Empower patients with pain management strategies.

CHRONIC PAIN is a prevalent and complex health issue among older adults. As noted by Chan and Chan, persistent, long-term pain has far-reaching effects on an individual’s physical, emotional, and social well-being. According to Tinnirello and colleagues, chronic pain, which may result from age-related conditions such as osteoarthritis, neuropathy, and other chronic illnesses, can reduce mobility and function.

Pain, however, isn’t just a physical burden; it also can trigger emotional challenges, including depression and anxiety. These emotional challenges can contribute to social isolation as older adults may begin to withdraw from activities they once enjoyed, further diminishing their overall quality of life. These effects on nearly every aspect of life can create a cycle of discomfort, reduced independence, and diminished well-being.

According to Markovics and colleagues, nurses can have a significant impact on older adults who live with chronic pain. By addressing the complex nature of chronic pain and providing holistic care that integrates both medical and emotional support, nurses can help improve a patient’s quality of life and guide them in managing their condition in a way that promotes both physical comfort and emotional resilience. Using a structured approach, nurses and collaborative treatment teams have the opportunity to implement comprehensive, patient-centered care strategies that improve comfort, enhance coping, and promote overall quality of life.

Chronic pain in older adults

A study by Chan and Chan indicated that 50% of individuals age 65 and older report persistent pain, and this burden is expected to increase as the number of older adults rises. According to Markovics and colleagues, common causes of chronic pain in this population include osteoarthritis, nerve damage, neuropathy, and spinal degeneration or injuries.

Various age-related factors can influence how patients perceive pain and respond to treatment. Tinnirello and colleagues explained that age-related physiological and mental changes, multiple chronic conditions, and altered pain perception may lead some older adults to experience pain differently than younger individuals. Mullins and colleagues discussed how nervous system changes can alter pain in older adults, blunting or exacerbating pain and making it difficult to diagnose and manage. According to Rajput and colleagues, as adults age, their metabolic rate may decline, slowing the ability to break down medications and increasing the risk of adverse reactions. All these components can contribute to underrecognized or undertreated pain.

As noted by Chan and Chan, cognitive decline and polypharmacy related to comorbidities can impact treatment choices in older adults with chronic pain. Markovics and colleagues defined polypharmacy as regular use of five or more medications, which can increase the risks of drug interactions and hinder safe treatment management.

When managing chronic pain, special consideration should be given to frail older adults. According to Liau and colleagues, frailty is associated with increased vulnerability to adverse drug events and medication-related harm, and medication management recommendations specific to frail older adults are rare. Always refer to best practice guidelines to achieve optimal outcomes for this vulnerable population, as well as all older adults.

Pain assessment

Herr and colleagues recommended several pain-scale tools for measuring and evaluating patient pain. For patients with cognitive impairment or confusion who can’t provide a verbal response to questions about their pain level, nurses can use the Nonverbal Pain Assessment Tool (NPAT), which associates behaviors with pain. The Pain Assessment in Advanced Dementia (PAINAD) is appropriate for those with advanced dementia or Alzheimer’s disease. Both scales offer an opportunity to help assess pain and evaluate pain intensity in patients who can’t reliably self-report. Markovics and colleagues discussed the subjectivity of pain reporting. For example, as patients age, their ability to accurately report pain using verbal scales or visual tools may decline, making PAINAD important in pain assessment.

Markovics and colleagues also noted that nurses can assess the emotional and psychological toll of pain by asking patients about their mood and daily activities. Although many of the reporting components of pain are subjective, objective signs also exist and can be identified using data obtained with the PAINAD scale. It’s commonly accepted that subjective changes in blood pressure, heart rate elevation, and respiratory rate fluctuations can signal pain. However, Markovics and colleagues identified that objective changes in muscle tension, facial reactions, and posture can signal pain in a patient who may not be able to vocalize. Herr and colleagues discussed NPAT use in patients who are confused, cognitively impaired, or at the end of life.

Involving family members or caregivers can provide a more comprehensive understanding of the patient’s pain experience. Markovics and colleagues discussed the importance of using observation of facial expressions, vocalization, body posture, and activity level in the PAINAD scale. Changes observed by nurses and family members, although subjective, can help determine appropriate interventions. Herr and colleagues described the importance of the familiarity families have with patients’ mannerisms as well as individual pain reporting strategies. In addition, the family may be aware of a pain-reporting process that works best for the patient.

Herr and colleagues discussed the importance of building rapport between caregivers and nurses. In collaboration with family members or caregivers, nurses can gain insight into the patient’s perception of pain, their preferred method of reporting, and their baseline at home. In addition, Dagnino and colleagues noted that determining the origin of pain can help decipher pain intensity. They note that older adults may tolerate acute pain better than chronic pain, possibly because of differences in duration and underlying causes of these pain types. Pain perception in older adults also may be influenced by sensory, behavioral, hormonal, and social factors, including changes in nociceptive pathways, pain acceptance, self-efficacy, catastrophizing, estrogen levels, and social support.

