Pain Management in Older Adults

 

OVERVIEW

Pain, a common, subjective experience for many older adults, is associated with acute (e.g., surgery, trauma) and chronic (e.g., osteoarthritis) conditions. Despite its prevalence, evidence suggests that pain is often poorly assessed and poorly managed, especially in older adults. Cognitive impairment related to dementia and related disorders represents a challenge to pain management because older adults with these conditions may be unable to communicate their pain. Nurses, leaders in the interdisciplinary care team, need to be knowledgeable about pain assessment and management to provide optimal care and to educate patients and families about managing pain.

 

BACKGROUND

A. Definitions

  1. Pain: This is defined as “an unpleasant sensory and emotional experience” (Raja et al., 2020, p. 1976) and also as “whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1968, p. 95). These definitions highlight the multidimensional and highly subjective nature of pain. Pain is usually characterized according to the duration of pain (e.g., acute vs. persistent) and the cause of pain (e.g., nociceptive vs. neuropathic). These definitions have implications for pain management strategies.
  2. Acute pain: This refers to pain that results from injury, surgery, or trauma. It may be associated with autonomic activity such as tachycardia and diaphoresis. Acute pain is usually time-limited and subsides with healing.
  3. Chronic pain: This refers to pain that lasts for a prolonged period (usually more than 3–6 months) and is associated with chronic disease or injury (e.g., osteoarthritis; AGS, 2009). Persistent pain is not always time-dependent, however, and can be characterized as pain that lasts longer than the anticipated healing time. Autonomic activity is usually absent, but persistent pain is often associated with functional loss, mood disruptions, behavior changes, and reduced quality of life.
  4. High-impact chronic pain: This represents persistent pain associated with substantial restriction in life activities or disability lasting 6 months or more. These individuals often report more severe pain, mental health effects and cognitive impairments, and difficulty caring for self.
  5. Nociceptive pain: This refers to pain caused by stimulation of specific peripheral or visceral pain receptors. This type of pain results from disease processes (e.g., osteoarthritis), soft tissue injuries (e.g., falls), and medical treatment (e.g., surgery, venipuncture). It is usually localized and responsive to treatment.
  6. Neuropathic pain: This refers to pain caused by damage to the peripheral nervous system or CNS. This type of pain is associated with diabetic neuropathies, postherpetic and trigeminal neuralgias, stroke, and chemotherapy treatment for cancer. It is usually more diffuse and less responsive to analgesic medications.

B. Epidemiology

  1. Approximately 50% of community-dwelling older adults and 85% of nursing home residents experience persistent pain.
  2. The Centers for Disease Control and Prevention estimated that more than 60% of older adults in the United States experience chronic pain (Dahlhamer et al., 2018).

C. Etiology

  1. Older adults have chronic medical conditions that are typically associated with chronic pain, such as osteoarthritis and peripheral vascular disease, or experience injurious events like falls that contribute to acute and chronic pain.
  2. Older adults often have multiple medical conditions, both chronic and/or acute, and may suffer from multiple types and sources of pain.

D. Significance

  1. Untreated or ineffectively treated moderate to severe persistent pain has major implications for older adults’ health, functioning, and quality of life (Horgas, 2017).
    • Pain is associated with depression, social withdrawal, sleep disturbances, impaired mobility, decreased activity engagement, and increased healthcare use.
    • Other geriatric conditions that can be exacerbated by pain include falls, cognitive decline, deconditioning, malnutrition, gate disturbances, and slowed rehabilitation.
  2. The promotion of comfort and relief of pain is fundamental to nursing practice. Nurses need to be knowledgeable about pain and evidence-based treatments in late life to provide optimal care, to educate patients and families, and to work effectively in interdisciplinary healthcare teams.

