Abbey Pain Scale: how to use it in care homes

The Abbey Pain Scale is a short observation tool that helps staff judge whether a person who can't tell you they're in pain is likely to be in pain, and roughly how much. It was designed for people living with dementia who can't put their pain into words, and it's widely used in the UK, including in care homes. This guide explains what it looks at, how the score works, when to use it, what to do with the result, and the other tools you might use instead.

The short answer

The Abbey Pain Scale scores six areas by observation: vocalisation, facial expression, change in body language, behavioural change, physiological change and physical changes. Each scores 0 to 3, giving a total out of 18: 0–2 no pain, 3–7 mild, 8–13 moderate, 14 or more severe. Repeat it after pain relief to see if it worked.

What the Abbey Pain Scale is

The scale was developed in Australia by Abbey and colleagues, and published in 2004 in the International Journal of Palliative Nursing as a one-minute indicator of pain for people with end-stage dementia. It was built for residential aged care, for people who can't tell staff what they need. It doesn't ask the person anything. You watch the person, ideally while they move, and score what you see.

It's a prompt for clinical judgement, not a diagnosis. A score tells you pain is likely and gives you a number to compare against later. It doesn't tell you where the pain is or what's causing it, and it can't tell pain apart from other distress such as fear, delirium or an unmet need.

Where to get a copy

Use the version in your local NHS trust's or your home's policy, so everyone scores from the same form. NHS Scotland's Right Decisions service publishes a current adapted copy (2025), written for hospital use, linked in the sources below. NHS-hosted copies carry the authors' acknowledgement and a note that the document may be reproduced with that acknowledgement kept, so keep it on any copy you print. Some trusts have adapted the wording or linked the score to their own charts, so check which version you're using rather than retyping one.

The six areas, in brief

These are short descriptions, not the form itself.

Area	What you're looking for
1. Vocalisation	Sounds of discomfort, such as moaning, calling out or crying
2. Facial expression	Looking tense, worried or frightened; frowning or wincing
3. Change in body language	Restlessness, rocking, protecting part of the body, or withdrawing
4. Behavioural change	More confused than usual, not eating, or a change in usual habits
5. Physiological change	Temperature, pulse or blood pressure that's unusual for the person, sweating, a flushed face or unusual paleness
6. Physical changes	Conditions or injuries on the body that can hurt, such as pressure sores, torn or fragile skin, stiff or fixed joints, arthritis or past injuries

Area names and scoring from the Abbey Pain Scale: Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D and Lowcay B; funded by the JH & JD Gunn Medical Research Foundation, 1998–2002.

How the score works

Score each of the six areas as absent (0), mild (1), moderate (2) or severe (3), then add them up. The total runs from 0 to 18.

Total	What the form says it suggests
0–2	No pain
3–7	Mild pain
8–13	Moderate pain
14 or more	Severe pain

Two things matter more than the exact number. First, "change" is the key word in several areas: you're comparing the person with how they usually are, so staff who know the person score more reliably. Second, a low score doesn't rule pain out. If you think the person is in pain, act on it.

When to use it

NICE's dementia guideline, NG97, recommends considering a structured observational pain assessment tool alongside standard clinical assessment for people living with dementia who can't self-report pain, and alongside self-reported pain and standard clinical assessment for people living with moderate to severe dementia (recommendation 1.8.3). NICE doesn't name a particular tool. It also says to repeat pain assessments for people who seem to be in pain, for people showing behavioural changes that may be caused by pain, and after any pain management intervention (1.8.5).

In a care home, that usually means using it:

as a baseline, soon after admission and when the person is settled, so you know what "usual" looks like;
when something changes: new agitation, calling out, refusing care, not eating, poor sleep, a fall, or a new wound or pressure area;
before and after pain relief, to see whether it worked;
before treating distress: NICE NG97 asks for a structured assessment that checks for causes such as pain before starting any treatment for distress in dementia (1.7.1). An unexplained rise in behaviour can be pain.

The guidance on the form is to score while or just after the person moves, for example during repositioning, pressure area care or washing, because pain often shows most then.

What to do with the score

Look for the cause. Common causes of pain in care homes include constipation, urine infections, dental and mouth problems, pressure damage, arthritis and injuries from falls. Check the obvious things and record what you find; a body map helps show where.
Act on it. If the person has a PRN painkiller with a protocol, follow the protocol. If not, or if the pain is new, severe or unexplained, contact the GP or NHS 111, or call 999 in an emergency. Don't wait for the next GP visit.
Use comfort measures too. Repositioning, warmth, a drink, the toilet, reassurance from someone they know. Record what you tried.
Score again. The guidance on the form suggests a second score about an hour after any intervention. If the score is the same or worse, consider further action. The form suggests scoring hourly until the pain is mild, then every four hours for 24 hours; follow your home's policy. If the pain or distress continues, review the whole of the person's care, and tell the GP of the scores and what you've done.
Record it. The date, time, total score, who scored, what was given or done, and the repeat score. A run of scores tells the GP far more than "seems in pain".
Update the plan. If pain is ongoing, the care plan and the PRN protocol should say how this person shows pain and what helps.

