Is the faces pain scale reliable and valid in older adults? A comprehensive guide

Oct 17, 2025 4 min read •

senior care Healthy Aging Pain Management

Chronic pain is common among older adults, with some studies indicating a high prevalence in nursing home residents. However, pain assessment is often challenging due to various factors. The Faces Pain Scale is one of the tools used in this context. The question is, is the faces pain scale reliable and valid in older adults? Let's explore the evidence.

Quick Summary

The Faces Pain Scale is a reliable and valid tool for pain assessment in older adults, particularly those who are cognitively intact or have mild-to-moderate cognitive impairment, though its effectiveness decreases with severe impairment. Its visual nature makes it especially useful for individuals with low literacy or communication difficulties.

Key Points

Reliable & Valid: The Faces Pain Scale, particularly the revised version (FPS-R), is a reliable and valid tool for pain assessment in older adults.
Helpful with Impairment: It is especially useful for seniors with mild-to-moderate cognitive impairment or low literacy who may struggle with other pain scales.
Not for Severe Cases: For individuals with severe cognitive impairment or advanced dementia, self-report tools like the FPS are not sufficient and should be supplemented with observational assessments.
Favored by Some: Studies have shown that the FPS-R is often preferred by cognitively impaired individuals, as well as those with low literacy, over numerical scales.
Requires Context: The FPS should be used as part of a multi-modal assessment, considering the patient's cognitive status, communication skills, and personal preference for the most accurate results.
Cross-Cultural Evidence: Research has provided cross-cultural evidence supporting the usefulness of the FPS, though it is important to remain sensitive to individual differences.

Understanding the Faces Pain Scale (FPS)

The Faces Pain Scale (FPS) is a visual tool designed to help individuals, particularly those who have difficulty verbally describing their pain, communicate their pain intensity. Originally developed for children, it has been adapted and validated for use across a range of populations, including older adults. Different versions exist, including the Wong-Baker FACES® Pain Rating Scale and the Faces Pain Scale–Revised (FPS-R). The FPS-R, in particular, was created to address potential confusion between pain and other emotions like sadness by eliminating smiling faces and using a clear 0-10 scale for scoring.

The Validity of the Faces Pain Scale in Older Adults

Research has explored the psychometric properties of the FPS in older adults, focusing on different aspects of its validity and reliability. The consensus is that it is a valuable tool, but its utility depends on the patient's specific circumstances.

Construct Validity

Construct validity refers to whether a tool accurately measures what it's supposed to measure—in this case, pain. Multiple studies confirm that older adults generally perceive the faces on the FPS as representing pain rather than other constructs like sadness or anxiety. A study involving Korean older adults, for example, found that subjects perceived the 11-face FPS as a pain measure, with near-perfect agreement on the ranking of faces by pain intensity.

Concurrent Validity

Concurrent validity is established by comparing the FPS's results to those of other established pain scales, such as the Numerical Rating Scale (NRS) or the Visual Analogue Scale (VAS). Strong correlations have been found between the FPS and these other scales, demonstrating that the FPS provides similar pain intensity estimates. For instance, studies have reported strong Spearman rank correlation coefficients between the FPS and NRS and VAS in older adults with chronic pain. This indicates that the FPS is a credible alternative for measuring pain intensity.

Test-Retest Reliability

Test-retest reliability assesses the consistency of a tool's results over time. In cognitively intact older adults, studies have shown acceptable to excellent test-retest reliability for the FPS. One study using a two-week interval found acceptable reliability in cognitively intact subjects. It's worth noting that reliability can be affected by memory bias, which is why appropriate time intervals between tests are crucial.

Faces Pain Scale vs. Other Pain Scales: A Comparison

Selecting the right pain scale is critical for accurate assessment. The choice often comes down to the patient's individual capabilities. Below is a comparison of the Faces Pain Scale-Revised (FPS-R) with two other common scales:


Feature	Faces Pain Scale-Revised (FPS-R)	Numerical Rating Scale (NRS)	Verbal Descriptor Scale (VDS)
Ease of Use	Very easy; uses visual cues that require no reading or number concepts.	Easy for those who understand and are comfortable with numbers.	Moderate; requires understanding of word descriptors like "mild," "moderate," and "severe."
Cognitive Impairment	Effective for those with mild-to-moderate impairment; preferred by this group over other scales. Not for severe impairment.	Not appropriate for individuals with significant cognitive impairment.	Depends on the individual's ability to process and comprehend the word choices.
Low Literacy	Excellent for individuals with low literacy or limited education, as it requires no reading.	Ineffective for individuals with poor number comprehension.	Ineffective for those with low reading skills.
Best For...	Non-verbal or partially verbal patients, those with cognitive impairment, or low literacy.	Cognitively intact individuals with strong verbal and numerical skills.	Those who prefer to use words to describe their pain rather than numbers or faces.

