Pain is one of the most universal human experiences — and one of the most poorly managed in residential aged care settings around the world, including in Australia. For families with a loved one in aged care, the thought that they might be experiencing pain that is going unrecognised or undertreated is genuinely distressing. For older Australians themselves, living with unmanaged pain in what should be a place of comfort and safety represents a profound failure of care.

The good news is that pain management in aged care in Australia has improved significantly in recent years, driven by advances in assessment tools, a stronger regulatory framework under the new Aged Care Act 2024, and growing awareness of the particular challenges of identifying and treating pain in people living with dementia or other cognitive impairments. The bad news is that it remains one of the most under-addressed quality issues across the sector — and understanding how it works, what good practice looks like, and what questions to ask your loved one’s care provider is still essential knowledge for every Australian family.

This guide covers everything you need to know about pain management in Australian residential aged care: how common pain is in this population, why it is so frequently underreported and undertreated, how pain is assessed and reviewed, what both pharmacological and non-pharmacological management strategies look like, and what your rights are under the current legislation.

How Common Is Pain in Residential Aged Care?

Pain in residential aged care is not a rare or exceptional concern. It is the norm. Research consistently shows that more than 80% of residents in aged care facilities experience persistent pain — making it one of the most prevalent clinical conditions in this population. Yet despite this extraordinary prevalence, pain remains one of the most systematically underassessed and undertreated conditions across Australian residential aged care homes.

The causes of persistent pain in aged care residents are numerous and overlapping. The most common diseases experienced by people in residential aged care — cardiovascular conditions, musculoskeletal disorders, neurological conditions, cancer, and injuries related to falls — all carry significant pain burdens. Many residents are managing three or more chronic conditions simultaneously, creating complex, multi-site pain presentations that are difficult to assess and challenging to treat without causing additional harm through polypharmacy or adverse medication interactions.

Pain in this population is not just a physical experience. Unmanaged pain in aged care has direct, measurable consequences across multiple domains of wellbeing. It limits mobility and functional independence. It disrupts sleep. It reduces appetite. It diminishes social engagement and participation in activities. It causes anxiety and depression. And perhaps most significantly, it strips people of the sense of dignity and comfort that residential aged care should, above all, provide.

Sources: BJGP Open 2019; Journal of Clinical Nursing 2025; Dementia Australia 2022.

Why Pain in Aged Care Is So Often Missed

If pain is this prevalent, why does it remain so frequently underassessed and undertreated? The answer involves a complex web of clinical, systemic, and communication challenges that are specific to the aged care context — and understanding them is the first step towards better care.

The Dementia Communication Barrier

The single biggest challenge in pain assessment in aged care is dementia. More than two-thirds of people in Australian residential aged care have moderate to severe cognitive impairment. For these residents, the ability to reliably communicate pain — to say “my hip hurts” or “I have a headache” — is significantly compromised or entirely absent.

What makes this particularly concerning is that the behavioural signs of unmanaged pain in people with dementia are often misinterpreted. Agitation, aggression, resisting personal care, calling out, withdrawal from social activities, changes in facial expression — all of these can be manifestations of underlying pain. Yet in practice, these behaviours are frequently attributed to dementia itself rather than to pain, leading to inappropriate prescriptions of psychotropic medications rather than appropriate pain management.

Research published in the Journal of Clinical Nursing in 2025 found that over 90% of registered nurses, general practitioners, and psychiatrists struggle to accurately assess pain in people with dementia. This is not a reflection of poor intent — it is a reflection of how genuinely difficult the task is without the right tools, training, and systems in place.

Underreporting by Residents Themselves

Even among residents who can communicate pain verbally, underreporting is common. Many older Australians grew up in an era when stoicism around pain was culturally expected — particularly among men. Some residents worry that reporting pain will lead to increased medication, reduced independence, or being seen as a burden to busy care staff. Others have come to accept chronic pain as an inevitable part of ageing, not realising that effective management options exist.

This cultural and generational tendency towards underreporting means that waiting for residents to report their own pain is not a sufficient pain management strategy. Proactive, regular, structured assessment is essential — and it is now an explicit expectation under Australia’s strengthened Aged Care Quality Standards.