ASSESSMENT PARAMETERS

A. Assumptions

  1. Most hospitalized older patients suffer from both acute and persistent pain.
  2. Older adults with cognitive impairment experience pain but are often unable to verbalize it.
  3. Both patients and healthcare providers have personal beliefs, prior experiences, insufficient knowledge, and mistaken beliefs about pain and pain management that (a) influence the pain management process and (b) must be acknowledged before optimal pain relief can be achieved.
  4. Pain assessment must be regular, systematic, and documented to accurately evaluate treatment effectiveness.
  5. Self-report is the gold standard for pain assessment.
  6. Pain assessments should not rely only on intensity as the sole measure of the experience.
  7. Effective pain management requires an individualized approach.

B. Strategies for pain assessment

  1. Initial, quick pain assessment (Horgas, Bruckenthal et al., 2022)
    • Say “Tell me where you are hurting.”
    • Assess pain location, intensity, duration, quality, and onset.
  2. Comprehensive pain assessment (Booker et al., 2020; Horgas, Bruckenthal, et al., 2022)
    • Review medical history, physical examination, and laboratory and diagnostics to understand the sequence of events contributing to pain.
    • Assess cognitive status (e.g., dementia, delirium), mental state (e.g., anxiety, agitation, and depression), and functional status. If there is evidence of cognitive impairment, do not assume that the patient cannot provide a self-report of pain. Augment self-report with observational measures and proxy report using the hierarchical approach.
    • Assess present pain, including intensity, character, frequency, pattern, location, duration, and precipitating and relieving factors during movement, using a standardized measurement tool (e.g., NRS, VDS, and FPS) consistently.
    • Assess pain history, including prior injuries, illnesses, and surgeries; pain experiences; and pain interference with daily activities.
    • Review medications, including current and previously used prescription drugs, OTC drugs, and complementary therapies (including home remedies). Determine what pain control methods have previously been effective for the patient. Assess the patient’s attitudes and beliefs about pain and the use of analgesics, adjuvant drugs, and nonpharmacological treatments. Assess history of medication or alcohol misuse.
    • Assess pain regularly and frequently, at least every 4 hours. Pain assessments may be individualized based on patterns of pain; for example, pain may be worse upon awakening in the morning or late at night after physical activity throughout the day. Monitor pain intensity after giving medications to evaluate effectiveness.
    • Observe for nonverbal and behavioral signs of pain, such as facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalizations, and crying. Also watch for changes in behavior from the patient’s usual patterns.
    • Gather information from family members about the patient’s pain experiences. Ask about the patient’s verbal and nonverbal/behavioral expressions of pain, particularly in older adults with dementia.
    • When pain is suspected but assessment instruments or observation is ambiguous, institute a clinical trial of pain treatment (i.e., in persons with dementia). If symptoms persist, assume that pain is unrelieved and treat accordingly.

NURSING CARE STRATEGIES

A. General approach

  1. Pain management requires an individualized and compassionate approach that incorporates personal goals and uses multidimensional, evidence-based strategies to minimize the pain and reduce its consequences on functioning, sleep, mood, and behavior.
  2. Advanced care plans may be helpful in guiding pain management in older adults with declining physical and cognitive status before they become unable to participate in their care.

B. Pain prevention

  1. Develop a written pain treatment plan on admission to the hospital or before surgery or treatments. Help the patient set realistic pain treatment goals and document the goals and plan.
  2. Anticipate and aggressively treat pain before, during, and after painful functional activities and diagnostic and/or therapeutic treatments. Administer analgesics 30 minutes before activities.
  3. Educate patients, families, and other healthcare providers about:\
    • Use of analgesic medications before and after painful procedures or activities
    • Their pain medications, including their side effects, with discussion and answering questions about issues of addiction, dependence, and tolerance
    • Timing of medications for pain, to use on a regular basis, and to avoid allowing pain to escalate
    • Appropriate use of nonpharmacological strategies to manage pain, such as relaxation, massage, and the use of heat and cold

