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Moderating effect of communication difficulty on the relationship between depression and pain: a study on community-dwelling older adults in Hong Kong a
b
Wallace Chi Ho Chan , Chi Wai Kwan & Iris Chi a
cd
Department of Social Work, Chinese University of Hong Kong, Shatin, Hong Kong
b
Department of Statistics & Actuarial Science, University of Hong Kong, Pokfulam, Hong Kong c
Golden Age Association Frances Wu Chair, School of Social Work, University of Southern California, Los Angeles, CA, USA d
Sau Po Centre on Aging, The University of Hong Kong, Pokfulam, Hong Kong Published online: 15 Oct 2014.
Click for updates To cite this article: Wallace Chi Ho Chan, Chi Wai Kwan & Iris Chi (2014): Moderating effect of communication difficulty on the relationship between depression and pain: a study on community-dwelling older adults in Hong Kong, Aging & Mental Health, DOI: 10.1080/13607863.2014.967172 To link to this article: http://dx.doi.org/10.1080/13607863.2014.967172
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Aging & Mental Health, 2014 http://dx.doi.org/10.1080/13607863.2014.967172
Moderating effect of communication difficulty on the relationship between depression and pain: a study on community-dwelling older adults in Hong Kong Wallace Chi Ho Chana, Chi Wai Kwanb and Iris Chic,d* a Department of Social Work, Chinese University of Hong Kong, Shatin, Hong Kong; bDepartment of Statistics & Actuarial Science, University of Hong Kong, Pokfulam, Hong Kong; cGolden Age Association Frances Wu Chair, School of Social Work, University of Southern California, Los Angeles, CA, USA; dSau Po Centre on Aging, The University of Hong Kong, Pokfulam, Hong Kong
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(Received 4 May 2014; accepted 12 September 2014) Objectives: This study examined the relationship between depression and pain, and the moderating effect of communication difficulty on this relationship, among community-dwelling older adults in Hong Kong. Method: We used logistic regression to analyze secondary data regarding 12,402 Chinese older adults applying for longterm care service in Hong Kong in 2012. Results: Approximately 30% of participants were depressed and 37% experienced communication difficulty. Depression was associated with increased pain. Communication difficulty was found to moderate the relationship between depression and pain. Pain scores increased more when individuals who experienced communication difficulty reported being depressed, compared to those who did not experience communication difficulty. Conclusion: The moderating effect of communication difficulty may be explained by the interaction between depression and communication difficulty. Participants who were depressed and concurrently experienced communication difficulty may be more likely to catastrophize their pain and may tend to report or experience more pain. Health care professionals need to be aware of the different effects of communication difficulty on the pain experiences of older adults. Psychosocial intervention may be provided to minimize older adults’ communication barriers to pain management. Keywords: pain; depression; communication; Chinese; moderating effect
Introduction Studies have reported that pain among community-dwelling older adults is high (Herr, 2011; Tsai, Liu, & Chung, 2010), especially when compared with younger populations (Wong & Fielding, 2011). For example, a survey reported that 72.4% of 7878 adults aged 50 or older in North Staffordshire, United Kingdom, reported the presence of pain during a four-week period (Thomas, Peat, Harris, Wilkie, & Croft, 2004). Pain is also a common symptom experienced by older adults and may negatively affect their activities of daily living (ADL) and quality of life (Takai, Yamamoto-Mitani, Okamoto, Koyama, & Honda, 2010). In particular, older adults with depression may be more likely to report higher levels of pain, although research on the causal relationship between depression and pain remains inconclusive (Hawker et al., 2011; Hilderink, Burger, Deeg, Beekman, & Oude Voshaar, 2012). Some studies reported that this causal relationship may be reciprocal (Chou, 2007; Kroenke et al., 2011). One strategy to better understand the relationship between depression and pain is to examine how other psychosocial factors may affect this relationship, because different physical and psychosocial symptoms may coexist as a ‘symptom cluster’ (Dodd et al., 2001). For example, the positive relationship between depression and pain was found to be non-significant after accounting for the moderating effect of loneliness. Older adults who experience
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
both depression and loneliness may tend to alienate and isolate themselves, and are thus less likely to report their pain (Chan, Kwan, Chi, & Chong, 2014). Another study found that some psychosocial factors, such as being unaware of their diagnosis and prognosis and alienating others, may reduce the tendency of palliative care patients to report their pain (Chan, 2013). These studies have indicated that psychosocial factors may affect how pain is reported among older adults and may represent psychosocial barriers to pain management (Chan et al., 2014; Zaza & Baine, 2002). Difficulty with or unwillingness to communicate with others may be another psychosocial factor that affects older adults’ pain reporting. Previous studies indicated that pain assessment and management may become more challenging among older adults when their subjective reporting of pain is limited by problems with communication (Fuchs-Lacelle & Hadjistavropoulos, 2004; Herr, 2011). The direct effect of communication difficulty on pain among older adults is obvious, i.e., older adults with communication problems, such as difficulty making themselves understood, tend to underreport more severe pain (Brown, 2010). However, whether and how communication difficulty moderates the relationship between depression and pain has not been explored. Therefore, in this study, we aimed to examine the moderating effect of a psychosocial factor, communication
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difficulty, on the relationship between depression and pain. Older adults may be more likely to experience communication difficulty due to issues such as cognitive impairment (Park, O’Connell, & Thomson, 2003) and hearing loss (Gopinath et al., 2012). In particular, they may experience additional difficulty communicating with health care professionals due to limited health literacy (Amalraj, Starkweather, Nguyen, & Naeim, 2009; Baker, Gazmararian, Sudano, & Patterson, 2000). Therefore, exploring how communication difficulty may influence the relationship between depression and pain among older adults is critical, and findings may indicate how best to manage the pain of older adults with depression who also experience communication difficulty.
