Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.

General Principles of Pain Management covering Acute, Palliative Care and Persistent Pain in the Older Adult

This guideline is aimed at providing quick and general guidance on acute, palliative care and persistent pain in the older adult. Many of the principles remain the same for all three origins, however differences in prescribing are detailed in separate sections, prescribing notes for acute care and palliative care and persistent pain in the older patient.

This guideline does not replace the more detailed local guidelines available at each site, which should be referred to as appropriate. If the patient's pain remains unresolved despite using this guideline, or more detailed local guidelines, then refer to the appropriate pain team for further advice.


There is good evidence that effective pain relief reduces patient morbidity, helps facilitate early recovery, mobilisation and discharge from hospital. As pain is subjective, drug regimens need to be tailored to meet individual requirements. There are local variations in which particular drugs from each class of analgesics may be preferred and may be indicated in a specialty specific analgesic ladder.

Assessment / monitoring

Detailed pain assessment is essential. The pain score and pain descriptors obtained from the patient may influence the choice of analgesic within the WHO analgesic ladder.

General principles for all types of pain:

  • Use pain scores to assess initial analgesic requirements and the effects of treatment.
  • Pain should be considered the fifth vital sign. Assess pain on movement and record score within the NEWS chart when routine observations are carried out. Ensure the scores are documented daily, or more frequently if required.
  • If pain scores are increasing, always consider that there may be a reason for this e.g. worsening of condition, presence of wound infection, constipation, etc.

N.B. Pain assessment tools will vary between hospitals in NHSGGC.

Acute pain:

In addition to the general principles of assessing pain above:

  • For post-operative pain, monitor pain regularly. This should begin as soon as the patient is admitted to the recovery room and continued onto the ward thereafter.

Chronic persistent pain in older patients / Palliative Care Patients:

In addition to the general principles of assessing pain above:

  • Use a more detailed assessment tool – Generic Pain Tool recording pain 4 hourly if pain is uncontrolled or pain score is recorded as >3.
  • In patients with severe communication difficulties or cognitive impairment consider using a specifically designed observational assessment tool e.g. Abbey Pain Tool.

Treatment options

General principles of pain management (read before prescribing)

Ascertain whether patient is intolerant to any analgesic. If intolerant to opioid, establish which one as most patients are not intolerant of every opioid.

Prescribe analgesia regularly according to guidelines further below or as per local guidelines, bearing in mind any documented sensitivities / allergies. Use oral route whenever possible and appropriate, also consider potential side effects of analgesia.

Review analgesia at least daily and always at discharge.

If an analgesic has failed to control the pain, step up to the analgesic on the next step of the ladder. N.B. Some patients may not respond to codeine but may respond to other Step 2 analgesics.

For older patients early review of response to analgesia is required as they are more likely to experience side effects like confusion and constipation.

Analgesic Step Ladder

Below is the basic analgesic pain ladder which is used to manage most types of pain. The differences in pharmacological management between the types of pain are outlined in the Prescribing Notes section so establish which type of pain your patient has, then manage as for:


STEP 1: Mild Pain

e.g. Paracetamol (see relevant prescribing notes, links above).


STEP 2: Moderate Pain

Use weak opioid e.g. co-codamol 30/500 (see relevant prescribing notes, links above)


STEP 3: Severe Pain

Use opioid for moderate to severe pain (see relevant prescribing notes, links above)


Adjuvant, paracetamol and anti-emetics can be considered in each step for palliative pain or persistent pain in the older adult (see prescribing notes for palliative care and persistent pain in the older patient). N.B. Remember that analgesia can be stepped down as well as up

Content last updated: November 2019

Page last updated: September 2022