Pain is an understudied problem in frail elderly patients, especially those with cognitive impairment, delirium, or dementia. The focus of this study was to describe the pain experienced by patients in skilled nursing homes, which have a high prevalence of cognitive impairment. A random sample of 325 subjects was selected from ten community skilled nursing homes. Subjects underwent a cross-sectional interview and chart review for the prevalence of pain complaints, etiology, and pain management strategies. Pain was assessed using the McGill Pain Questionnaire and four unidimensional scales previously utilized in younger adults. Thirty-three percent (33%) of subjects were excluded because they were either comatose (21%), non-English speaking (3.7%), temporarily away (sick in hospital) (4.3%), or refused to participate (3.7%). Of 217 subjects in the final analysis, the mean age was 84.9 years, 85% were women, and most were dependent in all activities of daily living. Subjects demonstrated substantial cognitive impairment (mean Folstein Mini-Mental State exam score was 12.1 +/- 7.9), typically having deficits in memory, orientation, and visual spatial skills. Sixty-two percent reported pain complaints, mostly related to musculoskeletal and neuropathic causes. Pain was not consistently documented in records, and pain management strategies appeared to be limited in scope and only partially successful in controlling pain. None of the four unidimensional pain-intensity scales studied in this investigation had a higher completion rate than the Present Pain Intensity Scale of the McGill Pain Questionnaire (65% completion rate). However, 83% of subjects who had pain could complete at least one of the scales. We conclude that cognitive impairment among elderly nursing home residents present a substantial barrier to pain assessment and management. Nonetheless, most patients with mild to moderate cognitive impairment can be assessed using at least one of the available bedside assessment scales.