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Methods Participants and procedures This secondary analysis used data collected from a large cohort of community-dwelling Chinese older adults applying for long-term care service in Hong Kong in 2012. When an older adult applies for such services, a trained and accredited assessor, usually a social worker, a nurse, or a paramedical professional, assesses the applicant using the Minimum Data Set for Home Care (MDS-HC) to ascertain care needs and match the applicant with appropriate services. Generally, an accredited assessor visits the applicant’s home to meet the applicant and any key caregivers. The assessor conducts the assessment by communicating with the applicant and any caregivers and making observations of the applicant’s living environment. Assessments typically take 45 to 60 minutes to complete. A detailed account of the assessment procedure has been reported elsewhere (Leung, Leung, & Chi, 2012). This sample was considered to be representative of the older population in Hong Kong. It included a majority of frail older adults living in Hong Kong who applied for long-term care services. Because Hong Kong has no means test for applying for long-term care services, this sample included applicants from all socioeconomic classes. The analysis consisted of examining data regarding 12,402 Chinese participants aged 60 or older.
Measures All measures were adopted from the MDS-HC, which is one of the Resident Assessment Instrument tools specifically developed for the home care setting to provide a comprehensive assessment of long-term care needs of older community dwellers (Carpenter, 2006). The instrument used in this study was the Hong Kong Chinese version of the Resident Assessment Instrument-Home Care, which has been validated in previous studies (Kwan, Chi, Lam, Lam, & Chou, 2000).
Dependent variable Pain was evaluated by two items: pain frequency and pain intensity (interRAI, 2014). Pain frequency was coded as 0
(no pain), 1 (less than daily), 2 (daily one period), and 3 (daily multiple periods). Pain intensity was coded as 0 (no pain), 1 (mild), 2 (moderate), 3 (severe), and 4 (horrible or excruciating). The overall score of the pain scale ranged from 0 to 4. A score of 0 indicated no pain and a score of 4 indicated severe pain. Cronbach’s alpha was .93.
Independent variables Depression was operationalized in this study based on a validated negative mood scale that measures the intensity of nine negative mood symptoms: (1) feelings of sadness or being depressed; (2) persistent anger with self or others; (3) expressions of what appear to be unrealistic fears; (4) repetitive health complaints; (5) repetitive anxious complaints and concerns; (6) sad, pained, or worried facial expressions; (7) recurrent crying and tearfulness; (8) withdrawal from activities of interest; and (9) reduced social interaction (Leung et al., 2012). Scores ranged from 0 to 18, with higher scores indicating higher levels of depression. This scale was used in other studies that also adopted MDS instruments (Chan et al., 2014; Leung, Leung, & Chi, 2014). Because only a few older adults in the sample experienced multiple negative mood symptoms, we recoded the depression measure as a dichotomous variable: 0 (no negative mood symptoms) and 1 (one or more negative mood symptoms).
Moderator Communication difficulty was based on the sum of two items: (1) ability to make oneself understood and (2) ability to understand others (HCPro, 2008; Sau Po Centre on Ageing, 2000). Total scores ranged from 0 (no communication difficulty) to 8 (severe communication difficulty). Cronbach’s alpha was .91. To study moderation effects, scores of communication difficulty were recoded into two groups: 0 (no communication difficulty) and 1 8 (communication difficulty).