For more on writing a protocol that names the pain tool and when to re-check, see our guide to PRN medication protocols.

How good is the evidence?

The Abbey Pain Scale is popular because it's quick and simple. But the UK national guidelines on assessing pain in older people, developed by the British Geriatrics Society, the British Pain Society and the Royal College of Nursing (published in Age and Ageing in 2018, the latest edition we could find), note that there's been no recent evaluation of the Abbey scale, although it is widely used in the UK. For people with severe cognitive impairment, those guidelines recommend PAINAD and Doloplus-2. That doesn't mean you must stop using Abbey. It means using it consistently, alongside clinical judgement, and knowing why your home chose it.

The same guidelines stress that self-report is the most reliable measure of pain, including for many people with cognitive impairment. Always ask first. People who deny "pain" may say yes to "sore", "aching" or "uncomfortable", or to "Do you hurt anywhere?"

Other pain scales and tools

Pain scales for people who can tell you. A numerical rating scale (0 to 10) or a verbal descriptor scale (none, mild, moderate, severe) can be used by many people with mild to moderate cognitive impairment, according to the BGS and BPS guidelines. Picture-based faces scales are another option for some people.
PAINAD (Pain Assessment in Advanced Dementia). An observation tool developed in the United States, which scores five things: breathing, negative vocalisation, facial expression, body language and how easily the person is consoled. Each scores 0 to 2, for a total out of 10. Recommended by the BGS and BPS guidelines for people with severe cognitive impairment.
DisDAT (Distress and Discomfort Assessment Tool, originally the Disability Distress Assessment Tool). Developed in Northumberland by a learning disability and palliative care team, and now published by St Oswald's Hospice. It's often used with people who have a learning disability and severely limited communication. It isn't a scoring tool: it records how the person looks and behaves when content and when distressed, so changes stand out. It sits well alongside a communication passport.
App-based tools. Some commercial apps use a phone or tablet camera to look at facial expressions alongside other observations. If you consider one, check the published evidence for people like those you support, the cost, and the data protection terms, as you would for any system.

Whichever you choose, use one tool per person consistently, so scores can be compared over time.

How Kiwi handles this

Kiwi (our product) doesn't include the Abbey Pain Scale or any other observational pain tool, and it doesn't add up a tool score for you, so use the Abbey form or your chosen tool as your policy sets out. Staff can record a pain score out of 10 as an observation, which is a different measure from an Abbey total out of 18. Each resident's care plan has a Communication section with a heading for how the person shows pain, and a Physical health section with a heading for pain assessment, where you can note which tool you use. Like the other care plan sections, each can have its own next review date, and when one is changed the earlier version is kept. A member of staff can sign a section to confirm they've read it and will follow it; Kiwi shows who signed last and when, and flags it for re-signing if it's been updated since. PRN protocols are recorded for each resident, and daily logs and incident reports include a body map for marking where on the body a problem is.

If you'd like to see how Kiwi's care plan, PRN protocols and body maps fit together, book a demo.

Frequently asked

What is the Abbey Pain Scale?

The Abbey Pain Scale is an observation tool that helps staff judge whether a person who can't say they're in pain is likely to be in pain, and how much. It was developed in Australia and published in 2004, for people with dementia who can't put their pain into words. Staff watch the person and score six areas.

How is the Abbey Pain Scale scored?

Each of six areas (vocalisation, facial expression, change in body language, behavioural change, physiological change and physical changes) is scored from 0 for absent to 3 for severe. The total is out of 18: 0–2 suggests no pain, 3–7 mild, 8–13 moderate and 14 or more severe pain. A low score doesn't rule pain out.

When should you use the Abbey Pain Scale?

Use it for people who can't reliably tell you about their pain, often people with moderate to severe dementia. Score a baseline when the person is settled, then again when their behaviour changes, after a fall or new wound, and before and after pain relief. Score during or just after movement, such as repositioning or washing.

How often should you repeat the Abbey Pain Scale?

There's no single national frequency. NICE's dementia guideline says to repeat pain assessments when the person seems to be in pain, when their behaviour changes, and after any pain relief. The guidance on the form suggests re-scoring about an hour after an intervention, then at regular intervals until the pain has settled. Follow your home's policy.

What is the difference between the Abbey Pain Scale and PAINAD?

Both are observation tools for people with dementia who can't self-report pain. Abbey scores six areas from 0 to 3, giving a total out of 18. PAINAD scores five behaviours from 0 to 2, giving a total out of 10. UK guidelines from the British Geriatrics Society and British Pain Society recommend PAINAD or Doloplus-2 for people with severe cognitive impairment; Abbey remains widely used.

Sources

Sources last checked: 29 October 2026.