Factors Influencing the FPS’s Effectiveness

Cognitive Status

An individual's cognitive status is the most significant factor affecting the use of the FPS. While it is highly effective for patients with mild to moderate cognitive impairment, its value diminishes as impairment becomes more severe. For individuals with advanced dementia, pain assessment must rely on observational tools that focus on behavioral changes, such as grimacing, withdrawal, or vocalizations.

Literacy and Education

The FPS is advantageous for older adults with limited education or low literacy levels because it doesn’t require them to read or understand a numerical system. This visual simplicity ensures that a wider range of patients can participate in their own pain management, promoting patient-centered care.

Cultural Considerations

It is important to be aware of how cultural background might influence the expression and perception of pain. While some cross-cultural studies have supported the FPS's usefulness, clinicians should consider cultural norms regarding pain expression. For more information on the history and various versions of the Faces Pain Scale, visit The Faces Pain Scale Foundation website.

Best Practices for Using the Faces Pain Scale

To ensure the most accurate results when using the FPS in older adults, consider the following best practices:

Clear Instructions: Explain the purpose of the scale simply and clearly. Use phrases like, "Point to the face that shows how much it hurts." Ensure the patient understands that the faces range from no pain to the worst imaginable pain.
Quiet Environment: Conduct the assessment in a calm, distraction-free setting to help the patient focus.
Multi-Modal Assessment: Never rely on a single tool. Combine the FPS with verbal reports (when possible), physical examination, and observation of behavior to get a comprehensive understanding of the patient's pain.

Conclusion

In conclusion, the Faces Pain Scale has demonstrated reliability and validity for assessing pain in older adults, particularly those who are cognitively intact or have mild-to-moderate cognitive impairment. Its visual nature and independence from literacy make it an invaluable tool for vulnerable populations. However, it is not a perfect solution for all seniors. For those with severe cognitive deficits, observational tools are necessary. The key is to use the right tool for the right patient, ensuring that pain is accurately and consistently assessed to provide optimal care and improve quality of life.

Frequently Asked Questions

The Faces Pain Scale-Revised (FPS-R) is an updated version of the Faces Pain Scale that addresses concerns about emotional confounding. It uses a series of six faces, ranging from a neutral expression (no pain) to a face indicating intense pain, and is scored from 0 to 10.

Yes, for those with mild to moderate dementia, the FPS can be an effective tool. Its visual nature bypasses some of the verbal communication difficulties. However, for patients with severe dementia, relying on self-report is not reliable, and clinicians must use observational pain assessment tools.

The effectiveness depends on the patient. The FPS is often preferred by those with cognitive or literacy challenges, as it does not rely on number comprehension. For cognitively intact patients, a Numerical Rating Scale (NRS) may be equally or even more responsive for tracking changes.

Instructions should be simple and clear. The provider should point to each face and ask the patient to choose the face that best represents their current pain level. It's helpful to explain the scale's extremes: "This face means no pain at all, and this face means the worst pain you can imagine."

Limitations include its unsuitability for patients with severe cognitive impairment who cannot make choices or communicate reliably. Furthermore, some variations of the scale have been criticized for potentially measuring emotions other than just pain, though the FPS-R was designed to mitigate this.

Assessing pain in older adults is challenging due to age-related communication issues, fear of addiction, the belief that pain is a normal part of aging, co-existing health conditions, and potential cognitive impairments that hinder accurate self-report.

The right choice depends on the patient's capabilities. If they are cognitively intact and comfortable with numbers, the NRS is a good option. If there is any cognitive impairment or low literacy, the FPS-R is often the most reliable self-report tool. For severe cognitive impairment, observational scales are needed.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.