A systematic review evaluating pain assessment strategies for patients with dementia in the emergency department: the geriatric ED guidelines 2.0

Objectives

Pain is common among patients presenting to the emergency department (ED) but is frequently underdetected and undertreated in older people living with dementia (PLWD). This systematic review examined whether dementia-specific pain assessment tools improve pain management compared with usual care in the ED.

Methods

We conducted a systematic review and have reported the methods and results following PRISMA (PROSPERO: CRD420251044828). Eligible studies included randomized, quasi-experimental, and observational designs enrolling ED patients aged ≥ 65 years with dementia or cognitive impairment. Interventions were pain assessment tools developed for PLWD, and comparisons were with standard pain scales. Primary outcomes were patient-reported outcome measures and analgesia administration; secondary outcomes included repeated pain scores, ED revisits, functional decline, mortality, and adverse events. Five databases (Ovid MEDLINE, Embase, Cochrane Library, CINAHL, PsycInfo) and two clinical trial registries were searched without language or date restrictions on April 22, 2025, and December 16, 2025, respectively. Two reviewers independently screened, extracted data, and assessed risk of bias using Cochrane RoB-2.

Results

Of 987 records identified, 18 underwent full-text review, and one study met eligibility criteria. Fry et al. (2017) conducted a multicenter, cluster-randomized controlled trial of 602 older adults with suspected long bone fractures, comparing the Pain Assessment in Advanced Dementia (PAINAD) tool with standard pain scales. No significant differences were observed in median time to first analgesia (83 vs. 82 min, p = 0.42) or proportion receiving analgesia within 60 min (28% vs. 32%, p = 0.19). Evidence certainty was rated very low.

Conclusions

Evidence on dementia-specific pain assessment tools in the ED is extremely limited. Available data suggest PAINAD does not improve timeliness of analgesia, underscoring the urgent need for rigorous studies to guide pain management for PLWD in the ED.