Covariates We controlled for key demographic variables, cognitive, ADL, and instrumental activities of daily living (IADL) impairment, and changes in health status. Demographic variables of the care receiver included gender, age, marital status, and education level. Marital status was assessed as married or not married. Because the average education level of participants was very low, education was categorized as no education or some education. Cognitive impairment was measured with the five-item Cognitive Performance Scale, a hierarchical scale that assesses short-term memory, cognitive skills for daily decision making, ability to make oneself understood, comatose status, and dependence in eating (Morris et al., 1994). Scores ranged from 0 (cognitively intact) to 6 (very severe impairment). Its Cronbach’s alpha was .69. This scale has been widely adopted to measure the cognitive level of
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Aging & Mental Health older adults in previous studies (Onder et al., 2012; Zwakhalen, van der Steen, & Najim, 2012). ADL impairment was measured with a validated hierarchical scale that assesses dressing, hygiene, transfer, locomotion, toileting, bed mobility, and eating (Hirdes, 1996). The scale ranges from 0 (independent) to 6 (dependent; Morris, Fries, Morris, Philips, & Mor, 1995). Its Cronbach’s alpha was .91 in the current study. IADL impairment was measured based on the ability to perform seven tasks: meal preparation, ordinary housework, managing finances, managing medications, phone use, shopping, and transportation (Leung et al., 2012). The scale ranged from 0 (independent) to 48 (dependent). Its Cronbach’s alpha was .81 in the current study. The Changes in Health, End-Stage Disease, Signs, and Symptoms (CHESS) instrument was designed to identify individuals at risk of serious decline. This measure can serve as an outcome when the objective is to minimize problems related to declines in function or as an indicator of individuals with unstable health conditions (interRAI, 2014). CHESS measures changes in decision making, changes in ADL status, edema, shortness of breath, weight loss, insufficient fluid, decrease in food or fluid, and endstage disease. The 6-point scale ranges from 0 (not at all unstable) to 5 (highly unstable). Data analysis Means, standard deviations, frequencies, and percentages were used to summarize variables as appropriate. To examine the effects of the moderator and the independent variables on pain, we employed an ordinal logistic regression model. The moderation effects of depression on the independent variables were measured based on interaction terms. The analysis was conducted using SAS Version 9.3 for Windows. Results A sample of 12,402 older adults was included in the analysis. A majority of the participants were women and many were old old adults (older than 80). A significant proportion of respondents had not received any education, and more than one-third were married. Most participants were in stable physical condition and their cognitive function was only slightly impaired. Using a hearing aid when necessary, 44.06% of participants reported adequate hearing, 42.10% had minimal hearing difficulty, 13.76% could only hear in special situations, and 0.98% were highly impaired in terms of hearing. In addition, 27.16% of participants had stroke, 8.56% had Alzheimer’s disease, and 13.57% had a form of dementia other than Alzheimer’s disease. Concerning the ability to make oneself understood, 70.92% of participants always could make themselves understood by others, 17.34% could usually do so, 7.55% could often do so, 3.24% could sometimes do so, and 0.95% could rarely or never make themselves understood. Regarding their ability to understand others, 67.43% could always understand others, 20.27% could usually do so, 8.57% could often do so, 2.93% could
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Table 1. Summary statistics of older adults (N D 12,402). n (%) Depressed mood (>0) Communication difficulty (>0) Pain 0 1 2 3 4 Male Married Some education Age ADL IADL CHESS CPS 0 1 2 3 4 5 6
M (SD)
3752 (30.26) 4609 (37.18) 6176 (49.81) 2056 (16.85) 3637 (29.34) 510 (4.11) 19 (0.15) 5094 (41.09) 4775 (38.51) 7125 (57.47) 81.89 (7.78) 0.93 (1.12) 20.06 (6.40) 1.46 (1.05) 1.60 (0.85) 83 (6.75) 4614 (37.2) 6303 (50.82) 201 (1.62) 289 (2.33) 133 (1.07) 25 (0.20)
Note: ADL, activities of daily living; CHESS, Changes in Health, EndStage Disease, Signs, and Symptoms scale; CPS, Cognitive Performance Scale; IADL, instrumental activities of daily living.
sometimes do so, and 0.80% could rarely or never understand others. The cognitive impairment of participants was relatively low; they were all community-dwelling individuals and most of them applied for long-term care services before they experienced more serious cognitive impairment. According to our definition, approximately 30% of participants had depression and about 37% experienced communication difficulty. Details are shown in Table 1. An ordinal logistic regression model was employed to study the effects of depression on pain. Without considering the moderators, depression was positively associated with pain among Chinese older adults in Hong Kong (beta D 0.671, p < .001). When added to the model, communication difficulty had significant moderation effects (beta D 0.258, p < .001) on depression and pain. Pain increased for participants with no communication difficulty but depressed mood (beta D 0.593). For participants with communication difficulty, pain scores increased more when they reported depressed mood (beta D 0.851). Whether the participants had depression (beta D ¡0.048) or not (beta D ¡0.306), communication difficulty reduced pain scores. Men (beta D ¡0.684, p < 0.001) and more educated participants (beta D ¡0.101, p < .01) reported less severe pain. Severity of pain decreased with IADL (beta D ¡0.026, p < 0.001) and cognitive (beta D ¡0.438, p < .001) performance, and increased with changes in health status (beta D 0.300, p < .001). Details of the logistic regression analysis are shown in Table 2.
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Table 2. Ordinal logistic regression of pain on depression and its moderators.
