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Persistent pain is defined as pain that continues beyond the expected healing time, usually longer than 3 months. Persistent pain is widely prevalent in older adults. Up to 50% of community-dwelling older adults report pain that has a negative impact on function; a similar percentage of nursing home residents report experiencing daily pain. Pain from musculoskeletal disorders including back pain and arthritis, neuropathy, and pain related to chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease are most common. Persistent pain may or may not be associated with identifiable underlying pathology or may be out of proportion to the pathology observed. Older adults are at risk for undertreatment of pain due to underreport of pain, variable presentations of pain, cognitive impairment, and unconscious bias.

Pain limits functional status in older adults, can amplify frailty, and can result in diminished quality of life or appetite, sleep disturbances, falls, social isolation, depression, delirium, and increased health care costs and resource utilization. Relief of suffering and promotion of patient dignity are primary tenets of the practice of medicine. Timely and effective assessment and management of persistent pain in older adults will help in alleviating their suffering, while maintaining and augmenting quality of life.


A. Key Principles

A thorough assessment is a necessary first step. Any pain that affects function or quality of life should be evaluated. Specific goals of the pain assessment include determining the type and cause of the pain; understanding the impact of the pain on the patient’s daily life including function, sleep, emotional well-being, and safety; identifying chronic conditions influencing pain; and reviewing patient and caregiver beliefs, attitudes, and expectations toward the pain.

B. History

The patient’s and/or caregiver’s description of pain is likely to be the highest yield information to formulate a treatment plan. During history taking, it is critical to attend to any communication deficits the patient may be experiencing, including hearing, vision, and cognition. Strategies include using a pocket-talker for those with decreased hearing, selecting appropriate pain assessment scales for those with decreased vision, observing for behaviors that may indicate pain, and relying more heavily on caregiver report for those with cognitive impairment. It is important to remember that older adults are more likely to underreport pain than their younger counterparts due to misconceptions that pain is a natural part of aging, a reluctance to burden their clinician or caregiver with a complaint of pain, or not wanting to detract from the clinician’s attention on other medical concerns. Older adults may also use different descriptors for their pain than younger adults (eg, aching, soreness, or discomfort).

When discussing pain, clinicians should assess pain location(s), radiation, timing, onset, and quality; alleviating and exacerbating factors; and associated neurologic symptoms.

During the initial ...

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