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Using the FACES Scale for Pain Self-Report in Dementia

Even when dementia makes words hard, a person can often still point to a face that shows how they feel. The FACES scale is a simple tool that lets someone with early to moderate dementia tell you about their pain without needing to find the right words. This article walks you through exactly how to use it, what to watch for, and when to switch to other methods. You have real, concrete steps to try today.

Key points

  • The FACES scale works for many people with dementia who have MMSE scores as low as 15—it is not just for people who can talk.
  • Always demonstrate the scale yourself first before asking your loved one to use it.
  • If they cannot point, try nodding or blinking to indicate which face matches their pain.
  • The FACES scale is for early to moderate stages; switch to PAINAD in late-stage dementia.
  • Pain is common but often missed in dementia—use the scale regularly, not just when they seem upset.
  • Combine the scale with your own observations—if the face says 'no pain' but they are grimacing, trust the grimace and use PAINAD.

Why the FACES Scale Works When Words Fail

As dementia progresses, the ability to find and say words like 'aching' or 'stabbing' fades. But the ability to recognize a facial expression and match it to an internal feeling often stays longer. The FACES scale—a row of faces from smiling to crying—taps into this preserved skill. Research shows that people with Mini-Mental State Examination (MMSE) scores as low as 15 out of 30 can still reliably use a faces scale to report their pain intensity. This means even when your loved one can't tell you 'it hurts,' they can point to the face that looks like how they feel inside.

What Is Happening in the Brain

Dementia damages the parts of the brain that handle language and abstract thinking—like rating pain on a 0-to-10 number line. But the emotional centers and the ability to recognize faces often remain more intact. The FACES scale works because it uses a visual, emotional language that bypasses the damaged word-finding areas. Your loved one isn't 'failing' at communication; their brain is using a different route to send the message. Your job is to provide the map—the faces—and then watch and listen.

When the FACES Scale Is Most Useful

The FACES scale is best for people in the early to middle stages of dementia—when they can still understand simple instructions and point or nod. It is not a tool for someone who is nonverbal or in the late stages (FAST stage 7). For those later stages, you will need to use observational tools like the Pain Assessment in Advanced Dementia (PAINAD) scale, which looks at breathing, vocalizations, facial expression, body language, and consolability. But for now, while your person can still engage, the FACES scale gives them a voice in their own care.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Step 1: Choose the right moment. Wait until your loved one is calm and you have a few minutes of quiet. Do not try this when they are agitated, hungry, or tired. Sit facing them at eye level, in good light, so they can clearly see the faces.

  2. Step 2: Get a printed FACES scale. You can find free versions online from pain organizations or your doctor's office. Print it in color on a plain white sheet of paper—no glossy finish that might glare. Laminate it or put it in a clear plastic sleeve so it stays clean and can be used again.

  3. Step 3: Introduce the scale gently. Say something like, 'I have a picture here that helps people show how they feel. See these faces? This one is happy, no hurt. This one hurts a little bit. This one hurts a whole lot. Can you point to the face that shows how you feel right now?' Use a calm, warm voice. Do not rush.

  4. Step 4: Demonstrate first. Point to the 'no pain' face and say, 'This is how I feel right now—no ouchies.' Then point to the 'worst pain' face and say, 'This would be if I had a really bad headache.' This modeling helps your loved one understand the task.

  5. Step 5: Ask them to point. Hold the scale in front of them and say, 'Show me which face is like your body feels right now.' If they hesitate, you can gently guide their hand toward the paper, but do not force it. Give them time—up to 30 seconds of silence is okay.

  6. Step 6: If they cannot point, try another method. Some people can nod or blink to indicate the face you are pointing to. Say, 'Is it this one?' while pointing to each face in turn. Watch for a yes (a nod, a blink, a vocalization) or a no (turning away, silence).

  7. Step 7: Record the number. Most FACES scales have a number (0-10) under each face. Write down the number and the date and time. This gives you a record to share with the doctor and to track if pain is getting better or worse.

  8. Step 8: Act on the result. If the score is 4 or higher (moderate to severe pain), or if the person points to any face other than the 'no pain' one, assume pain is present. Offer a non-drug comfort measure first (repositioning, a warm blanket, a gentle massage) and then discuss with the doctor about medication. Do not ignore a low score—even a '1' or '2' may mean discomfort that needs attention.

