Q: My 88-year old mother often complains of various aches and pains. What is the safest over-the-counter painkiller for her to take? Aren’t some of them bad for your liver and kidneys?
A: Frequent aches and pains are a common problem for older adults.
If your mother has been complaining, you’ll want to make sure she gets a careful evaluation from her doctor. After all, frequent pain can be a sign of an important underlying health problem that needs attention. You’re also more likely to help your mom reduce her pain if you can help her doctors identify the underlying causes of her pain.
That said, it’s a good idea to ask what over-the-counter (OTC) pain relievers are safest for older people.
That’s because improper use of OTC painkiller tablets is actually a major cause of harm to older adults.
So let me tell you what OTC pain relievers geriatricians usually consider the safest, and which very common group of painkillers can cause serious side-effects in aging adults.
What’s the safest OTC painkiller for an aging parent?
For most older adults, the safest oral OTC painkiller for daily or frequent use is acetaminophen (brand name Tylenol), provided you are careful to not exceed a total dose of 3,000mg per day.
Acetaminophen is usually called paracetamol outside the U.S.
It is processed by the liver and in high doses can cause serious — sometimes even life-threatening — liver injury. So if an older person has a history of alcohol abuse or chronic liver disease, then an even lower daily limit will be needed, and I would strongly advise you to talk to a doctor about what daily limit might be suitable.
The tricky thing with acetaminophen is that it’s actually included in lots of different over-the-counter medications (e.g. Nyquil, Theraflu) and prescription medications (e.g. Percocet). So people can easily end up taking more daily acetaminophen than they realize. This can indeed be dangerous; research suggests that 40% of acetaminophen overdose cases are accidental.
But when taken at recommended doses, acetaminophen has surprisingly few serious side effects and rarely harms older adults. Unlike non-steroidal anti-inflammatory drugs (NSAIDs, see below), it does not put older adults at risk of internal bleeding, and it seems to have minimal impacts on kidney function and cardiovascular risk.
Be careful or avoid this common class of painkillers
At the drugstore, the most common alternatives to acetaminophen are painkiller tablets such as ibuprofen (brand names Advil and Motrin) and naproxen (brand names Aleve, Naprosyn, and Anaprox).
Both of these are part of a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Many people are familiar with these medications. But in fact, older adults should be very careful before using NSAIDs often or regularly.
Unlike acetaminophen, which usually doesn’t become much riskier as people get older, NSAIDs cause side effects that are especially likely to become dangerous as people get older. These include:
- Increased risk of bleeding in the stomach, small bowel, or colon. Seniors who take a daily aspirin or a blood thinner are at especially high risk.
- Problems with the stomach lining, which can cause stomach pain or even peptic ulcer disease.
- Decreased kidney function. This can be especially problematic for those many older adults who have already experienced a chronic decline in kidney function.
- Interference with high blood pressure medications.
- Fluid retention and increased risk of heart failure.
Experts have estimated that NSAIDs cause 41,00 hospitalizations and 3,300 deaths among older adults every year.
Recent research has also suggested that NSAIDs cause a small but real increase in the risk of cardiovascular events (e.g. heart attacks and strokes).
Because of these well-known serious side effects of NSAIDs in older adults, in 2009 the American Geriatrics Society recommended that older adults avoid using NSAIDS for the treatment of chronic persistent pain. Today, oral NSAIDs remain on the Beer’s List of medications that older adults should avoid or use with caution. (For more on the Beer’s list, see this article: Medications Older Adults Should Avoid or Use with Caution: The American Geriatrics Society Beers Criteria 2019 Update.)
Now, it’s important to know NSAIDs can also be prescribed as creams or gels. These topical forms are much safer, and can be effective for pain relief.
Despite this fact, NSAID painkiller tablets are often bought by seniors at the drugstore. Perhaps even worse, NSAIDs are often prescribed to older adults by physicians, because the anti-inflammatory effect can provide relief from arthritis pain, gout, and other common health ailments.
(Commonly prescribed NSAIDs include indomethacin, diclofenac, sulindac, meloxicam, and celecoxib. These tend to be stronger than the NSAIDs available without a prescription. However, stronger NSAIDs are associated with higher risks of serious side effects, unless they are used as a cream or gel, in which case the risks are much less.)