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Depression Communication difficulty Communication difficulty £ depression Age Male Married Some education ADL IADL CHESS CPS
Beta
SE
95% CI
.593 ¡.306 .258
.049 .054 .078
.497, .690 ¡.411, ¡.200 .105, .411
.002 ¡.684 .026 ¡.101 .016 ¡.026 .300 ¡.438
.002 .042 .041 .039 .020 .003 .018 .029
¡.002, .007 ¡.767, ¡.601 ¡.055, .107 ¡.177, ¡.024 ¡.024, .057 ¡.033, ¡.020 .265, .335 ¡.495, ¡.382
Note: ADL, activities of daily living; CHESS, Changes in Health, EndStage Disease, Signs, and Symptoms scale; CPS, Cognitive Performance Scale; IADL, instrumental activities of daily living. p < .05, p < .01, p < .001
Discussion Our findings showed that communication difficulty exerted a moderating effect on the relationship between depression and pain after controlling for key factors such as cognitive impairment. When compared with older adults who did not experience communication difficulty, older adults with communication difficulty experienced more rapid increases in pain scores when they were depressed. At first glance, our findings may be surprising; it may be expected that communication difficulty would inhibit either older adults’ reporting of pain or the assessor’s ability to accurately assess their pain, thus, weakening the association between depression and pain. Our findings showed that communication difficulty was negatively associated with the pain scale. However, the inhibiting effect of communication difficulty on pain reporting or assessment was only valid when we focused on the relationship between communication and pain. In terms of the relationship between depression and pain, the moderating effect of communication difficulty suggests that communication difficulty may prompt older adults with depression to report more pain or assessors to overestimate their pain. One reason for our findings may be related to the interacting effect between depression and communication difficulty. Older adults who experienced depressed mood and communication difficulty at the same time may have experienced more distress and in turn tended to catastrophize their pain (Sullivan et al., 2001). Catastrophizing can be understood as having an exaggerated negative appraisal of a pain experience (Wood, Nicholas, Blyth, Asghari, & Gibson, 2013), and thus people who catastrophize their pain may tend to report or experience more pain (Khan et al., 2011; Sullivan, Martel, Tripp, Savard, & Crombez, 2006). It may be possible that when older adults who experience depression, including symptoms measured in this study (e.g., repetitive health complaints; repetitive anxious complaints and concerns; sad, pained, worried facial expressions; recurrent crying and
tearfulness), concurrently experience communication difficulty, their worry and anxiety regarding their pain may be exacerbated, leading them to catastrophize their pain experience. This postulation seems to be supported by our findings that pain was positively associated with repetitive health complaints (x2 D 67.7, p < .001) and repetitive anxious complaints and concerns (x2 D 331.8, p < .001), and that communication difficulty was positively associated with repetitive health complaints (x2 D 6.6, p < .05). Communication regarding pain between older adults and health care professionals has been acknowledged as very challenging (Cavalieri, 2005; Kenny, 2004; Weiland et al., 2012). Our findings further suggested that health care professionals may need to differentiate between the direct effect of communication difficulty on pain and its interacting effect with depression and pain among older adults. For example, our findings showed that communication difficulty may be associated with lower assessed pain scores among older adults. This may be related to difficulty communicating their pain to others in a limited time frame, leading them to underreport their pain. A previous study reported that older adults may underreport their pain when they believe that a health care professional is too busy to listen to their description of pain experiences (Catananti & Gambassi, 2010). Alternatively, their communication difficulty may inhibit the ability of assessors to reach an accurate understanding of their pain, again leading to underestimated severity of pain. However, health care professionals should be aware that when older adults experience communication difficulty and depression at the same time, the interacting effect may result in more pain being reported or experienced, instead of underreporting. Therefore, when conducting pain assessments with older adults, health care professionals should be sensitive to how communication difficulty may affect the reporting and experience of pain. For example, they may need to provide more time and space to explore pain among older adults who are experiencing depression and communication difficulty to minimize the possibility of catastrophizing the pain. Helping professionals, such as social workers, may also benefit from exploring the difficulties and worries of older adults in communicating their pain to better understand their pain experience. Psychosocial interventions may minimize psychosocial barriers to pain management (Chan et al., 2014). Limitations and future directions One of the limitations of this study is that depression was measured using a negative mood scale, which differed from other commonly used scales that measure depression. The preliminary results of this study highlight the need for further verification using a validated depression scale in future studies. Also, in this study, we assumed that pain was chronic in our older adult sample. Future studies may include items that measure the duration of pain, which may help identify whether the pain experienced was chronic. We tried to explain the moderating effect of communication difficulty by the phenomenon of
Aging & Mental Health pain catastrophizing. We acknowledge this explanation may be tentative and should be explored and verified in future studies. Qualitative research may also be conducted to explore how communication difficulty and depressive moods affects pain reporting and the overall pain experience of older adults.
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Conclusion In this study, communication difficulty was found to moderate the relationship between depression and pain among community-dwelling older adults living in Hong Kong. Pain scores increased more among older adults who experienced communication difficulty coupled with depression, compared to participants with no communication difficulty. This moderating effect may be explained by catastrophizing of pain by older adults. Health care professionals should pay more attention to the effects of communication difficulty on pain reporting and experiences among older adults. Psychosocial interventions may be provided to minimize older adults’ communication barriers regarding pain management. Acknowledgements The authors would like to thank the members of the RAI research team in Hong Kong for their comments and suggestions at the early stage of manuscript development.
