Age and Ageing Advance Access published May 9, 2014 Age and Ageing 2014; 0: 1–6 doi: 10.1093/ageing/afu052
© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]
More attention to pain management in community-dwelling older persons with chronic musculoskeletal pain NIINA MARIA KARTTUNEN1, JUHA TURUNEN2, RIITTA AHONEN3, SIRPA HARTIKAINEN3 1
School of Pharmacy, University of Eastern Finland, PO Box 1627, Kuopio 70211, Finland Farenta Oy, Vantaa, Finland 3 School of Pharmacy, University of Eastern Finland, Kuopio, Finland 2
Address correspondence to: N. M. Karttunen. Tel: (+358) 503831882. Email: [email protected]
Background: persistent pain is a major problem in older people, but little is known about older persons’ opinion about the treatment of persistent pain. Objective: the objective of this study was to investigate the factors associated with older participants having chronic musculoskeletal pain and hoping persistently that physician would pay more attention to the pain management. Methods: this 3-year follow-up study was a part of large population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study. The population sample (n = 1000) of the GeMS study was randomly selected from older inhabitants (≥75 years) of Kuopio city, Finland, and participants were interviewed annually in the municipal health centre or in the participant’s current residence by three study nurses. The current substudy included participants with chronic musculoskeletal pain (n = 270). Participants were asked specifically whether they hoped that more attention would be paid to pain management by the physician. Results: at baseline, 41% of the community-dwelling older participants with chronic musculoskeletal pain hoped the physician would pay more attention to pain management. Of those participants, 49% were still continuing to hope after 1 year and 31% after 2 years. A persistent hope to receive more attention to pain management was associated with poor self-rated health (OR: 2.94; 95% CI: 1.04–8.30), moderate-to-severe pain (OR: 3.46; 95% CI: 1.42–8.44), and the daily use of analgesics (OR: 4.16; 95% CI: 1.08–16.09). Conclusion: physicians need to take a more active role in the process of recognising, assessing and controlling persistent pain in older people. Keywords: older, community-dwelling, chronic pain, pain management, older people
Introduction Chronic pain, affecting approximately half of communitydwelling older people, is a multidimensional health problem [1]. It is known to have a negative impact on the functioning, mood, sleep and overall health of the individual [2–5]. Medication is the most common component of treatment, although effective treatment may include also nonpharmacological approaches such as psychological, behavioural or physical therapy [6]. Persistent pain is a common reason for seeking medical care, but it seems to be inadequately assessed and treated [7–9]. Uncontrolled pain is a significant problem increasing the cost of healthcare services [10, 11] and individuals’ suffering that fosters hopelessness
[12]. However, the assessment and treatment of persistent pain in older people is challenging, because the pain might have existed for a long time and older individuals often have complicating factors such as multiple illnesses, several medications and susceptibility to medication-related adverse events due to age-related changes in pharmacokinetics and dynamics [13]. There have been reports that older persons adopt a stoical attitude and this phenomenon may reduce helpseeking behaviour and encourage older people to live with persistent pain conditions [14, 15]. Furthermore, physicians tend to underestimate patients’ pain experience, which may explain why there is inadequate management of pain [16]. Considering subjective nature of the pain experience and the
1
Downloaded from http://ageing.oxfordjournals.org/ at Anadolu University on May 20, 2014
Abstract
N. M. Karttunen et al.
Methods Study setting and participants
This study is a part of larger population-based GeMS study (Geriatric Multidisciplinary Strategy for the Good Care of the Elderly) [19], which was a health intervention study focusing on clinical epidemiology, medication and functional capacity in people aged 75 years and older. The flow chart of the study population is presented in Figure 1. All the participants of the GeMS study were interviewed and examined annually by three study nurses during the years 2004–07. Interviews and examinations were performed in municipal health centre or in participant’s current residence. The study nurses used a structured questionnaire and information collected during the interviews and examinations were entered into the SPSS for the statistical tests and analyses. The current substudy investigates individuals with non-malignant chronic musculoskeletal pain. Since information of chronic pain was incomplete in 2004, we analysed data from the years 2005, 2006 and 2007. There was a total of 270 participants (203 women and 67 men) aged 76 years and older (mean age 82.3 ± 4.5, range 76.5–100.0), 127 (47.0%) in the intervention group and 143 (53.0%) in the control group. For the purpose of this study, we pooled the intervention and control groups together, because pain was not the focus of interventions and pre-analyses confirmed the similarity of characteristics between groups. The participants’ age at the baseline was categorised into three groups: 76–79, 80–84 and 85 years or older. Years of education was classified into two categories: 6 years or less and more than 6 years. Participants were asked whether they were living alone (yes or no). The
2
Figure 1. The flow chart of the study. In the substudy of GeMS (Geriatric Multidisciplinary Strategy for the Good Care of the Elderly), intervention and control groups were combined, because pain was not the focus of interventions and preanalyses confirmed similarity of groups*. MMSE, Mini Mental State Examination score.
