Associations between facial expressions and observational pain in residents with dementia and chronic pain

Lihui Pu*, Michel W. Coppieters, Martin Smalbrugge, Cindy Jones, Joshua Byrnes, Michael Todorovic, Wendy Moyle

*Corresponding author for this work

Research output: Contribution to journalArticleResearchpeer-review

1 Citation (Scopus)
44 Downloads (Pure)


To identify specific facial expressions associated with pain behaviors using the PainChek application in residents with dementia.

This is a secondary analysis from a study exploring the feasibility of PainChek to evaluate the effectiveness of a social robot (PARO) intervention on pain for residents with dementia from June to November 2021.

Participants experienced PARO individually five days per week for 15 min (once or twice) per day for three consecutive weeks. The PainChek app assessed each resident's pain levels before and after each session. The association between nine facial expressions and the adjusted PainChek scores was analyzed using a linear mixed model.

A total of 1820 assessments were completed with 46 residents. Six facial expressions were significantly associated with a higher adjusted PainChek score. Horizontal mouth stretch showed the strongest association with the score, followed by brow lowering parting lips, wrinkling of the nose, raising of the upper lip and closing eyes. However, the presence of cheek raising, tightening of eyelids and pulling at the corner lip were not significantly associated with the score. Limitations of using the PainChek app were identified.

Six specific facial expressions were associated with observational pain scores in residents with dementia. Results indicate that automated real-time facial analysis is a promising approach to assessing pain in people with dementia. However, it requires further validation by human observers before it can be used for decision-making in clinical practice.

Pain is common in people with dementia, while assessing pain is challenging in this group. This study generated new evidence of facial expressions of pain in residents with dementia. Results will inform the development of valid artificial intelligence-based algorithms that will support healthcare professionals in identifying pain in people with dementia in clinical situations.

Reporting Method
The study adheres to the CONSORT reporting guidelines.

Patient or Public Contribution
One resident with dementia and two family members of people with dementia were consulted and involved in the study design, where they provided advice on the protocol, information sheets and consent forms, and offered valuable insights to ensure research quality and relevance.
Original languageEnglish
Pages (from-to)1-10
Number of pages10
JournalJournal of Advanced Nursing
Publication statusPublished - 9 Feb 2024


Dive into the research topics of 'Associations between facial expressions and observational pain in residents with dementia and chronic pain'. Together they form a unique fingerprint.

Cite this