RESEARCH
Pain and Depression in Older Adults With Arthritis Uloma D. Onubogu
The experience of chronic pain negatively impacts the general health of individuals. Evidence shows that depression and chronic pain co-occur, and both experiences tend to worsen as the number of comorbidities increases. PURPOSE: The purpose of this study was to examine the relationships between pain and depression as well as the impact of number of comorbidities in older adults with arthritis. METHOD: A cross-sectional analysis of existing data was conducted with a sample of 1,592 community-dwelling older adults (mean age = 74.3 years, SD = 5.9 years). FINDINGS: The majority of participants reported the presence of bodily pain. Mild depressive symptoms and multimorbidities were found. More severe pain correlated with a higher number of comorbidities and worsening depression. IMPLICATIONS: Prevalence and impact of pain and other co-occurring conditions suggest their importance in planning care for the elderly with arthritis. BACKGROUND:
C
hronic pain is a complex, multidimensional experience that can affect individuals physically, socially, emotionally, and psychologically. Chronic musculoskeletal joint disorders such as arthritis are the most common cause of chronic pain and pain-related disability among older adults (American Geriatric Society [AGS], 2009; Brooks, 2005). Individuals with osteoarthritis alone account for more than 10% (27 million) of the U.S. adults with chronic pain, making it a significant healthcare problem (Murphy & Helmick, 2012). This prevalence contributes to the overall problem of chronic pain, which affects more than 50% of older adults (Hall-Lord, Johansson, Schmidt, & Larsson, 2003; Hutt, Pepper, Vojir, Fink, & Jones, 2006; Won et al., 2004). Chronic pain is prevalent among older adults and contributes to an array of adverse consequences that include psychological or emotional symptoms such as depression and anxiety (AGS, 2009; Huber, Suman, Biasi, & Carli, 2008; Leville, Cohen-Mansfield, & Guranik, 2003). A recent study found that more than 90% of persons aged 50 years and older who were assessed for chronic musculoskeletal pain had moderate to severe pain that was always present (Silva, Alvarelhao, Queiros, 102
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
& Rocha, 2013). With associated pain, there is interference in daily activities and functioning. Persistent pain and other forms of physical comorbodities can have adverse effects on depressive symptoms, thereby delaying improvement of symptoms (Mavandadi et al., 2007). Depression and chronic pain commonly co-occur and the risk of depression among older adults with chronic pain increases in the presence of comorbidities. More than 19% of older adults with chronic pain have depressed mood (Iliffe et al., 2009). Multiple chronic conditions (multimorbidity) are reported in as many as 50%–98% of older adults with results that include disability, poor quality of life, increased risk for mortality, and cumulative effects that challenge optimal care (AGS, 2012; Marengoni et al., 2011). The high prevalence of chronic and comorbid diseases contributes to equally high prevalence and complexity of chronic persistent pain experience including depression (AGS, 2009; Harden et al., 2005; Manning & Jackson, 2013). More recent studies found that numerous disorders—musculoskeletal (e.g., chronic back pain) and nonmusculoskeletal (e.g., diabetes)—coexist with arthritis causing disabling limitations (Reeuwijk et al., 2010; van Dijk et al., 2008, 2010). The presence or diagnosis of arthritis was found to be associated with depressed moods in people with persistent pain. This association is attributable to the role of arthritis (attributable risk = 18.1%) in creating functional limitations among the individuals affected (Donald & Fay, 2004; Dunlop, Lyons, Manheim, Song, & Chang, 2004; Duong, Kerns, Towle, & Reid, 2005). The occurrence of depression may exacerbate the pain experience and pain-related interferences (the degree to which pain interferes with normal activities such as house and outside work) as outcomes of negative self-perceived health and functional limitation (Mantyselka, Turunen, Ahonen, & Kumpusalo, 2003; Oster, Harding, Dukes, Edelsberg, & Cleary, 2005; Silkey et al., 2005). With the presence of arthritis and other comorbidities, patients may experience more pain and depression.