Systemic and Workforce Challenges

Beyond individual communication barriers, there are systemic challenges that make pain management in residential aged care difficult even in well-intentioned facilities. Time pressure is a real factor: care staff managing large numbers of residents under significant workload constraints may not have the time to conduct thorough, validated pain assessments on a regular basis. Inconsistent documentation means that pain observations made by one staff member may not be communicated effectively to the next shift. And the sheer complexity of pain in older adults — often multi-site, often overlapping with psychiatric conditions, and often requiring careful navigation of polypharmacy risks — means that good pain management requires a level of clinical expertise that not all facilities have readily available.

How Pain Is Assessed in Australian Aged Care

Effective pain assessment in aged care is the foundation of everything that follows. Without a systematic, validated approach to identifying and measuring pain, management strategies cannot be appropriately targeted, their effectiveness cannot be evaluated, and improvements cannot be made. Here is how pain assessment works in Australian residential aged care — and what best practice looks like.

Self-Report: The First Line of Assessment

For residents who can communicate reliably, self-report remains the gold standard of pain assessment. Tools used for self-report pain assessment in aged care include:

• Numerical Rating Scale (NRS): The resident rates their pain on a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable. Simple, quick, and widely understood.
• Visual Analogue Scale (VAS): The resident marks their pain level on a horizontal line, offering a more nuanced measure that some people find easier than a numerical scale.
• Faces Pain Scale: Particularly useful for residents with mild to moderate cognitive impairment, this scale presents a series of facial expressions ranging from comfortable to distressed, and the resident points to the face that best reflects how they feel.
• Verbal Descriptor Scale: Offers descriptive options such as “no pain,” “mild pain,” “moderate pain,” “severe pain,” and “very severe pain” — again, particularly accessible for people who struggle with numerical or abstract scales.

These tools should be used at admission, at regular scheduled intervals (at minimum quarterly, and more frequently if pain is identified), after any change in clinical condition or medication, and whenever a resident or family member raises a concern about pain or comfort.

Observational Tools for Non-Communicative Residents

For residents who cannot reliably self-report — primarily those with moderate to severe dementia — validated observational assessment tools are essential. These tools train staff to observe and systematically record specific behavioural and physiological indicators of pain. The most widely used in Australian aged care settings include:

The Abbey Pain Scale

Developed in Australia and specifically validated for use with people with end-stage dementia who cannot self-report, the Abbey Pain Scale assesses six observable indicators: vocalisation (whimpering, groaning, crying), facial expression (grimacing, clenched teeth, looking distressed), changes in body language (fidgeting, rocking, pacing), behavioural change (confusion, refusing food, altered routines), physiological change (temperature, pulse, blood pressure), and physical changes (skin tears, pressure areas, arthritis). Each indicator is scored 0 to 3, giving a total score that indicates absent, mild, moderate, or severe pain.

PAINAD (Pain Assessment in Advanced Dementia)

The PAINAD scale assesses five observable items: breathing (independent of vocalisation), negative vocalisation, facial expression, body language, and consolability. It produces a score from 0 to 10 and is particularly useful for residents with severe dementia. It has been validated across multiple settings internationally and is recommended by the Royal Australian College of General Practitioners (RACGP) Silver Book guidelines on pain management in aged care.

PainChek® — AI-Assisted Pain Assessment

One of the most significant advances in pain management in aged care in recent years is the development and widespread adoption of PainChek® — a clinically validated, AI-driven medical device that uses facial recognition technology to detect and quantify micro-expressions associated with pain in people who cannot communicate verbally. PainChek® is now licensed in over 1,900 aged care facilities internationally, with more than 15.9 million cumulative pain assessments conducted to date.

PainChek® integrates directly into care management systems and can be operated from up to three metres away from the resident — reducing the intrusiveness of the assessment. It is particularly valuable in dementia care, providing an objective, technology-assisted assessment that complements (but does not replace) clinical observation and professional judgement. For facilities caring for residents with dementia, PainChek® represents the current standard of best practice in pain assessment technology in Australia.

 

When and How Often Should Pain Be Assessed?