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Tsai, Y.-F., Liu, L.-L., & Chung, S.-C. (2010). Pain prevalence, experiences, and self-care management strategies among the community-dwelling elderly in Taiwan. Journal of Pain and Symptom Management, 40(4), 575 581. doi:10.1016/j. jpainsymman.2010.02.013 Weiland, A., Van de Kraats, R.E., Blankenstein, A.H., Van Saase, J.L.C.M., Van der Molen, H.T., Bramer, W.M., . . . Arends, L.R. (2012). Encounters between medical specialists and patients with medically unexplained physical symptoms; influences of communication on patient outcomes and use of health care: A literature overview. Perspectives on Medical Education, 1(4), 192 206. doi:10.1007/s40037012-0025-0 Wong, W.S., & Fielding, R. (2011). Prevalence and characteristics of chronic pain in the general population of Hong Kong. Journal of Pain, 12(2), 236 245. doi:10.1016/j. jpain.2010.07.004 Wood, B.M., Nicholas, M.K., Blyth, F., Asghari, A., & Gibson, S. (2013). Catastrophizing mediates the relationship between pain intensity and depressed mood in older adults with persistent pain. Journal of Pain, 14(2), 149 157. doi:10.1016/j. jpain.2012.10.011 Zaza, C., & Baine, N. (2002). Cancer pain and psychosocial factors: A critical review of the literature. Journal of Pain and Symptom Management, 24(5), 526 542. doi:110.1016/ S0885-3924(02)00497-9] Zwakhalen, S.M.G., van der Steen, J.T., & Najim, M.D. (2012). Which score most likely represents pain on the observational PAINAD pain scale for patients with dementia? Journal of the American Medical Directors Association, 13(4), 384 389. doi:10.1016/j.jamda.2011.04.002
Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20
Moderating effect of communication difficulty on the relationship between depression and pain: a study on community-dwelling older adults in Hong Kong a
b
Wallace Chi Ho Chan , Chi Wai Kwan & Iris Chi a
cd
Department of Social Work, Chinese University of Hong Kong, Shatin, Hong Kong
b
Department of Statistics & Actuarial Science, University of Hong Kong, Pokfulam, Hong Kong c
Golden Age Association Frances Wu Chair, School of Social Work, University of Southern California, Los Angeles, CA, USA d
Sau Po Centre on Aging, The University of Hong Kong, Pokfulam, Hong Kong Published online: 15 Oct 2014.
Click for updates To cite this article: Wallace Chi Ho Chan, Chi Wai Kwan & Iris Chi (2014): Moderating effect of communication difficulty on the relationship between depression and pain: a study on community-dwelling older adults in Hong Kong, Aging & Mental Health, DOI: 10.1080/13607863.2014.967172 To link to this article: http://dx.doi.org/10.1080/13607863.2014.967172
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Aging & Mental Health, 2014 http://dx.doi.org/10.1080/13607863.2014.967172
Moderating effect of communication difficulty on the relationship between depression and pain: a study on community-dwelling older adults in Hong Kong Wallace Chi Ho Chana, Chi Wai Kwanb and Iris Chic,d* a Department of Social Work, Chinese University of Hong Kong, Shatin, Hong Kong; bDepartment of Statistics & Actuarial Science, University of Hong Kong, Pokfulam, Hong Kong; cGolden Age Association Frances Wu Chair, School of Social Work, University of Southern California, Los Angeles, CA, USA; dSau Po Centre on Aging, The University of Hong Kong, Pokfulam, Hong Kong
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(Received 4 May 2014; accepted 12 September 2014) Objectives: This study examined the relationship between depression and pain, and the moderating effect of communication difficulty on this relationship, among community-dwelling older adults in Hong Kong. Method: We used logistic regression to analyze secondary data regarding 12,402 Chinese older adults applying for longterm care service in Hong Kong in 2012. Results: Approximately 30% of participants were depressed and 37% experienced communication difficulty. Depression was associated with increased pain. Communication difficulty was found to moderate the relationship between depression and pain. Pain scores increased more when individuals who experienced communication difficulty reported being depressed, compared to those who did not experience communication difficulty. Conclusion: The moderating effect of communication difficulty may be explained by the interaction between depression and communication difficulty. Participants who were depressed and concurrently experienced communication difficulty may be more likely to catastrophize their pain and may tend to report or experience more pain. Health care professionals need to be aware of the different effects of communication difficulty on the pain experiences of older adults. Psychosocial intervention may be provided to minimize older adults’ communication barriers to pain management. Keywords: pain; depression; communication; Chinese; moderating effect
Introduction Studies have reported that pain among community-dwelling older adults is high (Herr, 2011; Tsai, Liu, & Chung, 2010), especially when compared with younger populations (Wong & Fielding, 2011). For example, a survey reported that 72.4% of 7878 adults aged 50 or older in North Staffordshire, United Kingdom, reported the presence of pain during a four-week period (Thomas, Peat, Harris, Wilkie, & Croft, 2004). Pain is also a common symptom experienced by older adults and may negatively affect their activities of daily living (ADL) and quality of life (Takai, Yamamoto-Mitani, Okamoto, Koyama, & Honda, 2010). In particular, older adults with depression may be more likely to report higher levels of pain, although research on the causal relationship between depression and pain remains inconclusive (Hawker et al., 2011; Hilderink, Burger, Deeg, Beekman, & Oude Voshaar, 2012). Some studies reported that this causal relationship may be reciprocal (Chou, 2007; Kroenke et al., 2011). One strategy to better understand the relationship between depression and pain is to examine how other psychosocial factors may affect this relationship, because different physical and psychosocial symptoms may coexist as a ‘symptom cluster’ (Dodd et al., 2001). For example, the positive relationship between depression and pain was found to be non-significant after accounting for the moderating effect of loneliness. Older adults who experience
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
both depression and loneliness may tend to alienate and isolate themselves, and are thus less likely to report their pain (Chan, Kwan, Chi, & Chong, 2014). Another study found that some psychosocial factors, such as being unaware of their diagnosis and prognosis and alienating others, may reduce the tendency of palliative care patients to report their pain (Chan, 2013). These studies have indicated that psychosocial factors may affect how pain is reported among older adults and may represent psychosocial barriers to pain management (Chan et al., 2014; Zaza & Baine, 2002). Difficulty with or unwillingness to communicate with others may be another psychosocial factor that affects older adults’ pain reporting. Previous studies indicated that pain assessment and management may become more challenging among older adults when their subjective reporting of pain is limited by problems with communication (Fuchs-Lacelle & Hadjistavropoulos, 2004; Herr, 2011). The direct effect of communication difficulty on pain among older adults is obvious, i.e., older adults with communication problems, such as difficulty making themselves understood, tend to underreport more severe pain (Brown, 2010). However, whether and how communication difficulty moderates the relationship between depression and pain has not been explored. Therefore, in this study, we aimed to examine the moderating effect of a psychosocial factor, communication
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difficulty, on the relationship between depression and pain. Older adults may be more likely to experience communication difficulty due to issues such as cognitive impairment (Park, O’Connell, & Thomson, 2003) and hearing loss (Gopinath et al., 2012). In particular, they may experience additional difficulty communicating with health care professionals due to limited health literacy (Amalraj, Starkweather, Nguyen, & Naeim, 2009; Baker, Gazmararian, Sudano, & Patterson, 2000). Therefore, exploring how communication difficulty may influence the relationship between depression and pain among older adults is critical, and findings may indicate how best to manage the pain of older adults with depression who also experience communication difficulty.
