Adopting Principles to Guide Pathways: The Best Model for Geriatric Pain Management

Background:

Older adults have the highest prevalence of chronic pain and the greatest risk for pain-related disability [1]. Compounding the problem is that the majority of pain management interventions utilized clinically are based on research in younger populations, and many may in fact be ineffective or unsafe for older adults or may require modifications for this population. Many such interventions are pharmacologic including non-steroidal anti-inflammatory drugs (NSAIDs), adjuvant drugs (e.g., antidepressants, gabapentinoids, muscle relaxants), and opioid drugs [2,3]. Recent large systematic reviews and Centers for Disease Control and Prevention (CDC) guidelines have noted the limited efficacy of both short-term and long-term opioid therapy for pain and function compared to other medication classes such as NSAIDs; moreover, these reports acknowledge significant safety limitations of these medications particularly in older adults [3–5]. Similarly, while various adjuvants may have some efficacy for specific types of pain, many have neurologic, cognitive and gastrointestinal side effects that pose risks of confusion, weakness and falls, limiting their appropriateness for older adults [3, 6]. Frustrating for many geriatric clinicians is that certain patients respond well to pharmacologic agents and report lasting pain relief while others are highly sensitive to the side effects of multiple classes of medications. The problem is not knowing who will respond or who will have an adverse reaction, leading to continued discord between applying research findings across populations and optimizing clinical care for the individual.

A potential explanation for such discord is the likely presence of mechanistic-based subgroup responses which, traditionally, clinical trials are not designed to identify or test. Instead, trials are often limited to presenting average effects across a large and ideally relatively homogenous sample. A second and related explanation is that clinical trials do not represent common approaches to clinical pain management. Drug trials, in particular, most often study a single agent against a tightly controlled comparator group to minimize the effect of other treatments or factors on pain outcomes. By contrast, clinical pain management involves a comprehensive and diverse combination of interventions with feedback from the patient over time to make treatment adjustments in order to optimize benefit and minimize harm. Moreover, within a “category” of pain (e.g. anatomical location, duration, character of pain), multiple etiologies and factors contributing to the pain condition exist and are unique to each individual; suggesting the importance of mechanistic-based subgroups and addressing overlapping mechanisms among individuals with a given pain condition. Empirical support for such pain subgroups is growing [7–9].

To address these limitations, more recent study innovations have included multimodal approaches whereby multiple interventions, or involvement of multiple disciplines, occur concurrently [10], stepped-care where interventions are delivered in escalating sequence [11], and stratified care which tailors interventions based on baseline risk criteria [12]. Many such approaches have supportive evidence and have been increasingly embedded in clinical pain management pathways and care models. However, incorporation of these approaches to innovate pain management for older adults has been slower. The first notable problem is that, like drug trials, older adults remain underrepresented in such research. Second, study findings to date are overall equivocal, with some showing efficacy and others reporting null effects over a population, again likely due to mechanistic-based subgroups [12, 13]. Even when an approach is deemed efficacious, there may be unanticipated and potentially adverse consequences for older adults. Take, for example, the recent trend of increased NSAID and gabapentinoid prescriptions to replace opioids; all of these medication classes have greater side effect profiles as patients age [11]. Finally, pain management pathways and models vary widely across different studies, clinical settings, pain conditions and patient populations, and can be highly convoluted, such that various elements of multimodal, stepped-care, and stratified care approaches are included at different stages of treatment and in variable combinations. This makes comparisons across studies—not to mention reproducibility, implementation, and application to older adults—difficult.

As a result of these inconsistencies and challenges in age-specific pathway/care model research, geriatric clinical pain management is, to some, akin to throwing a dart blindfolded. But crucially, this problem is not due to a “lack of tools”; the exemplary companion articles of this issue highlight many safe and effective pharmacologic and non-pharmacologic interventions for older adults in pain. Rather, the problem lies in identifying an individualized, pain-affirming approach for the patient in front of you; determining which intervention(s) are ideal for a particular patient, and how to package and deliver those interventions in a way that is most effective and suitable for that individual. We now provide key conceptual and applied principles, synthesized from both research and clinical experience, for safe, consistent, and effective geriatric pain management. We review how a clinician’s perspective—grounded in biopsychosocial understanding, communication, and alignment with individual patient expectations—can guide practice more reliably than searching for a one-size-fits-all pathway.