C. Treatment guidelines

  1. Pharmacological (Arnstein et al., 2023a, 2023b)
    • Administer pain drugs on a regular basis to maintain therapeutic levels and combine with nondrug strategies to prevent or minimize breakthrough pain.
    • For postoperative pain, choose the least invasive route. Intravenous analgesics are the first choice after major surgery. Avoid intramuscular injections. Transition from parenteral medications to oral analgesics, including when the patient has oral intake. Consider easily administered oral routes such as sublingual or buccal medications if there are issues with swallowing and safety based on the older adult’s metabolic profile.
    • Choose the correct type of analgesic. Use opioids for treating moderate to severe pain and nonopioids for mild to moderate pain. Select the analgesic based on thorough medical history, comorbidities, other medications, and history of drug reactions.
    • Among nonopioid medications, acetaminophen is the preferred drug for treating mild to moderate pain. Guidelines recommend not exceeding 3 g/d (maximum 2 g/d in frail elders). The maximum dose should be reduced to 50% to 75% in adults with reduced hepatic function or history of alcohol abuse. Monitor for excess acetaminophen intake from combination drugs (e.g., opioid + nonopioid) or OTC medications that include acetaminophen. Educate patients and families about this risk and the drugs to avoid.
    • The other major class of nonopioid medications, NSAIDs, should be used with caution or avoided in older adults. Monitor for GI bleeding and consider giving it with a proton pump inhibitor to reduce gastric irritation. Also monitor for nephrotoxicity and delirium.
    • Older adults are at increased risk for adverse drug reactions due to age- and disease-related changes in pharmacokinetics and pharmacodynamics. Monitor hepatic and renal functioning closely to avoid over- or undermedication and to detect adverse effects.
  2. Nonpharmacological (Booker et al., 2020)
    • Investigate older patients’ attitudes and beliefs about, preference for, and experience with nonpharmacological pain treatment strategies.
    • Cognitive behavioral strategies focus on changing the person’s perception of pain (e.g., relaxation therapy, education, and distraction) and may not be appropriate for cognitively impaired persons.
    • Physical pain relief strategies focus on promoting comfort and altering physiological responses to pain (e.g., heat, cold, and TENS units) and are generally safe and effective.

D. Follow-up assessment

  1. Monitor treatment effects within 1 hour of administration and at least every 4 hours.
  2. Evaluate the patient for pain relief and side effects of treatment.
  3. Document the patient’s response to treatment effects.
  4. Document treatment regimen in patient care plan to facilitate consistent implementation.

EXPECTED OUTCOMES

A. Patient will:

  1. Be either pain-free or pain will be at a level that the patient judges as acceptable
  2. Maintain highest level of self-care, functional ability, and activity level possible
  3. Experience no adverse complications, such as falls, GI upset/bleeding, or altered cognitive status

B. Nurse will:

  1. Demonstrate evidence of ongoing and comprehensive pain assessment
  2. Document evidence of prompt and effective pain management interventions
  3. Document systematic evaluation of treatment effectiveness
  4. Demonstrate knowledge of pain management in older patients, including assessment strategies, pain medications, nonpharmacological interventions, and patient/family education

C. Institution/facilities will:

  1. Maintain strong institutional commitment and leadership to improve pain management. Evidence of institutional commitment includes:
    • Providing adequate resources for staff (e.g., educational opportunities including compensation for staff education and time, print materials, access to web-based and app-based guidelines and information)
    • Clear communication of how better pain management is congruent with organizational goals
    • Establishment of policies and standard operating procedures for the organization
    • Requiring clear accountability for documentation and outcome measurement
  2. Establish an internal pain service team of committed and knowledgeable staff who can lead quality improvement efforts to improve pain management practices.
  3. Require evidence of documentation of pain assessment, intervention, and evaluation of treatment effectiveness. This includes adding pain assessment and reassessment questions to flow sheets and electronic forms.
  4. Provide evidence of using a multispecialty approach to pain management. This includes referral to specialists for specific therapies such as psychiatry, psychology, physical therapy, spiritual providers, and interdisciplinary pain treatment specialists; clinical pathways and decision support tools will be developed to improve referrals and multispecialty consultation.

