The trials
Stepwise pain treatment for agitation
Promising, not yet provenSystematic pain treatment reduced agitation in nursing home residents with moderate to severe dementia, in one well-designed trial.
The evidence
In a cluster randomised trial across 60 Norwegian nursing home units, 352 residents with moderate to severe dementia and significant behavioural disturbance received either eight weeks of individual daily pain treatment under a stepwise protocol, using paracetamol, morphine, a buprenorphine patch or pregabalin, or usual care. Agitation was reduced by an average of 17%, significantly more than with usual care. Neuropsychiatric symptoms and pain also improved, while daily activities and cognition did not change 43.
In practice
The authors suggested that effective pain management could reduce unnecessary prescribing of psychotropic medicines 43.
Algorithm-based pain management programs
Uncertain / conflictingCompared with usual care, a program may lower staff-rated pain. Compared with staff education alone, it made little or no difference.
The evidence
A 2022 Cochrane review found three cluster randomised trials with 808 nursing home residents with dementia, average ages 82 to 89. Against usual care, one study of 128 residents found lower proxy-rated pain on PAINAD (mean difference −1.49 on a 10-point scale, 95% CI −2.11 to −0.87; low certainty). Against staff pain education alone, there was little or no difference in self-rated or proxy-rated pain. No study assessed adverse effects 44.
Analgesics for depression in advanced dementia
Not supportedParacetamol or a buprenorphine patch did not improve depression, and buprenorphine was poorly tolerated.
The evidence
In 162 residents of 47 Norwegian nursing homes with advanced dementia and depression, 13 weeks of active analgesic treatment did not improve depression compared with placebo. In a subgroup analysis, paracetamol reduced pain from week 6 to week 13, without a change in depression. Of those given buprenorphine, 52.3% were withdrawn because of adverse reactions, deterioration or death 28.
What this means in practice
Together, the trials support looking for pain whenever behaviour changes, and treating it when it is found. They do not support giving pain medicines as a general treatment for agitation or low mood without a reason to think pain is the cause 2843.
For a resident who cannot ask for pain relief, it is worth checking whether a medicine charted as needed is ever given, and on what basis.
Related pages on this site
- Changed behaviours Dementia care section: the causes of changed behaviour and the approaches that work.
- Antipsychotics, benzodiazepines and chemical restraint Medicines section: sedating medicines for behaviour, and the rules on chemical restraint.
- Delirium: recognising it and finding the cause Deteriorating resident section: pain as one cause of delirium.
- Advanced dementia and end-of-life care Dementia care section: comfort care and pain in advanced dementia.
Sources cited on this page
- 28 Erdal A, Flo E, Aarsland D, Ballard C, Slettebo DD, Husebo BS. Efficacy and safety of analgesic treatment for depression in people with advanced dementia: randomised, multicentre, double-blind, placebo-controlled trial (DEP.PAIN.DEM). Drugs Aging. 2018;35(6):545–58. (47 Norwegian nursing homes.) View source
- 43 Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065. View source
- 44 Manietta C, Labonté V, Thiesemann R, et al. Algorithm-based pain management for people with dementia in nursing homes. Cochrane Database Syst Rev. 2022;4:CD013339. View source
Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at November 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. It gives no doses, and it does not recommend any procedure, clinic or practitioner. Evidence and Australian regulatory and PBS arrangements change — always confirm current advice with the treating GP, pharmacist or specialist.
This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.