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Abbey pain scale for patients with dementia

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When to use
Vocalization (whimpering, groaning, crying)
Absent
Mild
Moderate
Severe
Facial expression (looking tense, frowning, grimacing, looking frightened)
Absent
Mild
Moderate
Severe
Change in body language (fidgeting, rocking, guarding part of body, withdrawn)
Absent
Mild
Moderate
Severe
Physiological changes (temperature, pulse or blood pressure outside normal limits, perspiring, flushing or pallor)
Absent
Mild
Moderate
Severe
Physical changes (skin tears, pressure areas, arthritis, contractures, previous injuries)
Absent
Mild
Moderate
Severe
Behavioral changes (increased confusion, refusing to eat, alteration in usual patterns)
Absent
Mild
Moderate
Severe
Calculation
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