ORIGINAL ARTICLE

Old and in pain: Enduring and situational effects of cultural aging stereotypes on older people’s pain experiences S.F. Bernardes, S. Marques, M. Matos Instituto Universitário de Lisboa (ISCTE-IUL)/Centro de Investigação e Intervenção Social (CIS-IUL), Lisbon, Portugal

Correspondence Sónia F. Bernardes E-mail: [email protected] Funding sources None. Conflicts of interest None declared. Accepted for publication 15 October 2014 doi:10.1002/ejp.626

Abstract Background: This study aimed to investigate the interplay between enduring and situational aging stereotype (AS) effects in older adults’ self-reports of clinical and experimentally induced pain. We expected that, as compared with the situational activation of positive AS or a neutral condition, the activation of negative AS would lead to more severe self-reports of clinical pain (H1, hypothesis 1), higher cold pressor task (CPT) pain threshold (H2) and lower CPT pain tolerance (H3), especially among older adults who more strongly endorsed AS. Methods: This was a prospective study across two moments in time. At time 1 (T1), 52 older adults (Mage = 74.7; 51.9% women) filled out measures of cultural AS endorsement, clinical pain severity and interference. Three months afterwards (T2), some of these participants collaborated in an experimental study on the effects of AS activation on reported clinical pain (n = 40) and experimentally induced (using CPT) pain threshold and tolerance (n = 35). Results: Our results supported H2, i.e., as compared with the activation of positive AS or a neutral condition, when negative AS were activated older adults showed higher CPT pain thresholds, but this effect was more salient among those who more strongly endorsed AS at T1. Conclusions: This study stresses the influence of cultural AS in older adults’ pain experiences showing that the situational activation of negative AS greatly increases experimentally induced pain thresholds of elders who more strongly endorse those stereotypes. It also highlights the relevance of interventions at the level of the physical and/or social environments surrounding elders in pain.

1. Introduction More than 50% of older adults suffer from persistent (musculoskeletal) pain that is often disabling (Thomas et al., 2004; Pickering, 2005; Covinsky et al., 2009). Despite the urgency to better account for and manage older people’s pain experiences, research on its psychosocial determinants is still on its infancy (Gibson and Weiner, 2005). Moreover, much research has focused on the role of (perceived) social support (e.g., Evers et al., 2003; Gibson and Weiner, 2005; López-Martínez et al., 2008; Matos and Bernardes, 994 Eur J Pain 19 (2015) 994--1001

2013), often ignoring broader and more pervasive social influences like cultural aging stereotypes (AS). Cultural AS are shared representations of the characteristics typically associated with older adults in a given cultural context (Schmidt and Boland, 1986). AS are enduringly stored in individuals’ long-term memory and are prone to be activated in working memory when appropriate situational cues are present (Schneider, 2005). Because AS are internalized in childhood and reinforced throughout life, they become self-stereotypes at old age that, when situationally activated, may influence older people’s © 2014 European Pain Federation - EFICâ

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Old and in pain

What’s already known about this topic? • Aging stereotypes (AS), when activated in memory, may influence older adults’ healthrelated outcomes, especially of those who have stronger representations of AS in their long-term memory. • No studies have analysed the effects of AS on older adults’ pain experiences.

thresholds but a decline in pain tolerance (Gibson and Farrel, 2004; Edwards, 2005). Therefore, we expected that as compared with the situational activation of a positive AS or a neutral condition, the situational activation of a negative AS (at T2) would lead to higher pain thresholds (H2) and lower pain tolerance levels (H3), but especially among older people who more strongly endorsed AS at T1.

What does this study add? • It shows that the situational activation of negative AS hampers pain detection among older adults who strongly endorse AS. • It stresses the relevance of physical and/or social environment interventions.

