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.]
Douglas Walters says
. I have RLS and i struggle with it. I take Pramipexole usually 2 each evening space about 2 hrs apart. I have tried Requip and Gabapaten but with no success. It t sometimes requires 3 Pramipexole to quiet my RLS. Would you have any other recommendations? Thanks for your time and help
Leslie Kernisan, MD MPH says
Pramipexole is not an over-the-counter medication; as I imagine you know, it’s a prescription medication sometimes used to treat restless leg syndrome (RLS), and also certain other conditions.
If you are looking for help treating RLS, I would recommend talking to your usual provider, or getting a second opinion from a specialist. You can also try searching Pubmed for “restless leg syndrome treatment”, if you want to do some research before seeing your usual health providers. There are free full text articles available, you can probably find a good review article summarizing treatment options.
Last but not least, another option to research treatment options is to find a patient community online. Good luck!
Stacey duBell Mileti says
Thank you for this very helpful article. I’ve just learned that my 90 year old mother in law has been taking 1300 mgs of aspirin a day. After reading your post, it seems that she should discontinue the aspirin and switch to Acetaminophen, however, despite many hours of research I can’t find any recommended tapering schedule – especially for such a high dose – and am of course worried about the reported increases in CV events following aspirin discontinuation. Her physician was unable to help. We will be grateful for any suggestions you may have.
Leslie Kernisan, MD MPH says
Hm. Well, I have not heard of any tapering schedules for such an aspirin dose, especially in someone her age. I think you are in medically uncharted waters.
That said, I am a little surprised that her physician was unable to help and am wondering what he or she recommended. Continuing such a dose sounds a bit risky, so even if we have no guidelines or specific medical literature to help us know the “best” way to bring it down, I would think something still needs to be attempted, and it is for the involved physician to do his or her best to propose something.
You may want to start by asking the physician for help getting her down to a “usual” dose of 81mg per day, and then you could discuss whether or not to try stopping it. You could also try asking a pharmacist for advice. Good luck!
DOLORES LILLIAN MARTILINI says
Yes, there is a tapering off schedule for aspirin. I read it on the internet.
The article cited the dangers of going off aspirin “cold turkey”. It can cause
a heart attack to do so. Try finding this info. I cannot remember what I used
in “search” but I do not think it will be hard to find. You will have to keep
a schedule and it may take a while to get off the aspirin but well worth it.
I must mention: on none of these posts does anyone speak about using heat and cold for some pains.
Leslie Kernisan, MD MPH says
I agree that it’s worth considering whether heat or cold might alleviate aches and pains. How likely they are to help may depend on the underlying cause of the pain, so I would recommend checking with one’s health provider for guidance.
Regarding aspirin: in general medical practice, we have not usually tapered the dose of baby aspirin when people stop. Now, an observational study published in 2017 did conclude that stopping aspirin was associated with a 30% increase in the relative risk (not the absolute risk) of having a cardiovascular event; the authors said this corresponded to “an additional cardiovascular event observed per year in 1 of every 74 patients who discontinue aspirin.” So there is an increased risk but in absolute terms, it’s not very big.
Low-Dose Aspirin Discontinuation and Risk of Cardiovascular Events.
To date, I cannot find any articles published in Pubmed on the tapering of aspirin that is prescribed for cardiovascular prevention; I doubt it has been studied yet. I have not yet had a chance to ask my academic cardiology colleagues if they are changing their practices in regards to stopping preventive aspirins.
Laronda says
My father is an active 83, and has increased daily back, neck, pain due to nerves. Has rod in his back. He is an artist, I sure years of poor posture has helped contribute. Doctor has told him tramadol will do nothing and at his age has to live with the pain. He is on Elaquis and we definitely don’t want to take anything that will make him fall. He is walking for exercise and taking physical therapy with use of electrodes also. He is not overweight takes and another BP pill. Gabapentin 300 mg, 2x day.
His ability to sleep at night is getting worse and seems this is when the pain occurs most. What can be done for nerve pain?
I hate to see him have to be reduced to having to just live and bear it. The ability to not be as active seems to be bringing on some depression.
Leslie Kernisan, MD MPH says
Sorry to hear of his pain problem. Unfortunately, neuropathic pain can be hard to pharmacologically treat in general, and is especially challenging in older adults because the medications for neuropathic pain tend to have particular risks and side-effects that are more pronounced in older adults. In other words, the medications often used for neuropathic pain tend to affect either brain function or balance or both.
The options for treating neuropathic pain in older adults are reviewed here: An Algorithm for Neuropathic Pain Management in Older People
I would also recommend looking into a program for self-management of chronic pain, such as this one, which has been studied and shown to be helpful: Chronic Pain Self-Management Program
mike smith says
You look so busy I hate to ask, but I’m a 77 year old guy with leg rendon, knee, and some back pain. Ex jock. Osteoarthritis in knees. I take 100 sometimes 200 mgs of ibuprofen sometimes daily, sometimes every other day or I can’t walk very well. I am on no other medications, my blood work is perfect. Am I in any serious danger taking that dose?
Leslie Kernisan, MD MPH says
It doesn’t sound like a very high dose, which is good. How risky it is depends on the state of your kidneys, whether you’re at risk for ulcers or gastrointestinal bleeding, and some other factors relevant to your health history. I would recommend asking your usual health provider to discuss how risky this is likely to be for you. It would also be a good idea to explore other ways to manage your knee pain, either via topical medication or via non-drug methods. Good luck!
Lydia says
My father is almost 101 years old with sound mind. He is on Coumadin and other medications. He has very painful arthritis in his toes. What do you think about creams that contain Cannabinoids (such as Receptra Targeted Topical to name a few) ?
