of the present study was to validate the translation of the Doloplus-2 scale in
five languages, with regard to test–retest and inter-rater reliability. Pearson and intra-
11

12. class correlation coefficients reveled good to excellent results for the four languages,
English, Italian, Portuguese and Spanish. The Pearson correlation coefficient ranges
from 0.95 to 0.99 for test–retest reliability and from 0.92 to 0.97 for inter-rater
reliability; the intra-class correlation coefficient ranges from 0.83 to 0.98 for test–
retest reliability and from 0.84 to 0.97 for inter-rater reliability. Dutch correlations are
fair to moderate, inter-rater reliability is 0.75 and test–retest reliability is 0.57
(Pearson) or 0.62 (intra-class).
These results establish that reliability tests and correlations are good to excellent for
the English, Italian, Portuguese and Spanish versions, while the reliability correlations
are fair to moderate and more heterogeneous for the Dutch scale.
Responsiveness
This relates to how sensitive a particular instrument is at detecting meaningful and
clinically important changes over time. The first clinical trial using the Doloplus-2
scale has recently been published. A randomised, crossover, open label study was
carried out in 34 inpatients (aged 53–96 years) at hospitals in France to investigate the
use of nitrous oxide-oxygen mixture for pain relief while taking care of bedsores and
painful ulcers.23
Patients were randomised to receive: morphine only, nitrous-oxide-
oxygen mixture only, or a mixture of morphine plus nitrous oxide-oxygen mixture.
Results showed statistically significant differences between the morphine only and
nitrous oxide-oxygen mixture only treatment groups using the Doloplus-2 scale
(p<0.01). Similar findings were also obtained using the ECPA and VAS scales. This
study serves to demonstrate the responsiveness of the Doloplus-2 scale. However,
further studies are needed to confirm these findings. It should also be noted that the
Doloplus-2 is not designed to detect subtle changes in pain-related behaviour and
focuses mainly on indicators such as facial expressions.37
A number of other early validation studies have also been carried out on the Doloplus-
2 scale and the findings of these are discussed in the systematic review of behavioural
pain assessment tools carried out by Zwakhalen and colleagues in 2006.37
These
12

13. studies were conducted on patients in geriatric centres and palliative care settings and
investigated validity, test-retest reliability and inter-rater reliability.37
However, in
these studies, only a small proportion (1–5%) of the overall study sample was unable
to communicate verbally. Results confirmed the criterion validity of the scale,
demonstrating significant correlations between Doloplus-2 and the VAS (p<0.001).
Furthermore, Doloplus-2 showed good responsiveness. A test-retest reliability of 0.82
(using Cronbach’s alpha) was reported and correlation testing as a measure of inter-
rater reliability found no significant differences between different users. While these
results are undoubtedly encouraging, it must be remembered that the patient
population in these studies were largely able to communicate verbally which may
have had some bearing on the results obtained.
The Doloplus-2 is available in a number of languages including English, French,
Norwegian and Dutch but further investigation of the psychometric properties of each
of these different language versions is still needed.
Other factors to consider
In any evaluation of a particular outcome measure, it is important to consider whether
the instrument is user-centred. Assessment of pain in elderly patients with moderate
or severe cognitive impairment is challenging because of their lack of understanding
and verbal communication. By necessity, the Doloplus-2 scale is completed entirely
by the user with little or no input from the patient. As previously discussed, if the
nurse is unfamiliar with the patient or inexperienced in using this tool, it may not be
possible to make an accurate assessment. Behavioural pain assessment instruments
such as Doloplus-2 cannot therefore be considered as user-centred as self-reported
pain assessment measured such as the VAS which patients complete themselves.
Torvik et al32
compared reported pain scale ratings between a cohort verbal and non-
verbal elderly patients. The study was a cross-sectional, interviewer-assisted and
proxy-rated survey using the Doloplus-2. The patients were divided into two groups
depending on their cognitive functioning. Patients who were able to verbally respond
appropriately during the Mini-Mental Status Examination (MMSE) were classified as
self-reporting and those unable to respond verbally were entered into or the proxy-
13

