Pain and the aging brain: beyond association toward action

Chronic pain affects more than half of older adults and has been increasingly linked to cognitive decline, a relationship with profound implications for healthy aging. Ramezani and colleagues examined this association in 1,343 Iranian older adults from the Birjand Longitudinal Aging Study, a well‑characterised cohort from an understudied population. The study has notable strengths: a large sample size, population‑based recruitment, and DAG‑guided covariate selection. However, three methodological limitations warrant consideration. First, pain was measured only once, but longitudinal evidence shows that pain trajectories and multisite chronic pain, not single‑timepoint intensity, drive cognitive decline. Second, adjusting for employment, wealth, and living arrangement without distinguishing confounders from mediators may have introduced overadjustment bias. Third, the composite cognitive definition (failure on all three tests) has never been validated, raising questions about the 59.6% prevalence reported. Future studies should incorporate repeated pain assessments, distinguish single‑site from multisite pain, use careful causal modelling, and validate composite cognitive definitions.