Pain assessment in elderly patients presents unique challenges due to physiological aging, cognitive impairment, communication barriers, and persistent myths that pain is a normal part of aging. While peripheral nociceptor density decreases slightly with aging, central pain processing changes are complex and may actually increase pain sensitivity in some pathways. Older adults often present atypically: acute MI may present without chest pain, appendicitis without classic periumbilical pain, and infections without fever or pain. Cognitive impairment (dementia, delirium) significantly complicates pain assessment as patients may be unable to self-report. Behavioral pain scales (PAINAD - Pain Assessment in Advanced Dementia) use facial expressions, body language, vocalizations, consolability, and breathing patterns to assess pain in non-verbal patients. Pharmacological management requires careful dose adjustment: reduced hepatic and renal clearance increases drug half-life, decreased albumin increases free drug concentration, and age-related CNS sensitivity heightens sedation and respiratory depression risk with opioids. Start low, go slow applies to all analgesic dosing in the elderly.