14. rated group. Of the 214 patients in the study, 128 were classified, and able to, self-
report symptoms and 86 were unable to self-report and therefore assessed with the
Doloplus-2. In the self-report group, 80% were rated mildly or moderately impaired
on the MMSE.
The group assessed with the Doloplus-2, none of the selected variables were
significantly related to pain. The variables included Barthel index, pain-related
diagnosis, receiving pain medication, age and gender. There was no difference
between the groups with or without pain and therefore raises questions about the
whether the Doloplus-2 scale was used in the correct way or if it is sensitive enough
to discriminate between pain and other observed behaviors. The limitation o=f the
study was the criteria for stratification of the patients. The verbally responsive group
was assessed with the MMSE and by default those that could not appropriately
respond where classified in the other group. The degree of their dementia is not clear.
Additional research comparing cognitively equal verbal and non-verbal groups are
needed to study the raised questions.
Conclusions
Assessing pain for elderly patients with cognitive impairment presents a considerable
challenge for nurses and other care providers. Accordingly, reports suggest that pain
is frequently unrecognised and under treated among in this patient group.13
To date,
there is a lack of published literature on all of the behavioural pain assessment tools
which are available. This paper examined the available evidence of the clinical utility
and psychometric properties of the Doloplus-2 scale.
Available studies are limited in number and offer inconclusive evidence about the
validity, reliability, and responsiveness of the Doloplus-2 scale to measure pain in
older adults. Without a valid, reliable, and responsiveness tool, measuring
improvements in care quality is impossible.
While the problem of unrecognised pain in cognitively impaired individuals is a
serious one, the evidence does not support implementing the Doloplus-2 behavioural
pain assessment tool in the clinical setting. Evidence suggests that the Doloplus-2
14

15. scale requires knowledge of the patient in order to assess the patient accurately. The
information gathered by the scale may not always be easily interpreted by the nurse or
other care provider without the need for training to ensure competency, thus
increasing the costs associated with using this scale. While the face and content
validity of the Doloplus-2 scale are confirmed, there is insufficient evidence to
confirm the criterion validity of the Doloplus-2 scale in this patient population. It
must be noted that as there is no gold standard behavioural pain assessment tool,
either self-report instruments or expert pain ratings are currently used for comparison
which may not be ideal for comparison and thus limit the accuracy of the information
obtained on the criterion validity of Doloplus-2. Test-retest reliability of Doloplus-2
was shown to be high in one study but again; further investigation of this property is
required to confirm these findings. Only one randomised clinical trial has so far been
published which employs the Doloplus-2 scale and although findings demonstrated
the sensitivity of this scale, it should be noted the sample size in this study was small.
Behavioural pain assessment tools cannot be considered as user-centred as self-
reported pain measures but offer the only way of assessing pain in patients with
limited ability to communicate.
To conclude, following this review of the published literature on the Doloplus-2 scale,
currently the evidence to recommend the implementation of the Doloplus-2 in
everyday clinical practice are insufficient, particularly for inexperienced users or
those who are unfamiliar with the patients which they are assessing.
Appendices
Appendix 1
15

16. 16

17. 17

18. Disclosures
The author has received no funding and this article was written independently. No
funding sources were provided. This is a declaration statement stating there are no
conflicts of interest with the author and any material in this paper.
References
1. Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L, Lowcay B: The
Abbey pain scale: a 1-minute numerical indicator for people with end stage dementia.
Int J Pall Nur 10 (1):6-13, 2004
2. Ando C, Hishinuma M: Development of the Japanese DOLOPLUS-2: A pain
assessment scale for the elderly with Alzheimer's disease. Psychogeratrics 10(3): 131-
137, 2010
3. Brummel-Smith K, London M.R, Drew N: Outcomes of pain in frail older adults
with dementia. J Am Geriatr Soc 50 (11):1847-1851, 2002.
4. Chen, YH, Lin LC, Watson R: Evaluation of the psychometric properties and the
clinical feasibility of a Chinese version of the Doloplus-2 scale among cognitively
impaired older people with communication difficulty. Int J Nurs Stud 47(1): 78-88,
2010
5. Corr, S and Siddons, L: An introduction to the selection of outcome measures. Br J
Occup Ther 68 (5): 202-206, 2005
18

19. 6. Davies E, Male M, Reimer V, Turner M: Pain assessment and cognitive
impairment: part 1. Nur Stand 19 (12): 39-42, 2004
7. Davies E, Male M, Reimer V, Turner M: Pain assessment and cognitive
impairment: part 2. Nur Stand 19 (13): 33-40, 2004
8. Ferrell, B. A., Ferrell, B. R., Rivera, L: Pain in cognitively impaired nursing home
patients. J Pain Symptom Manage 10 (8): 591-598, 1995
9. Gibson S, Weiner D: Pain in Older Persons. Seattle: IASP Press. 2005
10. Glendinning C: Outcomes-focused services for older people. London: Social Care
Institute for Excellence. 2006
11. Helme R.D: How useful are currently available tools for pain evaluation in elderly
people with dementia. Postgrad Med J 83: 362-366, 2007
12. Herr K: Pain assessment in cognitively impaired older adults. Am J Nurs 102
(12): 65-67, 2002
13. Herr, K., Bjoro, K., Decker, S: Tools for assessment of pain in nonverbal older
adults with dementia: a state of the science review. J Pain Symptom Manage 31(2):
170-192, 2006
14. Holen J, Saltvedt I, Fayers P, Hjermstad M, Loge J, Kaasa S: Doloplus-2: a valid
tool for behavioural pain assessment. BMC Ger 7:29-37, 2007
15. Jensen M: The validity and reliability of pain measures in adults with cancer. J
Pain 4 (1): 2-21, 2003
16. Jerosch-Herold C: An evidence-based approach to choosing outcome measures: a
checklist for the critical appraisal of validity, reliability and responsiveness studies. Br
J Occup Ther 68 (8): 347-353, 2005
17. Lefebre-Chapiro, S. The Doloplus-2 scale – evaluating pain in the elderly. Eur J
Pall Care 8 (5): 191-194, 2001
19