2. Methods

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Fifty-two older adults (51.9% women), aged between 65 and 88 years old (M = 74.73, SD = 6.44), were invited and accepted to participate in this study at T1 (see Fig. 1 – a flow chart illustrating the study phases and number of participants in each). All participants were attending a day care

ENROLMENT

Participants invited (n = 52) Inclusion criteria: - Able to read and write - Normal cognitive functioning

Participants who filled out the protocol at T1 (n = 52)

Excluded (n =12):

FOLLOW-UP

Refused to participate (n = 5) Deceased (n =1 ) Unreachable (n = 6)

Participants who agreed to participate at T2 (n = 40)

Randomized (n = 40)

Allocated to Positive Condition (n = 13) Excluded from CPT (n = 2); met exclusion criteria

ALLOCATION

health-related performances at many levels. For example, studies showed that, as compared with the activation of positive AS (by presenting positive stereotypic traits, e.g., wise or sociable), the activation of negative AS (by presenting negative stereotypic traits, e.g., ill or forgetful) leads to older adults’ lower memory and walking performances (Levy, 1996, 2003; Hausdorff et al., 1999), higher cardiovascular reactivity (Levy et al., 2000) and lower will to live (Levy et al., 1999–2000). Moreover, and in line with the predictions of Bargh et al. (1986, 1988, 1996), some studies also showed that these situational effects were more salient among elders who had a stronger representation of AS in their long-term memory (O’Brien and Hummert, 2006). In sum, these studies suggest an interplay between enduring and situational AS effects in elders’ healthrelated outcomes, raising the question of whether AS could also influence pain perception. To the best of our knowledge, no studies have yet brought light to this issue. Therefore, this study, using two discrete time periods, analysed the interaction between enduring and situational effects of AS on older adults’ selfreports of clinical and experimentally induced pain. As regards clinical pain, and given that there is an age-related increase in self-reports of persistent pain (Kendig et al., 2000; Reyes-Gibby et al., 2002; Thomas et al., 2004; Pickering, 2005), we expected that as compared with the situational activation of a positive AS or a neutral condition, the activation of negative AS would lead to more severe self-reports of clinical pain (at T2), but especially among older people who more strongly endorsed AS at T1 (H1). As for experimentally induced pain responses, studies suggested an age-related increase in pain

2.1 Participants

Allocated to Neutral Condition (n = 13) Excluded from CPT (n = 1); met exclusion criteria

Allocated to Negative Condition (n = 14) Excluded from CPT (n = 2): met exclusion criteria

Figure 1 Flow chart of participants’ disposition in the study.

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centre in Lisbon. Their enrolment was based on two broad inclusion criteria: (1) the ability to read and write autonomously; and (2) the absence of signs and symptoms of cognitive impairment, according to clinical staff’s assessments. Most of the participants were widows (57.7%), lived alone (55.8%) and had 4 or less years of education (82.7%). Many participants reported suffering from cardiovascular (50%) or respiratory (12.5%) diseases, and more than half reported suffering from chronic pain (55%; mostly musculoskeletal). In spite of that, most of them reported having an average health status (67.5%) or above (15%). All participants were right handed. At T2, five participants refused to collaborate in the second part of the study, one was deceased and six were unreachable. Of the remaining participants (n = 40), five did not participate in the cold pressor task (CPT) because they fit the exclusion criteria (see description below). The excluded participants (n = 17), however, did not differ significantly from the remaining sample in terms of their socio-demographic characteristics (41.2% women; Mage = 75.0, SDage = 6.42) nor on the proportion of chronic pain (60%).

2.2 Design This study consisted of a prospective design, which assessed participants in two different moments in time. At T1, participants were asked to fill out measures of cultural AS endorsement, clinical pain severity and interference, and of sociodemographic and health-related characteristics. Three months later, at T2, participants collaborated in an experimental study that explored the effects of AS activation (adapted from the paradigm of Levy, 1996) on the same clinical pain-related measures used at T1 and on individuals’ pain tolerance and threshold in a CPT. This part of the study consisted of an experimental between-subjects design with one single factor – AS activation: positive versus negative versus neutral. Fig. 1 shows that the 40 older adults who were willing and able to participate at T2 were randomly assigned to the three experimental conditions. It should be noted that only because of the prospective nature of this study were we able to assess the effects of the chronic or enduring nature of cultural AS endorsement on pain experiences. Moreover, and in line with other authors’ suggestions (e.g., Devine, 1989), this design also allowed us to disentangle the measurement of AS endorsement (at T1) from the situational activation of AS, which occurred 3 months later.

