Older adults are more susceptible to pain. Does that mean you have to live with it? “No,” says Lauren A. Kelly, MD, a geriatrician at The Mount Sinai Hospital. “Pain is more common as we get older, but it should never be dismissed as a normal part of the aging process. There are a lot of consequences to living with pain, and in many cases, it’s treatable or preventable.”

Lauren A. Kelly, MD

In this Q&A, Dr. Kelly, Assistant Professor, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, explains what you should do if you have pain, what to expect, and how to talk to your doctor about your pain.

Where should I go to get treatment for my pain?

A great starting place is primary care, especially if you trust your primary care doctor and you’re happy with them. A primary care doctor can assess the situation and make referrals as needed.

In addition to primary care, there is a broad range of specialists who treat pain, including interventional pain, physiatry, neurology, surgery, palliative care, geriatrics, and integrative medicine practitioners. Even behavioral health specialists like psychiatrists and therapists can play a role.

What does an assessment consist of?

Assessment needs to take a whole person approach, considering how well a person is able to move through the world while living with their pain. This includes activities of daily living, such as dressing, showering, using the bathroom, as well as more complex tasks that contribute to independence such as managing money, cooking, and shopping. I find that understanding a patient’s daily challenges is much more helpful than identifying pain on a scale of 1-10. It is also important to understand how pain is interacting with our mood and our thinking (cognition), as pain is not simply a physical experience of the body but rather a condition that affects the total person: mind, mood, and body.

How should I talk to my doctor about my pain?

It is important to tell your doctor the details of your pain. How long have you been dealing with it? What are the descriptors of the pain? Is it sharp, aching, dull, burning, stabbing, shooting, numb, or tingling? How does it affect your function? Does it make it hard to get yourself out of bed in the morning? Is it challenging to shower? Are you not able to go grocery shopping? Are you communicating less with family and friends and leaving home less often? It’s important to share this information with your doctors so that they can best direct a pain treatment plan.

Why do some people avoid getting help?

Many patients shrug off pain as though it’s a normal part of aging, and this leads them to report it less to their doctors. Ignoring pain, however, can lead to more injury and disability. Often, older adults don’t want to call attention to their painful impairments. It can be a difficult transition for some older adults to begin using an assistive device like a cane or a walker. It can also impact our sense of self or independence to accept additional help at home when needing assistance to ensure our daily needs are being met. Some of my patients will go to great lengths to minimize their impairments in order to try and maintain autonomy. What I try to emphasize is that these modifications are not to diminish independence but to promote safety, prevent disability, and improve function and quality of life.

How can physicians be better advocates for patients experiencing pain?

One attitude to avoid is this: “Oh well, the patient is just getting older, and they’re going to have pain.” That’s a common misunderstanding on the part of some physicians and allied health professionals. We’re in a position where pain is being underreported and undertreated. We need to recognize that there’s a lot that can be done for pain, and it’s important for patients and/or their caregiver(s) to be strong advocates for improving their quality of life.

Some estimates suggest that approximately half of older adults living on their own experience chronic pain. Chronic pain is defined as pain that lasts more than three to six months or longer than the expected healing time. The good news is that there are treatments available.

Lauren A. Kelly, MD

“People often look for the magic pill,” says Lauren A. Kelly, MD, a geriatrician at The Mount Sinai Hospital. “But pain is complex. Taking a multifaceted approach to healing can help us achieve the most successful and enduring results.”

In this Q&A, Dr. Kelly, Assistant Professor, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, discusses why older adults experience pain and how it can be treated.

What causes pain among older adults?

There are many causes. Some can be attributed to health issues that more commonly occur as we age, such as osteoarthritis, chronic back pain, myofascial pain, peripheral neuropathy, fibromyalgia syndrome, falls, and the need for surgery. But the way we experience pain is complex and the way the nervous system processes pain changes as we age. Some studies show that older adults have a higher threshold for pain but are less able to tolerate it when it occurs. Mood and cognition, or the way our minds process the world around us, play an important part. Anxiety, depression, and loneliness can make pain more intense. Cognitive behavioral therapy for pain, as well as  social supports and services like home care can significantly improve quality of life for older adults living with pain. It’s important to note that  many of these factors are what we call “bi-directional,” which means each factor can influence the other. For instance, pain can increase social isolation, which in turn can lead to increased pain. This is why a comprehensive approach to addressing multiple factors is needed.

