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Overview of Spasticity in Elderly Patients - The Hong Kong Geriatrics ...

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PAINAD ScalePa<strong>in</strong> Assessment <strong>in</strong> Advanced Dementia (PAINAD) ScaleBreath<strong>in</strong>g<strong>in</strong>dependent <strong>of</strong>vocalisation: (0)Normal (1)Occasional, laboured breath<strong>in</strong>g.Short period <strong>of</strong> hyperventilation. (2)Noisy, laboured breath<strong>in</strong>g. Longperiod <strong>of</strong> hyperventilation.Cheyne-Stokes respirationNegativevocalization: (0)None (1)Occasional moan or groan. Lowlevel speech with a negative ordisapprov<strong>in</strong>g quality (2)Repeated, troubled, call<strong>in</strong>g out.Loud moan<strong>in</strong>g or groan<strong>in</strong>g. Cry<strong>in</strong>gFacialexpression: (0)Smil<strong>in</strong>g or<strong>in</strong>expressive (1)Sad. Frightened. Frown<strong>in</strong>g. (2)Facial grimac<strong>in</strong>g.Body language: (0)Relaxed (1)Tense. Distressed pac<strong>in</strong>g.Fidget<strong>in</strong>g. (2)Rigid. Fists clenched. Knees pulledup. Pull<strong>in</strong>g or push<strong>in</strong>g away.Strik<strong>in</strong>g out.Consolability: (0)No need toconsole (1)Distracted or reassured by voiceor touch. (2)Unable to console, distract, orreassureTotal Score <strong>of</strong> PAINAD Scale: __________________/10Warden V et al. J Am Med Dir Assoc. 2003

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