{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,3]],"date-time":"2026-11-03T21:23:49Z","timestamp":1793741029939,"version":"4.6.1"},"reference-count":34,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2021,11,2]],"date-time":"2021-11-02T00:00:00Z","timestamp":1635811200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000780","name":"European Commission","doi-asserted-by":"publisher","award":["COST TD1005"],"award-info":[{"award-number":["COST TD1005"]}],"id":[{"id":"10.13039\/501100000780","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Brain Sciences"],"abstract":"<jats:p>Facial expression is a key aspect in observational scales developed to improve pain assessment in individuals with cognitive impairments. Although these scales are used internationally in individuals with different types of cognitive impairments, it is not known whether observing facial expressions of pain might differ between regions or between different types of cognitive impairments. In a pilot study, facial responses to standardized experimental pressure pain were assessed among individuals with different types of cognitive impairments (dementia, mild cognitive impairment, Huntington\u2019s disease, and intellectual disability) from different countries (Denmark, Germany, Italy, Israel, and Spain) and were analyzed using facial descriptors from the PAIC scale (Pain Assessment in Impaired Cognition). We found high inter-rater reliability between observers from different countries. Moreover, facial responses to pain did not differ between individuals with dementia from different countries (Denmark, Germany, and Spain). However, the type of cognitive impairment had a significant impact; with individuals with intellectual disability (all being from Israel) showing the strongest facial responses. Our pilot data suggest that the country of origin does not strongly affect how pain is facially expressed or how facial responses are being scored. However, the type of cognitive impairment showed a clear effect in our pilot study, with elevated facial responses in individuals with intellectual disability.<\/jats:p>","DOI":"10.3390\/brainsci11111455","type":"journal-article","created":{"date-parts":[[2021,11,2]],"date-time":"2021-11-02T12:39:42Z","timestamp":1635856782000},"page":"1455","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Observing Pain in Individuals with Cognitive Impairment: A Pilot Comparison Attempt across Countries and across Different Types of Cognitive Impairment"],"prefix":"10.3390","volume":"11","author":[{"given":"Miriam","family":"Kunz","sequence":"first","affiliation":[{"name":"Department of Psychology and Sociology, Medical Faculty, University of Augsburg, Universitystreet 2, 86135 Augsburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Petra","family":"Crutzen-Braaksma","sequence":"additional","affiliation":[{"name":"Department of General Practice and Elderly Care Medicine, University Medical Center Groningen (UMCG), University of Groningen, 9713 Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4091-489X","authenticated-orcid":false,"given":"Lydia","family":"Gim\u00e9nez-Llort","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Forensic Medicine, School of Medicine, Universitat Aut\u00f2noma de Barcelona, 08193 Barcelona, Spain"},{"name":"Institut de Neuroci\u00e8ncies, Universitat Aut\u00f2noma de Barcelona, 08193 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0841-7770","authenticated-orcid":false,"given":"Sara","family":"Invitto","sequence":"additional","affiliation":[{"name":"INSPIRE Lab, Department of Biological and Environmental Sciences and Technologies, University of Salento, 73100 Lecce, LE, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5475-0243","authenticated-orcid":false,"given":"Gaya","family":"Villani","sequence":"additional","affiliation":[{"name":"INSPIRE Lab, Department of Biological and Environmental Sciences and Technologies, University of Salento, 73100 Lecce, LE, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6567-5373","authenticated-orcid":false,"given":"Marina","family":"deTommaso","sequence":"additional","affiliation":[{"name":"Applied Neurophysiology and Pain Unit, Bari Aldo Moro University, 70121 Bari, BA, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Petrini","sequence":"additional","affiliation":[{"name":"Center for Neuroplasticity and Pain (CNAP), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, 9220 Aalborg, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lene","family":"Vase","sequence":"additional","affiliation":[{"name":"Division for Psychology and Neuroscience, Department of Psychology and Behavioral Sciences, School of Business and Social Sciences, Aarhus University, 8210 Aarhus, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan","family":"Tomczak Matthiesen","sequence":"additional","affiliation":[{"name":"Division for Psychology and Neuroscience, Department of Psychology and Behavioral Sciences, School of Business and Social Sciences, Aarhus University, 8210 