A behavioural rating scale for acute pain in elderly people with verbal communication difficulties The ALGOPLUS scale was specifically developed to evaluate and manage acute pain in the elderly in all situations where reliable self-assessment is not feasible (verbal communication difficulties).

ALGOPLUS is therefore particularly recommended for screening and evaluating:

– acute painful conditions (e.g. fractures, postoperative pain, ischaemia, lumbago, herpes zoster, urinary retention etc.)

–transitory pain attacks (e.g. facial neuralgia, cancer breakthrough pain etc.)

– pain induced by treatment or medical diagnostic procedures
The scale is composed of five items (observational areas/domains). Observation of any 1 of the behaviours listed in a given item is sufficient to mark “yes” for the item in question. The simple observation of a behaviour, regardless of any aetiological interpretation of its pre-existence, requires that it be marked down as present.

In practice, to complete the grid, observe these items in order: facial expressions, look, complaints, body position and, lastly, atypical behaviours.
Each item marked “yes” is awarded one point and the total across all the items gives a total score out of 5. Scoring can be completed in less than one minute in 80% of cases. A score of 2 or above diagnoses pain with 87% sensitivity and 80% specificity, reliably indicating that pain management should be initiated. Further scoring should be undertaken on a regular basis to check the effectiveness of pain management. Care is satisfactory once the score remains firmly below 2.


Difficult in recognising: e.g.: grabbing should be marked down as “yes” regardless of what the patient grabs (him/herself, a caregiver, or any other item). Scoring on the basis of an aetiological interpretation of the sign, and not merely its presence: e.g.: “Complaints” marked down as “no” because the patient’s crying-out is attributed to dementia, or because the patient has been crying out for a long time. e.g. “Atypical behaviours” marked down as “no” because grabbing the safety rail is attributed to a fear of falling.


The scale was validated among 349 patients and published (Rat et al 2011):

– It shows good internal consistency (KR-20 = 0.712), excellent validity for discriminating between patients with pain and those without (p < 0.0001), highly significant correlation (p < 0.0001) with self-assessment rating scales (VAS, NRS, SVRS), very good inter-rater reliability (ICC = 0.812), excellent sensitivity (p < 0.0001) to changes before-during movement and before-after treatment (Rat et al. 2011).

– The sensitivity (= ability to detect the presence of pain) and specificity (certitude of pain) of the scale were tested in different care departments among patients with and without verbal communication difficulties and according to 2 threshold score values (cut-off).

The best results (see table) were found when the threshold score was 2 and for patients hospitalised in short-term care departments (96% sensitivity, 86% specificity). Sensitivity is lower (69%) in long-term care departments, probably because chronic pain is more frequent there than in short-term departments (see Caldol study, limitations of the ALGOPLUS scale, Martin et al. 2016): in this type of department it may therefore be wise to improve the sensitivity of pain detection by using behavioural rating scales with a larger number of items (see assessment algorithm, Rat et al. 2014)

ALGOPLUS scores by geriatrics unit
Note: at a threshold score of 2, the sensitivity of the scale (detection) is exceptional (100%) in emergency departments, but at the cost of low specificity (53% certitude only on the presence of a pain), which is why a threshold score of 3 is recommended in emergency departments for the introduction of step 3 treatment (indeed, given the frequency and potential seriousness of undesirable effects induced in elderly subjects by treatment of this type, prescription should only be envisaged once one is certain of the existence of pain).


A multicentre study (23 centres) covering 533 assessments (281 patients) compared the inter-rater reliability of the scale (= simultaneous assessment of a single patient using ALGOPLUS by 2 raters but with no dialogue between them).
– ALGOPLUS exhibits excellent inter-rater reliability:
ALGOPLUS total score ICC = 0.889 Agreement between ratings is absolute for 60% of pairs of raters. That percentage rises to 87% for a one-point difference between the two ratings.

