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.]
William Mitchell says
At 82 I’m in excellent health. I exercise regularly and eat a lot of fruits and vegetables. My one complaint are my knees. After 13 years my full knee replacement on my right knee aches a great deal, while my left knee is also bothering me. I see a knee specialist for the left knee, but am unsure what to do about the knee replacement as the surgeon does not take Medicare. I have found that 4% lidocaine patches have been very effective in relieving the pain. I put them on at night and cover them with a loose knee brace to keep them from falling off.
Nicole Didyk, MD says
Glad to hear you are enjoying good health! In this article: “Topical therapies for knee osteoarthritis”, E. C. Rodriguez-Merchan (Postgraduate Medicine, 2018), the author reviewed the evidence for numerous topical (skin-applied) therapies for knee OA, including diclofenac, ketoprofen; capsaicin, cream containing glucosamine sulfate, chondroitin sulfate, and camphor; nimesulide; civamide; menthol; drug-free gel containing ultra-deformable phospholipid vesicles (TDT 064); 4Jointz utilizing Acteev technology; herbal therapies; gel of medical leech (Hirudo medicinalis) saliva extract; and gel prepared using Lake Urmia mud. They found that the NSAID based preparations were the most effective, according to the evidence.
In contrast, a Cochrane collaboration review found that there was no good evidence for the benefit of lidocaine patches, at least for nerve-mediated pain (aka neuropathic pain).
But if it’s working for you and your doctor thinks it’s safe, then I am glad to hear it!
katijah says
I’m surprised you don’t mention diclofenac (voltaren) gel, a topical NSAID available by prescription. I’ve had a lot of success with that in my patients with chronic back & joint pain (I’m an NP).
Nicole Didyk, MD says
You are correct, some guidelines for the management of knee osteoarthritis do advise topical NSAIDs as a first line, but remember that even in topical therapy there is some systemic absorption, so some of the risks of NSAIDs are still present.
Lesa says
My 81 year old mom cannot take NASIDS due to being on Eliquis, Tylenol because of a severe allergic reaction, or narcotic pain meds because they make her sick. What OTC pain med can she safely take??
Lesa says
My 81 year old mom can’t take NASIDS due to being on Eliquis, can’t take narcotics because they make her sick, and now can’t take Tylenol because of a severe allergic reaction. She has migraines, so what OTC pain med can she safely take??
Nicole Didyk, MD says
Hi Lesa, sounds like your Mom has a bit of a dilemma. Migraine headache tends to be less common in older adults, with only 9% of those with migraine belonging to an over 65 age group. So, a first step might be to clarify whether the headache is related to migraine or to some other cause.
All of the pain relievers you mention can be used for headache, but depending on the cause of the headache, many other meds may be useful, for example blood pressure pills, antidepressants, anticonvulsants, or even prednisone. These are not usually sold over the counter, but they may be inexpensive, or covered by common drug plans. In addition to pills, other treatments can help headache such as massage, physiotherapy, mindfulness, acupuncture, and more.
The critical thing is to make sure you have the correct diagnosis and tailor the treatment to that. Hope that helps!
John Martinez says
I know NSAID’s can cause bleeding but Can Tylenol cause bleeding?
Nicole Didyk, MD says
Acetaminophen (also known as tylenol, or paracetamol) has a much lower risk of causing bleeding than aspirin or ibuprofen, and is generally regarded as a safer pain relief choice for those at risk of bleeding. Of course, it’s important to talk to a health care provider before taking any medication.
Chris says
I’m helping an elderly relative (97) who is struggling with the pain of post-herpetic neuralgia after shingles. She takes a total of 500 mg of Gabapentin spread out in 3 doses (which doesn’t alleviate the pain but is concerned that more will have her sleeping all day). She was also advised to limit Tylenol to 2000mg daily-so she spreads out 3 doses of regular Tylenol in the day. As she tries to increase her activity level, the pain has increased and we wondered if maintaining the totals of each (Gabapentin andTylenol) but playing with timing/dosage would help. For example, would it still be safe for her to take two extra-strength Tylenol twice a day to hit the pain harder but still keep to 2000 mg—or is that too much for an elderly person at one time? She is on heart and BP meds, Her kidney function is low but she has no liver issues.
Leslie Kernisan, MD MPH says
Sorry for delayed reply, we had a glitch in our system that we have just resolved.
It is generally considered safe to take 1000mg of acetaminophen in one dose, as long as the daily dose remains below a certain level. Now, it may or may not provide much relief…acetaminophen is not overall a very powerful analgesic, and post-herpetic neuralgia can be very painful.