20. 18. Macnee C, McCabe S: Understanding nursing Research: reading and using
research in evidence-based practice. Wolters Kluwer Health/Lippincott Williams and
Wilkins, Philadelphia, 2008.
19. Manfredi P, Breuer B, Meier D, Libow L: Pain assessment in elderly patients with
severe dementia. J Pain Symptom Manage 25 (1): 48-52, 2003
20. Matthews F, Dening T: Prevalence of dementia in institutional care. Lancet 360
(9328): 225-226, 2002
21. Melnyk B, Fineout-Overholt E: Evidence based practice in nursing and
healthcare: a guide to best practice, Lippincott Williams and Wilkins. Philadelphia,
London, 2005.
22. Melzack R, Wall P: Handbook of Pain Management, Churchill Livingstone,
Edinburgh, 2003.
23. Paris A, Horvath R, Basset P, Thiery S, Couturier P, Franco A, Bosson J: Nitrous
oxide-oxygen mixture during care of bedsores and painful ulcers in the elderly: a
randomized, crossover, open-label pilot study. J Pain Symptom Manage 35 (2): 171-
176, 2008
24. Pickering G, Gibson SJ, Serbouti S, Odetti P, Ferraz Gonçalves J, Gambassi G,
Guarda H, Hamers JP, Lussier D, Monacelli F, Pérez-Castejón Garrote JM,
Zwakhalen SM, Barneto D, Collectif Doloplus®e
, Wary B: Reliability study in five
languages of the translation of the pain behavioural scale Doloplus®
. Eur J Pain
14(5): 545.e1-545.e10, 2010
25. Pautex S, Herrman F, Michon A, Giannakopoulos P, Gold G: Psychometric
properties of the Doloplus-2 observational pain assessment scale and comparison to
self-assessment in hospitalised elderly. Clin J Pain 23 (9): 774-779, 2007
26. Polgar S, Thomas S: Introduction to research in the health sciences. Churchill
Livingstone, Edinburgh, 2000
27. Quigley, C: Opioid switching to improve pain relief and drug tolerability.
Cochrane Database of Systemic reviews, issue 3. Art, 2004
20

21. 28. Ramelet A, Huijer, Abu-Saad H, Rees N, McDonald S: The challenges of pain
measurement in critically ill young children. Aust Crit Care 17 (1): 33-45, 2004
29. Scherder EJ, Eggermont L, Plooij B, Oudshoorn J, Vuijk PJ, Pickering G:
Relationship between chronic pain and cognition in cognitively intact older persons
and in patients with Alzheimer’s disease. The Need to Control for Mood. Gerontology
54(1): 50–58, 2008
30. Simons W, Malabar R: Assessing pain in elderly patients who cannot respond
verbally. J Adv Nurs 22 (4): 663-669, 1995
31. Torvik k, Kaasa S, Kirkevold,O, RustøenT: Pain in patients living in Norwegian
nursing homes. Palliat Med 23(1): 8-16, 2009
32. Torvik K, Kaasa S, Kirkevold Ø, Saltvedt I, Hølen JC, Fayers P, Rustøen T:
Validation of Doloplus-2 among nonverbal nursing home patients--an evaluation of
Doloplus-2 in a clinical setting. BMC Ger 20(10): 1-9, 2010
33. Van Herk R, Van Dijk M, Baar F, Tibboel D, DeWit R: Observation scales for
pain assessment in older adults with cognitive impairments or communication
difficulties. Nurs Res 56 (1): 34-43, 2007
34. Villaneuva M, Smith T, Erickson J, Lee A, Singer C: Pain assessment for the
Dementing Elderly (PADE): reliability and validity of a new measure. Journal of the
Am Med Dir Assc 4 (1): 1-8, 2003
35. Warden V, Hurley A, Volicer L: Development and psychometric validation of the
Pain Assessment in Advanced Dementia (PAINAD) scale. Am Med Dir Assc 4(1): 9-
15, 2003
36. Wary B : Doloplus-2: une échelle pour évaluer la douleur. Soins Gérontologie 19 :
25-27, 1999
37. Zwakhalen S, Hamers J, Abu-Saad H, Berger M: Pain in elderly people with
severe dementia: a systematic review of behavioural pain assessment tools. BMC Ger
6 (3): 3-17, 2006
21

22. 38. Zwakhalen S, Hamers J, Berger M: The psychometric quality and clinical
usefulness of three pain assessment tools for elderly people with dementia. Pain
126(1-3): 210-220, 2006
22