  9. Step 9: Reassess after intervention. After giving pain relief (medication or comfort measure), wait 30-60 minutes and repeat the FACES scale. Did the score go down? If not, the pain may be undertreated or there may be another cause (like infection or constipation).

  10. Step 10: Know when to stop using the FACES scale. As dementia advances, your loved one may lose the ability to understand the scale at all. If they become confused, agitated, or unable to point or respond consistently, switch to an observational tool like PAINAD. This is not a failure—it is a natural progression.

What not to do

  • Do not assume that because they cannot speak, they cannot feel pain. Pain is still present even when words are gone. The FACES scale gives them a way to show you, but if they cannot use it, you must rely on other signs like grimacing, guarding, or agitation.

  • Do not use the FACES scale when the person is upset or in the middle of a behavior. Wait for a calm moment. Trying to assess pain during agitation will confuse both of you and give unreliable results.

  • Do not force the person to use the scale if they are resistant. If they push the paper away or turn their head, stop. Try again later or use a different approach. Forcing it can cause distress and erode trust.

  • Do not rely on the FACES scale alone for someone in late-stage dementia. By FAST stage 7, most people cannot understand or use the scale. Use PAINAD or another observational tool instead. The FACES scale is for early to moderate stages only.

  • Do not ignore a 'no pain' response if the person is showing other signs of pain (like moaning, restlessness, or guarding). Sometimes people with dementia cannot connect the internal feeling to the external scale. Trust your observations and the PAINAD tool over a single self-report if there is a mismatch.

  • Do not use the FACES scale as a one-time test. Pain changes throughout the day. Assess at different times—after movement, during care, and at rest. A single 'no pain' reading does not mean they are pain-free all day.

Practical tools

  • The FACES Pain Scale (Wong-Baker or similar)

    Print a color version of the Wong-Baker FACES Pain Rating Scale (0-10). Laminate it for durability. Keep it in the person's room or in your bag. Use it as described in the steps above. The faces range from a smiling 'no hurt' face (0) to a crying 'hurts worst' face (10).

  • The PAINAD Scale (for when FACES stops working)

    Download and print the Pain Assessment in Advanced Dementia (PAINAD) scale. It has five categories: breathing, vocalization, facial expression, body language, and consolability. Each is scored 0-2. A total score of 4 or more suggests pain. Keep this as your backup tool for later stages.

  • Exact Phrases to Say

    Use these exact phrases: 'I have a picture to help you show me how you feel. See these faces? This one means no hurt. This one means a little hurt. This one means a lot of hurt. Can you point to the face that shows how you feel?' If they cannot point: 'Is it this one? (point to each face) Nod or blink for yes.'

  • Comfort Measures Checklist

    Before reaching for medication, try these: reposition in bed or chair, offer a warm blanket, provide a gentle hand or foot massage (research shows massage can reduce agitation), check for a full bladder or constipation, offer a snack or drink, and ensure the room is not too hot or cold. Document what helped.

  • Pain Diary Template

    Create a simple log with columns: date, time, FACES score, activity (e.g., after walking, during bath), what you did (e.g., repositioned, gave Tylenol), and the new score 30 minutes later. This diary helps the doctor see patterns and adjust treatment.

  • Environment Setup for Assessment

    Choose a quiet, well-lit space with minimal distractions. Turn off the TV. Sit at the person's eye level. Hold the FACES scale about 12-18 inches from their face. Speak slowly and clearly. Give them time to process—up to 30 seconds of silence is okay.

Discuss with your clinician

Ask your doctor: 'My loved one can use the FACES scale. Can we use this instead of the 0-10 number scale for their pain assessment?'

If the FACES score is consistently 4 or higher, ask: 'What pain medication options are safe for someone with dementia? Are there non-drug approaches we should try first?'

If your loved one is in late-stage dementia and cannot use FACES, ask: 'Can you train me to use the PAINAD scale? I want to make sure I am not missing pain.'

If pain seems to spike at certain times (e.g., after meals, during baths), ask: 'Could there be a treatable cause like constipation, a UTI, or arthritis flare-up?'

If your loved one is on pain medication, ask: 'How often should I reassess with the FACES scale? What score should trigger a call to you?'

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