You could try asking her health providers if any topical analgesics might be an option.
If her pain is really severe and affecting her quality of life, it might also be reasonable to consider trying a very small dose of an opioid-type medication, such as a half-tab of Vicodin. You would need to discuss this with her health providers and if they do dispense any such drugs, it’s essential to make sure that they cannot be used or diverted by someone else in the house. (In my own experience, this is a bigger risk than addiction in a 97 year old).
Good luck, I hope she finds some relief soon.
Steve says
Wow, I had never heard this before. I heard acetaminophen was dangerous and have avoided it choosing NSAIDs instead. Although I ran out of my Sulindac, but thinking my Dr’s had me on this for years, I had forgotten why I was taking it. Last night after missing two doses I was awoken with horrible joint pain. I was looking for the best OTC NSAID to take until I got to my Doctor. Now I believe a cream I can use on my elbows, shoulders, hands, and knees will be my next search. Arthritis is what they tell me is the problem. I cleaned up my diet and am exercising more, but still need to find out what foods may be causing elevated pain levels. When the meds had it under control, it wasn’t a concern, but after reading this article I’m glad the bottle’s empty and I can search for safer alternatives. Thanks
Leslie Kernisan, MD MPH says
Yes, creams are generally much safer than oral NSAIDs. You may also want to talk to you health providers about other ways to mitigate arthritis pain; often a multi-dimensional approach that includes suitable exercises, weight loss (if relevant), and other approaches can be very helpful. Good luck!
Sharon Kay Lehr says
I have Hashimoto’s hyperthyroidism. I am miserable trying to feel normal. I have pain. I am allergic to Actephetimone. I can’t sleep. I have no energy. There are other problems. I don’t think doctors take this seriously. All they care about are blood tests and what they should prescribe. I never had a belly. All of a sudden there it was. I haven’t gained weight since.
Leslie Kernisan, MD MPH says
Hm. If your usual health providers haven’t been able to help you with your symptoms and new changes (the belly suddenly getting bigger doesn’t sound normal to me), then I would recommend considering a second opinion. You could look for another “regular” healthcare provider. Or, sometimes people find it’s helpful to see a functional medicine specialist. These often are not covered by insurance. They tend to include more in-depth assessments that address lifestyle issues, nutritional triggers, and other factors often overlooked by busy allopathic health providers. (Many functional medicine providers also have conventional training and may be able to uncover less common medical conditions.) Good luck!
dolores MAZZA says
“Icy – Hot” patches worked wonders for me when I had sciatica. They were prescribed by urgent care doctor. He also said to take 3 extra strength Tylenol every 4 hours. That I did not do! It sounded too risky.
I found laying flat on my back was helpful along with the patches.
Perhaps using topical rubs can help many with chronic pain.
I wish you all well.
Leslie Kernisan, MD MPH says
An extra strength Tyelonol usually contains 500mg of acetaminophen. So three would be 1500mg. I agree that seems like a hefty dose, and taking such a dose every 4 hours around the clock would quickly put one over what is usually considered a safe limit.
Topical patches are a great idea and anything topical is usually much less risky.
Luella S Garrett says
Dear Dr, Kernisan; I read your Comments regarding aging adults, their pains, and all the OTC medications. It is very interesting. One question I have, is Acetamenophen Extra Strength 500mg the same as Tylenol Extra Strength 500mg?
For the last two months my arthritis has bothered me with extreme pain especially while sleeping.
My physician recommended Glucosamine Condrotin, which I am taking. So far, 3 wks, no results. In the meantime, I have taken Aleve12 for 3 days now, which has lessened the pain alot during sleep. I am very cautious about taking more than 1 pill a day.
Leslie Kernisan, MD MPH says
Yes, in the US a common brand name for acetaminophen is Tylenol, so acetaminophen extra strength and Tylenol Extra Strength are basically the same thing.
Glucosamine is often taken for arthritis. Randomized blinded trials tend to find that the effect is negligible, compared to placebo, so I am not surprised if you find it’s not doing much. An NSAID such as Aleve usually does provide noticeable pain relief, but as noted in the article, it’s a little risky to take every day. You may want to consider a topical formulation. If your pain is getting much worse at night, I would also recommend making sure your health providers are aware, so that they can check for other causes of worsening pain. You may also want to ask for help with non-drug arthritis management, and some people find a chronic arthritis pain self-management program helpful. Good luck!