Leader(s): Thomas Hadjistavropoulos, Ph.d, FCAHS
Institution(s): University of Regina
Other Members: Lisa Lix, Ph.D., Harminder Guliania, Ph.D., Ying MacNab, Ph.D.

Why was the study done?
Research has shown that we can usually tell if someone with dementia is in pain by observing their facial expressions (such as grimacing). However, we do not know how much caregivers rely on these facial expressions when assessing whether people with dementia are experiencing pain.
The aim of this study was to find out which facial pain reactions are noticed the most by observers and how these facial cues are used when assessing pain in healthy people versus those with dementia, and in younger people versus older people.
We expected that our findings would help us understand whether we can assess pain in older adults with dementia by observing their facial reactions in the same way we can assess facial reactions of younger people with pain.

How was the study done?
This study involved 164 university student volunteers who watched videos of three groups of people experiencing pain. Our groups were:
• younger adults
• older adults without dementia
• older adults with dementia.
We used a special coding system to ensure that people included in all three groups in our videos had similar facial expressions of pain.
Each student observer wore an eye tracker (a device that records which parts of the face they watched). This helped us determine whether the students focused more on the eye or mouth or other areas of the face as they rated each person’s pain.

What were the study results?
Our students did not observe or recognize facial pain cues in dementia patients as consistently as they did for the other two groups.
The pain ratings for the older patients were also less accurate than pain ratings were for the younger patients.
These findings suggest that untrained student observers who evaluate pain in older adults, including dementia patients, are not as accurate as when they are evaluating pain in younger people. Perhaps their ability to evaluate pain can be improved by training caregivers to observe and recognize facial pain cues in these patients.
Better pain assessment can improve our ability to manage pain in people with dementia.

Was a patient-partner involved with your study?
Our caregiver partner, Mary Brachaniec, was not involved in carrying out this study but is helping us share our results with caregivers and patients, along with health professionals, policymakers and researchers.


Recent Updates:
We presented our results at the Canadian Association on Gerontology Conference in 2019.
Last updated: January 2021