Conceptual Principles

Principle 1: Explain Pain to Older Adults Using a Biopsychosocial Framework

The biopsychosocial model is the central framework of comprehensive geriatric assessment, including pain assessment. However, this framework in the context of pain is highly heterogeneous, even among geriatric clinicians. Moreover, older persons interact with many clinicians outside our field who do not ascribe to a biopsychosocial framework. As such, the first step is making sure patients understand that pain is more than just what shows up on a blood test or imaging study. Too often, they see “degeneration” or “arthritis” on an x-ray report and assume that this is the source of their pain. Then, when an injection or a surgery does not fix the pain, they are left confused and discouraged. Pain is not just coming from joints or discs or other specific anatomic structures. It is a complex process influenced by factors important in older persons, including multiple chronic conditions, stress, sleep, emotions, cognition, social support, physical function, and behavior. Imbalances in physiological, psychological, and behavioral factors are common due to the modern way of life. Explaining pain in this way can take time, but it has the power to cognitively reframe pain for older adults.

In addition, explaining pain appropriately can be time-saving in the long-run. A deeper understanding of pain can reinforce to a patient why they should not have that surgery compared with the feeling of being “denied” something they think will fix them, and the repeated confused conversations as a consequence of this misunderstanding. Patients start to see that there are multiple ways to reduce their suffering, not just through fixing or removing a structure. They begin to understand why pain can persist even without injury, or why it can improve even when structural problems remain [14]. This is not about dismissing pain or telling patients it’s in your head. As described by other articles in this issue, It is about validating that their pain is real while also broadening the lens and helping them to understand just how multifactorial theirpain is. We have to meet them where they are and carefully connect their lived experience with the science. Doing so reduces fear, builds trust, and opens the door to interventions that focus on function and quality of life.

Principle 2: Adopt the Biopsychosocial Framework for Geriatric Pain Management

It is not enough to explain pain differently to patients. We as clinicians must practice differently ourselves. Even though geriatric clinicians view the health of an older adult through a biopsychosocial lens, the reality is that most physicians were trained to think about pain specifically in purely biomedical terms. Medical education still provides very few hours on pain science compared to training in nursing or physical therapy [15, 16]. That leaves many physicians plagued with misconceptions about the nature of pain and unprepared to effectively address pain management. The consequences of these misconceptions is illustrated in what Eccleston and Crombez described as the “misdirected problem-solving model [17].” A patient with back pain is told the disc is the problem. The patient undergoes an injection or surgery. When pain persists, they are left worse off—discouraged, worried, and now recovering from an unnecessary procedure, sometimes with worse long-term pain and function a few years down the road. The story we told them was the problem.

Adhering to a biopsychosocial framework in an older person’s pain management will ensure we avoid contributing to suboptimal care. As geriatric clinicians, we already understand its value in contextualizing and managing pain influences, including multiple chronic conditions, cognitive impairment, depression, social isolation, and mobility disability. We must ensure that we adopt the framework orthopaedically, including the way we use imaging; we hold back when the evidence says it is not needed, and we are careful about what words we use when we do find abnormalities [18]. We must echo the “Choosing Wisely” movement, which reminds us to avoid unnecessary tests and treatments that may harm more than help [19] and emphasizes not only a collaborative approach but also empowered self-management. It also means building multidisciplinary team of referral partners—physical therapists, psychologists, pharmacists, complementary medicine specialists, among others—who share the same framework so patients hear one consistent story, not conflicting ones.

