The effect of race in older adults presenting for chronic pain management: a comparative study of black and white Americans.

In an aging society, chronic pain will increasingly have a significant impact on successful aging. Chronic pain may further differentially affect racial and ethnic minorities while diminishing their health and quality of life. This study addresses the potential differential effects of chronic pain cross-culturally in older Americans. A retrospective analysis of a group of subjects presenting for chronic pain management in a tertiary care multidisciplinary pain center was performed. This comparative study of black and white American adults (N [equals] 2040) was done to determine whether there were differences in (1). psychologic functioning, (2). pain characteristics, (3). pain disability, and (4). comorbidities. The black American population had more depressive symptoms and symptoms of posttraumatic stress disorder when compared with the white Americans. These results suggest that chronic pain adversely affects the quality of life and health status of black Americans to a greater extent than white Americans before initial presentation for treatment at a multidisciplinary pain center. This study of older Americans with chronic pain showed significant differences in pain and health status based on race. It further demonstrates a difference in the chronic pain experience based on race in older Americans.     

Modifiable risk factors for incidence of pain in older adults

Pain symptoms in aging populations have significant public health impact. The aim of this study was to determine risk factors for the incidence of pain in older adults, focusing on those factors that can be modified. Secondary analyses were performed of survey data from the nationally representative Health and Retirement Study of US adults older than 50 years. Generalized estimating equations logistic regressions were used to evaluate the effect of selected variables on the incidence of pain using biennial (1992 through 2006) data, determining the relationship between the incidence of pain and the potential risk factors. Of the 18,439 survey respondents in 2006, 34.1% (95% CI: 33.2%, 35.0%) reported that they were often troubled by pain; 24.3% reported having moderate to severe pain; and 22.3% reported that their daily life was affected by pain. Between 1992 and 2006, 7967 individuals reported new onset of pain in 169,762 person-years of follow-up, an incidence of 4.69 (4.59, 4.80) per 100 person-years. Depression and being overweight were independent predictors associated with an increased likelihood of incident pain. Current smoking increased the likelihood of incident pain only in those subjects who also reported depression. In conclusion, pain is a common symptom in older adults. Depression, smoking, and overweight are potentially modifiable risk factors and could be considered in the prevention and management of pain in older adults.     

The suicidal patient in long-term care institutions

In comparison with older adults living in the community, elders who are institutionalized are older, sicker, and more likely to have no living family members, factors that place them at risk for suicide. Somatization, or physical suffering, is a frequently overlooked symptom of elderly depression, perhaps because it is falsely assumed that such symptoms expressed by the older adult are normal concomitants of aging. Strengthening and extending existing family roles in supporting the elder who is suicidal and depressed is vital to reducing loneliness, emotional pain, loss of independence, and to increasing self-concept. An expanded knowledge of mental health needs of older adults and their families is critical in suicide prevention. A major step toward prevention is the recognition of depressive symptomatology and key elements and clues to suicide in the institutionalized elderly.     

Sleep in the older adult: implications for nurses (CE)

Normal aging is accompanied by sleep pattern changes that may result in daytime sleepiness and affect the quality of life in older adults. These changes also can signal more serious sleep problems, which become more prevalent with aging. More than half of adults older than 65 living at home and about two-thirds of those in long-term care facilities have some difficulties with sleep. It is important for nurses to understand the normal changes in sleep that accompany aging and be able to differentiate them from the symptoms of serious sleep disorders to ensure holistic care for older adults.     

Age and Race Effects on Pain Sensitivity and Modulation Among Middle-Aged and Older Adults

This study tested the effects of aging and race on responses to noxious stimuli using a wide range of stimulus modalities. The participants were 53 non-Hispanic blacks and 138 non-Hispanic white adults, ages 45 to 76 years. The participants completed a single 3-hour sensory testing session where responses to thermal, mechanical, and cold stimuli were assessed. The results suggest that there are selected age differences, with the older group less sensitive to warm and painful heat stimuli than middle-aged participants, particularly at the knee. This site effect supports the hypothesis that the greatest decrement in pain sensitivity associated with aging occurs in the lower extremities. In addition, there were several instances where age and race effects were compounded, resulting in greater race differences in pain sensitivity among the older participants. Overall, the data suggest that previously reported race differences in pain sensitivity emerged in our older samples, and this study contributes new findings in that these differences may increase with age in non-Hispanic blacks for temporal summation and both heat and cold immersion tolerance. We have added to the aging and pain literature by reporting several small to moderate differences in responses to heat stimuli between middle- and older-age adults.PerspectiveThis study found that the greatest decline in pain sensitivity with aging occurs in the lower extremities. In addition, race differences in pain sensitivity observed in younger adults were also found in our older sample.     