Under Australia’s strengthened Aged Care Quality Standards (Standard 5: Clinical Care), which took full effect on 1 November 2025, providers are required to have systematic processes in place for identifying, assessing, managing, and reviewing pain. This is not a discretionary standard — it is a legal requirement. Pain assessment should occur:

• At the time of admission to the facility — as part of the comprehensive care assessment
• At regular scheduled intervals — at minimum quarterly for all residents
• Following any significant change in health status — a fall, a new diagnosis, a change in behaviour or mood
• Following any change in medication — particularly any changes to analgesic medications
• Whenever a resident, family member, or staff member raises a concern about pain or comfort
• During end-of-life care, where pain management becomes the primary clinical priority

Critically, pain assessment should not be a one-time event at admission and then forgotten. Regular, documented, reviewed pain assessment is the backbone of good pain management in aged care — and it is the area in which many facilities still fall short. Research has found that only 22% of pain episodes in Australian facilities with residents living with dementia contained an evidence-based pain assessment — meaning the majority of pain events were managed without a standardised, validated assessment having been conducted.

Pharmacological Pain Management in Aged Care

When pain has been properly identified and assessed, the question becomes: how do we manage it? Pharmacological pain management — the use of medications to control pain — is one of two broad categories of treatment, and it remains the most commonly used approach in residential aged care settings.

In Australian aged care facilities, analgesic use is very high: one cross-sectional Australian study found that analgesics were administered to 76% of residents in the previous 24 hours. Nearly one-third of residents in some settings are prescribed regular opioids. This is a significant figure — not necessarily inappropriate, given the prevalence of severe pain in this population, but one that requires careful, individualised clinical management.

The WHO Analgesic Ladder in Aged Care

Pharmacological pain management in aged care generally follows a stepped approach aligned with the World Health Organization’s analgesic ladder — starting with the least potent medications and escalating as needed based on the severity of pain and the resident’s response to treatment.

Step 1 — Mild pain: Simple analgesics such as paracetamol are the first line of treatment. Paracetamol is generally well tolerated in older adults and is recommended as the first-line analgesic for mild to moderate pain in the RACGP Silver Book guidelines. Despite its familiarity, paracetamol is frequently underdosed in aged care settings — meaning residents are not receiving its full benefit.

Step 2 — Moderate pain: Weak opioids (such as codeine or tramadol) or low-dose strong opioids may be introduced. Non-steroidal anti-inflammatory drugs (NSAIDs) can also be considered, though with significant caution in older adults given the elevated risks of gastrointestinal bleeding, cardiovascular events, and renal impairment.

Step 3 — Severe pain: Strong opioids such as morphine, oxycodone, fentanyl, or hydromorphone are used for severe, persistent pain that has not been adequately controlled by less potent medications. Opioid use in aged care requires careful dose titration, regular review, monitoring for side effects (including sedation, constipation, and respiratory depression), and ongoing reassessment of whether the benefits continue to outweigh the risks.

Adjuvant Medications

Beyond the analgesic ladder, a range of adjuvant medications — drugs not primarily designed as analgesics but which contribute to pain relief in specific circumstances — play an important role in aged care pain management. These include antidepressants (particularly for neuropathic pain), anticonvulsants (for conditions such as post-herpetic neuralgia or diabetic neuropathy), topical analgesics (which can deliver pain relief with minimal systemic absorption, reducing side effect risk), and muscle relaxants for spasm-related pain.

The choice of adjuvant medications in older adults requires expert clinical judgement and awareness of polypharmacy risks. Regular pharmacist medication reviews — now a standard component of quality aged care — play an important role in ensuring that analgesic regimens are appropriately tailored, that drug interactions are identified, and that medications are not continued beyond the period in which they are providing genuine benefit.

Medication Safety and Review in Aged Care

One of the most important safeguards in pharmacological pain management in aged care is regular medication review. Under Australian regulatory requirements, residents in residential aged care are entitled to a Residential Medication Management Review (RMMR) conducted by an accredited pharmacist, in collaboration with the resident’s GP. This review examines the entirety of the resident’s medication regimen — identifying potentially inappropriate medications, dangerous interactions, unnecessarily high doses, and opportunities to simplify the regimen without compromising symptom control.

For families, it is worth asking whether your loved one has had a recent RMMR, whether their pain medications are reviewed regularly by both the facility’s clinical team and their GP, and whether the goals of pharmacological pain management are clearly documented in their care plan.