Principle 3: Apply the Biopsychosocial Framework with Nuance

Adopting a biopsychosocial framework does not mean swinging from one extreme to the other, nor does it mean applying it linearly by moving from biomedical to psychological to social. Instead, it is full integration of all the relevant biopsychosocial components at the outset of care. Some clinicians, once they accept that pain is not purely biomedical, start assuming it must always be psychological. It is crucial to emphasize that this not true either—pain is always a combination of factors, with each individual having different relative weights of specific factors which can change for a given individual over time. Not every older adult with chronic pain has depression or severe distress. Many confront their pain head-on, adapt, and keep moving. Others fall into the trap of avoidance—limiting activity out of fear, becoming deconditioned, and experiencing even more pain—a difference captured in the fear-avoidance model [20].

Our role as clinicians is to sort out which path each patient is on, and which factors are coming into play and to what degree. Is the pain keeping them from moving at all? Are they fearful and avoiding, or are they confronting and adapting, or does it depend on the specific movement or activity? Maybe they are having a hard time finding a place to be more active because they live in a small apartment on a busy street. Do they lack energy to move due to stress or poor sleep? Nuance means not forcing patients into a single category but recognizing the spectrum. It means helping those avoiding movement to re-engage, one step at a time, while supporting those who are already confronting to keep going and identifying strategies to address other limiting factors. This avoids the trap of extremes and keeps care centered on the actual patient in front of us.

Principle 4: Patient Expectation Is Powerful

Expectations may be the most overlooked influence on pain outcomes. Older patients come into visits with beliefs shaped by a lifetime of past experiences, family, culture, and what they have read or been told. If they expect a treatment to work, it is more likely to help. If they expect it to fail, it probably will. Research on placebo and nocebo effects makes this clear [21]. Novelty also matters. Sometimes a treatment feels effective simply because it is new or different, even if it is not inherently superior [22]. For older adults, self-efficacy - i.e., belief in one’s ability to complete or perform the treatment, particularly active treatments like physical therapy – has the potential to impact treatment effectiveness. Moreover, expectations are often influenced by the health system itself. Insurance requirements can send the wrong message. A patient may need to complete physical therapy before a surgical referral is authorized. Without explanation, the patient concludes: “The real solution is surgery; physical therapy is just a hoop to jump through.” That mindset undermines physical therapy before it even begins.

We cannot leave expectations unspoken. We must name what treatments are for, what they are not, and what success looks like. “We are not doing physical therapy to prove anything to insurance. We are doing it because movement is the most powerful tool we have to help you get back to walking, cooking, or attending church. And we want to help you find the movements that you can do that will help you on the road to healing.” Clear conversations like this are not add-ons—they are treatment themselves. Resetting expectations restores agency, builds trust, and improves adherence [23–25].

Applied Principles

Principle 5: Structure Time

During most geriatric visits, pain does not show up first in the conversation. The agenda is already full—heart failure, diabetes, atrial fibrillation, medication reconciliation, fall risk, caregiver issues. Pain becomes an afterthought. That is dangerous because untreated pain bleeds into everything else: sleep, mood, cognition, blood pressure, activity, treatment adherence. If we do not make deliberate space for it, we lose the chance to address the very symptom that drives decline.

There are two practical strategies. The first is to prepare before the visit. Intake questionnaires that combine narrative and numbers are powerful. Start with open questions: “Tell me about a typical day with your pain.” Add short scales on pain interference, sleep, and mood. This allows the patient to prepare, and it helps the clinician decide what to focus on when time is short. It creates a safe space to fully explore the experience of pain. The second is to extend the visit beyond the room. Pain care requires follow-up, not one-off encounters. Phone calls, secure messages, and nurse-led check-ins can keep the thread alive. Telehealth has proven especially valuable. In the VA, tablet-based programs allowed rural Veterans to check in about pain without driving hours to a clinic, which meant clinicians could adjust treatment plans in real time [26]. Structuring time like this acknowledges the reality of modern practice and keeps pain from slipping off the list.