What are some of the treatments that are available to treat pain?

Since pain is so multifaceted, pain treatment should also be many-sided. People often look for simple solutions to relieve pain, but it’s much more nuanced than that. That’s also why the pain assessment is so important. Geriatricians use a model of multiple considerations called the “5Ms of Geriatrics,” which include “mobility,” “mind,” “mood,” “medications,” “multi-complexity,” or the presence of multiple medical conditions, and “matters most,” which takes the patient’s goals into consideration.

Once the patient’s goals are identified, we can develop a meaningful pain management program. Some of the treatments that might be considered include physical therapy, medication, pain injections, surgery, and even behavioral therapy.

What does physical therapy consist of?

Physical therapy is very commonly recommended for older adults with chronic pain to help improve mobility and gait and to strengthen the muscles that support our joints.

An under-recognized specialty in medicine is physiatry, also called physical medicine and rehabilitation. Physiatrists often care for patients with complex conditions such as stroke or significant physical injuries and deformities. They are also highly skilled in diagnosing and managing various types of pain, particularly musculoskeletal pain, and collaborate closely with physical and occupational therapists to enhance pain relief and functional recovery.

There are various approaches to treating nerve-related pain, such as neuromodulation techniques. One of the most common is the use of a transcutaneous electrical nerve stimulation (TENS) device, which applies low-voltage electrical currents to the nerves to help block or reduce pain signals. Acupuncture is another method many people find effective, though it is often not covered by insurance.

Pain specialists often utilize interventional procedures for pain, such as cortisone injections into the joints or painful trigger points, or epidural steroid injections into the spine. In some cases, they may perform nerve ablation to reduce pain, which can be highly effective for certain conditions. Additionally, medications remain an important tool in pain management.

What do older adults need to know about pain medications?

It’s important to know all the medications you are taking to avoid adverse reactions when new medications are added. Certain medications that are commonly used can have untoward effects for older adults. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are a very powerful class of medication for inflammatory pain and osteoarthritis, but older adults need to be careful about overusing them due to negative effects on the gastrointestinal system, the kidneys, and the heart. With frequent daily use, we can see bleeding, ulcers in the GI tract, elevated blood pressure and kidney injury. It’s usually safe to use NSAIDs occasionally if you have never experienced these complications, but it’s best to talk with your doctor to understand what personalized recommendations they may have for you.

What medications might I be offered?

I think acetaminophen is undervalued and underutilized by patients. I usually advise my older adult patients with chronic pain who do not have significant liver impairment to take two extra strength 500 milligram acetaminophen tabs (1000mg total) up to two or three times a day. This is a safe dose that does not cause harm to your liver. Lidocaine patches or other topical treatments can also be effective. There are even topical NSAIDs available, which don’t get systemically absorbed when applied to the skin.

Low risk medications like acetaminophen and topical therapies, when combined with other treatments for pain, such as physical therapy, acupuncture, and a healthy routine that involves appropriate exercise, diet, and socialization may be all that one needs to hold chronic pain at bay.

For pain that requires more medication, there are several different classes of medications we reach for depending on the pain source. There is a class of drugs used for nerve-related pain, called neuropathic medications. These are medications like gabapentin and pregabalin. Some antidepressant medications have nerve pain effects, including the selective serotonin reuptake inhibitor (SNRI) class and tricyclic antidepressant (TCA) class, so we occasionally will use these medications for pain.

Opioids are sometimes prescribed after surgery or when other treatments have proven ineffective. Among this class of medications, I recommend buprenorphine. It has fewer side effects, including reduced cognitive effects, less sedation, and less constipation compared to other opioids. Most importantly, buprenorphine is associated with less respiratory depression compared to other opioids, making the likelihood of overdose much lower compared to traditional opioids..

What types of surgery are offered for pain?

Surgery for back pain and knee or hip replacement surgeries are becoming more common, especially with the increase in minimally invasive techniques. However, there are many remedies that can be tried before going that route. Even if you see an orthopedic surgeon or neurosurgeon, they will most often try non-surgical treatments first.

The good news is that there are a lot of treatments available. I encourage people to start with their primary care doctor who can refer you to the appropriate specialists as needed.

Older patients often describe pain as an inability to move through the world. Treating pain in older adults is crucial to supporting everyday activities, mobility, and independence. While many older adults live with pain—some estimates range as high as 50 percent of people living independently—there are many treatments available.

