Journal of Gerontological Nursing

Evidence-Based Practice Guideline 

Persistent Pain Management in Older Adults

Paul Arnstein, RN, PhD, FAAN; Keela A. Herr, PhD, RN, FAAN


More individuals develop and endure constant or recurring pain in older adulthood. Although 40% of these individuals receive no treatment, many evidence-based treatments are available. Accurate assessment of pain, its impact on functioning, and preventing treatment-related harms lay the foundation of safe, effective pain control. Analgesic agents are often necessary, but require a delicate balance to prevent under-treatment, the unnecessary abandonment of therapy, or exposure to potentially serious adverse effects. Nondrug therapies must be better integrated into the treatment plan to ensure overall safety. Evidence-based approaches help older adults thrive and survive longer despite living with persistent pain. [Journal of Gerontological Nursing, 43(7), 20–31.]


More individuals develop and endure constant or recurring pain in older adulthood. Although 40% of these individuals receive no treatment, many evidence-based treatments are available. Accurate assessment of pain, its impact on functioning, and preventing treatment-related harms lay the foundation of safe, effective pain control. Analgesic agents are often necessary, but require a delicate balance to prevent under-treatment, the unnecessary abandonment of therapy, or exposure to potentially serious adverse effects. Nondrug therapies must be better integrated into the treatment plan to ensure overall safety. Evidence-based approaches help older adults thrive and survive longer despite living with persistent pain. [Journal of Gerontological Nursing, 43(7), 20–31.]

The purpose of the current evidence-based practice guideline is to help nurses and other health care providers in the management of persistent pain in older adults through assessment and treatment strategies. The guideline is designed for older adults living with persistent pain lasting or frequently recurring for >3 months. Expected outcomes of effective persistent pain management in older adults include pain reduction, functional improvement, minimization of harm related to either pain or its treatment, and enhanced quality of life.

This article is a condensed version of the evidence-based guideline, Persistent Pain in Older Adults (Arnstein & Herr, 2015), with key recent updates. The full guideline, with complete evidence, recommendations, references, and tools, can be purchased and downloaded in an electronic format from the Csomay Center for Gerontological Excellence (access

Persistent Pain in Older Adults

More than one half of older adults in the community live with persistent pain, of whom 40% receive no treatment (Wranker, Rennemark, & Berglund, 2016). An even greater proportion of older adults living in institutions face this problem daily (Tse, Leung, & Ho, 2012), which is more frequently encountered during the final months of life (Smith et al., 2010). Adults between the ages of 65 and 85 are at a greater risk of developing persistent pain, especially when exposed to severe, acute pain. This greater risk highlights the importance of effective, expedient prevention and treatment of pain in older adults (Larsson, Hansson, Sundquist, & Jakobsson, 2017). Unfortunately, even patients with cancer pain often have strong analgesic agents withheld until the end of life (Ziegler, Mulvey, Blenkinsopp, Petty, & Bennett, 2016).

Assessment and management of pain is a responsibility of all health professionals and is within the scope and standards of an RN's practice (American Nurses Association & American Society for Pain Management Nursing, 2016). The most effective approach when pain persists is for the interprofessional team to perform a comprehensive assessment, establish realistic goals, and provide evidence-informed interventions that are tailored to patients' unique responses and preferences (U.S. Department of Health and Human Services [USDHHS], 2016). Recent actions by the U.S. Food and Drug Administration, Centers for Disease Control and Prevention, and policymakers have impeded access to weak opioid medications that many older adults have found helpful (Chambers et al., 2016). Guidelines that suggest opioid medications should be tapered or stopped unless a 30% improvement in both pain and functioning are sustained (Dowell, Haegerich, & Chou, 2016) have no research to support this in older adults as a realistic expectation for any available treatment (Tayeb, Barreiro, Bradshaw, Chui, & Carr, 2016). Older adults should not live or die with needless pain because of the negative effects pain has on health, longevity, and quality of life.

Biopsychosocial Impact of Persistent Pain on Older Adults

Persistent intense pain can harm an individual's mind, body, spirit, and social interactions, resulting in disability, financial hardships, despair, and medical frailty (Schofield et al., 2012; St. Marie & Arnstein, 2016; USDHHS, 2016; Wade et al., 2016). Experiencing intense ongoing pain creates degenerative changes throughout the nervous system, which intensifies, prolongs, and spreads the experience of pain (Aronoff, 2016). The loss of brain gray matter with persistent pain greatly outpaces that seen with normal aging and can explain the learning, memory, and emotional difficulties experienced by many living with pain (Coppieters et al., 2016). Individuals with severe persistent pain die at a much higher rate from cardiovascular events than those without pain (Torrance, Elliott, Lee, & Smith, 2010). Combining pain with mental defeat, being a burden to others, and pain-related disability drive many to consider or attempt suicide (Kowal, Wilson, McWilliams, Péloquin, & Duong, 2012; Tang, Beckwith, & Ashworth, 2016; Van Orden et al., 2015). Reports that the pain of many older adults goes untreated despite these known harms are unconscionable and demand significant changes in the current system of providing care (USDHHS, 2016; Wranker et al., 2016).

Although perception of some stimuli becomes less astute over time, aging does not predictably decrease sensitivity to pain (Cole, Farrell, Gibson, & Egan, 2010). Older adults are more vulnerable to developing persistent inflammatory or neuropathic pain due to the diminished ability to modulate pain through descending, endogenous systems that quiet nociceptive activity (Paladini, Fusco, Coaccioli, Skaper, & Varrassi, 2015). Table 1 summarizes physiological changes observed with aging that can affect pain and medications used to treat it. In general, the pharmacokinetic changes with age make many older adults more sensitive to desired and undesired effects of medications (Paladini et al., 2015).

Effect of Age-Related Physiological Changes on Pain and Pharmacokinetics

Table 1:

Effect of Age-Related Physiological Changes on Pain and Pharmacokinetics

Older adults may be better able to cope with chronic pain, or may attribute their experience of pain to aging and consequently fail to seek medical care. Withdrawing from social or spiritual routines is common, as some experience increasing disability and despair. Stoicism may reflect a character strength valued by the individual or a silenced fear of an unfavorable diagnosis or loss of independence (Savvas & Gibson, 2016). Some older adults may self-treat their pain and develop a substance use disorder (Alford et al., 2016; Han et al., 2015). The practice guideline further explores important biopsychosocial and spiritual dimensions of pain.

Description of the Practice Guideline

Assessment and management strategies are discussed in the guideline, along with key recommendations and evidence indicating strength of the recommendations. Assessment strategies include screening for pain and a comprehensive assessment. Techniques are also included for pain assessment in older adults with cognitive impairment and nonverbal older adults, as well as screening tools for cognitive impairment. Management strategies include pharmacological interventions and nonpharmacological (i.e., physical and cognitive behavioral) strategies. Education and other aspects of persistent pain management are addressed in the full guideline.