Now let me share a true story. Many years ago, a man in his 70s transferred to my patient panel. He had been taking a daily NSAID for several months, prescribed by the previous doctor, to treat his chronic shoulder arthritis.
I cautioned him about continuing this medication, explaining that it could cause serious internal bleeding. He seemed dubious, and said his previous doctor had never mentioned bleeding. He wanted to continue it. I decided to let it slide for the time being.
A few weeks later, he was hospitalized for internal bleeding from his stomach. Naturally, I felt terrible about it.
This is not to say that older adults should never use NSAIDs. They are often more effective pain relievers than acetaminophen, especially for conditions such as arthritis. So even in geriatrics, we sometimes conclude that the likely benefits seem to outweigh the likely risks.
But this conclusion really should be reached in partnership with the patient and family; only they can tell us how much that pain relief means to them, and how concerned they are about the risk of bleeding and other dangerous side effects. (It’s also possible to reduce the risk of bleeding by having a patient take a medication to reduce stomach acid.)
Unfortunately, far too many older adults are never informed of the risks associated with NSAIDs. And in the drugstore, they sometimes choose ibuprofen over acetaminophen, because they’ve heard that Tylenol can cause liver failure.
Yes, acetaminophen has risks as well. But every year, NSAIDs cause far more hospitalizations among older adults than acetaminophen does.
Aspirin: a special NSAID we no longer use for pain
Aspirin is another analgesic available over-the-counter.
It’s technically also an NSAID, but its chemical structure is a bit different from the other NSAIDs. This is what allows it to be effective in reducing strokes and heart attacks. It is also less likely to affect the kidneys than other NSAIDs are.
(For more on the risks and benefits of aspirin, see this MayoClinic.com article.)
Aspirin is no longer used as an analgesic by the medical community. But many older adults still reach for aspirin to treat their aches and pains, because they are used to thinking of it as a painkiller. Aspirin is also included in certain over-the-counter medications, such as Excedrin.
Taking a very occasional aspirin for a headache or other pain is not terribly risky for most aging adults. But using aspirin more often increases the risk of internal bleeding. So, I discourage my older patients from using aspirin for pain.
Tips on safer use of OTC painkillers
In short, the safest oral OTC painkiller for older adults is usually acetaminophen, provided you don’t exceed 3,000 mg per day.
If you have any concerns about liver function or alcohol use, plan to use the medication daily on an ongoing basis, or otherwise want to err on the safer side, try to not exceed 2,000 mg per day, and seek medical input as soon as possible.
You should also be sure to bring up any chronic pain with your parent’s doctor. It’s important to get help identifying the underlying causes of the pain. The doctor can then help you develop a plan to manage the pain.
And don’t forget to ask about non-drug treatments for pain; they are often safer for older adults, but busy doctors may not bring them up unless you ask. For example, chronic pain self-management programs can be very helpful to some people. Physical therapy, massage, and certain forms of exercise can play an important role in pain relief, especially when it comes to chronic pain.
Now if your older parent is taking acetaminophen often or every day, you’ll want to be sure you’ve accounted for all acetaminophen she might be taking. Remember, acetaminophen is often included in medications for cough and cold, and in prescription painkillers. So you need to look at the ingredients list for all medications of this type. Experts believe that half of acetaminophen overdoses are unintentional, and result from people either making mistakes with their doses or not realizing they are taking other medications containing acetaminophen.
Last but not least: be sure to avoid the “PM” version of any OTC painkiller. The “PM” part means a mild sedative has been included, and such drugs — usually diphenhydramine, which is the main ingredient in Benadryl — are anticholinergic and known to be bad for brain health. (See 7 Common Brain-Toxic Drugs Older Adults Should Use With Caution for more about the risks of anticholinergic drugs.)
My own approach, when I do house calls, is to check the older person’s medicine cabinet. If I find any NSAIDs or over-the-counter anticholinergic medications (e.g. antihistamines, sleep aids, etc), I discuss them with my older patient and usually remove them from the house unless there’s a good reason to leave them.
If acetaminophen isn’t providing enough pain relief
If acetaminophen doesn’t provide enough relief for your mom’s pains, then it may be reasonable to consider over-the-counter (or sometimes prescription) NSAIDs, preferably for a limited period of time. But be sure to discuss the risks and alternatives with the doctor first, and be sure to discuss possible non-drug approaches to lessen pain.