ABBREVIATIONS

AGS            American Geriatrics Society

CNS            central nervous system

FPS             Faces Pain Scale

GI               gastrointestinal

NRS            Numerical Rating Scale

NSAID        nonsteroidal anti-inflammatory drug

OTC            over-the-counter

TENS          transcutaneous electrical nerve stimulation

VDS            Verbal Descriptor Scale

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 18, Horgas, A.L., Booker, S.Q., Dillard, A.C. & Yoon, S.L. (2025) Pain Management in the Older Adult

 

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Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, X.-J., Stevens, B., Sullivan, M. D., Tutelman, P. R., Ushida, T., & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: Concepts, challenges, and compromises. Pain, 161(9), 1976–1982. https://doi.org/10.1097/j.pain.0000000000001939. Evidence Level I.

Reinhard, S. (2019). Home Alone Revisited: Family caregivers providing complex care. Innovation in Aging, 3(Suppl 1), S747–S748. doi.org/10.1093/geroni/igz038.2740. Evidence Level V.

Ribeiro, H., Rodrigues, I., Napoleão, L., Lira, L., Marques, D., Veríssimo, M., Andrade, J. P., & Dourado, M. (2022). Non- steroidal anti-inflammatory drugs (NSAIDs), pain and aging: Adjusting prescription to patient features. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 150, 112958. doi.org/10.1016/j.biopha.2022.112958. Evidence Level I.

Roland, C. L., Ye, X., Stevens, V., & Oderda, G. M. (2019). The prevalence and cost of Medicare beneficiaries diagnosed and at risk for opioid abuse, dependence, and poisoning. Journal of Managed Care & Specialty Pharmacy, 25(1), 18–27. doi.org/10.18553/jmcp.2019.25.1.018.Evidence Level III.

Schofield, P., Dunham, M., Martin, D., Bellamy, G., Francis, S. A., Sookhoo, D., Bonacaro, A., Hamid, E., Chandler, R., Abdulla, A., Cumberbatch, M., & Knaggs, R. (2022). Evidence-based clinical practice guidelines on the management of pain in older people—A summary report. British Journal of Pain, 16(1), 6–13. doi.org/10.1177/2049463720976155.Evidence Level I.

Shi, X., Yu, W., Zhang, W., Wang, T., Battulga, O., Wang, L., & Guo, C. (2021). A comparison of the effects of electroacupuncture versus transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: A Bayesian network meta-analysis of randomized controlled trials. Acupuncture in Medicine, 39(3), 163–174. https://doi.org/10.1177/0964528420921193. Evidence Level II.

Tick, H., Nielsen, A., Pelletier, K. R., Bonakdar, R., Simmons, S., Glick, R., Ratner, E., Lemmon, R. L., Wayne, P., Zador, V., & Pain Task Force of the Academic Consortium for Integrative Medicine and Health. (2018). Evidence-based non-pharmacologic strategies for comprehensive pain care: The consortium pain task force white paper. Explore, 14(3), 177–199. https://doi.org/10.1016/j.explore.2018.02.00. Evidence Level I.

Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., Cohen, M., Evers, S., Finnerup, N. B., First, M. B., Giamberardino, M. A., Kaasa, S., Korwisi, B., Kosek, E., Lavand’homme, P., Nicholas, M., Perrot, S., Scholz, J., Schug, S., … Wang, S. J. (2019). Chronic pain as a symptom or a disease: The IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain,160(1), 19–27. https://doi.org/10.1097/j.pain.0000000000001384. Evidence Level I.