2.3 Instruments and measures 2.3.1 Cultural AS scale This scale was adapted from a previously tested measure (Marques et al., 2014), and assessed the extent to which participants endorsed the cultural stereotype of older people, i.e., their enduring stereotypical beliefs regarding their own age group. Participants were presented with a list of four 996 Eur J Pain 19 (2015) 994--1001

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positive (wise, mature, calm and sociable) and four negative traits (lonely, dependent, forgetful and slow), which had been previously identified as part of the cultural AS in Portugal (Marques et al., 2006). They were asked to rate the extent to which they thought Portuguese people associated each of these traits to older people on an 11-point rating scale, going from 0 (not at all associated) to 10 (completely associated). An exploratory factor analysis (principal axis factoring with orthogonal rotation) supported the unidimensionality of the measure (KMO = 0.762; Bartlett’s χ2 (28) = 118.074, p < 0.001); one factor was extracted with an eigenvalue above 1 and accounted for 39.5% of the variance. The scale showed good internal consistency (α = 0.78). A summary score was calculated by averaging scores across the eight items. Higher scores meant stronger endorsement of cultural AS. It should finally be noted that there were no significant differences in the levels of cultural AS endorsement at T1 between the 17 participants who did not participate at T2 and/or the CPT (M = 6.48; SD = 1.42) and the remaining sample (M = 7.12; SD = 1.68), t(50) = −1.36, p = 0.178.

2.3.2 Pain severity and interference scales Pain severity and pain interference with daily life were assessed using the respective scales of the Portuguese version (Azevedo et al., 2007) of the Brief Pain Inventory (BPI). Like the original instrument (Cleeland, 1989), the Portuguese version of the BPI showed good psychometric properties with high levels of internal reliability (α = 0.98 and 0.84 for pain severity and interference, respectively). The pain severity scale consisted of four items and assessed pain intensity on a rating scale from 0 (no pain) to 10 (pain as bad as you can imagine) (Please rate your pain by circling the one number that best describes your pain at its worst/least/average in the last week). The pain interference scale consisted of seven items and assessed the degree of pain interference in people’s lives on a scale from 0 (does not interfere) to 10 (completely interferes) (Circle the one number that describes how, during the past week, pain has interfered with your: general activity, mood, walking ability, normal work, relations with other people, sleep and enjoyment of life). To assess the psychometric properties of these scales in our sample, an exploratory factor analysis (principal axis factoring with oblique rotation) was conducted (KMO = 0.808; Bartlett’s χ2 (15) = 201.337, p < 0.001). Items with high cross loadings (i.e., a difference between factor loadings below 0.300) were progressively eliminated from the factor structure. Based on the Kaiser criterion, only one general factor – pain disability – was extracted, accounting for 59.1% of the total variance (n = 6 items, α = 0.893), which included three items from the pain severity scale (pain at its worst, least and average) and three items from the pain interference scale (interference in general activity, walking ability and work). This same structure was replicated at T2 (77.66% of total explained variance; KMO = 0.835; Bartlett’s χ2 (15) = 268.484, p < 0.001; α = 0.94). © 2014 European Pain Federation - EFICâ

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It should be noted that the assessment of pain self-reports at T1 was conducted exclusively for control purposes. Furthermore, there were no significant differences in the levels of pain disability at T1 between the 17 participants who did not participate at T2 and/or the CPT (M = 4.75; SD = 2.85) and the remaining sample (M = 4.39; SD = 2.72), t(50) = 0.45, p = 0.66.

