Pain severity and pharmacologic pain management among community-living older adults: the MOBILIZE Boston study.

BACKGROUND: Concerns about polypharmacy and medication side effects contribute to undertreatment of geriatric pain. This study examines use and effects of pharmacologic treatment for persistent pain in older adults. METHODS: The MOBILIZE Boston Study included 765 adults aged ≥70 years, living in the Boston area, recruited from 2005 to 2008. We studied 599 participants who reported chronic pain at baseline. Pain severity, measured using the Brief Pain Inventory (BPI) severity subscale, was grouped as very mild (BPI <2), mild (BPI 2-3.99), and moderate to severe (BPI 4-10). Medications taken in the previous 2 weeks were recorded from medication bottles in the home interview. RESULTS: Half of participants reported using analgesic medications in the previous 2 weeks. Older adults with moderate to severe pain were more likely to use one or more analgesic medications daily than those with very mild pain (49 versus 11%, respectively). The most commonly used analgesic was acetaminophen (28%). Opioid analgesics were used daily by 5% of participants. Adjusted for health and demographic factors, pain severity was strongly associated with daily analgesic use (moderate-severe pain compared to very mild pain, adj. OR 7.19, 95% CI 4.02-12.9). Nearly one third of participants (30%) with moderate to severe pain felt they needed a stronger pain medication while 16% of this group were concerned they were using too much pain medication. CONCLUSION: Serious gaps persist in pain management particularly for older adults with the most severe chronic pain. Greater efforts are needed to understand barriers to effective pain management and self-management in the older population.

The association between pain and prevalent and incident motoric cognitive risk syndrome in older adults.

BACKGROUND: The Motoric Cognitive Risk Syndrome (MCR) is a pre-dementia syndrome characterized by subjective cognitive complaints and slow gait in the absence of dementia and mobility disability. Worse cognitive and motoric function is associated with chronic pain in older adults. Our aim was to study the association between pain and prevalent and incident MCR in adults aged 65 years and older. METHODS: We analyzed the cross-sectional association between severity of pain and prevalent MCR in 3244 older adults participating in the Health and Retirement Study (2008 wave) using logistic regression analysis adjusting for demographic, peripheral, central or biological risk factors. Additionally, we analyzed the longitudinal association between severity of pain and incident MCR in 362 participants in the Central Control of Mobility in Aging Study, using Cox regression analysis. RESULTS: The 155 Health and Retirement Study participants with severe pain had an increased risk of prevalent MCR (n = 249), compared to 2245 individuals without pain (adjusted for demographics OR: 2.78, 95 % CI:1.74-4.45). Over a mean follow-up of 3.01 years (SD 1.38), 29 individuals in the Central Control of Mobility in Aging Study developed incident MCR. Older adults with severe pain had over a five times increased risk of developing incident MCR, compared to those without pain even after adjusting for demographic variables (HR: 5.44, 95 % CI: 1.81-16.40). CONCLUSION: Older adults with severe pain have a higher prevalence and incidence of MCR. These findings should be further explored to establish if pain is a potentially modifiable risk factor to prevent cognitive decline.

The Effect of Pain on Major Cognitive Impairment in Older Adults.

Older adults frequently report pain; cross-sectional studies have shown that pain is associated with worse cognitive function. However, longitudinal studies are lacking. We prospectively studied 441 participants without dementia, including 285 with pain, aged 65 years and older, enrolled in the Central Control of Mobility in Aging study, a prospective cohort study. We analyzed the longitudinal association between pain (measured with the Medical Outcomes Study pain severity scale) and major cognitive impairment (measured with the Repeatable Battery for the Assessment of Neuropsychological Status and the Trail Making Test Delta) using Cox regression analysis adjusted for age, gender, ethnicity, and education. Over a mean follow-up of 2.75 years (standard deviation = 1.94), there was no difference in the risk of developing cognitive impairment between participants with pain and participants without pain. However, among those with pain, risk for developing major memory impairment was higher among those with high levels of pain than those with low levels of pain (adjusted hazard ratio = 3.47, 95% confidence interval = 1.42-8.46). The association with pain and incident impairments in attention or executive function was not significant. We did not find that pain is associated with incident cognitive impairment in general, but among older adults with pain, a high level of pain is associated with increased risk of developing incident memory impairment. PERSPECTIVE: Our study results suggest that high levels of pain may contribute to incident memory impairment. Further research is needed to determine whether a high level of chronic pain is a modifiable risk factor for cognitive impairment in older adults.