You may also want to ask about topical painkillers, such as gels, creams, and patches. These are generally safer than oral medications, because less of the body is exposed to side effects.
For severe pain, it may also be reasonable to discuss other prescription drug options. Depending on the type of pain, in some cases it can be reasonable to consider using very small doses of opioids, or other types of painkillers. That said, bear in mind that all prescription pain relievers come with risks and can cause serious side effects. In older adults, most will affect brain function and balance.
The truth is that it’s often not possible to treat pain effectively and 100% safely, when it comes to using oral painkiller tablets. But by being informed and proactive, your family can help your mom get better care for her pain, while minimizing the risk of harm from pain relievers.
Good luck!
This article was reviewed & updated in March 2023.
[As we are approaching 200 comments, comments have been closed.]
Mira says
Hi, my mother is 71years old she was complaining from menescus tear , osteoarthritis,inflamed knee joint, her doctor advised her to take anti Cox group of anti inflammatory or diclofinat ..what’s your opinion
Leslie Kernisan, MD MPH says
As explained in the article, the anti-inflammatories you describe are known to be risky in older adults, especially if taken daily for chronic arthritis. So, it’s generally advisable to try other ways to manage the arthritis pain before resorting to oral NSAIDs. Topical NSAIDs can provide some pain relief with less risk of kidney dysfunction, bleeding and other systemic side-effects.
For older adults considering oral NSAIDs, it’s important to discuss the risks with prescribing doctor and to check that safer alternatives have been tried. After that, some older adults or families decide the risks of NSAIDs are acceptable to them.
What is most important is to be well-informed and also to try other approaches before resorting to a risky medication.
Sherri says
My mother was given Tramadol and told she could take that or Tylenol, so I try to give her the Tylenol instead – but was wondering if Tramadol affects the mind more? Seems like her confusion and drowsiness get worse with Tramadol. Tried Gabapentin also, and it almost knocks her out. Do pain medicines make people with dementia worse?
Leslie Kernisan, MD MPH says
Tramadol does tend to have more “psychoactive” side-effects, so I almost never use it. Gabapentin is often well tolerated but not by everyone, sounds like it’s very sedating in your mother. (It’s also probably mainly effective for nerve pain and not so much for other types of pain.)
One problem with Tylenol is that it’s really not a very strong painkiller. It can help a little bit in some cases, but rarely is effective for moderate or worse pain. And it’s not anti-inflammatory, so tends to provide less relief than NSAIDs do. So it’s safer but usually less effective from a pain management perspective.
In terms of other pain medications making a person with dementia worse, it depends on the medication and on the person. It is sometimes necessary to do a little trial and error, and it’s always a good idea to start with a very small dose. good luck!
George Mann says
I have intense burning and itchiness on my skin, especially the lower back. I use creams (1 percent hydro cortisone and clotrimazole) for relief but also use Benadryl upon retiring. It helps the itchiness thru the night I take one half tablet during the discomfort time and consume approximately a 60 tablet bottle over a two year period. What are the side effects I should be aware of.
I am 80 years young.
Leslie Kernisan, MD MPH says
The problem with diphenhydramine (brand name Benadryl) is that it is quite anticholinergic. Anticholinergic drugs interfere with acetylecholine, a neurotransmitter that is important for proper brain function. Chronic use of anticholinergic medications is associated with a higher risk of developing dementia, and seem related to the cumulative dose. I have more information in this article
4 Types of Medication to Avoid if You’re Worried About Memory
Probably it’s a little safer and better if you can find a way to manage your itching without Benadryl. Would more moisturizers or other creams help? I would recommend talking to a dermatologist and asking for help. Be sure to specify that you’d like to minimize your use of oral anticholinergics. good luck!
Janice says
Thanks so much for sharing this article. —Very helpful.
Leslie Kernisan, MD MPH says
Glad you found it useful.
Rod says
Thanks for clarification. At age 79 last year I made an emergency room visit–my first hospital visit ever. I drove myself there due to a protrusion in my abdominal area begun due to heavy coughing from a bronchitis 10 day problem. At my arrival, I was asked to sit in a wheelchair-the next thing I heard was
60 over 40 and I awoke in intensive care from a major hematoma which I had never heard of. It was contained inside a large muscle and I was released 2 days later to rebuild my blood lost inside the hematoma. It was several months before it was absorbed by my body. I had been taking daily Advil for muscle-joint discomfort from a back problem I did not know was serious. I still was not told by any of my several routine doctors about NSAID until I asked last week and was told to use tylenol rather than advil.