study participants provided written informed consent to participate and the study procedures were approved by the Research Ethics Committee of the Hospital District of Northern Savo. Health and functional status of the study participants
Participants were asked to rate their health with five options (good, fairly good, moderate, poor or very poor) [20]. In this analysis, the health categories 1–2 (good and fairly good selfrated health) and 3–5 (moderate, poor and very poor selfrated health) were combined. The participants’ comorbid conditions were computed using a modified version of functional comorbidity index (FCI).[21] In the GeMS study, data on the following 13 medical conditions were available [22]: (i) rheumatoid arthritis and other inflammatory connective tissue diseases, (ii) osteoporosis, (iii) diabetes (type I or II), (iv) chronic asthma or chronic obstructive pulmonary disease (COPD), (v) coronary artery disease, (vi) heart failure, (vii) myocardial infarction, (viii) stroke, (ix) depressive disorder, (x) visual impairment, (xi) hearing impairment, (xii) Parkinson’s disease or multiple sclerosis and (xiii) obesity (body mass index, BMI > 30). The presence of each of the
Downloaded from http://ageing.oxfordjournals.org/ at Anadolu University on May 20, 2014
possible discrepancy between patients’ and physicians’ estimation of pain, it is important to take into account the patients’ perspectives. There are many studies investigating the perspective of patients experiencing pain, but the research specific to older people and their hopes is limited. Hope is a multidimensional concept; it is both universal (as general belief in the future) and specific hope for something (such that a treatment will be successful in chronic disease) [17]. Hopefulness fosters coping strategies that increase participation in treatment regimens and strengthen the belief that difficulties can be managed [18]. To optimise pain control and prevent suffering, it is important to recognise older people’s hopes concerning pain management and factors associated with those who persistently hope more attention to pain management. We could not identify studies concerning older persons’ perception of whether they hope to receive more attention from the physician in the management of their pain. This longitudinal study is based on the question ‘Do community-dwelling older persons with chronic musculoskeletal pain hope to receive more attention to pain management?’ The aim was to examine persistence of those hopes and the factors associated with participants, who persistently hope that physician would pay more attention to the pain management.
More attention to pain management in community-dwelling older persons hope that more attention would be paid to pain management. All the statistical analyses were conducted using the SPSS statistical software for Windows (SPSS, Inc., Chicago, IL, USA) version 19.0 and P-values 6 years 82 (51.9) Living alone, yes 91 (56.9) Body mass index >30 48 (30.0) FCI mean ± SD 3.1 ± 1.8 COPD/asthma 19 (11.9) Cardiovascular disease 99 (61.9) Diabetes (type I or II) 35 (21.9) Stroke 25 (15.6) Depressive symptoms 13 (8.1) Osteoarthritis 87 (55.1) IADL 0–6 53 (33.1) Self-rated mobility, able to walk 400 m Yes, without difficulty 78 (48.8) With difficulty/not without 82 (51.2) help Self-rated health Excellent/good 75 (46.9) Moderate/poor 85 (53.1) Pain intensity, NRS 1–10 Mild (2–4) 93 (58.1) Moderate or severe (5–10) 67 (41.9) Use of analgesics No 46 (28.8) As needed 98 (61.2) Daily 16 (10.0)
45 (40.9) 65 (59.1)
0.094
47 (42.8) 37 (33.6) 26 (23.6) 85 (77.3)
0.230 0.510
61 (56.0) 48 (44.0) 68 (61.8) 32 (29.1) 3.1 ± 2.0 14 (12.7) 60 (54.5) 22 (20.0) 14 (12.7) 23 (20.9) 72 (67.9)
0.206 0.417 0.872 0.742 0.834 0.229 0.711 0.506 0.002 0.036
46 (41.8)
0.145
40 (36.4) 70 (63.6)
0.044
33 (30.0) 77 (70.0)
0.005
32 (29.1) 78 (70.9)
© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: [email protected]
More attention to pain management in community-dwelling older persons with chronic musculoskeletal pain NIINA MARIA KARTTUNEN1, JUHA TURUNEN2, RIITTA AHONEN3, SIRPA HARTIKAINEN3 1
School of Pharmacy, University of Eastern Finland, PO Box 1627, Kuopio 70211, Finland Farenta Oy, Vantaa, Finland 3 School of Pharmacy, University of Eastern Finland, Kuopio, Finland 2
Address correspondence to: N. M. Karttunen. Tel: (+358) 503831882. Email: [email protected]