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Methods Participants and procedures This secondary analysis used data collected from a large cohort of community-dwelling Chinese older adults applying for long-term care service in Hong Kong in 2012. When an older adult applies for such services, a trained and accredited assessor, usually a social worker, a nurse, or a paramedical professional, assesses the applicant using the Minimum Data Set for Home Care (MDS-HC) to ascertain care needs and match the applicant with appropriate services. Generally, an accredited assessor visits the applicant’s home to meet the applicant and any key caregivers. The assessor conducts the assessment by communicating with the applicant and any caregivers and making observations of the applicant’s living environment. Assessments typically take 45 to 60 minutes to complete. A detailed account of the assessment procedure has been reported elsewhere (Leung, Leung, & Chi, 2012). This sample was considered to be representative of the older population in Hong Kong. It included a majority of frail older adults living in Hong Kong who applied for long-term care services. Because Hong Kong has no means test for applying for long-term care services, this sample included applicants from all socioeconomic classes. The analysis consisted of examining data regarding 12,402 Chinese participants aged 60 or older.
Measures All measures were adopted from the MDS-HC, which is one of the Resident Assessment Instrument tools specifically developed for the home care setting to provide a comprehensive assessment of long-term care needs of older community dwellers (Carpenter, 2006). The instrument used in this study was the Hong Kong Chinese version of the Resident Assessment Instrument-Home Care, which has been validated in previous studies (Kwan, Chi, Lam, Lam, & Chou, 2000).
Dependent variable Pain was evaluated by two items: pain frequency and pain intensity (interRAI, 2014). Pain frequency was coded as 0
(no pain), 1 (less than daily), 2 (daily one period), and 3 (daily multiple periods). Pain intensity was coded as 0 (no pain), 1 (mild), 2 (moderate), 3 (severe), and 4 (horrible or excruciating). The overall score of the pain scale ranged from 0 to 4. A score of 0 indicated no pain and a score of 4 indicated severe pain. Cronbach’s alpha was .93.
Independent variables Depression was operationalized in this study based on a validated negative mood scale that measures the intensity of nine negative mood symptoms: (1) feelings of sadness or being depressed; (2) persistent anger with self or others; (3) expressions of what appear to be unrealistic fears; (4) repetitive health complaints; (5) repetitive anxious complaints and concerns; (6) sad, pained, or worried facial expressions; (7) recurrent crying and tearfulness; (8) withdrawal from activities of interest; and (9) reduced social interaction (Leung et al., 2012). Scores ranged from 0 to 18, with higher scores indicating higher levels of depression. This scale was used in other studies that also adopted MDS instruments (Chan et al., 2014; Leung, Leung, & Chi, 2014). Because only a few older adults in the sample experienced multiple negative mood symptoms, we recoded the depression measure as a dichotomous variable: 0 (no negative mood symptoms) and 1 (one or more negative mood symptoms).
Moderator Communication difficulty was based on the sum of two items: (1) ability to make oneself understood and (2) ability to understand others (HCPro, 2008; Sau Po Centre on Ageing, 2000). Total scores ranged from 0 (no communication difficulty) to 8 (severe communication difficulty). Cronbach’s alpha was .91. To study moderation effects, scores of communication difficulty were recoded into two groups: 0 (no communication difficulty) and 1 8 (communication difficulty).