Principle 6: Communicate to Uncover Pain Factors

Pain is not revealed on a lab test; it is revealed in conversation. Communication is the only way we find out what really drives an older adult’s suffering. But that communication must be intentional. Motivational interviewing provides a blueprint: open questions, reflective listening, affirming strengths, and guiding gently instead of dictating. Even small changes matter—sitting at or below eye level, leaving pauses, nodding, or asking “What matters most to you right now?” Importantly, as a clinician you must show you really care and are here to help. It is easy in the biomedical model to dismiss pain as not an important medical issue, and for managing pain to feel like a burdensome task clinically, which can be perceived by your patient as indifference to their concerns. But pain is important to your patient and can impact every aspect of their lives. Engaging and empowering them to work with you as a team to understand their pain experience and develop their own plan of treatment improves not only engagement but both patient and clinician satisfaction.

Patients can be supported with resources before they walk in. Handouts like Communicating About Pain With Your Healthcare Team (geriatricpain.org), Communicating With Your Provider to Manage Chronic Pain (American Institutes for Research), and Clear Communication: Conversation Starters and Enhancers for older adults (available upon request from Dr. Booker’s (bookers@ufl.edu)) help them gather their thoughts and bring specific language into the clinic. The payoff is not just better rapport. Strong therapeutic alliance—the agreement on goals and tasks, plus the bond between clinician, patient and caregivers — predicts outcomes across back pain, knee osteoarthritis, and other chronic pain conditions [23, 24]. And when patients share in the decisions, they are more satisfied and more likely to follow through [25]. Communication is not a soft skill—it is a key clinical skill.

Principle 7: Coach, Don’t Command

We as clinicians do not live with a patient’s pain. That means the patient is the expert on what pain feels like in their body, and our role is not to dictate but to coach using therapeutic and pain-affirming language. Coaching means walking alongside, guiding, and equipping them with strategies they can use on their own. In practice, this looks like pacing—teaching a patient or caregiver to break housework into smaller parts to avoid flare-ups. It looks like graded exposure—encouraging a patient who avoids bending because of fear to start with safe, small movements. It looks like creating a flare-up plan—steps they can take when pain spikes so they do not feel helpless. Research shows self-management programs reduce pain-related disability and improve quality of life in older adults [27, 28]. The clinician’s role is to make these strategies part of everyday practice. Coaching is how we give patients the tools to keep moving, even when pain is severe.

Principle 8: Focus on Function

Pain is the symptom that brings patients in, but as geriatric clinicians can acknowledge, function is what keeps older persons alive and independent. Pain drives inactivity, and inactivity is the real risk. Sedentary time is a predictor of falls, hospitalization, and mortality in older adults [29]. If our outcome measure is only pain intensity, we are (1) aiming at the wrong target, which should be mobility preservation, and (2) measuring the wrong goal, which should be improvements in movement-evoked pain and/or pain-related disability.

We cannot guarantee pain elimination. Age-related/senescent changes in nerves, neurotransmitters, and brain processing mean pain is often chronic. What we can promise is that we will work to limit its impact on function. That shift in language is crucial. Instead of saying, “We are going to get rid of your pain,” we say, “We are going to help you walk farther, cook again, visit your family, or garden.” Function-focused goals are meaningful, concrete, and motivating. They also give patients a way to see progress even when pain scores stay the same. This reframing can make the difference between giving up and moving forward. A strategy to help older adults understand the importance or re-engaging/maintaining physical activity and function is to use illustrations. Once such model – the Pain-Movement Interface [30] (FIG. 1) – describes how higher movement-evoked pain has the power to influence activity engagement, participation, and to influence (via feedback loops) individual biopsychosocial factors of the pain experience.

Fig. 1. Theoretical framework of MEP and the Pain-Movement Interface within the context of activity engagement, participation, and the broader pain experience.

Adapted from Butera KA, etal. Through the Lens of Movement-Evoked Pain: A Theoretical Framework of the “Pain-Movement Interface” to Guide Research and Clinical Care for Musculoskeletal Pain Conditions. J Pain. 2024 Jul;25(7):104486.

Principle 9: Use Pain-Modulatory Interventions to Enable Movement

Pain modulators—whether medication, TENS, or mindfulness—should be seen for what they are: tools to calm down a sensitive and hyperactive pain signaling system so patients can move. None of these is a cure. But each can create a window of opportunity. Transcutaneous electrical nerve stimulation (TENS) has been shown to provide relief in older adults with chronic musculoskeletal pain [31], and mindfulness meditation has growing evidence as a safe way to reduce pain intensity and improve coping [32].