Background: persistent pain is a major problem in older people, but little is known about older persons’ opinion about the treatment of persistent pain. Objective: the objective of this study was to investigate the factors associated with older participants having chronic musculoskeletal pain and hoping persistently that physician would pay more attention to the pain management. Methods: this 3-year follow-up study was a part of large population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study. The population sample (n = 1000) of the GeMS study was randomly selected from older inhabitants (≥75 years) of Kuopio city, Finland, and participants were interviewed annually in the municipal health centre or in the participant’s current residence by three study nurses. The current substudy included participants with chronic musculoskeletal pain (n = 270). Participants were asked specifically whether they hoped that more attention would be paid to pain management by the physician. Results: at baseline, 41% of the community-dwelling older participants with chronic musculoskeletal pain hoped the physician would pay more attention to pain management. Of those participants, 49% were still continuing to hope after 1 year and 31% after 2 years. A persistent hope to receive more attention to pain management was associated with poor self-rated health (OR: 2.94; 95% CI: 1.04–8.30), moderate-to-severe pain (OR: 3.46; 95% CI: 1.42–8.44), and the daily use of analgesics (OR: 4.16; 95% CI: 1.08–16.09). Conclusion: physicians need to take a more active role in the process of recognising, assessing and controlling persistent pain in older people. Keywords: older, community-dwelling, chronic pain, pain management, older people
Introduction Chronic pain, affecting approximately half of communitydwelling older people, is a multidimensional health problem [1]. It is known to have a negative impact on the functioning, mood, sleep and overall health of the individual [2–5]. Medication is the most common component of treatment, although effective treatment may include also nonpharmacological approaches such as psychological, behavioural or physical therapy [6]. Persistent pain is a common reason for seeking medical care, but it seems to be inadequately assessed and treated [7–9]. Uncontrolled pain is a significant problem increasing the cost of healthcare services [10, 11] and individuals’ suffering that fosters hopelessness
[12]. However, the assessment and treatment of persistent pain in older people is challenging, because the pain might have existed for a long time and older individuals often have complicating factors such as multiple illnesses, several medications and susceptibility to medication-related adverse events due to age-related changes in pharmacokinetics and dynamics [13]. There have been reports that older persons adopt a stoical attitude and this phenomenon may reduce helpseeking behaviour and encourage older people to live with persistent pain conditions [14, 15]. Furthermore, physicians tend to underestimate patients’ pain experience, which may explain why there is inadequate management of pain [16]. Considering subjective nature of the pain experience and the
1
Downloaded from http://ageing.oxfordjournals.org/ at Anadolu University on May 20, 2014
Abstract
N. M. Karttunen et al.
Methods Study setting and participants
This study is a part of larger population-based GeMS study (Geriatric Multidisciplinary Strategy for the Good Care of the Elderly) [19], which was a health intervention study focusing on clinical epidemiology, medication and functional capacity in people aged 75 years and older. The flow chart of the study population is presented in Figure 1. All the participants of the GeMS study were interviewed and examined annually by three study nurses during the years 2004–07. Interviews and examinations were performed in municipal health centre or in participant’s current residence. The study nurses used a structured questionnaire and information collected during the interviews and examinations were entered into the SPSS for the statistical tests and analyses. The current substudy investigates individuals with non-malignant chronic musculoskeletal pain. Since information of chronic pain was incomplete in 2004, we analysed data from the years 2005, 2006 and 2007. There was a total of 270 participants (203 women and 67 men) aged 76 years and older (mean age 82.3 ± 4.5, range 76.5–100.0), 127 (47.0%) in the intervention group and 143 (53.0%) in the control group. For the purpose of this study, we pooled the intervention and control groups together, because pain was not the focus of interventions and pre-analyses confirmed the similarity of characteristics between groups. The participants’ age at the baseline was categorised into three groups: 76–79, 80–84 and 85 years or older. Years of education was classified into two categories: 6 years or less and more than 6 years. Participants were asked whether they were living alone (yes or no). The
2
Figure 1. The flow chart of the study. In the substudy of GeMS (Geriatric Multidisciplinary Strategy for the Good Care of the Elderly), intervention and control groups were combined, because pain was not the focus of interventions and preanalyses confirmed similarity of groups*. MMSE, Mini Mental State Examination score.