Leslie Kernisan, MD MPH says
Thanks for sharing that story. Yes, that illustrates why NSAIDs are considered risky in older adults! Glad you were able to get emergency care in time.
Daniel says
My grandmother who is of 88 years has been taking diclofenac 50 mg once daily for more than 15 years without side effects. What do I do?
Leslie Kernisan, MD MPH says
I would recommend discussing this with her prescribing doctor. As people get older, it becomes more common for them to have some mild kidney dysfunction. They are also sometimes at higher risk of bleeding. Your grandmother’s doctor can help your grandmother and your family determine whether the benefit of this medication outweighs the risks, given her particular health situation. If she is at low risk for bleeding and her kidneys are working well, then it may be reasonable to continue, especially if stopping the medication would cause any chronic pain to get worse. Good luck!
Nancy M says
I have been taking Gabapentine for beurological pain in my lumbar spine while recoveting from a TKR. I was on opioids along with the Gabapentine, but they were hard on my digestive tract and I stopped taking them as soon as I could. Is Gabapentjne safe for seniors?
Leslie Kernisan, MD MPH says
Gabapentin is technically an anti-seizure medication, it works by reducing the excitability of neurons in the brain. It can also help treat pain related to nerves, and is FDA-approved for the treatment of post-herpetic neuralgia (nerve pain after shingles). Its effectiveness in treating other types of pain has been questioned, see here and here.
In terms of its safety, it’s generally been considered “well-tolerated”, especially compared to some of the other alternatives. It does often dampen brain function a bit (as to be expected, since it’s an anti-seizure medication).
When considering whether to continue a medication, you’ll want to think about whether the benefits justify the risks. Gabapentin is not particularly risky, but you may want to be sure that it’s providing good pain relief before deciding whether or not to continue. There are effective non-drug ways to manage chronic pain, but they can take some time to implement. Good luck!
Ann Swasko says
Thank you for your caring information.
Leslie Kernisan, MD MPH says
you’re welcome, glad to help
Irina says
Dear Leslie, somehow at 35 I got “lucky” and was diagnosed with arthritis, I’ve been managing pain, by trying to ignore it, for over 10 years now, first it started in my knee and now it spread to almost all of my joints. I try to stay away from pain medications, unless it’s extremely necessary, but right now I’m at the end of my rope, the pain is effecting my everyday life and I don’t want to feel like invalid.
When I read your article, I was ecstatic about trying acetaminophen, as it seems to be the lesser evil, although toxic epidermal necrosis does worry me, but it seems to be extreme rare side effect.
But in my follow-up readings, managed to find an article from Cochrane Library published in June 2016, article called its effectiveness into question. Now I am at loss. So is it worth trying?
Leslie Kernisan, MD MPH says
Sorry to hear of your arthritis. Obviously, I don’t have particular experience treating people your age, but it sounds unusual to have so much arthritis pain at your age, and your arthritis may be different from the more “garden variety” late life aches and pains that I mention in this article.
In general, acetaminophen is considered a weak analgesic. I would not expect it to make much of a dent in significant arthritis that is otherwise affecting everyday life. NSAIDs are usually found to be more effective in reducing pain, both in research and in people’s experience. But, at usual doses, they have more risks, especially as people get older.
You may want to look into a more “holistic” approach to managing pain and arthritis in people your age, such as that done through functional medicine. It’s not always easy to find evidence supporting every aspect of their approach, but many people seem to find it helpful. Just google functional medicine arthritis. Good luck!
Laura says
Is a200 mg tab of Motrin taken 2 x a day, 12 hours apart ok for a 74 yr old female. I take this amount 3 days a week. It’s the only med that gives me any relief at all from osteoarthritis.
Leslie Kernisan, MD MPH says
Well, a lower dose is generally considered safer in that it’s less likely to cause side-effects or adverse events. Your dose is certainly lower than many.
I can’t say whether it’s “ok.” How risky it is really depends on your other health factors, such as your other medications, your kidney function and whether you are at higher risk for bleeding in your stomach or bowel.
I would recommend discussing your concerns with your usual health providers. You may also want to ask about other options for managing your arthritis pain…sometimes non-drug approaches can be quite effective. Good luck!