This article critiques the literature on existing pain assessment instruments for cognitively impaired elders and reports findings of pilot testing of the Checklist of Nonverbal Pain Indicators. This instrument was designed to measure pain behaviors in cognitively impaired elders. Instrument testing was conducted on a population of elderly patients with hip fractures. Interrater reliability showed 93% agreement on the dichotomous checklist items. Behaviors occurred more frequently during movement in this population. Of the six pain-related behaviors in the instrument, facial grimaces/winces occurred in 44% of the patients tested. Observed pain behaviors were positively correlated with self-report of pain. No differences between observed pain behaviors in cognitively intact versus cognitively impaired older adults with hip fractures were noted. Limitations of the instrument and recommendations for tool use are discussed.