2.3.3 Activation of AS At T2, an adaptation of the method proposed by previous authors (Dijksterhuis and van Knippenberg, 1996, 1998; Levy, 1996) was used to activate positive and negative AS. This task was introduced to participants as a test of ‘Episodic memory’. It consisted of presenting participants with four aging stereotypical traits and, by imagining a typical older person, to list a behaviour that could reflect each one of the underlying traits, respectively. To activate a positive AS, four positive stereotypical traits were presented (wise, mature, calm and sociable). To activate a negative AS, four negative stereotypical traits were presented (lonely, dependent, forgetful and slow). Positive and negative traits had been previously tested for their match in the degree of prototypicality (Marques et al., 2014). Also following the proposal by Dijksterhuis and van Knippenberg (1996, 1998), we included a neutral condition where we presented four previously tested neutral words (also, number, none and mixed) and participants were asked to write a sentence that included each one of the words, respectively.

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2.4 Procedure This study was approved by the Institutional Review Boards of the Center for Social Research and Intervention (CIS-IUL) and the day care centre where the data collection took place. At T1, participants were asked to participate voluntarily in a study of health-related beliefs. None of the approached elders declined our invitation to participate in the study at this time. After giving their written consent, participants were requested to fill out a questionnaire including the following: the cultural AS scale; the pain severity and interference scales; one question on perceived health status; some questions about participants’ clinical history and diseases; and several socio-demographic questions. After being briefly tutored by the researcher on how to fill in all the scales, participants answered the questionnaire individually, which took an average of 25 min. During the application of the questionnaire, the researcher remained nearby in order to provide participants with any further assistance. Finally, they were thanked and debriefed. Three months later, at T2, the same participants were approached and requested to participate in two tasks, which were presented as being unrelated. The first task, presented as a test of episodic memory, aimed at activating AS. The second task, presented as a study on people’s pain perceptions, was comprised of the CPT and BPI scales. The BPI was only completed after the participant completed the CPT. All participants were requested to sign a written informed consent before being submitted to the CPT. Finally, participants were again thanked and debriefed.

2.3.4 Cold pressor task The CPT is a widely used experimental technique for inducing pain in humans that involves placing the non-dominant hand above the wrist in cold water and it ends with the voluntary withdrawal of the limb by the participant and time measurement by the experimenter (Walsh et al., 1989). In this study, the water temperature ranged from 2 to 4 °C and participants were requested to immerse their non-dominant hand 5 cm above the wrist. Participants were requested to inform the experimenter when they started feeling pain (pain threshold) and to withdraw their hands when pain reached an intolerable level (pain tolerance). The experimenter registered the elapsed time of both moments in seconds; higher values (in seconds) meant higher pain thresholds and tolerance levels. The participant was not allowed to leave his/her hand inside the water longer than 5 min and the experimenter was placed behind the participant so that no verbal or non-verbal information was communicated (Walsh et al., 1989). For this task, we used the following exclusion criteria: having previous clinical history of heart attack, stroke, angina pectoris, fainting, seizures, frostbite, an open cut or sore on the hand to be immersed, fracture of the limb to be immersed and general hypersensitivity to cold (von Baeyer et al., 2005). Based on these criteria, 10 participants from the initial sample at T1 were excluded from participation in the CPT. © 2014 European Pain Federation - EFICâ

2.5 Data analyses First, we ran a series of preliminary analyses (Pearson’s correlations, chi-square, t-tests, and one-way analyses of variance in order to explore the associations between sociodemographic characteristics, clinical history and our study variables. In order to avoid the inflation of type I error, we used a Bonferroni correction that reduced our critical value to p < 0.002. No significant associations were found between the variables of our study and participants’ sociodemographic characteristics. Some borderline effects were found for the presence/absence of chronic pain; as compared with elders with no chronic pain, elderly with chronic pain tended to report higher pain disability at T1 (M = 5.38 vs. 3.16; SD = 2.45 vs. 2.66; p = 0.009) and T2 (M = 4.80 vs. 2.22; SD = 2.49 vs. 2.98; p = 0.006). However, since elders with chronic pain (vs. without) did not show any significant differences on AS endorsement (p = 0.82), pain thresholds (p = 0.36) and pain tolerance (p = 0.59), and were present in similar proportions across the three experimental conditions (p = 0.08), this variable was not included in further analyses. Second, we conducted a set of Pearson’s correlation analyses between the variables at T1 and T2 (Table 1). Cultural AS endorsement at T1 showed no significant correlations with any of the pain-related variables at T2. Furthermore, pain disability at T1 only showed a significant correlation with Eur J Pain 19 (2015) 994--1001