Chronic Pain and Attention in Older Community-Dwelling Adults.

OBJECTIVES: To examine the cross-sectional relationship between chronic pain and complex attention in a population of community-living older adults. DESIGN: Prospective cross-sectional cohort study. SETTING: Population-based Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study II. PARTICIPANTS: Individuals aged 71 to 101 (N=354). MEASUREMENTS: Chronic pain was measured using the pain severity and interference subscales of the Brief Pain Inventory. Four subscales of the Test of Everyday Attention were used to measure domains of attention switching and selective, sustained, and divided attention. RESULTS: Before and after multivariable adjustment, pain severity was associated with poorer scores on measures of selective and sustained attention. Pain interference scores also were significantly inversely associated with selective attention. CONCLUSION: Chronic pain is associated with poorer performance in selective and sustained attention in community-dwelling older adults. Further research is needed to determine whether effective pain management could lead to better attentional performance in older adults. Older adults who live with chronic pain, often undertreated, are potentially at risk of cognitive difficulties and related functional consequences.

Measuring attention in very old adults using the Test of Everyday Attention.

There is a need for validated measures of attention for use in longitudinal studies of older populations. We studied 249 participants aged 80 to 101 years using the population-based MOBILIZE Boston Study. Four subscales of the Test of Everyday Attention (TEA) were included, measuring attention switching, selective, sustained and divided attention and a neuropsychological battery including validated measures of multiple cognitive domains measuring attention, executive function and memory. The TEA previously has not been validated in persons aged 80 and older. Among participants who completed the TEA, scores on other attentional measures strongly with TEA domains (R=.60-.70). Proportions of participants with incomplete TEA subscales ranged from 8% (selective attention) to 19% (attentional switching). Reasons for not completing TEA tests included failure to comprehend test instructions despite repetition and practice. These results demonstrate the challenges and potential value of the Test of Everyday Attention in studies of very old populations.

Pain and Cognitive Function Among Older Adults Living in the Community.

BACKGROUND: Pain related to many age-related chronic conditions is a burdensome problem in elderly adults and may also interfere with cognitive functioning. The purpose of this study was to examine the cross-sectional relationship between measures of pain severity and pain interference and cognitive performance in community-living older adults. METHODS: We studied 765 participants in the Maintenance of Balance Independent Living Intellect and Zest (MOBILIZE) Boston Study, a population-based study of persons aged 70 and older. Global pain severity and interference were measured using the Brief Pain Inventory subscales. The neuropsychological battery included measures of attentional capacity (Trail Making Test A, WORLD Test), executive function (Trail Making Test B and Delta, Clock-in-a-Box, Letter Fluency), memory (Hopkins Verbal Learning Test), and a global composite measure of cognitive function. Multivariable linear regression models were used to analyze the relationship between pain and cognitive functioning. RESULTS: Elderly adults with more severe pain or more pain interference had poorer performance on memory tests and executive functioning compared to elders with none or less pain. Pain interference was also associated with impaired attentional capacity. Additional adjustment for chronic conditions, behaviors, and psychiatric medication resulted in attenuation of many of the observed associations. However, the association between pain interference and general cognitive function persisted. CONCLUSIONS: Our findings point to the need for further research to understand how chronic pain may contribute to decline in cognitive function and to determine strategies that may help in preventing or managing these potential consequences of pain on cognitive function in older adults.