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HLT-LPN37-05 · Lesson 10 · 16 clock hours · theory

Pain Management in Older Adults

Objective. Students will select appropriate pain assessment tools for residents with and without cognitive impairment, differentiate pharmacological from non-pharmacological pain interventions within LPN scope, and identify signs of undertreated pain in nonverbal residents.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Pain Management in Older Adults

Pain is one of the most common problems in geriatric care, yet it is frequently undertreated. As an LPN, you are on the front line of identifying pain, selecting the right assessment tools, carrying out interventions, and communicating findings to the supervising nurse or provider. Understanding how pain works in older adults — and why it is so often missed — is a core safety skill.

How Pain Changes with Age

Older adults experience the same types of pain as younger people: nociceptive pain (from tissue damage such as arthritis or a pressure injury) and neuropathic pain (from nerve damage, as in diabetic neuropathy). However, aging changes pain perception in several ways. Nerve conduction slows, and some elders actually perceive pain less intensely — but this does not mean they suffer less damage. Many older adults also have multiple chronic conditions that produce overlapping pain signals, making the picture complicated.

Common pain sources in long-term care residents include osteoarthritis, compression fractures, peripheral vascular disease, cancer, and procedural pain from wound care.

Barriers to Accurate Pain Assessment

Several factors cause pain to be underreported and undertreated in older adults:

Pain Assessment Tools

Numeric Rating Scale (NRS)

The NRS asks the resident to rate pain on a scale from 0 (no pain) to 10 (worst pain imaginable). It is quick and widely understood. Use it for residents who are alert, oriented, and able to communicate verbally or in writing.

Wong-Baker FACES Scale

This scale uses drawings of faces ranging from happy (0, no hurt) to crying (10, hurts worst). It is useful for residents who have difficulty with abstract numbers but can still communicate and understand visual cues. It is also helpful for residents with mild cognitive impairment or limited English proficiency.

PAINAD Scale (Pain Assessment in Advanced Dementia)

The PAINAD scale is designed for residents who cannot self-report pain reliably due to advanced dementia or other causes of severely impaired communication. It scores five observable behaviors:

1. Breathing — normal, occasional labored breathing, or noisy labored breathing

2. Negative vocalization — none, occasional moaning, or repeated loud moaning/crying

3. Facial expression — smiling/calm, sad/frightened, or frowning/grimacing

4. Body language — relaxed, tense/fidgeting, or rigid/fists clenched/knees pulled up

5. Consolability — no need to console, distracted/reassured by voice or touch, or unable to console

Each item is scored 0, 1, or 2. Total scores range from 0 to 10. Higher scores indicate greater pain. A score of 1–3 suggests mild pain; 4–6 moderate; 7–10 severe. Always compare the score to the resident's baseline behavior.

Safety point: When in doubt about which tool to use, choose the tool matched to the resident's current cognitive and communication ability. Document which tool you used every time you assess pain.

Signs of Undertreated Pain in Nonverbal Residents

Residents who cannot speak their pain may show it through:

Safety point: Behavioral changes in a nonverbal resident should always prompt a pain assessment. Assuming the behavior is "just the dementia" is a patient safety error.

Pharmacological Interventions: LPN Scope

LPNs administer analgesics as ordered by a provider; they do not prescribe. Common analgesic categories include non-opioid analgesics (such as acetaminophen, which is often a first-line choice in elders), NSAIDs (used cautiously in elders due to risks of gastrointestinal bleeding, kidney impairment, and cardiovascular effects — see Beers Criteria), and opioid analgesics (used for moderate-to-severe pain with careful monitoring for sedation, respiratory depression, and constipation).

The Beers Criteria, published by the American Geriatrics Society, lists medications that are potentially inappropriate for older adults. LPNs should be familiar with it as a reference when reviewing medication lists and reporting concerns to the charge nurse.

Safety point: Never crush extended-release analgesic tablets unless specifically approved by pharmacy. Always monitor for over-sedation after opioid administration and keep the call light within reach.

Non-Pharmacological Interventions

Non-pharmacological strategies are a vital part of geriatric pain management and complement medications. Many can be initiated by the LPN based on standing orders or care plan direction; others require a specific provider order.

Safety point: Document all non-pharmacological interventions and the resident's response. If pain is not relieved or worsens, report to the supervising nurse promptly.

Key terms9

Nociceptive painPain arising from actual or potential tissue damage, such as from arthritis, wounds, or fractures; the most common type of pain in older adults.
Neuropathic painPain caused by damage or dysfunction of the nervous system itself, producing burning, shooting, or tingling sensations; examples include diabetic neuropathy and post-herpetic neuralgia.
PAINAD scalePain Assessment in Advanced Dementia scale; a validated behavioral observation tool scoring breathing, negative vocalization, facial expression, body language, and consolability on a 0–10 scale for residents unable to self-report pain.
Beers CriteriaA list published by the American Geriatrics Society identifying medications that are potentially inappropriate or require careful use in older adults due to increased risk of adverse effects.
Numeric Rating Scale (NRS)A self-report pain scale on which the patient verbally rates current pain intensity from 0 (no pain) to 10 (worst pain imaginable); used with cognitively intact, communicative patients.
Wong-Baker FACES ScaleA visual pain scale using drawings of faces from smiling to crying, rated 0–10; useful for patients who struggle with numeric abstractions but can interpret facial expressions.
StoicismA personal or cultural tendency to endure pain or discomfort without complaint; a common barrier to pain reporting in older adult populations.
Undertreated painA condition in which a patient's pain is not adequately assessed or managed, resulting in continued suffering and potential complications such as immobility, depression, or agitation.
Non-pharmacological interventionAny pain relief strategy that does not involve medication, such as repositioning, heat or cold application, distraction, or guided imagery.

