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. Untreated pain can have really disabling consequences for older adults and it should be taken seriously. In many cases, pain is treatable or even 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 for talking about pain is with your primary care doctor, especially if you trust them and are satisfied with their care. A primary care doctor can assess the situation and make referrals to specialists as needed.

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

What does a pain assessment consist of?

Pain 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 keeping house, shopping, and preparing meals. Understanding a patient’s daily challenges is much more helpful than identifying pain on a severity 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 sleep at night or 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 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 indicate that about half of older adults living independently experience chronic pain. Chronic pain is defined as pain that persists for more than three to six months or beyond the expected healing time. The good news is that effective treatments are 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 are linked to health issues that more commonly occur as we age, such as osteoarthritis, chronic back pain, myofascial pain, peripheral neuropathy, fibromyalgia, falls, and the need for surgery. However, pain itself is complex, and the way the nervous system processes it changes as we age. Research suggests that older adults may have a higher threshold for pain but are less able to tolerate pain when it occurs.

Mood and cognition, how we perceive and process the world, also plays a key role in pain. Conditions like anxiety, depression, and loneliness can make pain feel more intense. Treatments such as cognitive behavioral therapy for pain, along with social supports and services like home care, can significantly improve quality of life for older adults living with chronic pain. It’s important to note that many of these factors are “bi-directional,” meaning they influence each other. For example, pain can lead to social isolation, which in turn can worsen pain. This is why a comprehensive approach to addressing multiple factors is needed to manage chronic pain effectively.

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

Because 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. This is why a thorough pain assessment is essential. Geriatricians use the “5Ms of Geriatrics” model,  which considers multiple factors: “mobility,” “mind,” “mood,” “medications,” “multi-complexity” (the presence of multiple medical conditions), and “matters most,” (which focuses on the patient’s personal goals).

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, depending on the individual’s needs and circumstances.

What does physical therapy consist of?

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

An under-recognized specialty in medicine is physiatry, also called physical medicine and rehabilitation. Physiatrists focus on diagnosing and treating conditions that affect movement and function, often after injury or illness, such as stroke or spinal cord injury. 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.

Can you describe in more detail some of the other available pain treatments you mentioned?

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. Acupuncture is another method many people find effective, though it is often not rarely covered by insurance.

There are neuromodulation techniques for pain. One of the most commonly used is the transcutaneous electrical nerve stimulation (TENS) device, which applies low-voltage electrical currents to the nerves to help block or reduce pain signals.

Of course, 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, kidneys, and heart. With frequent daily use, we can see things like gastrointestinal bleeding, 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 generally safe dose that will not cause harm to your liver. Lidocaine patches or other topical treatments can also be effective. There are also 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 social interaction may be all that one needs to hold chronic pain at bay.

For pain that requires additional medication therapy, 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 like sleepiness, confusion, and euphoria, lower risk of addiction, and less constipation compared to other opioids. Most importantly, buprenorphine is associated with significantly less respiratory depression and overdose risk compared to traditional opioids, making it a much safer option.

What types of surgery are offered for pain?

Surgery for back pain and knee or hip replacement surgeries have become more common, especially with advances in minimally invasive techniques. However, there are many non-surgical remedies that can be tried before going that route. In most cases, orthopedic surgeons or neurosurgeons will recommend starting with non-surgical options first.

The good news is that a wide range of treatments is available. I encourage people to start with their primary care doctor, who can guide them and refer them to appropriate specialists if 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.

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

Lauren A. Kelly, MD

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 make it harder to do everyday activities or cope with simple daily stressors. Pain can also add to a cycle of frailty, whereby pain contributes to deconditioning, mobility problems, and poor nutrition—resulting in more frailty. It’s important to identify and treat pain to minimize its far reaching effects.

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, weakened physical abilities, and more disability, which can worsen the pain experience.

When patients have a sudden increase in their pain, such as after orthopedic surgery, this acute pain needs to be treated quickly and effectively. Allowing acute pain to go unchecked can lead to changes in how the brain processes pain, making it harder for older adults to recover and potentially leading to persistent chronic pain and decline in function.

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. 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 therefore more susceptible. For many older adults, these factors can add up and lead to significant problems with function and quality of life as a result of pain.

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 “bidirectional” 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, make it feel more intense, or 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 consider several key areas that we call the “5Ms of Geriatrics.” These 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. The 5Ms framework allows geriatricians to take a comprehensive approach to pain with respect to each of these domains.

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

If a person has cognitive 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 create 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. 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.