Grades are shown as the source states them. The 2026 guideline grades recommendations as strong (1) or weak (2) with evidence certainty from high (A) to very low (D), and gives good practice statements where evidence was lacking. The EAPC White Paper and the European prescribing consensus are expert consensus without grades.
Key recommendations
Offer an integrated palliative, geriatric and rehabilitative approach from the time frailty is recognised until the end of life, shifting the balance between the three according to the person's needs and wishes.
Domain 1; DiscussionEuropean Association for Palliative Care (EAPC) Reference Group on Aging and Palliative Care 2025
Make care holistic and person-centred — attending to capacities as well as needs — and goal-oriented and proactive, built on good communication and shared decision-making.
Domains 2–4European Association for Palliative Care (EAPC) Reference Group on Aging and Palliative Care 2025
Treat family carers as both providers and recipients of care, and support them through to bereavement.
Domain 6; AbstractEuropean Association for Palliative Care (EAPC) Reference Group on Aging and Palliative Care 2025
Manage pain by assessing it thoroughly (using observational tools if cognition or communication is impaired), matching analgesia to severity — a non-opioid for mild pain, a weak or low-dose strong opioid for moderate pain, a strong opioid for severe pain — titrating individually and watching for constipation, sedation, delirium, falls and respiratory depression.
Recommendation 1National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Use medicines to relieve symptoms, reassess them regularly, and deprescribe when the expected benefit no longer outweighs the burden or harm; needing several symptom drugs is not a licence for routine polypharmacy.
Diagnosis
Frailty brings declining function across organ systems and higher risks of admission, falls, fractures, disability and death. Cognitive decline can complicate communication and decisions, and people may have social, psychological and existential needs alongside physical ones.
IntroductionEuropean Association for Palliative Care (EAPC) Reference Group on Aging and Palliative Care 2025
Assess breathlessness fully — severity, triggers, oxygenation, anxiety, secretions, bronchospasm, pulmonary oedema, effusion, infection, anaemia — and treat reversible causes in line with the goals of care before or alongside symptom relief.
Good practice statementRecommendation 9National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Investigations
Not covered in this summary — see the original guideline.
Treatment
For mild to moderate pain, paracetamol is first line. If it is unsuitable, a topical NSAID such as diclofenac gel suits joint, muscle and soft-tissue pain.
Strong; high certainty (1A) and Strong; moderate certainty (1B)Recommendations 5–6National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Before an oral NSAID, weigh cardiovascular, bleeding, kidney, heart failure, blood pressure and interaction risks; avoid regular use with anticoagulants or high bleeding risk; if one is used, give the lowest dose for the shortest time with gastroprotection.
Strong; high certainty (1A)Recommendation 7National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Opioids are effective for pain in older people, but harms are more likely, so weigh benefit and risk before starting. For cancer pain, oral morphine, oral oxycodone and transdermal fentanyl work similarly, and starting a low-dose strong opioid with an adjuvant is an option for moderate pain.
Strong; moderate certainty (1B); Weak; low certainty (2C) for low-dose strong opioidRecommendations 2–3National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Choose the opioid with care: morphine and hydromorphone metabolites accumulate in kidney impairment; standard transdermal fentanyl doses are not for opioid-naive people; methadone is for experienced prescribers only. When switching opioids, reduce the calculated equivalent dose by 25–50%.
Recommendations 2–4: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
For neuropathic pain, use gabapentin, or pregabalin as an alternative, adjusting the dose to kidney function and avoiding other central nervous system depressants where possible.
Strong; moderate certainty (1B)Recommendation 8National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
For breathlessness, start with non-drug measures — a fan directed at the face, positioning, a cooler and better-ventilated room, relaxation. Give oxygen only for documented hypoxaemia (saturation 90% or below on air). Add an opioid such as morphine if these are not enough; benzodiazepines only cautiously for marked anxiety.
Good practice statement; fan and oxygen Strong; moderate certainty (1B)Recommendations 9, 15 and 16National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
For significant depression with a longer expected survival, an SSRI is recommended, preferably sertraline, starting low and reassessing. No medicine is recommended for anxiety alone.
Weak; very low certainty (2D)Recommendation 47; rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
For insomnia, treat causes and use non-drug measures first. If medication is needed, use the lowest dose short term; melatonin, ramelteon or lemborexant are options, while benzodiazepines and Z-drugs should not be used routinely in older people.
Strong; high certainty (1A)Recommendations 49–50National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
For constipation, an osmotic laxative (polyethylene glycol) is first line for chronic constipation, and a stimulant (senna or bisacodyl) for short-term or refractory constipation; a stool softener can be added if one class is not enough.
