Given the current demographic changes there are an increasing number of elderly and very elderly patients in outpatient and inpatient care. Elderly and very elderly patients often suffer from pain and musculoskeletal conditions are a common cause of pain in the elderly. An effective pain management should not be withheld from elderly patients with rheumatic diseases. Untreated pain in elderly patients leads to functional impairment and immobility. In addition, the quality of life of patients is negatively affected and can lead to a loss of autonomy and/or social withdrawal. The treatment of elderly and very elderly patients is particularly challenging. There are special features that need to be considered in the choice of treatment. Altered pain presentation, comorbidities, nonadherence, polypharmacy and side effects of pain medications require a critical risk-benefit assessment and ongoing treatment monitoring of this special group of patients.