Pain

Core Concepts

Pain is subjective: the person's report comes first

There is no laboratory test, scan, or vital sign that measures pain. The person's own description — location, quality, intensity, timing, and what helps or hurts — is the single most reliable source of information. Classic research from the late 1970s and early 1980s (for example, Cohen's 1980 study of postoperative patients) compared patients' own pain ratings with the estimates of nurses caring for them and found that nurses systematically underestimated the pain patients reported. Methodologically, that work showed how easily an observer's judgment substitutes for the patient's report; ethically, it reinforced that dismissing someone's pain is a form of harm. The lesson has not changed: when a person can report pain, the report outranks behavior, facial expression, and vital signs, which can all be misleading.

Acute versus chronic pain

• Acute pain warns of injury or illness — a fracture, surgery, an infection. It is expected to resolve as tissue heals (commonly within three months) and is usually tied to a clear cause.
• Chronic pain persists beyond the expected healing time. The nervous system changes (central sensitization: the "volume knob" of the pain system turns up), so pain can continue — and even spread — without ongoing tissue damage.

Older adults often live with both at once: chronic arthritic pain plus a new acute injury. Both deserve assessment and treatment; neither should be dismissed.

Nociceptive versus neuropathic pain

Mechanism matters because it guides management (always as prescribed by the provider):

• Nociceptive pain — from tissue damage or inflammation. Examples: osteoarthritis, a hip fracture, a pressure injury. Often described as aching, throbbing, or sharp.
• Neuropathic pain — from damage or disease of the nervous system itself. Examples: diabetic neuropathy, post-herpetic neuralgia (shingles pain), radiculopathy. Often described as burning, shooting, electric, or tingling.

Why pain goes unrecognized in older adults

Several forces work together. The person may under-report: they may assume pain is normal at their age, worry about the cost of treatment, fear addiction or dependence on medications, or not want to "bother" busy staff. Clinicians may compound the problem by assuming "no complaint means no pain" or by attributing distress to dementia. Sensory changes (hearing loss, vision loss) make communication harder. The result is that pain is both under-assessed and under-treated in this group — a well-documented pattern, not an isolated anecdote.

Assessing pain when self-report is difficult

Start with self-report whenever possible, using the simplest tool the person can manage: a 0–10 numeric scale, a verbal descriptor scale (none, mild, moderate, severe), or a faces scale. For people with advanced dementia who cannot self-report, use a structured observational tool such as PAINAD (Pain Assessment in Advanced Dementia), which scores breathing, vocalization, facial expression, body language, and consolability. Observational tools are estimates, not replacements for self-report: they flag possible pain so the team can investigate. A key clinical habit: in a person with dementia, consider pain before labeling behavior as "the dementia" — agitation, calling out, or pulling at clothing may be a pain signal.

Consequences of undertreated pain — and the nursing role

Untreated pain in older adults is associated with sleep disruption, reduced mobility and deconditioning, increased fall risk, poor appetite, social withdrawal, depressed and anxious mood, and, in hospitalized or acutely ill people, delirium. The nursing role includes: assessing pain regularly and reassessing after any intervention; using nonpharmacologic measures (comfortable positioning, appropriate heat or cold, activity pacing, distraction and relaxation, sleep routines); documenting findings and responses; administering medications only as prescribed with monitoring for sedation, falls, and interactions; and reporting inadequate relief to the provider. Polypharmacy — the use of many medications at once — is common in older adults and raises the stakes for monitoring.

Common Confusions