These results also suggest that pain continues to be under treated in NH residents with dementia, who are nonverbal and that this under treatment may be associated with physically aggressive symptoms. Most of the residents (89.6% who were able to self report pain had pain medications, whereas only 45.6% of the residents who could not verbalize pain had pain medications. In addition, in our multivariate analysis of all NH residents with dementia in pain, a nonverbal status was significantly associated with not receiving pain medication after adjusting for other explanatory variables. These results are consistent with previous studies, which report that persons with severe dementia receive less pain medication. Thus, it can be argued that a higher percentage of physical aggression in NH residents who cannot verbalize pain could be because of insufficient pain management. The pain self-report, which is the gold standard assessment in cognitively intact persons, is not feasible to use with persons with severe dementia because it impairs their ability to remember, interpret, and respond to pain. Instead, NH residents with severe dementia need comprehensive assessments that include measures of behavioral pain indicators, which are critical to determining the level and direction of treatment, and these assessments should be applied thoroughly and followed up with appropriate pain treatment Incomplete pain assessment may result in under treatment of pain and increase the odds that a resident may exhibit symptoms of physical aggression. However, the cross-sectional nature of this study could not provide a temporal direction for the relationship between pain treatment and aggressive behavioral symptoms; thus, future studies should use a longitudinal design with experimental components to identify temporal associations.