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Pain in older adults and in dementia
Pain in older adults is common and undertreated, especially in dementia, where the patient does not report it; assess pain with observational tools as well (PAINAD), start with regular paracetamol and non-drug treatment, avoid long-term NSAIDs and dangerous drugs, and use a low-dose opioid when pain is moderate to severe and impairs function.
Why it matters in the exam
The exam presents a patient with advanced dementia who has become restless, refuses to get up and groans when touched, and asks for the next step: pain assessment with an observational tool and a trial of regular paracetamol — in a randomised trial, stepwise pain treatment in care-home residents with dementia reduced agitation. Candidates are also asked about drug choice according to the American guideline on persistent pain in older people.
Recurring points: paracetamol is first line (up to 4 g a day, less with liver disease or alcohol use); oral NSAIDs — avoid long term (bleeding, kidneys, heart), while a topical NSAID suits localised osteoarthritis; pethidine — no; tramadol — with caution (hyponatraemia, serotonin syndrome, seizures); neuropathic pain — duloxetine, or low-dose gabapentin and pregabalin adjusted for kidney function (drowsiness, falls); and non-drug treatment — exercise, physiotherapy, heat, cognitive behavioural therapy.
Untreated pain in an older adult causes depression, sleep disturbance, functional decline, falls and delirium. In an older adult who cannot communicate look for signs: facial expression, vocalisation, guarding posture, restlessness, changes in eating and sleep. The aim of treatment is better function and quality of life, not necessarily complete disappearance of pain.
Key points
- Pain is common and undertreated, especially in dementia.
- In dementia — PAINAD and observation; a change in behaviour may be pain.
- Regular paracetamol — first line; topical NSAID for localised pain.
- Neuropathic — duloxetine or a low-dose gabapentinoid.
- Low-dose opioid for moderate-to-severe pain; no pethidine.
Summary table
| Step | What is done | Exam point |
|---|---|---|
| Assessment | Direct question and numerical scale; in dementia — PAINAD (0–10) | A change in behaviour may be pain |
| First line | Regular paracetamol, up to 4 g a day | Less with liver disease or alcohol |
| Topical | Topical NSAID, topical lidocaine | For osteoarthritis and localised pain |
| Neuropathic | Duloxetine; low-dose gabapentin or pregabalin | Adjust for kidneys; drowsiness and falls |
| Opioid | Low dose for moderate-to-severe pain with functional impairment | Regular laxative; no pethidine |
| Avoid | Long-term oral NSAIDs, pethidine, muscle relaxants | Beers 2023 |
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Sources
- American Geriatrics Society clinical practice guideline — Pharmacological management of persistent pain in older persons, 2009 — Drug choice and dosing
- PAINAD scale (Pain Assessment in Advanced Dementia), 2003 — Observational pain assessment
- American Geriatrics Society Beers Criteria, 2023 update — Analgesics to avoid
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.