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pain disability at T2. Consequently, pain disability at T1 was only controlled for in the regression models that had selfreported pain disability at T2 as a criterion variable. Finally, and following the procedures suggested by Cohen et al. (2003), we ran a set of regression analyses to investigate whether the stereotype activation at T2 influenced the self-reported clinical pain (BPI) and the experimentally induced pain (CPT), and whether the endorsement of cultural AS at T1 moderated these effects. In model 1, we independently regressed the pain-related criterion variables (CPT pain threshold, CPT pain tolerance and BPI pain disability) on AS activation and AS endorsement in order to test the main effects of the latter. To introduce the variable AS activation in the regression models, we created two dummy variables using the neutral stereotype condition as the reference level; one, where we compared the positive stereotype activation with the neutral condition (positive condition = 1 and neutral condition = 0), and the other, where we compared the negative stereotype activation with the neutral condition (negative condition = 1 and neutral condition = 0). The unstandardized regression coefficients (B) for these dummy variables correspond to the mean differences in the criterion variable between the neutral condition and the positive or negative activation conditions, respectively (see, e.g., Table 2). As for the cultural AS measured at T1, since it was a continuous variable, it was therefore centred at its mean. B coefficients for this variable consist of the increase/decrease on the criterion variable per unit of increase in AS endorsement (across all AS activation conditions). Afterwards, in order to test the interaction effect of AS endorsement × AS activation, in model 2, we also entered the interaction between these two predictor variables. The interaction term was created by multiplying each dummy variable with the centred cultural AS (see Table 2). B coefficients for these interaction terms correspond to the differences in the regression slopes of the criterion variable on AS endorsement (i.e., the change in the criterion variable per unit of increase in AS

Table 1 Descriptive statistics and Pearson’s correlations between cultural aging stereotype (T1), pain disability (T1 and T2), pain threshold (T2) and pain tolerance (T2). Variables

1

2

3

4

5

1. Cultural aging stereotype_T1 2. Pain disability_T1 3. Pain disability_T2 4. Pain threshold_T2 5. Pain tolerance_T2 Mean Standard deviation Min Max N











0.24 0.01 0.22 0.20 6.91 1.61 3.13 10 52



– – −0.08 −0.20 3.61 2.99 0 10 39

– – –

– – – –

0.61* 0.01 −0.02 4.51 2.74 0 10 52

0.80* 28.3 19.09 5 96 32

56.80 54.83 7 180 35

Note: Cultural aging stereotype and pain disability scores ranged from 0 to 10; pain threshold and tolerance levels were measured in seconds. *p < 0.001.

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Table 2 Regression analysis for pain threshold on cultural aging stereotype endorsement (T1) and aging stereotype activation (T2): main and interaction effects. Pain threshold

Variables Constant Aging stereotype (AS) endorsement Positive stereotype activation Negative stereotype activation Positive stereotype activation × AS Negative stereotype activation × AS Radj2 F

Model 1

Model 2

B 22.25** 3.37 −3.30 17.71* – – 0.21 3.66*

B 24.22** 0.09 −4.08 16.83* 0.85 10.33* 0.34 4.13**

Note: AS is a continuous variable centred at its mean; positive stereotype activation is a dummy variable where positive condition = 1 and neutral condition = 0; negative stereotype activation is a dummy variable where negative condition = 1 and neutral condition = 0. *p < 0.05. **p < 0.001.

endorsement) between the neutral condition and the positive or negative activation conditions, respectively.

