Can We Spot Pain When Dementia Takes Away Words?

A new approach helps nursing home staff recognize pain and avoid the risks of unnecessary medication. 

For Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP, this approach starts by helping others rethink what pain looks like. In residents with dementia, it’s rarely as simple as someone saying, “I hurt.” 

“If you’re in pain but can’t tell me you’re in pain, how are you going to express it?” asked Resnick, a professor at the University of Maryland School of Nursing. “Well, it might be through just being kind of cranky — you get a little cranky when you’re hurting. You might hit me because I’m trying to move something that hurts. But that’s not perceived as pain, it’s perceived as bad behavior, so we miss a lot of pain in this population.”  

That misinterpretation can trigger a cascade of harm: resistance to care, skipped meals or hygiene, infections, and hospitalizations. To change that, Resnick is helping nursing home staff implement updated national guidelines from PALTmed — the Post-Acute and Long-Term Care Medical Association. These guidelines support better pain recognition, emphasize identifying the root cause, and encourage non-drug strategies as a first line of care. 

Resnick’s approach promotes practical, low-risk interventions that can make a meaningful difference. Sometimes, it’s as simple as trimming long nails or talking with a resident about a happy memory. She also points out that non-pharmacological approaches are safer for people with dementia, noting, “If you start using opioids, they’re going to have an increase in confusion. There’s also a big risk for increase in falls.” 

In a new video Q&A, Resnick explains how rethinking pain in dementia care could dramatically improve the quality of life for millions without added risk. You can read a few of her answers below or watch and listen as she shares more about this essential work. 

Questions

What do you think families should understand about pain and dementia care?

“We have certain behavioral things that we look at. And I always say to people, ‘How do you respond when you have pain? Do you curl up into a ball, or do you lash around? Or what do you do?’ Because those are the things that we look for in the people we take care of,” Resnick said.

“The other big, big missing piece is to diagnose the underlying cause of the pain, and this is so often missed,” she added, saying the cause might be as simple as too long nails digging into skin. “If I was to talk with a family, I’d say, make sure pain is being assessed in your Mom or Dad and make sure somebody’s looking for the cause.”

You’re helping nursing home staff use updated guidelines to assess and manage pain — what would care for people with dementia look like without this work?

“The care without this type of work would continue to be the same — lack of assessment, lack of documentation of pain, big lack of diagnosis for underlying cause,” Resnick said.

She added that when treating pain in patients with dementia, it’s best to use non-pharmacological interventions first due to side effects that include a risk for increased confusion in the patient and an increased risk of falls.

Instead, Resnick said, “You could sit down and talk with somebody for a few minutes, acknowledge the pain, maybe have them talk about a happier event in their life, one of the happiest things, best days of their life. And that takes your mind away from the pain, and that might be good enough for that day — way better than giving an opioid.”