Cancer Pain Management Considerations in Older Adults

ObjectiveTo address the pharmacokinetics and pharmacodynamics of aging and its impact on the complexities of pain management in older adults with cancer. To describe assessment and nursing strategies for individualized care and side effect managementData SourcesPeer-reviewed articles.ConclusionCancer pain is a complex problem in older adults because of the variations in aging and alterations in pharmacokinetics and pharmacodynamics. Pain management must be based on thorough assessment, incorporating the unique factors of each patient. Ongoing follow-up is critical to ensure adequate pain control with optimization of functional status.Implications for Nursing PracticeAwareness of physiological changes of aging is important in caring for older adults. Oncology nurses can play a key role in the assessment of older adults with cancer and education of patients and caregivers regarding pain medications, side-effects, and oral adherence.     

Prevalence,Incidence, and Factors Associated With Non-Specific Chronic Low Back Pain in Community-Dwelling Older Adults Aged 60 Years and Older: A Systematic Review and Meta-Analysis

Chronic low back pain (CLBP) is common among older adults. This systematic review aimed to summarize: (1) the prevalence and incidence of CLBP in older adults, and (2) demographic, psychological, and clinical factors positively/negatively associated with prevalence/incidence of CLBP among older adults. Four databases were searched to identify relevant publications. Ten studies (31,080 older adults) were included after being screened by 5 independent reviewers using predetermined criteria. The methodological quality of these studies was evaluated by standardized tools. The quality of evidence for all factors were appraised by modified GRADE for cohort studies. Twenty-eight and 1 factors were associated with a higher prevalence and a lower 5-year cumulative incidence of CLBP, respectively. No prognostic factor was identified. There was very limited to limited evidence that females, obesity, anxiety, depression, mental disorders, self-expectation of recovery, self-perceived health status, lifestyle (smoking, daily fluoride consumption), previous falls or lower body injury, retirement/disability due to ill health, family history of body pain, comorbidity (knee osteoarthritis, or chronic obstructive pulmonary disease with/without hypertension), weak abdominal muscles, leg pain, leg pain intensity, widespread pain, pain interference on functioning, use of pain medication, occupational exposure (driving for >20 years, or jobs involving bending/twisting for >10 years), disc space narrowing and severe facet osteoarthritis were significantly related to a higher prevalence of CLBP in older adults. However, very limited evidence suggested that intermediate level of leisure-time physical activity was associated with a lower prevalence of CLBP in older adults. Given the aging population and limited information regarding risk factors for CLBP in older adults, future high-quality prospective studies should identify relevant risk factors to help develop proper preventive and treatment strategies.PerspectiveDespite the high prevalence of non-specific chronic low back pain among older adults, there is only very limited to limited evidence regarding factors associated with a higher prevalence of chronic low back pain in this population. Given the aging population, high-quality prospective studies are warranted to address this gap.     

The impact of self-compassion on mental health,sleep, quality of life and life satisfaction among older adults

Given South Korea's rapidly aging population, mental health and quality of life (QoL) in older adults are increasingly becoming important. Self-compassion (SC), defined as extending compassion to oneself in times of suffering, has been found to have associations with positive mental health outcomes. This study was performed to examine associations between self-compassion and mental health symptoms, sleep disturbance, life satisfaction, and health-related quality of life (HR-QoL) among older Korean adults. The participants in this cross-sectional study included 203 older Korean adults aged 65 and over. Findings of this study suggest that self-compassion in older adults protects them from developing mental health and sleep disturbance symptoms while enhancing their life satisfaction, self-care, and usual activities. Therefore, interventions fostering self-compassion may benefit older adults’ mental health and quality of life.     

Effect of a Virtual Pain Coach on Pain Management Discussions: A Pilot Study

There is a need to enhance patient and practitioner pain communications. A pain communication plus virtual pain coach intervention was tested in the primary care setting for the effect on communication of osteoarthritis pain information by older adults aged ≥60 years, on practitioners’ pain management changes, and on older adults’ reduced pain and depressive symptoms 1 month later. A randomized controlled pilot study design was used. Twenty-three older adults with osteoarthritis pain were randomly assigned to the pain communication plus virtual pain coach group or the pain communication–only group. Pain communication consisted of a video of important osteoarthritis pain information. The coach consisted of practicing out loud with a virtual pain coach via laptop computer. Pain and depressive symptoms were measured with, respectively, the Brief Pain Inventory Short Form and the Beck Depression Inventory II before intervention and 1 month later. Immediately after the intervention, older adults had their primary care visits, which were audiotaped, transcribed, and content analyzed for older adults’ communicated pain information and practitioners’ pain management changes. Older adults in the pain communication plus virtual pain coach group described significantly more pain source information and were prescribed significantly more osteoarthritis pain treatments than older adults in the pain communication–only group. A nonsignificant trend in pain intensity and depressive symptoms reduction resulted for older adults in the pain communication plus virtual pain coach group 1 month later. The virtual pain coach presents a possible strategy for increasing pain management discussions between practitioners and older adults with persistent pain.     