An important starting point is to screen all older adults at the initial encounter and periodically thereafter for the presence of persistent pain, changes in physical/mental functioning, and substance use. A simple way to screen for pain is to ask: “Are you having any pain or discomfort?” For persistent pain, the PEG tool is a simple, three-item validated screening tool for use with older adults that entails rating the average pain intensity over the past week and the extent it interferes with usual activities and the ability to enjoy life (de Waal, den Elzen, Achterberg, Gussekloo, & Blom, 2014). Cognitive, sensory, and communication impairments should be screened, as they present challenges in conveying pain using self-report methods. The Short Form of the Mini-Mental State Examination, Mini-Cog, The Clock Drawing Test, and other brief cognitive screens are validated, clinically useful tools to identify cognitive impairment (Lin, O'Connor, Rossom, Perdu, & Eckstrom, 2013) that can affect the reliability of self-report pain assessments. There are a variety of screening tools used in older adults to identify substance use disorder, which, combined with brief interventions, can refer them to needed treatment (Kuerbis, Sacco, Blazer, & Moore, 2014).

Self-report is the gold standard for pain assessment given that pain is a personal experience with genetic, cultural, and biopsychosocial factors all contributing to individual differences in the way it is perceived. Common unidimensional tools that provide reliable measures of pain intensity in older adults include the Numeric, Faces-revised, Functional, Verbal Descriptor, and Iowa Pain Thermometer-revised pain scales (Booker & Herr, 2016) (described and accessible in the full guideline).

To overcome impairments in hearing and vision that can impede pain assessment, nurses should ensure patients who wear glasses or hearing aids are using them, while optimizing patient positioning, environmental lighting, and limiting extraneous noises or interruption. Showing older adults the assessment tool with large, simple bold lettering, adequate line spacing, on non-glare paper using simple, clear explanations facilitates understanding. A family member, or interpreter (including sign language for deaf individuals), can help those with communication deficits. If necessary, simple questions can be repeated, uninterrupted time to respond should be provided, and pain “right now” should be the focus, rather than relying on memory (Booker & Herr, 2016).

Additional important assessment aspects include:

Factors that limit treatment options include polypharmacy, comorbidities, functional limitations, access to pain specialists, and regulatory and payer constraints (Savvas & Gibson, 2016).

Assessment Strategies for Cognitively Impaired Older Adults

Modified approaches can be used for patients with communication deficits (e.g., aphasia) or mild to moderate levels of cognitive impairment. With more severe impairment, a hierarchical approach can be used consisting of quantifying pain behaviors, obtaining surrogate reports from those who know the patient best, and observing responses to analgesic agents (Herr, Coyne, McCaffery, Manworren, & Merkel, 2011). Cognitively impaired older adults report less pain despite feeling it just as strongly as cognitively intact older adults. Their perception, communication ability, and behavioral responses may account for these differences (Stubbs et al., 2016). For noncommunicative older adults, directly observable behaviors, such as grimacing, moaning, guarding, bracing, posturing, agitation, aggression, restlessness, resisting care, and changes in usual behavior patterns, may be indicators of pain to be monitored (Ahn & Horgas, 2013; Hadjistavropoulos et al., 2014; Herr et al., 2011; Sheu, Versloot, Nader, Kerr, & Craig, 2011).

Systematic reviews have documented strengths and limitations of more than 20 validated tools, concluding that no single tool can be recommended for use across all care populations and settings (Closs et al., 2016; Lichtner et al., 2014). Among frequently used scales, the Checklist of Nonverbal Pain Indicators (CNPI), Pain Assessment in Advanced Dementia (PAINAD) scale, and the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC or PACSLAC-II) are widely used in a variety of settings (Ersek, Herr, Neradilek, Buck, & Black, 2010; Guo, Li, Liu, & Herr, 2015; Hadjistavropoulos et al., 2007) and are described and accessible in the full guideline.

Studies have evaluated the use of an analgesic trial in older adults with agitated or disruptive behaviors (Figure) as a guide to assess and improve behaviors associated with pain in this population (Chen & Lin, 2016). An analgesic trial is part of a comprehensive evaluation of pain in nonverbal patients when the etiology of behaviors is not obvious.

Pain assessment in older adults with severe cognitive impairment.Reprinted with permission from Reuben, D., Herr, K., Pacala, J., Pollock, B., Potter, J., & Semla, T. (2016). Geriatrics at your fingertips (18th ed.). New York, NY: American Geriatrics Society. Copyright © American Geriatrics Society.


Pain assessment in older adults with severe cognitive impairment.

Reprinted with permission from Reuben, D., Herr, K., Pacala, J., Pollock, B., Potter, J., & Semla, T. (2016). Geriatrics at your fingertips (18th ed.). New York, NY: American Geriatrics Society. Copyright © American Geriatrics Society.

Pharmacological Pain Management Strategies

Analgesic agents are the cornerstone of acute pain management in older adults, with a multimodal approach, including nondrug methods, being most beneficial. Persistent pain problems require careful consideration of all treatment options, weighing the risks and benefits of each in developing a tailored treatment plan. General principles of pharmacological management relevant to older adults are noted below:

  • Selection of analgesic agents should be based on consideration of coexisting morbidities and drug treatments that may interact or impact the effect of analgesic treatment and treatment goals (Abdulla et al., 2013; Chou et al., 2016).
  • The least invasive (e.g., not intramuscular) route should be used and inappropriate medications that pose a greater risk of harm to older adults should be avoided. Barbiturate, benzodiazepine, and hypnotic agents; pentazocine; meperidine; and skeletal muscle relaxants should not be used in older adults, regardless of frailty (American Geriatrics Society [AGS] 2015 Beers Criteria Update Expert Panel, 2015).
  • Nonessential medications that may contribute to polypharmacy should be tapered or discontinued (Mohanty et al., 2016).
  • “Start low, go slow, and follow-up” is more successful than “starting low and staying low,” which can contribute to undertreatment (Guerriero, Bolier, Van Cleave, & Reid, 2016, p. 52).
  • Side effects should be treated proactively because approximately one quarter of older adults abandon analgesic therapy because of the side effect burden (Makris, Kohler, & Fraenkel, 2010; Noble et al., 2010; Yu, Tang, Yeh, Kuo, & Yu, 2011). Alternatively, the dose can be lowered or the drug can be changed to another in the same class to reduce side effects.
  • Side effects, drug interactions (with other drugs, foods, or diseases), and concerns that affect treatment adherence should be reassessed vigilantly (Savvas & Gibson, 2016).

Analgesic Options

Analgesic options include nonopioid, opioid, and adjuvant medications (Table 2). Determination of appropriate analgesic treatment is based on a careful risk–benefit analysis, considering the individual's unique characteristics, risk factors, comorbidities, and personal preferences. Nonopioid analgesic drugs are effective and appropriate for mild to moderate pain and as coanalgesic agents with opioid medications as part of a multimodal approach (Abdulla et al., 2013; AGS Panel on Pharmacological Management of Persistent Pain in Older Persons, 2009). Controversy over chronic opioid drug therapy arises from the observation that no double-blind, placebo-controlled, randomized clinical trial has been performed with a duration of more than a few months (Dowell et al., 2016). There is no efficacy study using this definition of “evidence” for any treatment of persistent pain (Tayeb et al., 2016). Adjuvant analgesic agents include drugs from a variety of classes found to help individuals with pain that target pain amplifiers. Some agents within this class have analgesic properties (e.g., antidepressant agents, corticosteroid agents, botulinum toxin) that target the underlying pain generators. Potential risks, benefits, burdens, and drug–disease interactions are considered when selecting adjuvant agents. Topical analgesic medications may be a more acceptable option for patients and prescribers who are concerned about the effects of systemic analgesic agents. Nonopioid, opioid, and adjuvant pain relievers are available in topical preparations (Arnstein & Herr, 2015), and the act of rubbing medicine on a hurt body part may enhance relief.

