OBJECTIVES Facial expression may be a surrogate marker of pain in Alzheimer disease (AD) when self-report of pain is compromised. Recent studies have demonstrated increased pain sensitivity in AD; however, experimental pain studies analyzing facial expressions in AD are limited and report inconsistent results. The aims of this study were to examine facial expression of pain in AD patients and its relationship to sum-scored measures of multiple pain behavioral domains and subjective pain ratings. MATERIALS AND METHODS The Facial Action Coding System (FACS) was used to characterize facial expressions in 35 AD patients and 33 healthy seniors during pressure algometry. To improve pain specificity, facial responses were categorized as pain-relevant or pain-irrelevant before group analyses. We also assessed the relationship of AD severity to differential facial responsiveness by correlating FACS-based results with clinical pain scales (portions of the Pain Assessment in Advanced Dementia scale and the Faces Pain Scale-Revised [FPS-R]). RESULTS No significant relationship was found between AD severity and FACS scores. Pain-relevant, but not irrelevant, FACS scores were increased in AD patients compared with seniors without AD. Pain Assessment in Advanced Dementia scale stimulus-response slopes were correlated with those of pain-relevant FACS and FPS-R in both the groups. Pain-relevant FACS slopes showed no relationship with those of the FPS-R in either group. DISCUSSION Pain sensitivity is increased across all severities of AD when measured using the FACS. Clinical observational pain scales support the relevance of facial expression as a partial compensatory pain communication modality for AD. However, measures of pain behavior that sum across objective coding of several domains provide a better indicator of subjective pain than measures of facial expression alone.