Covariates We controlled for key demographic variables, cognitive, ADL, and instrumental activities of daily living (IADL) impairment, and changes in health status. Demographic variables of the care receiver included gender, age, marital status, and education level. Marital status was assessed as married or not married. Because the average education level of participants was very low, education was categorized as no education or some education. Cognitive impairment was measured with the five-item Cognitive Performance Scale, a hierarchical scale that assesses short-term memory, cognitive skills for daily decision making, ability to make oneself understood, comatose status, and dependence in eating (Morris et al., 1994). Scores ranged from 0 (cognitively intact) to 6 (very severe impairment). Its Cronbach’s alpha was .69. This scale has been widely adopted to measure the cognitive level of
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Aging & Mental Health older adults in previous studies (Onder et al., 2012; Zwakhalen, van der Steen, & Najim, 2012). ADL impairment was measured with a validated hierarchical scale that assesses dressing, hygiene, transfer, locomotion, toileting, bed mobility, and eating (Hirdes, 1996). The scale ranges from 0 (independent) to 6 (dependent; Morris, Fries, Morris, Philips, & Mor, 1995). Its Cronbach’s alpha was .91 in the current study. IADL impairment was measured based on the ability to perform seven tasks: meal preparation, ordinary housework, managing finances, managing medications, phone use, shopping, and transportation (Leung et al., 2012). The scale ranged from 0 (independent) to 48 (dependent). Its Cronbach’s alpha was .81 in the current study. The Changes in Health, End-Stage Disease, Signs, and Symptoms (CHESS) instrument was designed to identify individuals at risk of serious decline. This measure can serve as an outcome when the objective is to minimize problems related to declines in function or as an indicator of individuals with unstable health conditions (interRAI, 2014). CHESS measures changes in decision making, changes in ADL status, edema, shortness of breath, weight loss, insufficient fluid, decrease in food or fluid, and endstage disease. The 6-point scale ranges from 0 (not at all unstable) to 5 (highly unstable). Data analysis Means, standard deviations, frequencies, and percentages were used to summarize variables as appropriate. To examine the effects of the moderator and the independent variables on pain, we employed an ordinal logistic regression model. The moderation effects of depression on the independent variables were measured based on interaction terms. The analysis was conducted using SAS Version 9.3 for Windows. Results A sample of 12,402 older adults was included in the analysis. A majority of the participants were women and many were old old adults (older than 80). A significant proportion of respondents had not received any education, and more than one-third were married. Most participants were in stable physical condition and their cognitive function was only slightly impaired. Using a hearing aid when necessary, 44.06% of participants reported adequate hearing, 42.10% had minimal hearing difficulty, 13.76% could only hear in special situations, and 0.98% were highly impaired in terms of hearing. In addition, 27.16% of participants had stroke, 8.56% had Alzheimer’s disease, and 13.57% had a form of dementia other than Alzheimer’s disease. Concerning the ability to make oneself understood, 70.92% of participants always could make themselves understood by others, 17.34% could usually do so, 7.55% could often do so, 3.24% could sometimes do so, and 0.95% could rarely or never make themselves understood. Regarding their ability to understand others, 67.43% could always understand others, 20.27% could usually do so, 8.57% could often do so, 2.93% could
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Table 1. Summary statistics of older adults (N D 12,402). n (%) Depressed mood (>0) Communication difficulty (>0) Pain 0 1 2 3 4 Male Married Some education Age ADL IADL CHESS CPS 0 1 2 3 4 5 6
M (SD)
3752 (30.26) 4609 (37.18) 6176 (49.81) 2056 (16.85) 3637 (29.34) 510 (4.11) 19 (0.15) 5094 (41.09) 4775 (38.51) 7125 (57.47) 81.89 (7.78) 0.93 (1.12) 20.06 (6.40) 1.46 (1.05) 1.60 (0.85) 83 (6.75) 4614 (37.2) 6303 (50.82) 201 (1.62) 289 (2.33) 133 (1.07) 25 (0.20)
Note: ADL, activities of daily living; CHESS, Changes in Health, EndStage Disease, Signs, and Symptoms scale; CPS, Cognitive Performance Scale; IADL, instrumental activities of daily living.
sometimes do so, and 0.80% could rarely or never understand others. The cognitive impairment of participants was relatively low; they were all community-dwelling individuals and most of them applied for long-term care services before they experienced more serious cognitive impairment. According to our definition, approximately 30% of participants had depression and about 37% experienced communication difficulty. Details are shown in Table 1. An ordinal logistic regression model was employed to study the effects of depression on pain. Without considering the moderators, depression was positively associated with pain among Chinese older adults in Hong Kong (beta D 0.671, p < .001). When added to the model, communication difficulty had significant moderation effects (beta D 0.258, p < .001) on depression and pain. Pain increased for participants with no communication difficulty but depressed mood (beta D 0.593). For participants with communication difficulty, pain scores increased more when they reported depressed mood (beta D 0.851). Whether the participants had depression (beta D ¡0.048) or not (beta D ¡0.306), communication difficulty reduced pain scores. Men (beta D ¡0.684, p < 0.001) and more educated participants (beta D ¡0.101, p < .01) reported less severe pain. Severity of pain decreased with IADL (beta D ¡0.026, p < 0.001) and cognitive (beta D ¡0.438, p < .001) performance, and increased with changes in health status (beta D 0.300, p < .001). Details of the logistic regression analysis are shown in Table 2.
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Table 2. Ordinal logistic regression of pain on depression and its moderators.
