Intended for healthcare professionals

CCBYNC Open access

Rapid response to:


Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial

BMJ 2011; 343 doi: (Published 17 July 2011) Cite this as: BMJ 2011;343:d4065

Rapid Response:

A clarion call for more systematic and standardized pain assessment and management for those with dementia

This study is of enormous benefit in terms of prompting clinicians to
think harder about the origins of behavioural disturbance in people with
dementia (1). In particular, it should motivate us to identify and manage
pain in a more systematic way, particularly in vulnerable groups whose
ability to articulate the symptoms of pain may be limited (2). This study
occurs against a background of international concern over neglect of pain
in residents in nursing homes (3).

For physicians and nurses, one of the key imperatives arising from
the study is to ask ourselves (and our professional organizations) whether
we have done enough to develop an agreed suite of pain scores in order to
obtain a common language of pain assessment among healthcare professionals
across a range of healthcare settings, including nursing homes.

Our own national survey among geriatricians in the Republic of
Ireland last year revealed a marked lack of consistency in the use of pain
scales: for patients with moderate to severe cognitive impairment, 76% of
consultants were not using a pain scale routinely, with a minority using
the Faces Pain Scale. On the positive side, there was a high level of
support for designating pain as the fifth vital sign for prioritizing pain
assessment at the bedside, although the evidence of benefit of this change
in practice is not yet certain (5).

It is clear that considerable scope exists for more standardized and
systematic assessment and care of pain, particularly for those with
cognitive impairment, and this study should motivate all involved in the
care of older people to urgently join in this endeavour.


1. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of
treating pain to reduce behavioural disturbances in residents of nursing
homes with dementia: cluster randomised clinical trial. BMJ.

2. Stolee P, Hillier LM, Esbaugh J, Bol N, McKellar L, Gauthier N.
Instruments for the assessment of pain in older persons with cognitive
impairment. J Am Geriatr Soc 2005;53:319-326

3. Wylie K, Nebauer M. The fragmented story of pain: a saga of economic
discourse, confusion and lack of holistic assessment in the residential
care of older people. Collegian 2011;18:11-8.

4. Keane RA, Williams C, O'Neill, D. Pain assessment in specialist
services for older people-A National Perspective. J Am Geriatr Soc

5. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L.
Measuring pain as the 5th vital sign does not improve quality of pain
management. J Gen Intern Med. 2006;21:607-12.

Competing interests: No competing interests

20 July 2011
Ruth-Anne Keane
Desmond O'Neill
Centre for Ageing, Neuroscience and the Humanities, Trinity College, Dublin 2, Ireland