OBJECTIVES: When applying accepted health economic methods, it is not uncommon to find valuations of patients’ health states that are worse than dead. Hypothetical valuations (the UK value set) of states according to the EQ-5D resulted in 82 of 243 possible states being valued as worse than dead. The presence of health states valued worse than dead risks giving rise to counter-intuitive consequences when incorporated in health economic analyses. The purpose of this study was therefor to investigate the presence of such states in an exposed population, namely people 65 years and older. METHODS: Based on a Swedish epidemiological population survey study directed to 10 000 persons 65 years and older the occurrence of states worse than dead were investigated and related to prevalence and intensity of chronic pain. RESULTS: Health states worse than dead were found in 1.8 % of the 6618 responders to the questionnaire. Among persons with severe chronic pain the prevalence was 16.7 % and among persons with moderate and no or mild chronic pain the prevalence of states worse than dead were 2.7 % and 0.8 % respectively. Prevalence of these states clearly increased with age and female gender.  Of women 85 years and older with severe chronic pain 38.7 % were in states worse than dead. CONCLUSIONS: Health states worse than dead are not rare in an elderly population and covariate with chronic pain, age and female gender.  The prevalence of states worse than dead are highly dependent on the value set applied, and will have consequences for assessments of treatments for elderly with chronic pain. Based on the results of this study it should be investigated whether and to what extent health states worse than dead exist when using experience based valuation methods, which is the preferred approach in some settings/countries.