CONTEXT:Pain may be a potentially modifiable risk factor for expensive and burdensome Emergency Department (ED) visits near the end-of-life for older adults with dementia. OBJECTIVES:To assess the effect of pain and unmet need for pain management on ED visits in the last month of life in older adults with dementia. METHODS:Mortality follow-back study of older adults with dementia in the National Health and Aging Trends Study (NHATS) who died between 2012-2014, linked to Medicare claims. RESULTS:281 NHATS decedents with dementia met criteria (mean age 86, 61% female, 81% white). Fifty-seven percent had at least one ED visit in the last month of life, and 46.5% had an ED visit that resulted in a hospital admission. Almost ¾ (73%) of decedents experienced pain in the last month of life, and 10% had an unmet need for pain management. After adjustment for age, gender, race, educational attainment, income, comorbidities, and impairment in activities of daily living, pain was not associated with increased ED use in the last month of life (Adjusted Incident Rate Ratio (aIRR 0.87, 95% Confidence Interval (CI) 0.64-1.17). However, decedents with unmet need for pain management had an almost 50% higher rate of ED visits in the last month of life than those without unmet needs (aIRR 1.46, 95% CI 1.07-1.99). CONCLUSIONS:Among older adults with dementia, unmet need for pain management was associated with more frequent ED visits in the last month of life.