The design and methods of the aging successfully with pain study

Chronic low back pain (CLBP) is widespread among older adults (≥ 65 years) and is often treated inadequately. With a rapidly growing aging population, CLBP will increase and so will the demand for treatment. We believe that mind-body therapies can help to meet this demand. We present the methodology of a randomized, controlled clinical trial of 300 individuals with CLBP aged 65 years or older. The specific aims are, 1) to determine the effectiveness of a mindfulness meditation program in increasing function and reducing pain among older adults with CLBP, and 2) to evaluate the impact of mindfulness meditation on neuropsychological performance in older adults with CLBP. The intervention program is modeled on the Mindfulness-Based Stress Reduction Program (MBSR) and the control is adapted from the 10 Keys to Healthy Aging. We will measure self-reported and objectively measured physical function and include a variety of measures to assess pain intensity and pain interference and psychological function. Our primary hypothesis is that the MBSR program will be more effective than the 10 Keys program in increasing function and decreasing pain. The proposed study represents the first large, well-controlled, comprehensive examination of the effects of a mind-body program on older adults with chronic pain.     

Effects of age on temporal summation and habituation of thermal pain: Clinical relevance in healthy older and younger adults

Although the effects of aging on the experience of clinical pain seem relatively clear, investigations of age-related changes in pain perception using laboratory-based pain assessment procedures have yielded contradictory findings. One potential source of variability in this literature is the type of experimental noxious stimulus that is used. Although thermal pain thresholds are the most commonly reported measure of pain sensitivity, use of suprathreshold stimuli in pain assessment procedures may yield additional, more clinically relevant information concerning the effects of aging on the experience of pain. The present study examined the effects of age on temporal summation of both the intensity and unpleasantness of thermal pain at multiple stimulus temperatures. Specifically, responses to repetitive thermal stimuli delivered to the volar forearm at 47 degrees C, 50 degrees C, and 53 degrees C were assessed in 34 younger (mean age, 22.4 years) and 34 older (mean age, 62.2 years) healthy volunteers. Results suggested that for the 47 degrees C and 50 degrees C stimulus trains, older adults exhibited higher ratings of the intensity and unpleasantness of thermal pain and enhanced temporal summation of thermal pain relative to younger adults. Moreover, thermal pain sensitivity was inversely related to perceptions of general health and to reports of recent clinical pain among younger, but not older, subjects. Collectively these findings may indicate small, although potentially significant, age-related alterations in the plasticity of the central nervous system or endogenous pain-modulatory capacities.     

The Decline of Endogenous Pain Modulation With Aging: A Meta-Analysis of Temporal Summation and Conditioned Pain Modulation

The purpose of this article was to examine age-related changes in conditioned pain modulation (CPM) and temporal summation (TS) of pain using meta-analytic techniques. Five electronic databases were searched for studies, which compared measures of CPM and TS among healthy, chronic pain-free younger, middle-aged, and older adults. Eleven studies were included in the final review for TS and 11 studies were included in the review of CPM. The results suggested a moderate magnitude of difference in TS among younger and middle-aged/older adults, with the older cohorts exhibiting enhanced TS of pain. Considerable variability existed in the magnitude of the effect sizes, which was likely due to the different experimental methodologies used across studies (ie, interstimulus interval, stimulus type, and body location). In regards to CPM, the data revealed a large magnitude of difference between younger and older adults, with younger adults exhibiting more efficient pain inhibition. Differences in CPM between middle-aged and older adults were minimal. The magnitude of pain inhibition during CPM in older adults may depend on the use of concurrent versus nonconcurrent protocols. In summary, the data provided strong quantitative evidence of a general age-related decline in endogenous pain modulatory function as measured by TS and CPM.PerspectiveThis review compared CPM and TS of pain among younger, middle-aged, and older adults. These findings enhance our understanding of the decline in endogenous pain modulatory function associated with normal aging.     

Achieving self-management goals among low income older adults with functional limitations

Although self-management interventions can improve symptoms and disease among older adults, there is a dearth of literature on how self-management behaviors may improve factors related to the older adults’ physical function. To fill this gap in the literature, we describe the patient-directed self-management goals in nursing visits that relate to physical function as part of a multi-component program. We analyze the self-management goals and outcomes of 367 low- income older adults with functional limitations who participated in the CAPABLE program: a program to reduce the health effects of impaired physical function in low-income older adults. We focus on the following self-management goals that participants chose with the nurses: pain management, depressive symptoms, incontinence, fall prevention, and communication with healthcare providers. The majority of participants chose pain (50%) or fall prevention (51%) as goals and partially or fully met their goals. Improvements across these areas may lead to improved physical function.     