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Depression Communication difficulty Communication difficulty £ depression Age Male Married Some education ADL IADL CHESS CPS
Beta
SE
95% CI
.593 ¡.306 .258
.049 .054 .078
.497, .690 ¡.411, ¡.200 .105, .411
.002 ¡.684 .026 ¡.101 .016 ¡.026 .300 ¡.438
.002 .042 .041 .039 .020 .003 .018 .029
¡.002, .007 ¡.767, ¡.601 ¡.055, .107 ¡.177, ¡.024 ¡.024, .057 ¡.033, ¡.020 .265, .335 ¡.495, ¡.382
Note: ADL, activities of daily living; CHESS, Changes in Health, EndStage Disease, Signs, and Symptoms scale; CPS, Cognitive Performance Scale; IADL, instrumental activities of daily living. p < .05, p < .01, p < .001
Discussion Our findings showed that communication difficulty exerted a moderating effect on the relationship between depression and pain after controlling for key factors such as cognitive impairment. When compared with older adults who did not experience communication difficulty, older adults with communication difficulty experienced more rapid increases in pain scores when they were depressed. At first glance, our findings may be surprising; it may be expected that communication difficulty would inhibit either older adults’ reporting of pain or the assessor’s ability to accurately assess their pain, thus, weakening the association between depression and pain. Our findings showed that communication difficulty was negatively associated with the pain scale. However, the inhibiting effect of communication difficulty on pain reporting or assessment was only valid when we focused on the relationship between communication and pain. In terms of the relationship between depression and pain, the moderating effect of communication difficulty suggests that communication difficulty may prompt older adults with depression to report more pain or assessors to overestimate their pain. One reason for our findings may be related to the interacting effect between depression and communication difficulty. Older adults who experienced depressed mood and communication difficulty at the same time may have experienced more distress and in turn tended to catastrophize their pain (Sullivan et al., 2001). Catastrophizing can be understood as having an exaggerated negative appraisal of a pain experience (Wood, Nicholas, Blyth, Asghari, & Gibson, 2013), and thus people who catastrophize their pain may tend to report or experience more pain (Khan et al., 2011; Sullivan, Martel, Tripp, Savard, & Crombez, 2006). It may be possible that when older adults who experience depression, including symptoms measured in this study (e.g., repetitive health complaints; repetitive anxious complaints and concerns; sad, pained, worried facial expressions; recurrent crying and
tearfulness), concurrently experience communication difficulty, their worry and anxiety regarding their pain may be exacerbated, leading them to catastrophize their pain experience. This postulation seems to be supported by our findings that pain was positively associated with repetitive health complaints (x2 D 67.7, p < .001) and repetitive anxious complaints and concerns (x2 D 331.8, p < .001), and that communication difficulty was positively associated with repetitive health complaints (x2 D 6.6, p < .05). Communication regarding pain between older adults and health care professionals has been acknowledged as very challenging (Cavalieri, 2005; Kenny, 2004; Weiland et al., 2012). Our findings further suggested that health care professionals may need to differentiate between the direct effect of communication difficulty on pain and its interacting effect with depression and pain among older adults. For example, our findings showed that communication difficulty may be associated with lower assessed pain scores among older adults. This may be related to difficulty communicating their pain to others in a limited time frame, leading them to underreport their pain. A previous study reported that older adults may underreport their pain when they believe that a health care professional is too busy to listen to their description of pain experiences (Catananti & Gambassi, 2010). Alternatively, their communication difficulty may inhibit the ability of assessors to reach an accurate understanding of their pain, again leading to underestimated severity of pain. However, health care professionals should be aware that when older adults experience communication difficulty and depression at the same time, the interacting effect may result in more pain being reported or experienced, instead of underreporting. Therefore, when conducting pain assessments with older adults, health care professionals should be sensitive to how communication difficulty may affect the reporting and experience of pain. For example, they may need to provide more time and space to explore pain among older adults who are experiencing depression and communication difficulty to minimize the possibility of catastrophizing the pain. Helping professionals, such as social workers, may also benefit from exploring the difficulties and worries of older adults in communicating their pain to better understand their pain experience. Psychosocial interventions may minimize psychosocial barriers to pain management (Chan et al., 2014). Limitations and future directions One of the limitations of this study is that depression was measured using a negative mood scale, which differed from other commonly used scales that measure depression. The preliminary results of this study highlight the need for further verification using a validated depression scale in future studies. Also, in this study, we assumed that pain was chronic in our older adult sample. Future studies may include items that measure the duration of pain, which may help identify whether the pain experienced was chronic. We tried to explain the moderating effect of communication difficulty by the phenomenon of
Aging & Mental Health pain catastrophizing. We acknowledge this explanation may be tentative and should be explored and verified in future studies. Qualitative research may also be conducted to explore how communication difficulty and depressive moods affects pain reporting and the overall pain experience of older adults.
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Conclusion In this study, communication difficulty was found to moderate the relationship between depression and pain among community-dwelling older adults living in Hong Kong. Pain scores increased more among older adults who experienced communication difficulty coupled with depression, compared to participants with no communication difficulty. This moderating effect may be explained by catastrophizing of pain by older adults. Health care professionals should pay more attention to the effects of communication difficulty on pain reporting and experiences among older adults. Psychosocial interventions may be provided to minimize older adults’ communication barriers regarding pain management. Acknowledgements The authors would like to thank the members of the RAI research team in Hong Kong for their comments and suggestions at the early stage of manuscript development.
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