– 5 different types of pairings of caregivers were thus evaluated (see table):

– Inter-rater reliability by professional experience is largely the same:
< 5 vs. > 5 years’ experience ICC = 0.91 vs. 0.87<10 vs. >10 years’ seniority: ICC = 0.93 vs. 0.88
– Similarly, inter-rater reliability according to whether the caregivers have benefited or not from special training (in geriatrics or in the area of pain management, but not specifically on ALGOPLUS) is acceptable even if the caregivers have received no training at all, and is excellent when both raters have been trained:
ICC = 0.76 (no training)
ICC = 0.77 (1 rater trained)
ICC = 0.91 (both raters have received special training)


Multicentre study (6 centres) among 171 patients, comparing the psychometric qualities of ALGOPLUS in 4 sub-groups of patients: nondepressive with dementia, depressive with dementia, depressive without dementia and nondepressive without dementia (control group).
Despite average scores generally being higher compared to the control group, ALGOPLUS© demonstrates good psychometric qualities among elderly depressive patients with or without dementia (see table):

However, depression has a negative impact on the rating of items (only 2 items differ significantly between depressive patients with pain and depressive patients without pain). Pain detection sensitivity is also affected (see table). Under these conditions, the use of additional tools which specifically assess depression (GDS, RRS 14 etc.) is recommended.
Nevertheless, this study confirms that the value of the score chosen for the study to validate the ALGOPLUS scale can also be used to enable reliable detection of the presence of acute pain in elderly patients with dementia or with dementia and depression, and consequently to introduce an analgesic treatment regime.


Use of the scale was studied upon its introduction in an aftercare and rehabilitation unit, then after 3 months. The study showed good appropriation of the tool (see figure):
Similar results were obtained from another aftercare and rehabilitation unit (26% after 3 months compared with 0% upon introduction) This demonstrates that caregivers find it easy to use and understand the scale, especially when these figures are viewed within the context of the survey conducted by HAS in 2006 among voluntary services (only 10% usage of behavioural rating scales such as DOLOPLUS or ECPA), or in comparison with the ideal percentage of hetero-assessments theoretically required within those two aftercare and rehabilitation departments according to the actual number of patients with verbal communication difficulties (cf. approximately 40%).


The experience of appropriation of the ALGOPLUS scale by caregivers (Vieillard et al. 2017) and a national survey (Interviews with SFETD caregivers on the use of ALGOPLUS) have highlighted the difficulties encountered when assessing elderly patients with verbal communication difficulties:
Identification of patients with verbal communication difficulties
Recognition of certain behaviours cited on the ALGOPLUS scale
Selection of the behavioural rating scale to use: ease and speed of use but risk of underestimating pain with scales having a small number of items versus under-use and risk of overestimation with scales including a large number of items (see advantages/disadvantages of behavioural rating scales: Michel and Rat, pain assessment in the elderly; Pain and the elderly, coordinated by G. Pickering ; publisher: UPSA Pain Institute 2010).
To answer these questions, the group created a film with the following sections:
21 minute film:
Use of ALGOPLUS in the Emergency Department: Dr Arnaud Delpil-Duval (Emergency Admissions Department, Evreux), example of rating
Presentation of the ALGOPLUS scale: Dr Patrice Rat (Pain and Geriatrics, Marseille)
Use of behavioural rating scales: Dr David Lussier (Geriatrics, Montreal)
Use of ALGOPLUS in geriatrics departments: Dr Sylvie Chapiro, Florine Courtin IDE and Sabrina Campos AS (Pain, Geriatrics and Palliative Care, Paris), example of rating
DOLOPLUS group: Dr Bernard Wary (Palliative Care, Metz-Thionville)
Algorithm for use of behavioural rating scales: Dr Cyril Guilaumé (Pain and Palliative Care, Caen)


Les cas cliniques sont classés par ordre de difficultés croissantes en fonction de l’apprentissage réalisé.

Télécharger le fichier PDF de chaque cas clinique.


Mrs R Antoinette, aged 87, was admitted to a short-term care unit at the Geriatrics Centre because of a stroke.


Mrs K, aged 86, a widow, was described as being an active woman, and belonged to a number of associations in her village. Sadly, over the course of the summer, her family noticed a change in higher functions, with memory problems, behavioural problems and episodes of confusion; this was combined with coordination problems, particularly when walking.


Mrs Y, aged 89, with a medical history of polyvascular disease against a background of type 2 diabetes detected 2 years previously, had recently suffered an infarctus resulting in partially regressive stroke with resulting dysarthria and confusion.