Strong; moderate certainty (1B); softener Weak; low certainty (2C)Recommendations 39–41; Table 2National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
To improve appetite, megestrol acetate or a short course of a corticosteroid may be considered after discussion with the person and family; benefits are modest.
Weak; moderate certainty (2B) and Weak; low certainty (2C)Recommendations 26–27National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
For overactive bladder in palliative care, mirabegron is first line to limit anticholinergic burden; antimuscarinics (solifenacin, extended-release tolterodine, fesoterodine, trospium or an oxybutynin patch) are alternatives.
Strong; high certainty (1A); alternatives Strong; moderate certainty (1B)Recommendations 42–43National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Important geriatric considerations
Older people at the end of life combine frailty, multimorbidity, altered drug handling and a high risk of adverse drug events, so start low, titrate slowly and review often.
Introduction; DiscussionNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Gabapentinoids add to sedative burden: watch for dizziness, drowsiness, confusion, unsteadiness and falls, and pause or reduce the dose if cognition worsens.
Recommendation 8: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Benzodiazepines and Z-drugs carry risks of delirium, cognitive impairment, falls, fractures, dependence and (with opioids) respiratory depression.
Recommendations 12–13 and 50: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
NSAIDs cause about a quarter of adverse-drug-reaction admissions in older adults; avoid them in end-stage heart failure, severe kidney impairment, active gastrointestinal bleeding or with anticoagulants unless no safer option exists.
Recommendations 5–7: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Consider stopping drugs whose benefit takes longer to appear than the person is expected to live, or whose target no longer fits their goals of care.
IntroductionEuropean expert panel (Delphi consensus) 2018
Care should be culturally sensitive and ethically grounded, recognise people's own strengths rather than casting them as a burden, and guard against ageism.
Domains 9 and 11; DiscussionEuropean Association for Palliative Care (EAPC) Reference Group on Aging and Palliative Care 2025
Drug doses
Paracetamol for mild to moderate pain: 1–2 g a day by mouth, with caution in liver impairment or heavy alcohol use.
Strong; high certainty (1A)Recommendation 5National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Gabapentin: 100 mg once on day 1, twice on day 2 and three times on day 3, then titrate as tolerated to a maximum of 900–1800 mg a day. Pregabalin: from 75 mg twice daily up to 300 mg a day.
Strong; moderate certainty (1B)Recommendation 8National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Breakthrough pain: an immediate-release opioid dose of 10–20% of the total opioid dose taken in the previous 24 hours.
Recommendation 1: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Sertraline for depression: start at 25 mg once daily and adjust to 50–100 mg once daily according to effect and tolerability.
Weak; very low certainty (2D)Recommendation 47National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Insomnia (short term): prolonged-release melatonin 2 mg, ramelteon 8 mg or lemborexant 5 mg at night.
Strong; high certainty (1A)Recommendation 50National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Laxatives: polyethylene glycol 10–30 g once daily (up to 4 weeks); bisacodyl 10 mg once daily (up to 4 weeks); senna for no more than a week; docusate 100–300 mg once daily as an add-on.
Megestrol acetate for appetite: 160–800 mg a day, usually for 1–3 months; higher doses add no benefit.
Weak; moderate certainty (2B)Recommendation 26National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Mirabegron: 25 mg once daily, increasing to 50 mg if needed and tolerated.
Strong; high certainty (1A)Recommendation 42National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
When to refer
For refractory pain, seek multidisciplinary input from pain specialists, anaesthetists and clinical pharmacists.
Recommendation 8National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Older people living with frailty should have access to integrated, interdisciplinary services and to professionals competent in palliative, geriatric and rehabilitative care.
Domains 7–8European Association for Palliative Care (EAPC) Reference Group on Aging and Palliative Care 2025
Constipation from defecatory (outlet) dysfunction needs specialist assessment rather than more laxatives.
Recommendations 39–41: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Red flags
On opioids, check breathing rate, oxygen saturation and alertness after starting or increasing the dose. If the rate falls below 8 a minute or saturation below 88% without another cause, withhold the next dose and reduce by 25–50%.
Recommendations 10–11: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Megestrol acetate may increase the risk of thromboembolism and oedema.
Recommendations 26–27: rationaleNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026
Recent updates
The 2025 EAPC White Paper is the first international consensus (82 panellists from 28 countries) on integrating palliative, geriatric and rehabilitative care for older people with frailty; the evidence behind many recommendations is still limited.
Abstract; DiscussionEuropean Association for Palliative Care (EAPC) Reference Group on Aging and Palliative Care 2025
The 2026 geriatric guideline is GRADE-based and covers 15 symptoms, but much of its evidence is indirect, drawn from younger palliative, cancer, COPD and heart failure populations.
Abstract; DiscussionNational Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (guideline working group) 2026