Guideline Recommendations for Drug Management of Chronic Pain

Table 2:

Guideline Recommendations for Drug Management of Chronic Pain

Key points of nonopioid analgesic agent use include:

  • Although acetaminophen is the preferred nonopioid agent for mild to moderate pain (Abdulla et al., 2013), its nonsuperiority to placebo questions its status as a first-choice analgesic agent for older adults to treat all types of pain (Marcum, Duncan, & Makris, 2016).
  • High-dose chronic acetaminophen use has the same serious gastrointestinal (GI), renal, and cardiovascular (CV) adverse drug events that are often observed with nonsteroidal anti-inflammatory drugs (NSAIDs), suggesting a 3,250 mg per day dose cap be used for ongoing therapy (Herndon et al., 2016; Marcum et al., 2016; Roberts et al., 2016).
  • NSAID use should be avoided in patients with a history of peptic ulcers, renal disease, or congestive heart failure. For those at risk for CV, GI, or renal side effects, Celecoxib® (200 mg/day) may be best (Nissen et al., 2016).
  • The benefits of gastroprotection with proton pump inhibitors must be weighed against the risk of bone loss, fractures, C. difficile infections, and subacute cutaneous lupus erythematosus (Aggarwal, 2016; AGS 2015 Beers Criteria Update Expert Panel, 2015).
  • Patients taking NSAIDs must be monitored for signs of GI bleeding, renal impairment, congestive heart failure, and cognitive impairment (Abdulla et al., 2013; American Pain Society [APS], 2008).

Key points of opioid analgesic agent use in older adults include:

  • Opioid analgesic drugs are effective as a coanalgesic agent after establishment of a nonopioid foundation, and the determination that potential benefits outweigh potential harm.
  • Opioid analgesic drugs are considered safer than long-term NSAID therapy for older adults with persistent pain (AGS Panel on Pharmacological Management of Persistent Pain in Older Persons, 2009). Concurrent opioid-sparing medications should be used to minimize the dose and duration of exposure to opioid agents with the exception of cancer pain with advanced disease (National Comprehensive Cancer Network, 2016).
  • Opioid drug therapy should be initiated at 25% to 50% lower than the standard dose in opioid-naïve older adults (Marcum et al., 2016).
  • Every patient should be screened regardless of age for opioid use disorder prior to initiating opioid therapy, and patients being treated by an addiction professional should be comanaged if they screen positive (Dowell et al., 2016).
  • Patients on long-term opioid therapy should be periodically reassessed for aberrant behaviors, sleep disordered breathing, endocrinopathy, and bone mass density regardless of gender (Naples, Gellad, & Hanlon, 2016); and for coercion by others who threaten violence or withhold transportation or necessary care to divert opioid drugs for their own use (Green et al., 2013).
  • Patients and caregivers must be educated on safe storage, a system to prevent missed or duplicate doses, and safe disposal of medications no longer being used (Guerriero et al., 2016; Silvestre et al., 2016).
  • Newer weak opioid agents (e.g., tramadol, tapentadol, buprenorphine) may be safer and better tolerated by older adults for long-term use than traditional first-line opioid agents (e.g., codeine, hydrocodone) that rely on liver enzymes to produce the active metabolites that relieve pain (Naples et al., 2016; Whittle, Richards, Husni, & Buchbinder, 2011).
  • Morphine should be avoided in patients with compromised renal function because accumulated metabolites could result in neurotoxicity and possibly an overdose (McLachlan et al., 2011).
  • Methadone should be prescribed only by those with considerable familiarity with selecting a safe starting dose, after an electrocardiogram establishes the absence of QTc prolongation (signaling a risk for Torsade de Pointes), which is repeated if the methadone is titrated above 50 to 100 mg/day and when new medications (e.g., ketoconazole) are added (Chou et al., 2014).
  • Levorphanol has similar desirable properties as methadone and has advantages for older adults when prescribed by clinicians familiar with its use (Atkinson, Fudin, Pandula, & Mirza, 2013).

Key points of adjuvant analgesic agent use include:

  • Gabapentin and pregabalin are first-line adjuvant agents for neuropathic pain in individuals without renal impairment. Slow titration to limit side effects and delayed onset of action may require extended duration trials to determine effectiveness (Finnerup et al., 2015).
  • Serotonin and norepinephrine reuptake inhibitor or tricyclic antidepressant agents are also considered first-line therapy for a variety of neuropathic pain conditions. Tricyclic antidepressant agents have strong evidence of analgesic effects for neuropathic pain, but anticholinergic effects and cognitive impairment limit their use in older adults (Marcum et al., 2016).
  • Carbamazepine and other anticonvulsant agents are indicated for certain neuropathic pain states; however, an unfavorable toxicity profile and required periodic blood testing limit use for older adults (AGS Panel on Pharmacological Management of Persistent Pain in Older Persons, 2009; Wiffen, Derry, Moore, & McQuay, 2011).
  • Muscle relaxants, such as cyclobenzaprine, carisoprodol, and metaxolone, are inappropriate due to their sedative and anticholinergic effects, which impede functioning and increase the risk for falls (AGS 2015 Beers Criteria Update Expert Panel, 2015).
  • Tizanidine may be effective and better tolerated at low doses, but patients must be screened for the possibility of drug interactions and prolonged QT intervals (Marcum et al., 2016).
  • Topical high potency capsaicin 8% (applied in a clinic setting) and topical lidocaine patches may help with certain peripheral neuropathic conditions (Finnerup et al., 2015).
  • Benzodiazepine agents compound the risk of opioid drug overdoses and have no known analgesic benefit (Dasgupta et al., 2016; Guerriero et al., 2016).
  • Cannabinoid, antispasmotic, alpha 2-adrenergic agonist, ketamine, and a variety of other medications in the pipeline appear to have analgesic properties for some forms of pain and merit further study in older adults (Marcum et al., 2016).

Key points of topical analgesic agent use include:

Nondrug Pain Management Strategies

Although analgesic medications may be necessary for some persistent pain states affecting older adults, they often provide only partial, temporary relief. Rather than filling analgesic gaps with higher dose analgesic agents, nondrug therapies are usually a safer addition to the treatment plan. Although these therapies should not be used as a substitute for analgesic agents, many older adults could benefit from nondrug pain-relieving methods alone if they are unwilling or unable to take medications. Non-drug strategies are often underused, including interventional approaches such as injections, surgery, neuro-stimulation, complementary and integrative approaches, and/or self-management strategies that may be appropriate in selected older adults (Brooks & Udoji, 2016; Reid et al., 2015).

