This dissertation is an exploration of psychosocial and behavioral concepts related to the experience of pain in persons with severe dementia and whether the use of an observational pain scale would provide better pain management and comfort for these individuals. Pain has been under-detected, under-reported, and under-treated in this population mainly because persons with dementia (PWD) are unable to self-report pain. Cognitive decline associated with dementia is commonly accompanied by loss of ability to communicate and neuropsychiatric behaviors known as need-driven behaviors (NDB). Nurses must correctly interpret ‘pain behaviors’ in order to assess and treat appropriately. The overlapping of NDBs and pain behaviors presents a methodological and clinical challenge that indicates the need for more research. The reader will notice these concepts threaded throughout the dissertation. The researcher determined a gap in current evidence related to NDBs, which may be the only expressions of pain for persons with severe dementia. The first manuscript, Comparison of Pain Assessment Tools Used for Persons with Dementia, written as a state-of-the-science literature review examines the most frequently used observational pain scales (OPS) in comparison to the American Geriatric Society Guideline for Persistent Pain in Older Adults and reliability and validity. In the Eyes of the Beholder: The Historical Basis for an Integrated Model of Pain Management is the second manuscript in this portfolio dissertation. This manuscript provides a non-traditional analysis of the concept pain by providing a historical basis for an integrated pain management model. The fourth chapter presents the primary research study. Using a local memory-care organization, an embedded mixed methods study was undertaken with a hypothetical model as the foundation to determine the utility of two OPS in clinical practice. A qualitative element was included to capture the nurses’ perceptions of pain interpretation with PWD. Further analysis revealed the utility of the OPSs and the impact on NDB and pain medication administration. In completing this dissertation, the researcher was able to contribute to the extant knowledge on pain, need-driven behavior in dementia, and nurses’ perceptions.

Date of publication

Summer 8-1-2018

Document Type




Persistent identifier


Committee members

Beth Mastel-Smith, Gloria Duke, Sandra Petersen, Anthony McGuire


Doctor of Philosophy in Nursing

Included in

Nursing Commons