Lauren A. Kelly, MD

“Patients often grin and bear it,” says Lauren A. Kelly, MD, a geriatrician at The Mount Sinai Hospital. “But pain has many consequences—socially, medically, and psychologically.”

In this Q&A, Dr. Kelly, Assistant Professor, Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, says it is important for older adults to get treatment for their pain—since just living with it puts you at risk in many ways.

How does pain affect older adults?

Pain can affect physical and mental well-being, accelerate physical disability, impair focus and sleep, and contribute to an inability to cope with daily living activities or simple daily stress. Pain can also add to a cycle of frailty, where pain contributes to deconditioning, immobility, and poor nutrition—resulting in more frailty.

How common is pain among older adults?

Unfortunately, chronic pain is very common with estimates suggesting that between a quarter to half of adults aged 65 and older experience it. In nursing home settings, the prevalence rises to over 80 percent.

How does pain put me or my loved one at risk?

Pain is often an accelerator of functional decline. Pain puts patients at greater risk for falls, impaired physical performance, and progression of disability, which can further compound the pain experience.

When patients suffer acute-on-chronic worsening of their pain, such as after orthopedic surgery, this acute pain must be aggressively managed. Allowing acute pain to go unchecked can lead to changes in central nervous system processing of pain, making older adults vulnerable to persistent pain and further decline in functional baseline.

Is pain a natural part of aging? What are some of the causes?

Aging, as a factor by itself, is not a cause of pain. We see many older adults who don’t experience chronic pain. But as people get older, health issues such as osteoarthritis, chronic back pain, surgery, falls, and pain related to your muscles and nerves—like myofascial pain, peripheral neuropathy, fibromyalgia syndrome—all become more common. Also, as we age, there are changes in the way the nervous system processes pain that make us less able to tolerate it and thus more susceptible. For many older adults, these cumulative effects can impair physical functioning and be quite disabling.

You mentioned pain affects mobility and vice versa. How does that work?

The relationship between pain and things like mobility and mood is complex. We call these relationships “bi-directional” because often, each factor can influence each other. For example, we know that pain is more likely in patients with impaired mobility, gait issues, or a history of falls. If a person’s gait or mobility gets worse, or if they suffer a fall, that can then influence the severity of pain. Another example is that we see much higher rates of pain in patients with depression, anxiety, or even social isolation.

How does mental health affect pain?

Mood is a modulator of pain pathways in the brain, particularly the pathways that inhibit pain signaling. Worsening depression can deepen the pain experience even further, make it feel more intense, or feel like it’s lasting longer. Conversely, mental health treatment can significantly improve someone’s pain. Research shows that cognitive behavioral therapy for pain can have excellent results, so it’s important that when we’re treating pain that we recognize all the different factors at play and develop pain interventions that target each of those areas.

Are there special considerations in treating older adults for pain?

Older adults often face unique challenges—socially, financially, psychologically, and medically. Geriatricians have insight into the needs of older adults and look at multiple considerations that are called the “5Ms of Geriatrics,” which include “mobility,” “mind,” “mood,” “medications,” “multi-complexity,” or the presence of multiple medical conditions, and “matters most,” which takes the patient’s goals into consideration.

How do memory and/or cognitive problems affect pain management for older adults?

If a person has neurocognitive difficulties or dementia, it may be difficult for them to describe the pain they are experiencing. Things like behavioral agitation and delirium, or a sudden change in someone’s orientation to person, place, or situation as well as attention difficulties, are commonly seen. Additionally, since older adults may have multiple medical issues and often take many medications, care needs to be taken in prescribing new medications which can create more side effects and interactions. Many pain medications, particularly central nervous system depressants, can worsen cognition.

As providers, we need to identify and work toward the patient’s goals. For patients with cognitive impairment, that often means working with patients’ designated caregivers or health care proxies to come up with tailored care plans.

What other challenges do older adults with pain often face?

Older adults may be socially isolated and face financial concerns. Getting social work colleagues involved to ensure access to insurance and benefits, including things like home care and medical supplies to promote function and independence is key. It’s also important for older adults to keep moving. While physical therapy can support mobility and help with pain, the simple fact of getting out of the house to physical therapy can also help patients feel like they’re doing something positive for themselves and thus help their mood. Getting out and seeing other people, making jokes with your physical therapist, talking to the lady sitting next to you who is also getting physical therapy—these things are all a part of the healing process.