ObjectivesThe aims of this study were to (1) identify behaviors that occur in noncommunicative nursing home residents that are perceived by nurses to be indicators of pain, (2) determine factors affecting the differentiation of pain behaviors from similar behaviors due to other causes, and (3) assess nurses' perceptions of the prevalence and importance of specific indicators of pain as well as barriers to the detection of pain in this population.Setting and PatientsSeventy-two staff members of three nursing homes were interviewed and surveyed about specific behaviors associated with pain. Focus groups were conducted with staff to validate pain indicators and investigate perceptions of their own ability to identify pain.ResultsNursing staff members agreed on a core group of behaviors that they perceive as pain indicators in elderly persons suffering from dementia. These indicators include specific physical repetitive movements, vocal repetitive behaviors, physical signs of pain, and changes in behavior from the norm for that person. The nursing staff members' level of familiarity with the residents was reported to have a significant effect on staff members' ability to identify and differentiate pain behaviors from other behaviors of impaired residents. Barriers to the detection of pain pertain to staff issues, resident behaviors, and resident–staff relationships.ConclusionsThe study of pain among the noncommunicative elderly and, in particular, the development of a tool that can be used to assess their pain may greatly improve the quality of life of the estimated 20% to 35% of nursing home residents who cannot adequately express their needs.