Tsai, Y. I., Browne, G., & Inder, K. J. (2021). The effectiveness of interventions to improve pain assessment and management in people living with dementia: A systematic review and meta-analyses. Journal of Advanced Nursing, 77(3), 1127–1140. doi.org/10.1111/jan.14660.Evidence Level I.

U.S. Department of Health and Human Services (HHS). (2019, May). Pain management best practices inter-agency task force report: Updates, gaps, inconsistencies, and recommendations. U. S. Department of Health and Human Services Website. https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html. Evidence Level I.

Vickers, A. J., Vertosick, E. A., Lewith, G., McPherson, H., Foster, N. E., Sherman, K. J., Irnich, D., Witt, C. M., Linde, K., & Acupuncture Trialists’ Collaboration. (2018). Acupuncture for chronic pain: Update of an individual patient data meta-analysis. Journal of Pain,19, 455–474. https://doi.org/10.1016/j.jpain.2017.11.005. Evidence Level I.

Voute, M., Morel, V., & Pickering, G. (2021). Topical lidocaine for chronic pain treatment. Drug Design, Development and Therapy, 15, 4091–4103. doi.org/10.2147/DDDT.S328228. Evidence Level VI.

Wang, S. J., Wang, Y. H., & Huang, L. C. (2021). Liquid combination of hyaluronan, glucosamine, and chondroitin as a dietary supplement for knee osteoarthritis patients with moderate knee pain: A randomized controlled study. Medicine, 100(40), e27405. https://doi.org/10.1097/MD.0000000000027405. Evidence Level II.

Warden, V., Hurley, A. C., & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. Journal of the American Medical Directors Association,4(1), 9–15. https://doi.org/10.1097/01.JAM.0000043422.31640.F7. Evidence Level IV.

Wu, L.-C., Weng, P.-W., Chen C.-H., Huang, Y.-Y., Tsuang, Y.-H., & Chiang, C.-J. (2018). Literature review and meta-analysis of transcutaneous electrical nerve stimulation in treating chronic back pain. Regional Anesthesia and Pain Medicine, 43, 425–433. https://doi.org/10.1097/AAP.0000000000000740.Evidence Level I.

Wu, Y., Zhu, F., Chen, W., & Zhang, M. (2022). Effects of transcutaneous electrical nerve stimulation (TENS) in people with knee osteoarthritis: A systematic review and meta-analysis. Clinical Rehabilitation, 36(4), 472–485. https://doi.org/10.1177/02692155211065636. Evidence Level I.

Yang, L.-H., Duan, P.-B., Hou,Q.-M., Du, S.-Z., Sun, J.-F., Mei, S.-J., & Wang, X.-Q. (2017). Efficacy of auricular acupressure for chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. Evidence-Based Complementary and Alternative Medicine, 2017, 6383649. https://doi.org/10.1155/2017/6383649.Evidence Level I.

Yeh, C. H., Kawi, J., Ni, A., & Christo, P. (2022). Evaluating auricular point acupressure for chronic low back pain self-management using technology: A feasibility study. Pain Management Nursing, 23(3), 301–310. https://doi.org/10.1016/j.pmn.2021.11.007.Evidence Level III.

You, T., Koren, Y., Butts, W. J., Moraes, C. A., Yeh, G. Y., Wayne, P. M., & Leveille, S. G. (2023). Pilot studies of recruitment and feasibility of remote Tai Chi in racially diverse older adults with multisite pain. Contemporary Clinical Trials, 128, 107164. https://doi.org/10.1016/j.cct.2023.107164. Evidence Level III.

You, T., Ogawa, E. F., Thapa, S., Cai, Y., Zhang, H., Nagae, S., Yeh, G. Y., Wayne, P. M., Shi, L., & Leveille, S. G. (2018). Tai Chi for older adults with chronic multisite pain: A randomized controlled pilot study. Aging Clinical and Experimental Research, 30, 1335–1343. https://doi.org/10.1007/s40520-018-0922-0.Evidence Level II.

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