Chronic musculoskeletal pain is a common, disabling condition that affects at least one in four elderly people. Figures are much higher in nursing homes, in which as many as 45-80% of residents has pain that contributes to functional impairment and decreased quality of life. Multiple comorbidity, under-reporting of symptoms and cognitive impairment make pain evaluation often difficult. Chronic pain is often associated with anxiety and depressive symptoms, but care must be taken to avoid attributing pain entirely to psychogenic causes. Indeed pain is an understudied problem in frail elderly patients, especially in those with cognitive impairment, delirium, or dementia. In a large Italian home care study, age of 85 years or more and low cognitive performance were predictors of failing to receive adequate analgesics. However, most patients with cognitive impairment and even those with severe dementia can be assessed using one of the available pain-intensity scales (verbal or not verbal). Structured programs are needed for routine pain assessment and treatment in older people.