Aarhus, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hanne","family":"Gottrup","sequence":"additional","affiliation":[{"name":"Department of Neurology, Demential Clinic, Aarhus University Hospital, 8200 Aarhus, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jone Ansuategui","family":"Echeita","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, 9713 Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Lautenbacher","sequence":"additional","affiliation":[{"name":"Department of Physiological Psychology, University of Bamberg, 96047 Bamberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth","family":"Defrin","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"468","DOI":"10.2174\/156720501405170403224615","article-title":"Editorial: Pain in Dementia: A Distressing Combination of Several Factors","volume":"14","author":"Achterberg","year":"2017","journal-title":"Curr. Alzheimer Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1016\/j.pmn.2019.07.005","article-title":"Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement","volume":"20","author":"Herr","year":"2019","journal-title":"Pain Manag. Nurs."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1007\/s00482-019-00411-6","article-title":"Assessing pain in patients with dementia","volume":"33","author":"Lautenbacher","year":"2019","journal-title":"Schmerz"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"431","DOI":"10.2147\/JPR.S239321","article-title":"Are Chronic Pain Patients with Dementia Being Undermedicated?","volume":"14","author":"Achterberg","year":"2021","journal-title":"J. Pain Res."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1002\/ejp.1536","article-title":"Pain assessment for cognitively impaired older adults: Do items of available observer tools reflect pain-specific responses?","volume":"24","author":"Kappesser","year":"2020","journal-title":"Eur. J. Pain"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1093\/ageing\/afy018","article-title":"Pain assessment in the older population: What the literature says","volume":"47","author":"Schofield","year":"2018","journal-title":"Age Ageing"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1002\/ejp.1477","article-title":"The Pain Assessment in Impaired Cognition Scale (PAIC15): A multidisciplinary and international approach to develop and test a meta-tool for pain assessment in impaired cognition, especially dementia","volume":"24","author":"Kunz","year":"2020","journal-title":"Eur. J. Pain"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1002\/ejp.1484","article-title":"Observational pain assessment in older persons with dementia in four countries: Observer agreement of items and factor structure of the pain assessment in impaired cognition","volume":"24","author":"Konstantinovic","year":"2020","journal-title":"Eur. J. Pain"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Corbett, A., Achterberg, W.P., Husebo, B.S., Lobbezoo, F., De Vet, H., Kunz, M., Strand, L.I., Constantinou, M., Tudose, C., and Kappesser, J. (2014). An international road map to improve pain assessment in people with impaired cognition: The development of the Pain Assessment in Impaired Cognition (PAIC) meta-tool. BMC Neurol., 14.","DOI":"10.1186\/s12883-014-0229-5"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Lautenbacher, S., Walz, A.L., and Kunz, M. (2018). Using observational facial descriptors to infer pain in persons with and without dementia. BMC Geriatr., 18.","DOI":"10.1186\/s12877-018-0773-8"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1784","DOI":"10.1016\/S0140-6736(99)01309-4","article-title":"Assessment of patients\u2019 reporting of pain: An integrated perspective","volume":"353","author":"Turk","year":"1999","journal-title":"Lancet"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1177\/204946370800100203","article-title":"Cultural Influences on Pain","volume":"1","author":"Peacock","year":"2008","journal-title":"Rev. Pain"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"551","DOI":"10.1016\/S0005-7967(01)00072-9","article-title":"A theoretical framework for understanding self-report and observational measures of pain: A communications model","volume":"40","author":"Hadjistavropoulos","year":"2002","journal-title":"Behav. Res. Ther."},{"key":"ref_14","unstructured":"Scherer, K., and Ekman, P. (1982). Conducting Judgment Studies. Handbook of Methods in Nonverbal Behavior Research, Cambridge University Press."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"522","DOI":"10.1111\/j.1526-4637.2012.01336.x","article-title":"A quantitative review of ethnic group differences in experimental pain response: Do biology, psychology, and culture matter?","volume":"13","author":"Riley","year":"2012","journal-title":"Pain Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1111\/joor.12683","article-title":"Cross-cultural differences in types and beliefs about treatment in women with temporomandibular disorder pain","volume":"45","author":"List","year":"2018","journal-title":"J. Oral Rehabil."