Selected Publications:
  • Newton, C., Hadjistavropoulos, T., Gallant, N.L., & McNab, Y.C. (in press). Age differences in attitudes about older adults with dementia. Ageing & Society.Zahid, N., Gallant, N.L., Hadjistavropoulos, T. & Stroulia, E. (in press). Behavioural pain assessment implementation using a tablet app: A case series and quasi experimental design. JMIR mhealth and uhealth.
  • Ghandehari, O.O., Gallant, N.L., Hadjistavropoulos, T., Williams, J. & Clarke, D. (in press). The Relationship between the pain experience and emotion regulation in older adults. Pain Medicine.
  • Hunter, P.V., McCleary, L., Akhtar-Danesh, N., Goodridge, D., Hadjistavropoulos, T., Kaasalainen, S., Sussman, T., Thompson, G., Venturato, L., & Wickson-Griffiths, A. (in press). Mind the gap: Is the Canadian long-term care workforce ready for a palliative care mandate? Ageing & Society.
  • Robichaud, M., Talbot, F., Titov, N., Dear, B., Hadjistavropoulos, H.D., & Hadjistavropoulos, T. (in press). Facilitating access to iCBT: A randomized controlled trial assessing a translated version of an empirically validated program using a minimally-monitored delivery model. Behavioural and Cognitive Psychotherapy.Hadjistavropoulos, T. (in press). Discussing and debating the American Psychological Association Ethical Principles of Psychologists and Code of Conduct. Ethics & Behavior
  • Whiting, S., Li, W., Singh, N., Quail, J., Dust, W., Hadjistavropoulos, T., & Thorpe, L. (in press). Predictors of hip fractures and mortality in long-term care homes in Saskatchewan: Does Vitamin D supplementation play a role? Journal of Steroid Biochemistry and Molecular Biology.
  • Guliani, H., Hadjistavropoulos, T., Jin, S. & Lix, L. (in press). Utilization of health care resources by long-term care residents as a function of pain status. Clinical Journal of Pain.
  • Hunter, P.V., Rissling, A., Pickard, L., Thorpe, L. & Hadjistavropoulos, T. (in press). Intervention fidelity of a volunteer-led Montessori-Based intervention within a Canadian long-term care home. Canadian Journal of Aging.
  • Kaasalainen, S., Hunter, P.V., Dal-Bello Haas, V., Froggart, K., Hadjistavropoulos, T., Markle-Reid, M., Ploeg, J., Simard, J., Thabane, L., van der Steen, J.T. and Volicer, L. (2020). Evaluating the feasibility and acceptability of the Namaste Care program in long-term care settings in Canada. BMC Pilot and Feasibility Studies, 6(34).
  • Gagnon, M.M., Hadjistavropoulos, T., McAleer, L.M & Stopyn, R.J.N. (2020). Increasing parental access to pediatric pain-related knowledge: A systematic review of implementation and dissemination research among parents. Clinical Journal of Pain, 36, 47-60.
  • Hunter, P.V., Thorpe, L., Hounjet, C. & Hadjistavropoulos, T. (2020). Using normalization process theory to evaluate the implementation of Montessori-based volunteer visits with a Canadian long-term care home. Gerontologist, 60, 182-192.
  • Kaasalainen S., Hunter, P.V., Hill, C., Moss, R. Kim, J., van der Steen, Dal-Bello Haas, V. & Hadjistavropoulos, T. (2019). Launching “Namaste Care” in Canada: Findings form training sessions and initial perceptions of an end-of-life programme for people with advanced dementia. Journal of Research in Nursing, 24, 403-417.
  • Taati, B., Zhao, S. Ashraf, A.B., Asgarian, A., Browne, M.E., Prkachin, A., Mihailidis, A., Hadjistavropoulos, T. (2019). Algorithmic bias in clinical populations-Evaluating and improving facial analysis technology in older adults with dementia. IEEE Access, 7, 25527-25534.
  • Azuero, C., Allen, R.S., & Hadjistavropoulos, T. (2019). Health geropsychology. In Hadjistavropoulos, T. & Hadjistavropoulos, H.D. Fundamentals of Health Psychology (2nd Edition), pp. 308-326. Oxford University Press.
  • Gagnon, M. & Hadjistavropoulos, T. (2019). Chronic health problems, risk factors, adjustment, and management. In Hadjistavropoulos, T. & Hadjistavropoulos, H.D. Fundamentals of Health Psychology (2nd Edition), pp. 162-187. Oxford University Press.
  • Mehta, S., Hadjistavropoulos, H.D., & Hadjistavropoulos, T. (2019). Eating, smoking and recreational substance use. In Hadjistavropoulos, T. & Hadjistavropoulos, H.D. Fundamentals of Health Psychology (2nd Edition), pp. 113-141. Oxford University Press.
  • Browne, M.E., Hadjistavropoulos, T., Prkachin, K., Ashraf, A., Taati, B. (2019). Pain expression in dementia: Validity of observers’ pain judgements as a function of angle of observation. Journal of Nonverbal Behavior, 43, 309-327.
  • Asgarian, A., Zhao, S., Ashraf, A.B., Browne, M.E., Prkachin, K.M., Mihailidis, A., Hadjistavropoulos, T & Taati, B. (2019). Limitations and biases in facial landmark detection – An empirical study on older adults with dementia. In Proceedings of the Face and Gesture Analysis for HealthInformatics Workshop, held in conjunction with the 2019 Conference on Computer Vision and Pattern Recognition (CVPR). Long Beach, CA, USA, June 2019. Peer reviewed paper available at
  • Hadjistavropoulos, T. & Martin, R. (2019). Information for caregivers of older adults who have dementia. In Hadjistavropoulos, T. & Hadjistavropoulos, H. (Editors) pp. 162-170. Pain management in older adults: A self-help guide (2nd Edition). Philadelphia: Wolters Kluwer.
  • Martin, R. R., Hadjistavropoulos, T. & Hadjistavropoulos, H.D. (2019). Pain among seniors. In Hadjistavropoulos, T. & Hadjistavropoulos, H. (Editors) pp. 1-14. Pain management in older adults: A self-help guide (2nd Edition). Philadelphia: Wolters Kluwer.
  • Martin, R. R., Hadjistavropoulos, T., Williams, J., & Hadjistavropoulos, H.D. (2019). Pain and psychology. In Hadjistavropoulos, T. & Hadjistavropoulos, H. (Editors), pp. 15-22. Pain management in older adults: A self-help guide (2nd Edition). Philadelphia: Wolters Kluwer.
  • Martin, R.R., Hadjistavropoulos, T., Hadjistavropoulos, H.D., Leforte, S. M., & Fuchs-Lacelle, S. (2019). Taking control: Effective pain management. In Hadjistavropoulos, T. & Hadjistavropoulos, H. (Editors). Pain management in older adults: A self-help guide (2nd Edition), pp. 23-39. Philadelphia: Wolters Kluwer.