The term nondrug is used herein interchangeably with the words nonpharmacological, interventional, alternative, complementary, and integrative. This catch-all phrase can refer to highly technical and invasive approaches, such as implanted spinal cord stimulators, as well as interventions that nurses can independently administer or teach patients to use on their own. The focus of this section will be interventions that are noninvasive and require little, if any, technology.

Combined nondrug methods have an additive, if not synergistic affect; thus, nurses are encouraged to integrate a variety of methods targeting the mind, body, spirit, and social interactions that are known to affect pain. From an “empirical evidence” perspective, significant methodological concerns have been raised about the way many of these nondrug interventions have been studied, which may limit conclusions that can be made about their efficacy for persistent pain in older adults (Park & Hughes, 2012). However, a considerable research base exists to support the safety of most nondrug methods used to relieve pain.

The National Center for Complementary and Integrative Health (NCCIH) differentiates these terms. Complementary health approaches refer to practices and products of non-mainstream origin. Conversely, integrative health refers to the incorporation of complementary approaches into mainstream health care (NCCIH, 2016). Most approaches fall into either the natural product (i.e., herbs, vitamins, minerals, and probiotics) or mind and body practice (i.e., yoga, meditation, acupuncture, relaxation techniques, and exercise) subgroups (Bruckenthal, Marino, & Snelling, 2016). Alternative health systems including Ayurvedic medicine, traditional Chinese medicine, homeopathy, and naturopathy are beyond the scope of the guideline, as some providers using these methods distance patients from mainstream medicine by reinforcing inaccurate notions about conventional therapies while touting the safety of their therapy. Not all nondrug therapies are cheap, harmless, or readily accessible (NCCIH, 2016), and older adults often do not disclose their use because professionals often lack knowledge, time, or an encouraging attitude toward their use (Geisler & Cheung, 2015).

Key points of nondrug pain-relieving methods include:

  • Therapeutic exercises, salves, supplements, and self-management techniques are commonly used and aid in reducing medication-related side effects while improving well-being (O'Gara et al., 2016; Tse, Tang, Wan, & Vong, 2014).
  • Safety precautions are needed for older adults receiving physical manipulation and body-based therapies (e.g., chiropractors, osteopaths, physical and massage therapists) because of the high risk for falls observed among individuals who use these therapies (Caron, Gallo, Durbin, & Mielenz, 2017).
  • Mind–body therapies and natural products have been shown to be cost-effective for many older adults (Herman, Poindexter, Witt, & Eisenberg, 2012).
  • Auricular point acupressure provides significant pain relief to some older adults with low back pain, but a high drop-out rate suggests it is not for everyone (Yeh et al., 2014).
  • Yoga may reverse pain and age-related loss of gray matter. With years of yoga practice, the brain structure favors parasympathetic over sympathetic drives, which are linked to positive mood states (Hariprasad et al., 2013; Villemure, Ceko, Cotton, & Bushnell, 2015).
  • Moderate pressure massage and Iyengar yoga (focusing on poses) may be best to reduce pain while improving balance and mobility (Field, 2016).
  • Older adults have better outcomes 6 months after completing acceptance and commitment therapy than cognitive-behavioral therapy (Wetherell et al., 2016).
  • Hospitalized older patients with chronic pain find hypnosis safe and helpful (Ardigo et al., 2016).
  • Nursing home residents found a peer-led pain management program feasible, with the potential to relieve chronic pain and enhance biopsychosocial well-being (Tse, Yeung, Lee, & Ng, 2016).
  • Digital and web-based technologies are making nondrug therapies more accessible to older adults who have difficulty accessing mind–body therapies (Ammann, Vandelanotte, de Vries, & Mummery, 2013; Parker, Jessel, Richardson, & Reid, 2013).

Additional specific nondrug methods are described and accessible in the full guideline.


Despite the accumulation of evidence to guide assessment and support interventions for treating older adults with persistent pain, many gaps in practice remain. Assessments may not accurately quantify pain, establish its impact on health and functioning, or identify known risks of treatment-related harms. Pharmacological therapy for persistent pain in older adults is often necessary, but requires a delicate balance of multiple factors to prevent undertreatment of pain, the unnecessary abandonment of therapy, or exposure to potentially life-threatening adverse effects. A growing array of targeted nondrug therapies are available for managing pain. Yet, given variability in responses, even to the same treatment type, individuals may need to undergo multiple therapeutic trials to refine the safest, most effective treatment plan.

The complete Persistent Pain Management in Older Adults guideline (Arnstein & Herr, 2015) provides detailed guidance and evidence for clinicians and systems for improving the pain experience and outcomes for older patients and their families. Attention to this vulnerable population is essential to address disparities in health care and ensure that all older adults receive evidence-based pain management appropriate for this unique segment of the population.