Non-Pharmacological Pain Management in Aged Care

Medications are not the only — or even always the best — way to manage pain in residential aged care. Non-pharmacological pain management strategies are a critically important complement to medication, and in many cases can reduce or eliminate the need for pharmacological intervention entirely. They carry no risk of adverse drug effects, no risk of medication interactions, and they address pain through pathways that medications simply cannot reach.

The Australian Pain Society’s clinical guidelines and the RACGP Silver Book both strongly advocate for a multimodal, biopsychosocial approach to pain management in aged care — one that treats pain as a physical, psychological, and social experience rather than purely a biological symptom requiring a pharmaceutical solution.

Physical and Allied Health Approaches

Physiotherapy is one of the most valuable non-pharmacological tools in aged care pain management. Physiotherapists assess musculoskeletal and movement-related pain, design individualised exercise programmes to improve strength, flexibility, and balance (which in turn reduces fall risk and pain from joint and muscle deconditioning), and provide hands-on techniques including manual therapy and therapeutic massage.

Exercise — even gentle, structured movement — has robust evidence for pain reduction in older adults. It stimulates the release of endorphins, reduces inflammation, improves mood, maintains functional capacity, and reduces the secondary pain that comes from immobility and deconditioning. Ask whether the facility has a physiotherapist on staff or available on regular referral, and whether exercise programmes are adapted for residents with different mobility levels and pain conditions.

Occupational therapy contributes to pain management by identifying environmental modifications and adaptive equipment that reduce the strain of daily activities, and by helping residents maintain functional independence in ways that avoid or minimise painful movements.

Other physical approaches with evidence of effectiveness in aged care settings include heat and cold therapy (heat packs for muscle pain and stiffness; cold packs for acute inflammatory pain), TENS (Transcutaneous Electrical Nerve Stimulation), and hydrotherapy where facility access permits.

Psychological and Mind-Body Approaches

Pain is not purely a physical experience. The psychological dimension of pain — the anxiety, depression, and catastrophising that commonly accompany chronic pain — can significantly amplify the subjective experience of pain and make it far more difficult to manage. This is particularly true in aged care residents, where isolation, loss of independence, and grief over changed life circumstances create a psychological context in which pain is experienced more intensely.

Cognitive-behavioural approaches — helping residents reframe their experience of pain and develop coping strategies — have evidence of effectiveness in older adults, even those with mild cognitive impairment. Relaxation techniques, including guided breathing, progressive muscle relaxation, and mindfulness-based approaches adapted for older adults, can meaningfully reduce pain perception and improve overall wellbeing.

Music therapy has an emerging and growing evidence base in aged care pain management. Studies show that music therapy can reduce pain scores, reduce anxiety, and improve mood in older adults — including those with dementia. Several Australian residential aged care facilities now offer regular music therapy sessions as a core component of their clinical care programme, not just as a lifestyle activity.

Social and Environmental Approaches

Perhaps the most underappreciated dimension of non-pharmacological pain management in aged care is the social and environmental context in which a resident lives. Loneliness and social isolation reliably amplify pain perception. Meaningful social connection, engagement in activities that bring purpose and pleasure, access to natural light and outdoor space, and an environment that feels like a home rather than a clinical institution all contribute to a resident’s pain experience — and to their overall comfort.

This is not a soft consideration. It is a clinical one. Facilities that invest in rich lifestyle programmes, warm and attentive care cultures, and environments designed for genuine comfort are — whether they frame it this way or not — delivering meaningful pain management through the quality of daily life they provide.

Pain Management in Dementia Care: The Particular Challenge

The intersection of pain and dementia in aged care deserves its own focused discussion — because it represents the most clinically complex and the most frequently mismanaged dimension of pain in the Australian residential aged care system.

The challenge is twofold. First, people with dementia are unable to reliably communicate their pain, meaning that standard self-report tools are ineffective and observational tools — which require trained, attentive staff and validated instruments like the Abbey Pain Scale or PainChek® — become essential. Second, the behavioural symptoms of unmanaged pain in dementia are routinely misidentified as symptoms of the dementia itself, leading to the wrong clinical response.

