# An 82-year-old client with dementia is admitted to the medical unit. The client appears restless, moaning intermittently, and has difficulty sleeping. The family reports the client has been more agitated than usual over the past few days. What is the most important assessment the nurse should perform first?

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## 문제

An 82-year-old client with dementia is admitted to the medical unit. The client appears restless, moaning intermittently, and has difficulty sleeping. The family reports the client has been more agitated than usual over the past few days. What is the most important assessment the nurse should perform first?

## 보기

1. Assess the client's cognitive status using the Mini-Mental State Examination
2. Review the client's medication list for potential drug interactions
3. Conduct a comprehensive pain assessment using appropriate tools for cognitively impaired clients **✔ 정답**
4. Evaluate the client's sleep patterns and environmental factors

**정답: 3**

## 해설

Restlessness, moaning, and agitation in dementia patients are nonverbal pain indicators. A specialized pain assessment tool (e.g., PAINAD) is prioritized to identify and manage pain effectively, preventing complications like confusion and sleep disturbances.

## 심화 해설

Understanding the Clinical Scenario

An 82-year-old client with dementia presents with restlessness, moaning, and insomnia, with a family report of increased agitation. In clients with dementia, these behavioral changes are often the primary indicators of an underlying physiological stressor, most commonly pain. The inability to verbally communicate discomfort due to neurocognitive decline makes a direct symptom report unreliable.

Why Pain Assessment Is the Priority

The most critical first step is to conduct a comprehensive pain assessment using tools designed for cognitively impaired clients. Neuropathological changes in dementia compromise communicative abilities, causing pain to present atypically through behaviors like agitation, restlessness, and vocalizations rather than through a clear verbal report [1]. Because individuals with dementia, especially in later stages, have difficulty verbally reporting their pain experience, underassessment and undertreatment are common, making systematic observation for pain cues essential [2]. The client's moaning and restlessness are observable pain cues that must be investigated before attributing the agitation to other causes.

Analyzing the Other Options

- Assessing cognitive status with the MMSE (Option 1) establishes a baseline for dementia severity but does not address the acute change in condition. The priority is to identify the physiological trigger for the new-onset agitation, not to re-stage a known diagnosis.

- Reviewing the medication list for interactions (Option 2) is a valuable intervention for a client with agitation, but it is a secondary step. A pharmacokinetic or pharmacodynamic interaction is a possible cause of altered mental status; however, untreated pain is a more immediate and common driver of acute behavioral changes in this population and should be ruled out first.

- Evaluating sleep patterns and environmental factors (Option 4) addresses non-pharmacological comfort and is part of a holistic care plan. However, environmental modification will not be effective if the root cause of the sleep disturbance is unrelieved pain. Pain management is a prerequisite for successful sleep and behavioral interventions.

Pathophysiology and Clinical Reasoning

Pain in Alzheimer's disease and related dementias involves a disrupted integration of nociceptive signals with affective and cognitive processing. While nociceptive input may remain partially preserved, the clinical expression of pain becomes altered, manifesting as behavioral and psychological symptoms rather than a localized complaint . This means the client’s brain may still receive pain signals, but the ability to interpret and localize the sensation is impaired, leading to generalized distress. In postoperative or acute medical settings, such as with a hip fracture, cognitive impairment complicates pain assessment and significantly raises the risk of delirium, making prompt recognition and treatment of pain a cornerstone of preventing further decompensation . The nurse must assume that restlessness and moaning in a non-verbal client are pain until proven otherwise, using validated observational scales like the PAINAD or PACSLAC to quantify the discomfort.References (research sources)

- [1]Observing and treating pain in people living with dementia in long-term care facilities.Research articleKruijer SD, Achterberg WP, van Dalen-Kok A, Caljouw MAA. (2026) · DOI: 10.3389/fpain.2026.1812648

- [2]Pain Cues in People With Dementia: Scoping Review.Research articleSmrke U, Milošič A, Mlakar I, Kadiš M, Mulej Bratec S. (2025) · DOI: 10.2196/75671

## 임상 시나리오

Pain Assessment in Nonverbal DementiaBehavior as a Pain Cue
In clients with advanced dementia, pain often manifests as agitation, restlessness, or moaning rather than a verbal report. New-onset behavioral changes should trigger a pain assessment first.

Use observational scales like PAINAD (Pain Assessment in Advanced Dementia) which evaluates breathing, vocalization, facial expression, body language, and consolability. A score of ≥2 often indicates pain.

CautionNever assume agitation is purely psychiatric in dementia. Rule out physiological causes (pain, infection, constipation) first. Untreated pain accelerates functional decline.

## 핵심 개념

- **PAINAD Scale** — Pain Assessment in Advanced Dementia; an observational tool scoring breathing, vocalization, facial expression, body language, and consolability to detect pain in nonverbal patients.
- **Behavioral and Psychological Symptoms of Dementia (BPSD)** — Symptoms of disturbed perception, thought content, mood, or behavior frequently occurring in dementia, often triggered by unmet needs like pain.
- **Atypical Pain Presentation** — In cognitively impaired elders, pain may present as agitation, restlessness, aggression, or withdrawal rather than a direct verbal complaint.

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