  • Abdulla, A., Adams, N., Bone, M., Elliott, A.M., Gaffin, J., Jones, D. & Schofield, P. (2013). Guidance on the management of pain in older people. Age and Ageing, 42(Suppl. 1), i1–i57. doi:10.1093/ageing/afs199 [CrossRef]
  • Aggarwal, N. (2016). Drug-induced subacute cutaneous lupus erythematosus associated with proton pump inhibitors. Drugs–Real World Outcomes, 3, 145–154. doi:10.1007/s40801-016-0067-4 [CrossRef]
  • Ahn, H. & Horgas, A. (2013). The relationship between pain and disruptive behaviors in nursing home residents with dementia. BMC Geriatrics, 13, 14. doi:10.1186/1471-2318-13-14 [CrossRef]
  • Alford, D.P., German, J.S., Samet, J.H., Cheng, D.M., Lloyd-Travaglini, C.A. & Saitz, R. (2016). Primary care patients with drug use report chronic pain and self-medicate with alcohol and other drugs. Journal of General Internal Medicine, 31, 486–491. doi:10.1007/s11606-016-3586-5 [CrossRef]
  • American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63, 2227–2246. doi:10.1111/jgs.13702 [CrossRef]
  • American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57, 1331–1346. doi:10.1111/j.1532-5415.2009.02376.x [CrossRef]
  • American Nurses Association & American Society for Pain Management Nursing. (2016). Pain management nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
  • American Pain Society. (2008). Principles of analgesic use in the treatment of acute pain and cancer pain (6th ed.). Glenview, IL: Author.
  • Ammann, R., Vandelanotte, C., de Vries, H. & Mummery, K. (2013). Can a website-delivered computer-tailored physical activity intervention be acceptable, usable, and effective for older people?Health Education & Behavior, 40, 160–170. doi:10.1177/1090198112461791 [CrossRef]
  • Ardigo, S., Herrmann, F.R., Moret, V., Déramé, L., Giannelli, S., Gold, G. & Pautex, S. (2016). Hypnosis can reduce pain in hospitalized older patients: A randomized controlled study. BMC Geriatrics, 16, 14. doi:10.1186/s12877-016-0180-y [CrossRef]
  • Arnstein, P. & Herr, K. (2015). Persistent pain management in older adults. In Butcher, H.K. (Series Ed.), Series on evidence-based practice guidelines. Iowa City, IA: The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence.
  • Aronoff, G.M. (2016). What do we know about the pathophysiology of chronic pain? Implications for treatment considerations. Medical Clinics of North America, 100, 31–42. doi:10.1016/j.mcna.2015.08.004 [CrossRef]
  • Atkinson, T.J., Fudin, J., Pandula, A. & Mirza, M. (2013). Medication pain management in the elderly: Unique and underutilized analgesic treatment options. Clinical Therapeutics, 35, 1669–1689. doi:10.1016/j.clinthera.2013.09.008 [CrossRef]
  • Booker, S.Q. & Herr, K.A. (2016). Assessment and measurement of pain in adults in later life. Clinics in Geriatric Medicine, 32, 677–692. doi:10.1016/j.cger.2016.06.012 [CrossRef]
  • Brooks, A.K. & Udoji, M.A. (2016). Interventional techniques for management of pain in older adults. Clinics in Geriatric Medicine, 32, 773–785. doi:10.1016/j.cger.2016.06.003 [CrossRef]
  • Bruckenthal, P., Marino, M.A. & Snelling, L. (2016). Complementary and integrative therapies for persistent pain management in older adults: A review. Journal of Gerontological Nursing, 42(12), 40–48. doi:10.3928/00989134-20161110-08 [CrossRef]
  • Caron, A., Gallo, W.T., Durbin, L.L. & Mielenz, T.J. (2017). Relationship between falls and complementary and alternative medicine use among community-dwelling older adults. Journal of Alternative and Complementary Medicine, 23, 41–44. doi:10.1089/acm.2016.0095 [CrossRef]
  • Chambers, J., Gleason, R.M., Kirsh, K.L., Twillman, R., Webster, L., Berner, J. & Passik, S.D. (2016). An online survey of patients' experiences since the rescheduling of hydrocodone: The first 100 days. Pain Medicine, 17, 1686–1693. doi:10.1093/pm/pnv064 [CrossRef]
  • Chen, Y.H. & Lin, L.C. (2016). Ability of the Pain Recognition and Treatment (PRT) protocol to reduce expressions of pain among institutionalized residents with dementia: A cluster randomized controlled trial. Pain Management Nursing, 17, 14–24. doi:10.1016/j.pmn.2015.08.003 [CrossRef]
  • Chou, R., Cruciani, R.A., Fiellin, D.A., Compton, P., Farrar, J.T., Haigney, M.C. & Zeltzer, L. (2014). Methadone safety: A clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. Journal of Pain, 15, 321–337. doi:10.1016/j.jpain.2014.01.494 [CrossRef]
  • Chou, R., Gordon, D.B., de Leon-Casasola, O.A., Rosenberg, J.M., Bickler, S., Brennan, T. & Wu, C.L. (2016). Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' committee on regional anesthesia, executive committee, and administrative council. Journal of Pain, 17, 131–157. doi:10.1016/j.jpain.2015.12.008 [CrossRef]
  • Closs, S.J., Dowding, D., Allcock, N., Hulme, C., Keady, J., Sampson, E.L. & Lichtner, V. (2016). Towards improved decision support in the assessment and management of pain for people with dementia in hospital: A systematic meta-review and observational study. Southampton, UK: NIHR Journals Library.
  • Cole, L.J., Farrell, M.J., Gibson, S.J. & Egan, G.F. (2010). Age-related differences in pain sensitivity and regional brain activity evoked by noxious pressure. Neurobiology of Aging, 31, 494–503. doi:10.1016/j.neurobiolaging.2008.04.012 [CrossRef]
  • Coppieters, I., Meeus, M., Kregel, J., Caeyenberghs, K., De Pauw, R., Goubert, D. & Cagnie, B. (2016). Relations between brain alterations and clinical pain measures in chronic musculoskeletal pain: A systematic review. Journal of Pain, 17, 949–962. doi:10.1016/j.jpain.2016.04.005 [CrossRef]
  • Dasgupta, N., Funk, M.J., Proescholdbell, S., Hirsch, A., Ribisl, K.M. & Marshall, S. (2016). Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Medicine, 17, 85–98.
  • Derry, S., Rice, A.S., Cole, P., Tan, T. & Moore, R.A. (2017). Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews, 1, CD007393. doi:10.1002/14651858.CD007393.pub4 [CrossRef]
  • Derry, S., Wiffen, P.J. & Moore, R.A. (2011). Relative efficacy of oral analgesics after third molar extraction: A 2011 update. British Dental Journal, 211, 419–420. doi:10.1038/sj.bdj.2011.905 [CrossRef]
  • de Waal, M.W., den Elzen, W.P., Achterberg, W.P., Gussekloo, J. & Blom, J.W. (2014). A postal screener for pain and need for treatment in older persons in primary care. Journal of the American Geriatrics Society, 62, 1832–1837. doi:10.1111/jgs.13064 [CrossRef]
  • Dowell, D., Haegerich, T.M. & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recommendations and Reports, 65, 1–49. doi:10.15585/mmwr.rr6501e1 [CrossRef]
  • Ersek, M., Herr, K., Neradilek, M.B., Buck, H.G. & Black, B. (2010). Comparing the psychometric properties of the Checklist of Nonverbal Pain Behaviors (CNPI) and the Pain Assessment in Advanced Dementia (PAIN-AD) instruments. Pain Medicine, 11, 395–404. doi:10.1111/j.1526-4637.2009.00787.x [CrossRef]
  • Field, T. (2016). Knee osteoarthritis pain in the elderly can be reduced by massage therapy, yoga and tai chi: A review. Complementary Therapies in Clinical Practice, 22, 87–92. doi:10.1016/j.ctcp.2016.01.001 [CrossRef]
  • Finnerup, N.B., Attal, N., Haroutounian, S., McNicol, E., Baron, R., Dworkin, R.H. & Wallace, M. (2015). Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis. Lancet Neurology, 14, 162–173. doi:10.1016/S1474-4422(14)70251-0 [CrossRef]
  • Geisler, C.C. & Cheung, C.K. (2015). Complementary/alternative therapies use in older women with arthritis: Information sources and factors influencing dialog with health care providers. Geriatric Nursing, 36, 15–20. doi:10.1016/j.gerinurse.2014.08.013 [CrossRef]