The Dementia Support Australia five-step approach — Identify, Assess, Manage, Reassess, and Monitor — provides a structured, evidence-informed framework for managing pain in people living with dementia in aged care. This approach begins with the recognition that any behaviour change in a person with dementia should prompt the question: could this be pain? It moves through formal assessment using a validated tool, to a management response that may be pharmacological, non-pharmacological, or both, to reassessment of the response, to ongoing monitoring.

For families whose loved one is living with dementia in residential aged care, the key questions to ask about pain management are:

 

Pain Management at End of Life in Aged Care

End-of-life care represents the most acute dimension of pain management in aged care. As a resident approaches the final stages of life, effective pain and symptom management becomes the primary clinical goal — and the measure by which the quality of a person’s dying is most directly assessed.

Australian clinical guidelines, including the RACGP Silver Book and the Australian Pain Society’s Pain Management Guidelines for Residential Aged Care, dedicate specific attention to end-of-life pain management. Key principles include the shift from curative to comfort-focused care, the use of continuous subcutaneous infusion (CSCI) for medications when oral administration is no longer possible, the importance of anticipatory prescribing so that medications are available promptly when needed, and the critical role of the GP and palliative care team in guiding clinical decision-making at this stage.

For families, the most important conversation to have well before the end-of-life stage is about the resident’s advance care plan. An advance care plan documents the person’s preferences and values for their end-of-life care — including their wishes around pain management and comfort. Having this documentation in place ensures that care decisions at the most vulnerable stage of life are guided by the resident’s own values, not made under pressure in the absence of prior conversation.

Pain Management and the New Aged Care Quality Standards 2025

Under the strengthened Aged Care Quality Standards, which took full effect on 1 November 2025, pain management in aged care is explicitly addressed within Standard 5 — Clinical Care. The standard requires providers to have processes in place that are:

• Safe, coordinated, and appropriate to each resident’s individual needs and preferences
• Based on evidence-based assessment using validated tools
• Regularly reviewed and updated in response to changes in the resident’s condition
• Transparent and involving the resident and their family or substitute decision-maker in care decisions
• Subject to escalation processes when pain is not adequately controlled or when a resident’s condition changes

The Aged Care Quality and Safety Commission is responsible for assessing provider compliance with these standards. If you have concerns about the quality of pain management at your loved one’s facility, you have the right to raise them — with the facility directly, with the Commission on 1800 951 822, or through an independent aged care advocate via the National Aged Care Advocacy Program (NACAP) on 1800 700 600.

What Families Can Do: A Practical Guide

Families and carers play a vital role in pain management in aged care — not just as emotional support, but as clinical partners who observe their loved one outside of scheduled assessment times and can provide crucial information that care staff may not have access to. Here is what you can do to advocate effectively for your loved one’s comfort.

• Know the baseline: Understand what your loved one’s pain history is — existing conditions, known pain triggers, what has worked for them in the past, and what they find distressing. Share this information with the care team at admission and update it regularly.
• Observe and report changes: You know your loved one better than any care staff member. If you notice they seem more withdrawn, more agitated, less engaged with food or activities, or more resistant to personal care than usual — report it. These changes can be signs of unmanaged pain, even if your loved one is not saying so.
• Ask about the care plan: Every resident should have a care plan that explicitly addresses pain management. Ask to see it. Ask when it was last reviewed. Ask what assessment tools are being used and how frequently pain is formally assessed.
• Ask about medication reviews: Ask whether your loved one has had a recent Residential Medication Management Review, and whether their GP is actively involved in reviewing pain management strategies.
• Advocate for non-pharmacological approaches: Ask whether physiotherapy, music therapy, massage, or other non-pharmacological approaches are part of your loved one’s pain management plan — not just as activities, but as clinically intentional comfort interventions.
• Raise concerns promptly: If you believe your loved one’s pain is not being adequately managed, raise it with the nursing team and facility manager promptly. Under the new Aged Care Act, you have explicit rights as a family member or registered supporter to be involved in care decisions and to raise concerns without fear of retribution.

Frequently Asked Questions: Pain Management in Aged Care Australia

How do I know if my loved one in aged care is in pain?

Signs that a person in aged care — including someone with dementia who cannot verbalise their pain — may be experiencing unmanaged pain include: increased agitation or restlessness; changes in facial expression (grimacing, frowning); resisting personal care or moving; changes in appetite or sleep; withdrawal from social activities; calling out, groaning, or crying; changes in posture or guarding of a body part; and general behavioural changes without an obvious explanation. If you notice any of these, raise it with the care team immediately.