3. Results Our goal was to test the interaction between enduring and situational effects of AS on older adults’ selfreports of clinical and experimentally induced pain. Results showed significant effects for the CPT pain threshold (Table 2). In model 1, we found a main effect of AS stereotype activation, accounting for 21% of the CPT pain threshold variance. More specifically, CPT pain threshold was higher in the negative stereotype activation condition than in the neutral condition. In other words, participants in the negative condition detected pain, on average, 17.71 s after participants in the neutral condition. Moreover, no significant differences were found on mean pain thresholds between participants in the neutral condition and the positive condition. However, model 2 showed that this effect was significantly moderated by the cultural AS endorsement at T1, ΔR2 = 0.16, ΔF(2, 26) = 3.75, p < 0.05. More specifically, the regression coefficients for the interaction terms in Table 2 only show a significant difference in the regression slopes of pain threshold on AS endorsement (i.e., the increase in pain threshold per unit of increase in AS endorsement) between the neutral and negative conditions. Again, no significant differences were found between the positive and neutral conditions. To better understand this interaction effect, we performed a simple slope analyses (Fig. 1) where the © 2014 European Pain Federation - EFICâ

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57.81

55 50 45 40

High AS

35

Low AS

30 25

24.36 24.19

20

24.06

21.66 18.55

15 Negative prime

Neutral prime

Positive prime

Figure 2 Simple slopes for the interaction between the cultural aging stereotype endorsement (T1) and aging stereotype activation conditions (T2) on pain threshold. Note: Values correspond to estimates of average pain threshold measured in seconds (Y axis). AS endorsement is measured on a scale from 0 to 10. Full line = high endorsement of cultural AS, i.e., one standard deviation above the mean; dashed line = low endorsement of cultural AS, i.e., one standard deviation below the mean.

values of pain threshold were estimated for each AS activation condition (positive, negative and neutral) at particular values of endorsement of cultural AS at T1, namely one standard deviation below the mean (low endorsement of AS) and one standard deviation above the mean (high endorsement of AS). As it can be seen in Fig. 1, this analysis revealed that when the endorsement of cultural AS at T1 was low, there were no significant differences in the pain threshold due to stereotype activation at T2. However, when the endorsement of cultural AS at T1 was high, the pain threshold in the negative stereotype condition was higher than in the neutral condition, B = 33.51, p < 0.001, but there were no differences between the positive and neutral conditions (Fig. 2). Finally, we did not find any significant effects of the situational activation of AS or of its interaction with cultural AS endorsement at T1 on CPT pain tolerance or on self-reported pain disability.

4. Discussion This study aimed to investigate the interplay between enduring and situational AS effects in older adults’ self-reports of clinical and experimentally induced pain. Generally, we expected that, as compared with the situational activation of positive AS or a neutral condition, the activation of negative AS would lead to more severe self-reports of clinical pain (H1), higher CPT pain thresholds (H2) and lower CPT pain toler© 2014 European Pain Federation - EFICâ