Managing Pain in the Elderly Population: Pearls and Pitfalls

While pain is a common symptom among older adults, it often is underdiagnosed and undertreated. Aging-related physiological changes, misperceptions about the use of pain medications by both patients and providers, and the lack of evidence-based clinical research on pain management in older adults are some of the reasons why pain in older adults is mismanaged. Using extrapolated evidence from pain research in younger patients, consensus statements, and best practice guidelines, this article summarizes and highlights areas of geriatric pain assessment and management that need special consideration. Some highlighted areas include 1) pain assessment in cognitively impaired patients; 2) medication choice and initiation doses; 3) duration of adequate medication trials; and 4) common medication side effects and suggested management.     

Characteristics and Factors Associated With Pain in Older Homeless Individuals: Results From the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) Study

Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0–10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4–3.7), arthritis (AOR: 4.8, 95% CI, 3.0–7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3–4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness.

Evidence on selection,optimization, and compensation strategies to optimize aging with multiple chronic conditions: A literature review

The self-regulation strategies of selection, optimization, and compensation (SOC) can be effective in optimizing aging with multiple chronic conditions (MCC). Nineteen articles on the use and effects of SOC among older adults with chronic conditions were reviewed. The studies' quality, evaluated by the Mixed Methods Appraisal Tool, ranged from medium to high (Mean?=?0.90, SD?=?0.10). SOC were found to improve the symptom experience for older adults, resulting in better health outcomes such as increased daily living activities, subjective well-being, life success, fewer falls/sick days, and use of medication for pain control. For those with MCC, higher degree of disabilities, serious health events, and negative self-perceived aging undermined the relationships between SOC and long-term physical functioning, self-rated health, and life satisfaction. Aging can be optimized by identifying and improving older individuals' coping using SOC. Future studies should utilize better MCC measures for comorbidity and chronic disabling symptoms to investigate the influence of SOC on MCC-associated health outcomes.     

Offset analgesia is reduced in older adults

Recent studies indicate that aging is associated with dysfunctional changes in pain modulatory capacity, potentially contributing to increased incidence of pain in older adults. However, age-related changes in offset analgesia (offset), a form of temporal pain inhibition, remain poorly characterized. The purpose of this study was to investigate age differences in offset analgesia of heat pain in healthy younger and older adults. To explore the peripheral mechanisms underlying offset, an additional aim of the study was to test offset at 2 anatomical sites with known differences in nociceptor innervation. A total of 25 younger adults and 20 older adults completed 6 offset trials in which the experimental heat stimulus was presented to the volar forearm and glabrous skin of the palm. Each trial consisted of 3 continuous phases: an initial 15-second painful stimulus (T1), a slight increase in temperature from T1 for 5 seconds (T2), and a slight decrease back to the initial testing temperature for 10 seconds (T3). During each trial, subjects rated pain intensity continuously using an electronic visual analogue scale (0–100). Older adults demonstrated reduced offset compared to younger adults when tested on the volar forearm. Interestingly, offset analgesia was nonexistent on the palm for all subjects. The reduced offset found in older adults may reflect an age-related decline in endogenous inhibitory systems. However, although the exact mechanisms underlying offset remain unknown, the absence of offset at the palm suggests that peripheral mechanisms may be involved in initiating this phenomenon.     

Epidemiology and natural history of low back pain

Low back pain is a common problem affecting most adults at some point during their lifetime. At any one time, around 1 in 5 adults will report symptoms of low back pain, rising to 40% when asked if they have experienced symptoms during the previous month. The majority of people who experience an episode of low back pain will improve over time. However a sizeable proportion experience repeated episodes or recurrences, and some report continuous symptoms for many years. A wide range of factors are linked to both the onset and persistence of low back pain. Some studies have related age and gender to low back pain, but the link overall is equivocal. Work-related factors such as heavy lifting, and socio-demographic factors such as smoking and obesity have been linked with the onset of low back pain. High levels of functional impairment and the presence of pain radiating to the leg have been cited as factors associated with a poor prognosis among primary care consulters with low back pain. Other characteristics associated with both the development and the persistence of low back pain include psychological factors such as depression and anxiety and workplace factors such as job satisfaction. Low back pain places large demands on health, social and welfare systems. Further research is needed to identify practical interventions to reduce this burden from low back pain.