Thank you.
Leslie Kernisan, MD MPH says
I don’t have any personal experience treating pain with cannabinoids, much less in someone his age. In general, creams tend to be safer than oral medications. Many families (and some health providers) are trying out cannabis-based products. It is too soon for us to have well-done clinical trials to guide us, however.
I would recommend talking to his doctor about the pros and cons of trying this for the pain. It may be reasonable to try, especially if you can help monitor for side-effects (and also for effectiveness, to make sure he’s actually benefiting). Good luck!
David Bennett says
I am 77 years old and have never had success from taking tylenol. Ibuprofen, Alieve and even the extra strength tylenol will not touch a headache for me. Since I was in my 30’s I get daily headaches mostly in my sinuses. I have always taken excedrin in the past which works great. Although it has been discontinued, excedrin had a product called “excedrin mild headache” relief. They had 325 mg tylenol and 65 mg caffein in each tablet. It worked great with less medication. I was very disappointed when it was discontinued until I did some experimenting. I now take one half of a 200 mg caffein tablet (100 mg) with two 325 mg regular strength tylenol and it works great and with lower dose medication. Somehow the caffein increases the effect of the tylenol. Works for me!
Shania says
Hi Leslie,
Great Article and replies to comments! My mother is 82 with early dementia…some days better than others. She takes daily aspirin (81mg) for arteriosclerosis (carotid and renal) and delayed release acetaminophen (650mg tables x2) for arthritis pain. Her liver function is fine and even though she has some kidney issues, her kidney function is still good.
Recently she fell on the ice and hurt her wrist so she took something stronger that my father had (I think it was Lenoltec). It helped her pain but I’m worried about her cognition, as it has been worsened by sedating substances. In fact, they gave her hydromorphone via IV last year in hospital and her cognition was not good while on it.
What is the best medication she can take for the acute pain? I’m considering additional Aspirin for it’s anti-inflammatory properties but worried about bleeding risk given she’s already taken daily low dose. I also thought about giving her 1000 mg dose of Acetaminophen when her pain is bad either in combination with the delayed release or stopping the delayed release? Of course staying within the 4 g daily limit. I also have other opioids on hand besides the lenoltec- 1mg Dilaudid and Tramadol but worried about giving them re: cognition. I’m leaning towards starting with the 1000mg acetaminophen. In the meantime, I rubbed on some over the counter topical voltaren and of course Icing, elevation, immobilization. It didn’t swell up as one would expect with a broken wrist and it’s not deformed so likely a bad sprain or maybe a small fracture.
Again, this is just for very acute moderate pain until we can get the wrist looked at. FYI: her GP and other doctors she has seen in the past are not well versed on pain management for this class of patient so I have to be proactive. Thank you.
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s fall and wrist pain, I hope it’s gotten better by now.
A topical choice is often a good idea, because those have less systemic side-effects.
As medical professionals, we no longer use aspirin for pain, only for its cardiovascular prevention properties.
For extra pain, we sometimes try NSAIDs for a limited period of time, provided the person has ok kidney function and doesn’t appear to be at high bleeding risk. Aspirin itself increases bleeding risk, so that should be considered when weighing the risks and benefits of using short-term NSAIDs.
Otherwise, we do sometimes use low-dose opiates, especially if topical and OTC approaches aren’t sufficient. Lenoltec is acetaminophen and codeine. People with early dementia have variable sensitivity to opiates, and may be more sensitive to some than others. Sometimes a little trial and error is needed. Tramadol is considered more psychoactive than other opiates, so I almost never use it myself.
Leonard Lelko says
I wake up at 1;30 – 2 AM. Sometimes with a headache . I take one metoprolol and this works . My normal is one in the morning an one at night.Along with hydrochlorothiazide , losartan , diltiazem and pravastatin at night. About 15 yrs.like this. I am 72 and a viet nam vet. I also take medformin for diabetes type 2 and tomsulosin for enlarged prostate . I walk a mile 3-4 times a week .Also stand 3′ back from the kitchen sink and touch my chest to it 40 times 3-4 times a week also.
Leslie Kernisan, MD MPH says
hm. Metoprolol is a heart medication that is sometimes used for high blood pressure. That is interesting that you find it works for your headache. We generally wouldn’t recommend using metoprolol in this way, in part because I don’t think it’s been studied for this purpose. I would recommend letting your health providers know that you’ve been doing this, they should be able to advise you as to how to manage your headaches.
andrea durrant says
what is your view of optalgil for elderly patients?
Leslie Kernisan, MD MPH says
This is not a medication we use in the US, so I cannot comment on it.
Michael says
I was diagnosed with Degenerative Disc Disease a few months ago. Unable to sleep one night I took an Excedrin PM. My pain was much less the next day. Not wanting to take diphenhydramine regularly I tried Claritin as it seems to have less side effects. So far it has reduced my pain considerably. Do you know why this would work for pain?
Leslie Kernisan, MD MPH says
I don’t usually think of loratadine (brand name Claritin) as a pain medication. I looked quickly on Pubmed (the free database for medical literature) and there are case reports of loratadine being effective for bone pain, although it’s not clear to me that the mechanism for this is understood (or even that it works for most people).
Loratadine is considered safer for older adults than diphenhydramine, because it is less anticholinergic. I would recommend that you discuss with your health providers before continuing to take it long term, but I would think occasional use would be low-risk.
Chris says
As an additional comment on use of Claritin for bone pain, I was actually advised to take it during chemotherapy given one of the drugs in the mix caused intense bone pain. I found it worked The doctor also mentioned that this result was based solely on the experience of patients.