Worked examples3

1. Score the following PAINAD observation: A resident with advanced dementia is lying in bed. Her breathing is normal and unlabored. She occasionally moans softly but is not crying. Her face shows a sad, worried expression. Her body appears tense and she is fidgeting with her blanket. When the nurse holds her hand and speaks soothingly, she calms down somewhat.
  1. Breathing: normal, unlabored = 0
  2. Negative vocalization: occasional moaning = 1
  3. Facial expression: sad or frightened = 1
  4. Body language: tense, fidgeting = 1
  5. Consolability: distracted or reassured by voice or touch = 1
  6. Add all five scores: 0 + 1 + 1 + 1 + 1 = 4
Answer: PAINAD score = 4, indicating moderate pain. Report to the supervising nurse and document findings; consider non-pharmacological comfort measures and follow the care plan for analgesic administration.
2. Score the following PAINAD observation: A resident with severe dementia is observed during a dressing change. He is breathing in a noisy, labored manner. He is crying loudly and repeatedly calling out. His face shows a deep grimace. His legs are pulled up toward his chest and his fists are clenched. No amount of reassurance from staff calms him.
  1. Breathing: noisy labored breathing = 2
  2. Negative vocalization: repeated loud moaning or crying = 2
  3. Facial expression: frowning or grimacing = 2
  4. Body language: rigid, fists clenched, knees pulled up = 2
  5. Consolability: unable to console or distract = 2
  6. Add all five scores: 2 + 2 + 2 + 2 + 2 = 10
Answer: PAINAD score = 10, indicating severe pain. Stop the procedure if safely possible, notify the supervising nurse and provider immediately, and document the score, behaviors observed, and actions taken.
3. Score the following PAINAD observation: A resident with moderate dementia is sitting in her wheelchair. She is breathing normally. She makes no sounds. Her face is relaxed, without tension. She is sitting comfortably and is not moving restlessly. She does not appear to need any consoling.
  1. Breathing: normal = 0
  2. Negative vocalization: none = 0
  3. Facial expression: smiling or content = 0
  4. Body language: relaxed = 0
  5. Consolability: no need to console = 0
  6. Add all five scores: 0 + 0 + 0 + 0 + 0 = 0
Answer: PAINAD score = 0, suggesting no observable pain at this time. Document the score and continue routine monitoring; reassess with any change in behavior or during activities such as repositioning or wound care.
In class: Lecture: pain physiology review, barriers to pain assessment in elders (stoicism, cognitive impairment, fear of addiction), overview of numeric rating scale, Wong-Baker FACES scale, and PAINAD scale for nonverbal residents; students practice scoring three sample PAINAD scenarios. · Video observation: students watch a short video of a simulated nonverbal resident displaying pain behaviors; each student independently scores the PAINAD, then the class compares scores and discusses discrepancies with instructor guidance. · Non-pharmacological intervention planning: given five geriatric pain scenarios, students identify two appropriate non-pharmacological interventions per scenario (positioning, heat/cold, distraction, guided imagery) and document them on a care plan template, noting which require an order.
Materials: PAINAD scale printouts, numeric rating scale and FACES scale handouts, pain video clip, care plan template, LPN pharmacology textbook (analgesics chapter), Beers Criteria summary
Check: PAINAD scoring accuracy: student scores must be within one point of instructor key score on all three practice scenarios; care plan template graded on rubric—two appropriate interventions documented per scenario with correct notation of order requirements = 80% minimum.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Basic Care and Comfort
1. A resident with advanced dementia cannot answer questions about pain. Which assessment tool is most appropriate for this resident?
Basic Care and Comfort
2. An LPN notices that a 78-year-old resident with dementia has become increasingly agitated and is resisting morning care. The resident is nonverbal. What is the LPN's priority action?
Psychosocial Integrity
3. A resident tells the LPN, 'I don't want any pain medicine — I've heard people get addicted to those drugs.' Which response by the LPN is most appropriate?
Basic Care and Comfort
4. Which of the following non-pharmacological pain interventions typically requires a provider order before an LPN can apply it to a geriatric resident?
Basic Care and Comfort
5. A student LPN calculates a PAINAD score of 7 for a resident. According to the PAINAD scale, this score indicates:
Pharmacological Therapies
6. The Beers Criteria is most useful to an LPN when:
Basic Care and Comfort
7. Which observation in a nonverbal resident most strongly suggests undertreated pain and should be reported to the supervising nurse?
Management of Care
8. An LPN is preparing a care plan entry for a resident with chronic low back pain and no cognitive impairment. The LPN selects 'guided imagery' as a non-pharmacological intervention. Which additional step is essential before the LPN begins this intervention?
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