Pain management plan

After the assessment, nurses can collaborate with the healthcare team to develop a personalized pain management plan, as noted by Raja and colleagues. This plan should consider the patient’s health history, preferences, cultural beliefs, mental status, health literacy, and source of pain as well as whether it’s acute, chronic, or neuropathic.

Markovics and colleagues described nurses’ responsibility for ensuring the individualization of the pain management plan so that it addresses the patient’s specific needs and goals. According to Rajput and colleagues, individualizing a care plan starts with patient and family discussions to clarify expectations and engage them in shared decision-making and treatment planning.

Rajput and colleagues noted that an individual’s acceptable level of pain may be based on many factors, including age, culture, beliefs, and whether the pain is acute or chronic. After determining the acceptable pain level, consider the appropriate type of intervention—nonpharmacologic, pharmacologic, or a combination. As noted by Rajput and colleagues, effective pain management requires flexibility and a team-based approach to address the multifaceted nature of chronic pain in older adults.

Family members and caregivers also play a crucial role in pain management. Herr and colleagues described how families can provide information on a patient’s usual demeanor and pain recognition. This information can prove crucial for pain management, especially in patients who can’t self-report. Herr and colleagues go on to discuss how nurses can educate family members on pain management techniques and stress the importance of caregiver self-care.

Pain management strategies

Several factors influence chronic pain treatment in older adults. Dagnino and Campos discussed how age-related physiological changes, such as decreased sensory perception and altered drug metabolism, can complicate pain assessment and treatment. Cognitive impairments, such as dementia, can further complicate pain communication, as older individuals may have difficulty verbalizing pain or recognizing it as a problem requiring treatment. Additionally, polypharmacy, common among older adults, can increase the risk of drug interactions, adverse effects, and challenges in managing pain safely.

Tinnirello and colleagues described how psychological and social factors, such as depression, anxiety, social isolation, and cultural beliefs, also influence pain perception and management.

Pain management also may play a role in palliative or end-of-life care. According to Coyne and colleagues, appropriate pain control at the end of life can improve quality of life. Ensuring the patient’s comfort also may help the family during bereavement. At end of life, the nurse’s role can include ongoing pain assessments appropriate for the individual patient, especially those who can’t articulate their pain. Coyne and colleagues noted that end-of-life pain management should prioritize effectiveness rather than focus on concerns about opioid addiction or overuse.

Effective nursing care requires ongoing assessment using appropriate pain tools, regular monitoring of treatment effectiveness, and clear communication with both patients and caregivers to ensure a holistic, patient-centered approach. Medication safety is particularly important when managing chronic pain in older adults. The American Geriatrics Society recommends using the Beers Criteria^®, updated in 2023, to identify medications whose risk of harm outweighs their benefits in older adults. The Beers Criteria also offer nonpharmacologic recommendations. Nurses can use these criteria to help guide plan-of-care conversations, advocate for patients, and educate patients and their families.

Nonpharmacologic interventions

According to Leung and colleagues, nonpharmacologic interventions can have a significant positive impact on pain management outcomes. These strategies should complement pharmacologic treatments and be incorporated into a comprehensive pain management plan.

Leung and colleagues outlined clinical guidelines for nonpharmacologic pain management strategies. Approaches may include physical activity, cognitive behavioral therapies, acupuncture, or electrotherapeutic modalities such as a TENS unit.

Leung and colleagues also described how cognitive behavioral interventions, such as relaxation techniques or mindfulness, can decrease a patient’s emotional distress. Herr and colleagues noted that decreasing distress may facilitate participation in activities such as physical therapy. According to van Veen and colleagues, art therapy, such as painting or drawing, can help reduce pain through distraction. (See Nonpharmacologic options.)

Pharmacologic interventions

Patient comorbidities, polypharmacy, individualized treatment, pain type, and pain severity guide pharmacologic pain management options. When administering pharmacologic interventions for chronic pain in older adults, nurses should vigilantly monitor for adverse effects, drug interactions, and changes in the patient’s response to therapy.

Mild pain. First-line treatment for mild pain, according to Sobieszczańska, includes acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). However, NSAIDs come with risks. Markovics and colleagues discussed the risks of worsening renal function, increased risk for gastric ulcers leading to risk of bleeding, and the potential for hypertension.

Moderate pain. For moderate pain, Sobieszczańska discussed the use of opioids, such as tramadol or codeine. As noted by Markovics and colleagues, opioid risks include confusion, constipation, and sedation. Confusion and sedation can increase the risk of falls, which can lead to injury. Therefore, these medications should start with the lowest effective dose. Patients should be reassessed frequently and monitored closely for adverse effects.

