Pain assessment relies largely on self-report, which can be particularly challenging when patients have cognitive impairment and are unable to self-report pain. Underrecognized and undertreated pain worsens quality of life and health outcomes of persons living with dementia and creates additional challenges in delivering optimal home healthcare (Osakwe et al., 2022). Our team is conducting research using Outcome and Assessment Information Set (OASIS-C) data. In our sample (n = 196,837), of those with severe pain (23.03%), 7.53% were unable to self-report pain. These numbers add to growing concerns about pain assessment for populations at risk for underrecognition and undertreatment of pain. Research suggests patients with dementia have a lower likelihood of receiving pain treatment and having severe pain documented (Wang et al., 2021). When patients are unable to self-report, we must rely on observable behaviors such as aggression, agitation, repetitive vocalizations, withdrawal, apathy, confusion, and/or declining functional status.

The OASIS item M2401 intervention synopsis (option d) focuses on interventions to monitor and mitigate pain. This response option emphasizes the need to use standardized, validated pain assessments to determine that a patient has no pain. The OASIS does not currently include a pain scale for patients unable to self-report pain. On an agency level, it is important to invest in ongoing clinician training around standardized assessment for these patients. The Pain Assessment in Advanced Dementia (PAINAD) scale is recommended for patients unable to self-report pain (Ersek et al., 2010; Warden et al., 2003). The PAINAD is a valid and reliable 5-item tool that assesses pain based on observation of behaviors common among individuals with pain: breathing, facial expression, negative vocalizations, body language, and ability to be consoled.

Lack of a standardized pain instrument within the OASIS to assess pain among individuals unable to self-report poses is a barrier to optimal care and outcomes. In nursing home settings, a checklist of nonverbal pain indicators is integrated in the Minimum Data Set 3.0, which evaluates pain intensity of nonverbal patients (Wei et al., 2021). As a comparable tool is yet integrated in the OASIS, clinical leaders and managers need to prioritize teaching and staff development around pain assessment using validated nonverbal behavior observational tools that are brief and require limited time to administer (Ersek et al., 2010).

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