Pharmacotherapy, while fraught with risks, can be appropriate when carefully chosen and monitored closely. But the message to patients must be clear: “We are not using this to erase pain, we are using it to help you get back on your feet.” Scheduled analgesics to maintain a steady blood level and pain control is the traditional approach to helping with movement. Another useful approach is the anticipatory use of an oral analgesic dose just prior to significant physical activity such as physical therapy, exercise, grocery shopping, etc. If used intermittently, older persons can receive the benefits of NSAIDS or opioids without the risk of chronic, sustained used. Alternatively, the use of topical analgesics over the affected area (e.g, topical NSAID for MSK pain, topical lidocaine for neuropathic pain) can also help enable movement.

Still, medications vary widely in their efficacy, particularly with a given individual; so, choice of medications can never be a one-size-fits all even for a given pain condition (e.g., the common use of gabapentinoids for neuropathic pain despite a low rate of efficacy [33]). It is important to listen to patient feedback on their individual response to specific medications, which can include a combination of benefits and side effects for each person, to identify the best balance of modulators for that patient that will overall improve and not impair function.

Summary

The search for the perfect care pathway in geriatric pain management is a distraction. What older adults need is not a single model but a set of durable principles. These principles give us a foundation to individualize care. Conceptually, we must explain pain in a biopsychosocial framework, adopt the framework ourselves, apply it with nuance, and manage expectations. Practically, we must structure time, communicate to uncover pain factors, coach rather than command, focus on function, and use pain modulatory interventions to create windows for movement. These are not add-ons; they are the model. By adopting such aging friendly principles in your approach, clinicians can provide safer, more consistent, and more effective pain management. The result is not only reduced suffering but preserved independence, dignity, and quality of life in older adults (TABLE 1).

TABLE 1.

Quick-Reference Table

Principle	Focus	Description
1. Explain Pain Using a Biopsychosocial Framework	Patient understanding	Help patients see that pain comes from multiple influences, not just structural damage.
2. Adopt the Framework in Clinical Practice	Clinical practice	Avoid misdirected care by using biopsychosocial explanations in decisions and referrals.
3. Apply the Framework with Nuance	Avoid extremes	Recognize that pain is not all biomedical or all psychological; tailor to the patient’s mix.
4. Patient Expectation Is Powerful	Set realistic outlooks	Reset expectations in plain language; frame treatments as tools for function, not hurdles.
5. Structure Time	Maximize visits	Use intake questions and telehealth to keep pain on the agenda and extend follow-up.
6. Communicate to Uncover Pain Factors	Listen and align	Use motivational interviewing and patient tools; build alliance and align priorities.
7. Coach, Don’t Command	Empower patients	Teach pacing, graded exposure, and self-management; support shared decision-making.
8. Focus on Function, Not Pain	Guide outcomes	Define success by activity, independence, and participation, not pain scores.
9. Use Pain-Modulatory Interventions to Enable Movement	Calm the system	Use TENS, mindfulness, and pharmacology to create windows for movement and recovery.

Key Points.

• Communication is the foundation for uncovering what drives pain in each patient encounter.

• Pain must be explained and understood through a biopsychosocial framework tailored to older persons.

• Patient expectations shape outcomes and must be addressed explicitly.

• Applied strategies that include structuring time, enhanced communication skills, coaching, function-first outcomes, and safe pain-modulatory interventions.

Synopsis.

Older adults experience the highest burden of chronic pain and pain-related disability. Existing pathways—multimodal, stepped, stratified—provide useful pieces but do not fully account for the complexity of geriatric care. This article argues for principles to guide pathways: explaining and adopting the biopsychosocial framework, applying it with nuance, addressing expectations, structuring limited time, communicating effectively, coaching rather than commanding, focusing on movement and function, and using safe pain-modulatory interventions. Together, these principles anchor individualized, patient-centered, and function-focused pain care.