  • Green, T.C., Bowman, S.E., Ray, M., Zaller, N., Heimer, R. & Case, P. (2013). Collaboration or coercion? Partnering to divert prescription opioid medications. Journal of Urban Health, 90, 758–767. doi:10.1007/s11524-012-9784-5 [CrossRef]
  • Guerriero, F., Bolier, R., Van Cleave, J.H. & Reid, M.C. (2016). Pharmacological approaches for the management of persistent pain in older adults: What nurses need to know. Journal of Gerontological Nursing, 42(12), 49–57. doi:10.3928/00989134-20161110-09 [CrossRef]
  • Guo, L.L., Li, L., Liu, Y.W. & Herr, K. (2015). Evaluation of two observational pain assessment scales during the anaesthesia recovery period in Chinese surgical older adults. Journal of Clinical Nursing, 24, 212–221. doi:10.1111/jocn.12677 [CrossRef]
  • Hadjistavropoulos, T., Herr, K., Prkachin, K.M., Craig, K.D., Gibson, S.J., Lukas, A. & Smith, J.H. (2014). Pain assessment in elderly adults with dementia. Lancet Neurology, 13, 1216–1227. doi:10.1016/S1474-4422(14)70103-6 [CrossRef]
  • Hadjistavropoulos, T., Herr, K., Turk, D.C., Fine, P.G., Dworkin, R.H., Helme, R. & Williams, J. (2007). An interdisciplinary expert consensus statement on assessment of pain in older persons. Clinical Journal of Pain, 23(Suppl. 1), S1–S43. doi:10.1097/AJP.0b013e31802be869 [CrossRef]
  • Han, B., Polydorou, S., Ferris, R., Blaum, C.S., Ross, S. & McNeely, J. (2015). Demographic trends of adults in New York City opioid treatment programs: An aging population. Substance Use & Misuse, 50, 1660–1667. doi:10.3109/10826084.2015.1027929 [CrossRef]
  • Hariprasad, V.R., Varambally, S., Shivakumar, V., Kalmady, S.V., Venkatasubramanian, G. & Gangadhar, B.N. (2013). Yoga increases the volume of the hippocampus in elderly subjects. Indian Journal of Psychiatry, 55(Suppl. 3), S394–S396. doi:10.4103/0019-5545.116309 [CrossRef]
  • Herman, P.M., Poindexter, B.L., Witt, C.M. & Eisenberg, D.M. (2012). Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations. BMJ Open, 2, e001046. doi:10.1136/bmjopen-2012-001046 [CrossRef]
  • Herndon, C.M., Arnstein, P., Darnall, B., Hartrick, C., Hecht, K., Lyons, M. & Sehgal, N. (Eds.). (2016). Principles of analgesic use (7th ed.). Chicago, IL: American Pain Society Press.
  • Herr, K., Coyne, P.J., McCaffery, M., Manworren, R. & Merkel, S. (2011). Pain assessment in the patient unable to self-report: Position statement with clinical practice recommendations. Pain Management Nursing, 12, 230–250. doi:10.1016/j.pmn.2011.10.002 [CrossRef]
  • Hochberg, M.C., Altman, R.D., April, K.T., Benkhalti, M., Guyatt, G., McGowan, J. & Tugwell, P. (2012). American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care & Research, 64, 465–474. doi:10.1002/acr.21596 [CrossRef]
  • Kowal, J., Wilson, K.G., McWilliams, L.A., Péloquin, K. & Duong, D. (2012). Self-perceived burden in chronic pain: Relevance, prevalence, and predictors. Pain, 153, 1735–1741. doi:10.1016/j.pain.2012.05.009 [CrossRef]
  • Kuerbis, A., Sacco, P., Blazer, D.G. & Moore, A.A. (2014). Substance abuse among older adults. Clinics in Geriatric Medicine, 30, 629–654. doi:10.1016/j.cger.2014.04.008 [CrossRef]
  • Larsson, C., Hansson, E.E., Sundquist, K. & Jakobsson, U. (2017). Chronic pain in older adults: Prevalence, incidence, and risk factors. Scandinavian Journal of Rheumatology. Advance online publication.
  • Leppert, W., Krajnik, M. & Wordliczek, J. (2013). Delivery systems of opioid analgesics for pain relief: A review. Current Pharmaceutical Design, 19, 7271–7293. doi:10.2174/138161281941131219130127 [CrossRef]
  • Lichtner, V., Dowding, D., Esterhuizen, P., Closs, S.J., Long, A.F., Corbett, A. & Briggs, M. (2014). Pain assessment for people with dementia: A systematic review of systematic reviews of pain assessment tools. BMC Geriatrics, 14, 138. doi:10.1186/1471-2318-14-138 [CrossRef]
  • Lin, J.S., O'Connor, E., Rossom, R.C., Perdue, L.A. & Eckstrom, E. (2013). Screening for cognitive impairment in older adults: A systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 159, 601–612.
  • Makris, U.E., Kohler, M.J. & Fraenkel, L. (2010). Adverse effects of topical nonsteroidal antiinflammatory drugs in older adults with osteoarthritis: A systematic literature review. Journal of Rheumatology, 37, 1236–1243. doi:10.3899/jrheum.090935 [CrossRef]
  • Marcum, Z.A., Duncan, N.A. & Makris, U.E. (2016). Pharmacotherapies in geriatric chronic pain management. Clinics in Geriatric Medicine, 32, 705–724. doi:10.1016/j.cger.2016.06.007 [CrossRef]
  • Mason, L., Moore, R.A., Edwards, J.E., McQuay, H.J., Derry, S. & Wiffen, P.J. (2004). Systematic review of efficacy of topical rubefacients containing salicylates for the treatment of acute and chronic pain. BMJ, 328, 995. doi:10.1136/bmj.38040.607141.EE [CrossRef]
  • Matthews, P., Derry, S., Moore, R.A. & McQuay, H.J. (2009). Topical rubefacients for acute and chronic pain in adults. Cochrane Database of Systematic Reviews, 3, CD007403. doi:10.1002/14651858.CD007403.pub2 [CrossRef]
  • McLachlan, A.J., Bath, S., Naganathan, V., Hilmer, S.N., Le Couteur, D.G., Gibson, S.J. & Blyth, F.M. (2011). Clinical pharmacology of analgesic medicines in older people: Impact of frailty and cognitive impairment. British Journal of Clinical Pharmacology, 71, 351–364. doi:10.1111/j.1365-2125.2010.03847.x [CrossRef]
  • Mohanty, S., Rosenthal, R.A., Russell, M.M., Neuman, M.D., Ko, C.Y. & Esnaola, N.F. (2016). Optimal perioperative management of the geriatric patient: A best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. Journal of the American College of Surgeons, 222, 930–947. doi:10.1016/j.jamcollsurg.2015.12.026 [CrossRef]
  • Naples, J.G., Gellad, W.F. & Hanlon, J.T. (2016). The role of opioid analgesics in geriatric pain management. Clinics in Geriatric Medicine, 32, 725–735. doi:10.1016/j.cger.2016.06.006 [CrossRef]
  • National Center for Complementary and Integrative Health. (2016) Pain: Considering complementary approaches. Retrieved from
  • National Comprehensive Cancer Network. (2016). NCCN clinical practice guidelines in oncology: Adult cancer pain (version 2.2016). Retrieved from
  • Nissen, S.E., Yeomans, N.D., Solomon, D.H., Lüscher, T.F., Libby, P., Husni, M.E. & Lincoff, A.M. (2016). Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. New England Journal of Medicine, 375, 2519–2529. doi:10.1056/NEJMoa1611593 [CrossRef]
  • Noble, M., Treadwell, J.R., Tregear, S.J., Coates, V.H., Wiffen, P.J., Akafomo, C. & Schoelles, K.M. (2010). Long-term opioid management for chronic noncancer pain. Cochrane Database of Systematic Reviews, 1, CD006605. doi:10.1002/14651858 [CrossRef]
  • O'Gara, T., Kemper, K.J., Birkedal, J., Curl, W., Miller, N. & Abadie, B. (2016). Survey of conventional and complementary and alternative therapy in patients with low back pain. Journal of Surgical Orthopaedic Advances, 25, 27–33.
  • O'Malley, P. (2008). Sports cream and arthritic rubs: The hidden dangers of unrecognized salicylate toxicity. Clinical Nurse Specialist, 22, 6–8. doi:10.1097/01.NUR.0000304178.13697.17 [CrossRef]
  • Paladini, A., Fusco, M., Coaccioli, S., Skaper, S.D. & Varrassi, G. (2015). Chronic pain in the elderly: The case for new therapeutic strategies. Pain Physician, 18, E863–E876.
  • Park, J. & Hughes, A.K. (2012). Nonpharmacological approaches to the management of chronic pain in community-dwelling older adults: A review of empirical evidence. Journal of the American Geriatrics Society, 60, 555–568. doi:10.1111/j.1532-5415.2011.03846.x [CrossRef]