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1177\/0022146514541446","article-title":"How health conditions translate into self-ratings: A comparative study of older adults across Europe","volume":"55","author":"Hardy","year":"2014","journal-title":"J. Health Soc. Behav."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1016\/j.pain.2009.10.008","article-title":"Pain in European long-term care facilities: Cross-national study in Finland, Italy and the Netherlands","volume":"148","author":"Achterberg","year":"2010","journal-title":"Pain"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1016\/j.pain.2007.09.007","article-title":"The facial expression of pain in patients with dementia","volume":"133","author":"Kunz","year":"2007","journal-title":"Pain"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1984827","DOI":"10.1155\/2016\/1984827","article-title":"The Influence of Executive Functioning on Facial and Subjective Pain Responses in Older Adults","volume":"2016","author":"Oosterman","year":"2016","journal-title":"Behav. Neurol."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Bunk, S., Emch, M., Koch, K., Lautenbacher, S., Zuidema, S., and Kunz, M. (2020). Pain Processing in Older Adults and Its Association with Prefrontal Characteristics. Brain Sci., 10.","DOI":"10.3390\/brainsci10080477"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1016\/j.neurobiolaging.2021.06.009","article-title":"Pain processing in older adults with dementia-related cognitive impairment is associated with frontal neurodegeneration","volume":"106","author":"Bunk","year":"2021","journal-title":"Neurobiol. Aging"},{"key":"ref_23","unstructured":"Fleiss, J. (1986). The Design and Analysis of Clinical Experiments, Wiley."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"219","DOI":"10.2217\/pmt.12.7","article-title":"Ethnic differences in pain and pain management","volume":"2","author":"Campbell","year":"2012","journal-title":"Pain Manag."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1901","DOI":"10.1097\/j.pain.0000000000001593","article-title":"The need for diversity in research on facial expressions of pain","volume":"160","author":"Dildine","year":"2019","journal-title":"Pain"},{"key":"ref_26","unstructured":"Blacking, J. (1977). Biological and cultural contributions to body and facial movement. The Anthropology of the Body, Academic Press."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1007\/BF00995569","article-title":"Cultural similarities and differences in display rules","volume":"14","author":"Matsumoto","year":"1990","journal-title":"Motiv. Emot."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s10919-016-0244-x","article-title":"Large-Scale Observational Evidence of Cross-Cultural Differences in Facial Behavior","volume":"41","author":"McDuff","year":"2017","journal-title":"J. Nonverbal Behav."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"501","DOI":"10.2174\/1567205013666160603010455","article-title":"Facial Pain Expression in Dementia: A Review of the Experimental and Clinical Evidence","volume":"14","author":"Lautenbacher","year":"2017","journal-title":"Curr. Alzheimer Res."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1396","DOI":"10.1097\/j.pain.0000000000000195","article-title":"Experimental pain processing in individuals with cognitive impairment: Current state of the science","volume":"156","author":"Defrin","year":"2015","journal-title":"Pain"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1097\/j.pain.0000000000001424","article-title":"Facial muscle movements encoding pain\u2014A systematic review","volume":"160","author":"Kunz","year":"2019","journal-title":"Pain"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1016\/j.jpsychores.2007.09.010","article-title":"Impact of age on the facial expression of pain","volume":"64","author":"Kunz","year":"2008","journal-title":"J. Psychosom. Res."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Defrin, R., Beshara, H., Benromano, T., Hssien, K., Pick, C.G., and Kunz, M. (2021). Pain Behavior of People with Intellectual and Developmental Disabilities Coded with the New PAIC-15 and Validation of Its Arabic Translation. Brain Sci., 11.","DOI":"10.3390\/brainsci11101254"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1849","DOI":"10.1111\/j.1365-2702.2010.03695.x","article-title":"Predictors of pain in nursing home residents with dementia: A cross-sectional study","volume":"20","author":"Lin","year":"2011","journal-title":"J. Clin. Nurs."}],"container-title":["Brain Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3425\/11\/11\/1455\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:24:34Z","timestamp":1760167474000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3425\/11\/11\/1455"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,2]]},"references-count":34,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2021,11]]}},"alternative-id":["brainsci11111455"],"URL":"https:\/\/doi.org\/10.3390\/brainsci11111455","relation":{},"ISSN":["2076-3425"],"issn-type":[{"value":"2076-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,2]]}}}