ance levels (H3) at T2, especially among older adults who had more strongly endorsed AS at T1. Our findings only clearly supported H2. More specifically, older adults in the negative AS condition showed higher CPT pain thresholds than older adults in the positive AS or neutral conditions, but this effect was more salient among older adults who more strongly endorsed AS 3 months earlier. This interaction effect accounted for more than a third of the variance of CPT pain thresholds, which according to Cohen (1988, 1992) is a large effect, especially considering the relatively small size of our sample. If several psychophysical studies have shown a significant age-related impairment in the speed of detection of superficial noxious stimuli (Gibson and Farrel, 2004; Edwards, 2005), this result shows that the situational activation of negative AS enhances this effect among older adults who more strongly endorse AS. This result is in line with previous studies showing that older people who more strongly endorse AS are more influenced by their situational activation, for instance, in memory tests (O’Brien and Hummert, 2006). The reason as to why the effects of AS were only significant for CPT pain thresholds and not for CPT pain tolerance or self-reports of clinical pain might be accounted for by the degree of controllability of the pain-related responses. In fact, as compared with clinical pain self-reports and CPT pain tolerance levels, CPT pain thresholds may be considered as the result of a more automatic and less controllable processing of information. Considering that more automatic and less controllable responses more often reflect assimilation effects of stereotype activation, i.e., people acting in line with the activated stereotype content (Bargh, 1989), this may account for the fact that only our hypothesis for CPT pain thresholds was confirmed. Considering the vital importance of the earlywarning functions of pain, the practical implications of our findings are striking. Our results stress the role of situational cues on hampering the efficacy of a basic psychophysical process – pain detection – which may lead to a delay in actions to prevent tissue damage. For example, studies showed that, although acute visceral pain is generally associated to diseases that are major causes of elders’ morbidity or mortality (e.g., myocardial infarction), older adults’ presentation of these clinical scenarios is often atypically painless (Pickering, 2005). This may often result in a delay in diagnosis and increased risks of complications or even death. Therefore, if the situational activation of AS eventually plays a role in enhancing these effects among older adults who more strongly endorse AS, implications for the development of psychosocial intervenEur J Pain 19 (2015) 994--1001

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tions aiming at preventing these situations may be considered. In fact, AS may be activated by several contextual cues, namely the characteristics of the settings in which older people live (Marques, 2011) or their caregivers’ behaviours (Baltes and Wahl, 1996). Hence, interventions at the level of the physical and/or social environment where elders live in, aiming at preventing the activation of negative AS, are an important path to pursue. In spite of the study’s robust methodological design and the strength of its findings, some limitations may be pointed out. First, the small sample size at T2 raises power-related concerns, namely on whether the effects on self-reports of clinical pain and CPT pain tolerance levels would be significant if we had a bigger sample. Moreover, the fact that all participants were attending the same day care centre and generally showed few years of education also hinders the generalizability of these findings. Consequently, it would be interesting to run a multi-centre study with a similar design and a bigger and more heterogeneous sample of older adults. Furthermore, despite the fact that there is some cross-cultural similarity in AS contents in Western societies (Marques et al., 2014), it would be interesting to replicate these findings with participants from other cultural backgrounds to expand the external validity of the study. In addition, since other studies suggest that a more aged central nervous system shows a propensity to up-regulation of pain processing after repeated noxious stimulation (Edwards, 2005), it would be interesting to explore the enduring and situational effects of AS on other psychophysical measures that could detect this phenomenon (wind-up). Because the central sensitization phenomenon may account for the development and maintenance of chronic pain among older adults (Yunus, 2007), exploring some of its psychosocial correlates is of high theoretical and practical relevance. Finally, it should be stressed that we entirely relied on clinical staff’s assessments to choose elders with normal cognitive functioning, but we were unaware of whether these were based on formal assessment procedures or not. The use of a formal test of cognitive functioning would be a more rigorous screening procedure. However, it is possible that including a cognitive function test may activate participants’ negative AS, therefore the pros and cons of its inclusion in future studies should be seriously weighted. In sum, this paper shows that AS may have a strong effect on older adults’ CPT pain thresholds, which stresses the importance of considering a broader psychosocial perspective to understanding and accounting for individuals’ pain experiences. 1000 Eur J Pain 19 (2015) 994--1001

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Acknowledgement We would like to thank Prof Cícero Pereira (Instituto de Ciências Sociais, Lisbon University) for his statistical support.

Author contributions All authors significantly contributed to the conception, design, data collection, analysis and interpretation of the results. S.F.B. and S.M. were responsible for writing the first draft of this manuscript. All authors participated in the draft revision and gave final approval of the version to be published. S.F.B. and S.M. take responsibility for the integrity of the work as a whole, from inception to published article.

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Eur J Pain 19 (2015) 994--1001

1001

Old and in pain: Enduring and situational effects of cultural aging stereotypes on older people's pain experiences.

This study aimed to investigate the interplay between enduring and situational aging stereotype (AS) effects in older adults' self-reports of clinical...
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