BACKGROUND: Objectively coded facial activity provides a useful index of pain among elders who have difficulty in reporting pain because of cognitive impairments. However, limitations of previous research include no direct assessment of participants' level of cognitive impairment; no comparison of the reactions of elders with cognitive impairments with those of nonimpaired elders; observers' expectations about pain levels could have influenced judgements about the severity of pain experienced when global rather than objectively coded measures were used because the painful medical procedure was visible on film.OBJECTIVE: To extend previous findings by incorporating improvements in design and methodology in response to the aforementioned limitations.PARTICIPANTS: Fifty-nine in-patients with a mean age of 73 years.METHODS: Facial reactions were filmed during routine blood tests and coded objectively using the Facial Action Coding System (FACS). Observer ratings of pain were also obtained.RESULTS: FACS indexes revealed substantial changes from baseline to venepuncture indiscriminate of whether elders were cognitively impaired. Furthermore, these changes were apparent to both nurse and student observers although the nurses rated the pain displayed by the patients as being lower.CONCLUSION: After addressing limitations of previous work in this area, the validity of nonverbal indexes of pain in the assessment of elders with cognitive impairments was demonstrated. Such indexes are uniquely suited as outcome measures within the context of clinical trial methodology.

BACKGROUND: Current definitions of pain suggest that emotion is an essential component of pain, however, the presumed relationship between emotion and pain, and the specific emotions that are involved in pain experiences have yet to be clarified.OBJECTIVE: To address these issues in order to assist in making current conceptualizations of pain more explicit.DESIGN: Thirty adult patients undergoing routine blood tests were videotaped. Spontaneous facial reactions were examined for distinct expressions of emotion and pain occurring at baseline, swabbing and venepuncture intervals. Expressions were assessed objectively with the Facial Action Coding System (FACS) and rated subjectively by 48 untrained judges. Patients also provided baseline and postneedle self-reports of experienced pain.RESULTS: Comparison of venepuncture, swabbing and baseline segments revealed that objective measures of pain-related facial activity, subjective ratings of pain expression and self-reported ratings of pain increased significantly from baseline to venepuncture and that measures of disgust, anger, fear and happiness also varied significantly across segments. Regression analyses indicated that measures of pain could be predicted from measures of specific emotions.CONCLUSIONS: Emotion is an essential component of the acute phasic pain experienced during venepuncture. Although the occurrence of specific emotions varied as a function of pain, objective behavioural indexes and subjective behavioural ratings of pain were predicted by different emotional components than patients' self-reports.

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