Can aged care residents refuse pain medication?

Yes. Under Australian law and the new Aged Care Act 2024, every resident with decision-making capacity has the right to refuse any treatment, including pain medication. Their decision must be respected. If a resident lacks decision-making capacity, their substitute decision-maker — as documented in their advance care plan — has the authority to make decisions on their behalf, guided by the person’s known values and preferences.

What is the Abbey Pain Scale used for in aged care?

The Abbey Pain Scale is a validated, Australian-developed observational pain assessment tool used for residents living with end-stage dementia who cannot reliably communicate their pain verbally. It assesses six observable indicators — vocalisation, facial expression, body language, behavioural change, physiological change, and physical changes — to produce a score indicating the severity of pain. It is one of the most widely used pain assessment tools in Australian residential aged care settings.

How often should pain be reviewed in residential aged care?

Under the strengthened Aged Care Quality Standards (Standard 5), pain should be formally assessed at admission, at least quarterly, after any significant change in health status, after any medication change, and whenever a concern is raised by a resident, family member, or staff member. In practice, pain assessment should be an ongoing, embedded part of daily care — not a periodic administrative exercise.

Conclusion: Comfort Is Not Optional — It Is the Standard

Pain is the most common clinical experience in Australian residential aged care. It is also one of the most profoundly addressable. The tools exist. The guidelines exist. The clinical frameworks exist. The technology — including AI-assisted assessment tools that give a voice to those who cannot speak for themselves — now exists at scale across the sector. What determines whether your loved one’s pain is identified, taken seriously, and managed effectively is the quality of the provider caring for them, the systems they have in place, the training and attentiveness of their clinical workforce, and the degree to which they genuinely treat comfort as a clinical priority, not a nice-to-have.

Pain management in aged care is not just about prescribing the right medication. It is about a culture of care that starts with the question: how is this person feeling right now? It is about staff who are trained to notice the subtle signs of pain in a person who cannot say “I hurt.” It is about care plans that are genuinely individualised, regularly reviewed, and actually followed. It is about physiotherapy, music, massage, warmth, human connection — all of the things that make a place feel less like a facility and more like a home. It is about families being welcomed as partners in care, not managed at a distance.

Under the new Aged Care Act 2024 and the strengthened Quality Standards, every older Australian has an enforceable right to safe, quality clinical care that includes effective pain management. Providers are now held to a higher and more specific standard than at any previous point in the sector’s history. But legislation only goes so far — the real work happens at the bedside, in the dining room, in the activity session, and in the quiet moments between a carer and a resident who trusts them to notice when something is wrong.

If you are thinking about aged care for yourself or a loved one in Queensland, Superior Care Group is one of Queensland’s leading aged care providers, with renowned residences in Redland City and on the Gold Coast.

Superior Care Group is family owned and operated — a distinction that matters deeply in the context of aged care. Family ownership means that the values driving every care decision are not commercial metrics on a corporate dashboard, but a genuine, personal commitment to the wellbeing of every resident. Superior Care Group has been living this commitment since 1979, when they opened Wellington Park Private Care — their founding residence. In 2011, they extended that commitment to the Gold Coast with the opening of Merrimac Park Private Care, bringing the same founding philosophy of warmth, attentiveness, and genuine personalised care to a new community.

At Superior Care Group, pain management in aged care is not an afterthought — it is woven into the fabric of how care is planned and delivered for every resident. Their compassionate clinical team develops personalised, tailored care plans for each resident that explicitly address comfort, clinical needs, individual preferences, and the full complexity of what it means to live well in aged care. Their management team, equipped with decades of aged care experience, provides the clinical leadership and governance oversight that ensures these plans are not just documented but actively lived.

Superior Care Group offers a wide variety of aged care services designed to help residents live comfortably, independently, and with dignity — whether that means expert clinical management of a complex pain condition, physiotherapy-led rehabilitation, allied health input, or simply the consistent attentiveness of a care team that notices when something has changed and acts on it. For families, this means the confidence of knowing that your loved one’s comfort is in the hands of people who genuinely care — and who have the experience, the training, and the systems to make that care count.