Summary Background:  Pain management is fundamental to good clinical care. All patients who are admitted into hospital with any acute condition should be assessed about the presence or absence of pain and managed appropriately at the time of admission. As the prevalence of pain is high in older people, we examined how well it is assessed and managed in the older people in a typical medical emergency setting in the UK. Methods:  We performed a retrospective audit in a district general hospital with catchment population of 250,000 in West Norfolk, UK. We included all patients admitted to care of the elderly wards during October–November 2007. We evaluated management of pain within the first 24 h of acute hospital admission. Results:  Of the 140 patients admitted, 74 (53%) were male and their median age was 84 years (range = 56–99; =< 70, n = 8). Only 93 (66%) were asked about the presence or absence of pain on admission. Of those who complained of pain (n = 45), severity of pain was documented in 5 (11%) and the management was documented in 17 (38%). Of 17 with documented pain management, only 4 (23%) had further assessment of effectiveness of pain management. Only 70 (50%) of the patients had their mental state assessed by the abbreviated mental test score (AMTS). Among those who complained of pain and AMTS ≤ 8 (n = 51), only 4 (8%) had objective documentation. Conclusions:  Our findings suggest that pain management may be sub‐optimal in older people in the acute medical settings. Regular monitoring and education may have potential to improve assessment and management of pain in these vulnerable older adults.