  • Parker, S.J., Jessel, S., Richardson, J.E. & Reid, M.C. (2013). Older adults are mobile too! Identifying the barriers and facilitators to older adults' use of mHealth for pain management. BMC Geriatrics, 13, 43. doi:10.1186/1471-2318-13-43 [CrossRef]
  • Patel, K., Guralnik, J.M., Dansie, E.J. & Turk, D.C. (2013). Prevalence and impact of pain among older adults in the United States: Findings from the 2011 National Health and Aging Trends Study. Pain, 154, 2649–2657. doi:10.1016/j.pain.2013.07.029 [CrossRef]
  • Rannou, F., Pelletier, J.P. & Martel-Pelletier, J. (2016). Efficacy and safety of topical NSAIDs in the management of osteoarthritis: Evidence from real-life setting trials and surveys. Seminars in Arthritis and Rheumatism, 45(Suppl. 4),S18–S21. doi:10.1016/j.semarthrit.2015.11.007 [CrossRef]
  • Reid, M.C., Eccleston, C. & Pillemer, K. (2015). Management of chronic pain in older adults. BMJ, 350, h532. doi:10.1136/bmj.h532 [CrossRef]
  • Rinaldi, P., Mecocci, P., Benedetti, C., Ercolani, S., Bregnocchi, M., Menculini, G. & Cherubini, A. (2003). Validation of the five-item geriatric depression scale in elderly subjects in three different settings. Journal of the American Geriatrics Society, 51, 694–698. doi:10.1034/j.1600-0579.2003.00216.x [CrossRef]
  • Roberts, E., Nunes, V.D., Buckner, S., Latchem, S., Constanti, M., Miller, P. & Conaghan, P.G. (2016). Paracetamol: Not as safe as we thought? A systematic literature review of observational studies. Annals of the Rheumatic Diseases, 75, 552–559. doi:10.1136/annrheumdis-2014-206914 [CrossRef]
  • Savvas, S.M. & Gibson, S.J. (2016). Overview of pain management in older adults. Clinics in Geriatric Medicine, 32, 635–650. doi:10.1016/j.cger.2016.06.005 [CrossRef]
  • Schofield, D., Kelly, S., Shrestha, R., Callander, E., Passey, M. & Percival, R. (2012). The impact of back problems on retirement wealth. Pain, 153, 203–210. doi:10.1016/j.pain.2011.10.018 [CrossRef]
  • Sheu, E., Versloot, J., Nader, R., Kerr, D. & Craig, K.D. (2011). Pain in the elderly: Validity of facial expression components of observational measures. Clinical Journal of Pain, 27, 593–601. doi:10.1097/AJP.0b013e31820f52e1 [CrossRef]
  • Silvestre, J., Reddy, A., de la Cruz, M., Wu, J., Liu, D., Bruera, E. & Todd, K.H. (2016). Frequency of unsafe storage, use, and disposal practices of opioids among cancer patients presenting to the emergency department. Palliative and Supportive Care. Advance online publication. doi:10.1017/S1478951516000158 [CrossRef]
  • Smith, A.K., Cenzer, I.S., Knight, S.J., Puntillo, K.A., Widera, E., Williams, B.A. & Covinsky, K.E. (2010). The epidemiology of pain during the last 2 years of life. Annals of Internal Medicine, 153, 563–569. doi:10.7326/0003-4819-153-9-201011020-00005 [CrossRef]
  • Smith, H.S. & Argoff, C.E. (2011). Pharmacological treatment of diabetic neuropathic pain. Drugs, 71, 557–589. doi:10.2165/11588940-000000000-00000 [CrossRef]
  • St. Marie, B. & Arnstein, P. (2016). Quality pain care for older adults in an era of suspicion and scrutiny. Journal of Gerontological Nursing, 42(12), 31–39. doi:10.3928/00989134-20161110-07 [CrossRef]
  • Stubbs, B., Thompson, T., Solmi, M., Vancampfort, D., Sergi, G., Luchini, C. & Veronese, N. (2016). Is pain sensitivity altered in people with Alzheimer's disease? A systematic review and meta-analysis of experimental pain research. Experimental Gerontology, 82, 30–38. doi:10.1016/j.exger.2016.05.016 [CrossRef]
  • Tang, N.K., Beckwith, P. & Ashworth, P. (2016). Mental defeat is associated with suicide intent in patients with chronic pain. Clinical Journal of Pain, 32, 411–419. doi:10.1097/AJP.0000000000000276 [CrossRef]
  • Tayeb, B.O., Barreiro, A.E., Bradshaw, Y.S., Chui, K.K. & Carr, D.B. (2016). Durations of opioid, nonopioid drug, and behavioral clinical trials for chronic pain: Adequate or inadequate?Pain Medicine, 17, 2036–2046. doi:10.1093/pm/pnw245 [CrossRef]
  • Torrance, N., Elliott, A.M., Lee, A.J. & Smith, B.H. (2010). Severe chronic pain is associated with increased 10 year mortality. A cohort record linkage study. European Journal of Pain, 14, 380–386. doi:10.1016/j.ejpain.2009.07.006 [CrossRef]
  • Tse, M., Leung, R. & Ho, S. (2012). Pain and psychological well-being of older persons living in nursing homes: An exploratory study in planning patient-centered intervention. Journal of Advanced Nursing, 68, 312–321. doi:10.1111/j.1365-2648.2011.05738.x [CrossRef]
  • Tse, M.M., Tang, S.K., Wan, V.T. & Vong, S.K. (2014). The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes. Pain Management Nursing, 15, 778–788. doi:10.1016/j.pmn.2013.08.003 [CrossRef]
  • Tse, M.M., Yeung, S.S., Lee, P.H. & Ng, S.S. (2016). Effects of a peer-led pain management program for nursing home residents with chronic pain: A pilot study. Pain Medicine, 17, 1648–1657. doi:10.1093/pm/pnv121 [CrossRef]
  • U.S. Department of Health and Human Services. (2016). National pain strategy: A comprehensive population health-level strategy for pain. Retrieved from
  • Van Orden, K.A., Wiktorsson, S., Duberstein, P., Berg, A.I., Fässberg, M.M. & Waern, M. (2015). Reasons for attempted suicide in later life. American Journal of Geriatric Psychiatry, 23, 536–544. doi:10.1016/j.jagp.2014.07.003 [CrossRef]
  • Villemure, C., Ceko, M., Cotton, V.A. & Bushnell, M.C. (2015). Neuroprotective effects of yoga practice: Age-, experience-, and frequency-dependent plasticity. Frontiers in Human Neuroscience, 9, 281. doi:10.3389/fnhum.2015.00281 [CrossRef]
  • Wade, K.F., Lee, D.M., McBeth, J., Ravindrarajah, R., Gielen, E., Pye, S.R. & O'Neill, T.W. (2016). Chronic widespread pain is associated with worsening frailty in European men. Age and Ageing, 45, 268–274. doi:10.1093/ageing/afv170 [CrossRef]
  • Wetherell, J.L., Petkus, A.J., Alonso-Fernandez, M., Bower, E.S., Steiner, A.R. & Afari, N. (2016). Age moderates response to acceptance and commitment therapy vs. cognitive behavioral therapy for chronic pain. International Journal of Geriatric Psychiatry, 31, 302–308. doi:10.1002/gps.4330 [CrossRef]
  • Whittle, S.L., Richards, B.L., Husni, E. & Buchbinder, R. (2011). Opioid therapy for treating rheumatoid arthritis pain. Cochrane Database of Systematic Reviews, 9, CD003113. doi:10.1002/14651858.CD003113.pub3 [CrossRef]
  • Wiffen, P.J., Derry, S., Moore, R.A. & McQuay, H.J. (2011). Carbamazepine for acute and chronic pain in adults. Cochrane Database of Systematic Reviews, 1, CD005451. doi:10.1002/14651858.CD005451.pub3 [CrossRef]
  • Wranker, L.S., Rennemark, M. & Berglund, J. (2016). Pain among older adults from a gender perspective: Findings from the Swedish National Study on Aging and Care (SNAC-Blekinge). Scandinavian Journal of Public Health, 44, 258–263. doi:10.1177/1403494815618842 [CrossRef]
  • Yeh, C.H., Morone, N.E., Chien, L.C., Cao, Y., Lu, H., Shen, J. & Glick, R.M. (2014). Auricular point acupressure to manage chronic low back pain in older adults: A randomized controlled pilot study. Evidence-Based Complementary and Alternative Medicine, 2014, 375173. doi:10.1155/2014/375173 [CrossRef]
  • Yu, H.Y., Tang, F.I., Yeh, M.C., Kuo, B.I. & Yu, S. (2011). Use, perceived effectiveness, and gender differences of pain relief strategies among the community-dwelling elderly in Taiwan. Pain Management Nursing, 12, 41–49. doi:10.1016/j.pmn.2009.10.002 [CrossRef]
  • Ziegler, L., Mulvey, M., Blenkinsopp, A., Petty, D. & Bennett, M.I. (2016). Opioid prescribing for patients with cancer in the last year of life: A longitudinal population cohort study. Pain, 157, 2445–2451. doi:10.1097/j.pain.0000000000000656 [CrossRef]