study participants provided written informed consent to participate and the study procedures were approved by the Research Ethics Committee of the Hospital District of Northern Savo. Health and functional status of the study participants
Participants were asked to rate their health with five options (good, fairly good, moderate, poor or very poor) [20]. In this analysis, the health categories 1–2 (good and fairly good selfrated health) and 3–5 (moderate, poor and very poor selfrated health) were combined. The participants’ comorbid conditions were computed using a modified version of functional comorbidity index (FCI).[21] In the GeMS study, data on the following 13 medical conditions were available [22]: (i) rheumatoid arthritis and other inflammatory connective tissue diseases, (ii) osteoporosis, (iii) diabetes (type I or II), (iv) chronic asthma or chronic obstructive pulmonary disease (COPD), (v) coronary artery disease, (vi) heart failure, (vii) myocardial infarction, (viii) stroke, (ix) depressive disorder, (x) visual impairment, (xi) hearing impairment, (xii) Parkinson’s disease or multiple sclerosis and (xiii) obesity (body mass index, BMI > 30). The presence of each of the
Downloaded from http://ageing.oxfordjournals.org/ at Anadolu University on May 20, 2014
possible discrepancy between patients’ and physicians’ estimation of pain, it is important to take into account the patients’ perspectives. There are many studies investigating the perspective of patients experiencing pain, but the research specific to older people and their hopes is limited. Hope is a multidimensional concept; it is both universal (as general belief in the future) and specific hope for something (such that a treatment will be successful in chronic disease) [17]. Hopefulness fosters coping strategies that increase participation in treatment regimens and strengthen the belief that difficulties can be managed [18]. To optimise pain control and prevent suffering, it is important to recognise older people’s hopes concerning pain management and factors associated with those who persistently hope more attention to pain management. We could not identify studies concerning older persons’ perception of whether they hope to receive more attention from the physician in the management of their pain. This longitudinal study is based on the question ‘Do community-dwelling older persons with chronic musculoskeletal pain hope to receive more attention to pain management?’ The aim was to examine persistence of those hopes and the factors associated with participants, who persistently hope that physician would pay more attention to the pain management.
More attention to pain management in community-dwelling older persons hope that more attention would be paid to pain management. All the statistical analyses were conducted using the SPSS statistical software for Windows (SPSS, Inc., Chicago, IL, USA) version 19.0 and P-values 6 years 82 (51.9) Living alone, yes 91 (56.9) Body mass index >30 48 (30.0) FCI mean ± SD 3.1 ± 1.8 COPD/asthma 19 (11.9) Cardiovascular disease 99 (61.9) Diabetes (type I or II) 35 (21.9) Stroke 25 (15.6) Depressive symptoms 13 (8.1) Osteoarthritis 87 (55.1) IADL 0–6 53 (33.1) Self-rated mobility, able to walk 400 m Yes, without difficulty 78 (48.8) With difficulty/not without 82 (51.2) help Self-rated health Excellent/good 75 (46.9) Moderate/poor 85 (53.1) Pain intensity, NRS 1–10 Mild (2–4) 93 (58.1) Moderate or severe (5–10) 67 (41.9) Use of analgesics No 46 (28.8) As needed 98 (61.2) Daily 16 (10.0)
45 (40.9) 65 (59.1)
0.094
47 (42.8) 37 (33.6) 26 (23.6) 85 (77.3)
0.230 0.510
61 (56.0) 48 (44.0) 68 (61.8) 32 (29.1) 3.1 ± 2.0 14 (12.7) 60 (54.5) 22 (20.0) 14 (12.7) 23 (20.9) 72 (67.9)
0.206 0.417 0.872 0.742 0.834 0.229 0.711 0.506 0.002 0.036
46 (41.8)
0.145
40 (36.4) 70 (63.6)
0.044
33 (30.0) 77 (70.0)
0.005
32 (29.1) 78 (70.9)