Severe and persistent pain. Medications recommended for severe and persistent pain, as described by Sobieszczańska, include strong opioids like morphine, buprenorphine, oxycodone, or fentanyl. However, according to Sobieszczańska, many older adults are hesitant to use opioids due to fears of addiction. Shared decision-making and education can increase acceptance of these medications when they’re clinically necessary.

Because of the complexity and variance of pain among individuals, a combination of medications from different classes may prove useful. Sobieszczańska noted using adjuvant or co-analgesic medications, such as antidepressants, anticonvulsants, corticosteroids, and muscle relaxants. A study by Zhang and colleagues discussed how adjuvant and pain medications work together. For example, antidepressants, anticonvulsants, and corticosteroids can be used as adjuvant analgesics to enhance pain control through mechanisms different from those of NSAIDs or acetaminophen. Anticonvulsants can signal the central nervous system to assist in controlling neuropathic pain, and corticosteroids can reduce inflammation.

Zhang and colleagues discussed how the use of adjuvant medications can prolong the effectiveness of opioids or even decrease the need for frequent dosages. Although adjuvants are frequently given alongside analgesics, they also can serve as first-line therapy for certain conditions, including neuropathic pain and fibromyalgia. (See Pharmacologic options.)

Emotional and psychological needs

Chronic pain frequently leads to emotional distress, including feelings of depression and anxiety, as discussed by Wei and colleagues. Nurses can address both the physical and emotional aspects of pain. In a study by Jimenez Martin and colleagues, patients described welcoming and resourceful hospitals as positive environments. Establishing a trusting patient–nurse relationship can help foster open communication, active listening, empathy, and emotional support. Through this trusting relationship, nurses can encourage patients to engage in pain management strategies and improve their emotional well-being.

Jimenez Martin and colleagues discussed the importance of group therapy (including the family) in fostering improved well-being. Group therapy can provide support for the patient and help family members better understand the patient’s experience. Jimenez Martin and colleagues also noted that group therapy can increase socialization between the patient and family and friends. As loved ones gain insight into the patient’s perspective, patients may feel better supported.

Ethics and safety

Pain management among older adults may be complicated by disease processes, such as dementia. As noted by Ewy, patients with dementia generally have decreased autonomy. Using pain scales, such as PAINAD, can help nurses ensure appropriate treatment that helps to maintain patient dignity and quality of life.

Long-term use of prescription opioids or muscle relaxants carries the risk of misuse. According to Schepis and colleagues, an association exists between medication misuse and depression, anxiety, suicidal ideation, limited physical ability, and decreased self-reported general health. Ewy described other risks, including falls.

Schepis and colleagues noted that nurses can help ensure effective pain relief without contributing to the risk of addiction or overdose. Careful assessment, monitoring, and patient education all play a role in this effort.

Cultural considerations

Cultural beliefs and values about pain and its treatment can vary. According to Okolo and colleagues, cultural beliefs, values, and practices can influence attitudes and behaviors around pain perception. Depending on cultural factors related to coping mechanisms and social systems, patients may express themselves differently.

Culturally sensitive care recognizes, respects, and integrates each patient’s unique cultural beliefs, values, and practices. When it comes to pain management, this sensitivity is especially important, since cultural background can deeply influence how patients express, perceive, and cope with pain, as well as what treatments they find acceptable.

According to Okolo and colleagues, cultural practices, rituals, and customs influence an individual’s pain experience, potentially impacting their willingness to seek care, adhere to treatment regimens, and engage with pain management interventions. Some cultures encourage verbal expression of pain, while others may encourage stoicism, creating variations in expression that can lead to assessment discrepancies and inappropriate treatment. Nurses can promote patient-centered care and improve outcomes by addressing cultural factors. For example, when traditional healing practices, such as herbal medicine or acupuncture, are deeply rooted in cultural beliefs, nurses can lead discussions about integrating these practices with conventional Western healthcare approaches.

A multifaceted approach

Chronic pain in an older adult can affect nearly every aspect of their physical, emotional, and social well-being. Nurses can support effective pain management through individualized care planning, ongoing reassessment, careful consideration of treatment risks, and attention to the patient’s physical, emotional, and social needs, including family involvement as appropriate. Because older adults are particularly vulnerable to medication-related adverse effects, nurses should remain vigilant throughout the course of treatment, balancing pain relief with patient safety. This approach can promote effective pain control while minimizing preventable complications and supporting overall well-being.

Lisa Justus is a nursing professional development specialist at the Cleveland Clinic in Euclid, Ohio.

American Nurse Journal. 2026; 21(11). Doi: 10.51256/ANJ112640

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Key words: chronic pain, chronic pain management, older adults