Effect of Age-Related Physiological Changes on Pain and Pharmacokinetics

Physiological ProcessChange With Advancing Age
Peripheral pain fibersStructural, functional, and biochemical changes of peripheral nerve, especially thinly myelinated fibers may raise pain threshold
Pain modulation systemFavors sensitization (amplification, spread, longer duration) of pain with diminished pain inhibitory system activity
Pain perceptual systemAltered structure and functioning of key pain processing centers of the brain
Immune systemAlterations in peripheral mast cells and central microglia contribute to neuroinflammation
Gastrointestinal systemPassive absorption unchanged, but slowed motility, blood flow, or active transport mechanisms may affect drug uptake
Drug distributionDecreased body water may cut distribution of water-soluble drugs
Fat soluble drugs can accumulate and have a longer effective half-life with increased body fat
Less serum albumin (especially with cachexia or sarcoidosis) alters protein binding and increases risk for drug interactions
Drug metabolismReduced liver size and hepatic blood flow impedes first-pass and metabolism of some drugs
Drug eliminationReduced kidney structure, function, and blood flow lessens excretion of drugs and metabolites
Pharmacodynamic changes
Decreased receptor density
Increased sensitivity to therapeutic and side effects
Drug actionsDecreased receptor density may reduce drug effects, but generally an increased sensitivity exists to the therapeutic and side effects for most medications

Guideline Recommendations for Drug Management of Chronic Pain

Analgesic ClassRecommendationaSafety ConcernsQuality of Evidenceb
AcetaminophenUse for mild to moderate pain. May not work for back pain, arthritis, or neuropathic pain. May work synergistically with NSAIDs or opioid agents.Liver toxicity a concern at higher doses, often with inadvertent exposure to acetaminophen in other drugs. With prolonged high dose use, renal, GI, or CV concerns similar to NSAIDs may occur.High
Oral NSAIDsUse for shortest time possible. Chronic use may be appropriate with gastroprotection. Celecoxib® or naproxen have less CV risks.May produce confusion or sedation. Selective and non-selective NSAIDs are associated with adverse GI, renal, and CV morbidity. Concurrent use of other NSAIDs (including aspirin), steroid, anticoagulant, and SSRI medications increase the risk of GI bleeds.High
Topical NSAIDsUse as alternative to oral NSAIDs, particularly when pain is localized.Safety of topical NSAIDs in patients receiving anticoagulation or with renal impairment remains unknown.Moderate
TramadolConsider for use in patients who do not respond to paracetamol/NSAIDs.Increased risk of seizures or serotonin syndrome when used with antidepressant agents; side effect profile similar to that of opioid drugs.Not reported
Opioid agentsUse for moderate to severe chronic non-cancer pain with substantially impaired function or cancer and end-of-life pain.Side effects (e.g., constipation, sedation, nausea) limit use; risk of falls, substance use disorder, or overdose.Low
Tricyclic antidepressant agentsAvoid tertiary tricyclics (e.g., amitriptyline) because of concerns over adverse side effects; consider trial of secondary amine (nortriptyline) for neuropathic pain.Side effects limit use, electrocardiographic monitoring required owing to risk of QTc prolongation; serum level monitoring also recommended.Moderate
Anticonvulsant agents (e.g., pregabalin, gabapentin)Use for neuropathic pain.Side effects (e.g., sedation, peripheral edema) limit use; dose adjustment necessary in those with renal impairment.Moderate

Dr. Arnstein is Clinical Nurse Specialist for Pain Relief, Massachusetts General Hospital, Boston, Massachusetts; and Dr. Herr is Professor, College of Nursing, The University of Iowa, Iowa City, Iowa.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Copyright © 2017 Csomay Center for Gerontological Excellence.

Address correspondence to Keela A. Herr, PhD, RN, FAAN, Professor, College of Nursing, The University of Iowa, 306 CNB, Iowa City, IA 52242; e-mail:


Sign up to receive

Journal E-contents
click me