Uloma D. Onubogu, PhD, MSN, MSEd, APRN-BC, Associate Professor, Florida A&M University, Tallahassee, FL. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/NOR.0000000000000035 © 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 102
3/13/14 8:42 AM
Chronic Pain and Comorbidities Depression is well documented as a correlate of persistent pain as well as a major indicator of emotional distress among patients with chronic pain (AGS, 2009; Greenberg & Burns, 2003). Depression is also known to initiate, exacerbate, and maintain the pain experience (McCracken, Spertus, Janeck, Sinclair, & Wetzel, 1999). Among a sample (N = 209) of individuals 60 years and older with reported persistent joint pain, 36% were diagnosed with depression (Adams, Plane, Fleming, Mundt, & Saunders, 2001). A higher prevalence of depression was reported by more than 50% of a general population of older adults with persistent pain (Mossey & Gallagher, 2004). More depressive symptoms in persons with persistent pain may be attributed to physical illness (Regan, Kearney, Savva, Cronin, & Kenny, 2013) or to their response to distressful stimuli—both sensory and emotional (AGS, 2002; Gonzales, Martelli, & Baker, 2000; Harden et al., 2005). For example, Ryan and Frederick (1997) found that vitality (indicator of affective well-being or disposition) was lower among older adults with chronic pain, especially if they perceive their pain to be disabling or frightening. This further contributes to their emotional distress. When assessed longitudinally at 6 points over a period of 21 months, Sharpe, Sensky, and Allard (2001) found that pain intensity was one of two variables that consistently predicted level of depression in a population of older adults. Recent study findings that show a high (80.5%) prevalence of undiagnosed mood disorder among older adults with comorbid chronic pain (Agüera-Ortiz, Failde, Cervilla, & Mico, 2013) raise concern about the extent of the problem. Following another longitudinal study of the relationships between pain severity, pain interference, and change in depressive symptoms in older adults at baseline and 3, 6, and 12 months, Mavandadi and colleagues (2007) found that at higher pain intensity levels, improvements in depressive symptoms of persons surveyed were blunted. However, when pain interference was considered in addition to pain intensity, the authors found that the extent to which pain interfered with functioning had a negative impact on the individual’s recovery from depression. Clearly, depressive symptoms in older adults with chronic pain have remained prevalent, despite ongoing research and awareness of the psychosocial impact of chronic pain, and advances in pain management. Thus, in older adults with arthritis who have a significant persistent pain experience, research is needed to evaluate the clinical consequences of comorbidities and adverse pain-related outcomes such as depression. The purpose of this study was to examine the relationships between pain and depression as well as the impact of the number of comorbidities in older adults with arthritis. Demographic differences (gender and race) were also examined. The following specific questions were addressed: 1. Are age, gender, and race associated with bodily pain intensity, pain interference severity, depression, and comorbidities among older adults with arthritis? © 2014 by National Association of Orthopaedic Nurses
2. What are the intercorrelations among the study variables (bodily pain, pain interference, depression, and comorbidities)?
Methods DESIGN AND SUBJECTS This study design was descriptive correlational. A crosssectional secondary analysis of data was conducted using data obtained from the Advanced Cognitive Training for Independent Vital Elderly (ACTIVE) trial (Tennstedt et al. 2010) through the Interuniversity Consortium for Political and Social Research (ICSPR). ACTIVE data accessed for this study are in the public domain (ICSPR #04248). Condition for access of data and the terms of agreement stipulated by ICSPR were satisfied. The ACTIVE study is a large National Institutes of Health–funded randomized and controlled 5-year clinical trial that was conducted by researchers in universities located in six U.S. metropolitan areas to determine the effects of cognitive training on memory and functioning. The ACTIVE study involved 2,802 independent living, cognitively intact (Mini-mental State Examination [MMSE] scores ≥22), older adults aged 65 years and older who had no diagnosis of terminal illness (e.g., cancers) or conditions causing functional decline (e.g., stroke or dementia). Participation in the ACTIVE study was voluntary, and persons were excluded from the study if they had two or more activities-of-daily-living disabilities (score on the self-rated activities-of-dailyliving/instrument activities of daily living [IADL] checklist), or verbally reported medical conditions associated with imminent functional decline or death (such as stroke or cancer); and/or exhibited severe loss of vision, hearing, or poor verbal communication. Study volunteers had to pass an initial first-level screening via a telephone interview and additional inperson cognitive testing to be eligible. Eligible participants were randomized into three groups to receive specific cognitive training or one control group to receive no training. Study assessments were conducted at baseline, immediately after intervention, and annually for 5 years. This study included only a subsample of 1,592 participants at baseline who reported a diagnosis of arthritis on the Older American Resources Service Checklist.
MEASURES Self-reported bodily pain (pain severity) and pain interference (extent to which pain interfered with normal work such as housework and outside work) were measured on the Medical Outcomes Short Form-36 (SF-36) Bodily Pain subscale (Ware, Snow, Kosinski, & Gandek, 1993). The SF-36 evaluates general health, the relative burden of diseases and symptoms such as pain, and the benefits of health interventions (Ware et al., 1993). Participants reported severity of bodily pain experienced during the past 4 weeks on a 6-point verbal descriptor scale from 1 (none) to 6 (very severe). Pain interference in the past 4 weeks was scored on a 5-point verbal descriptor scale as 1 (not at all) to 5 (extremely). The SF-36 Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
103
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 103
3/13/14 8:42 AM
demonstrates good overall reliability on both internal consistency and test-retest methods that have exceeded the minimum standard of 0.70 in many studies (McHorney Ware, Rachel, & Sherbourne, 1994; Tsai, Bayliss, & Ware, 1997; Ware et al., 1993; Ware, Kosinski, & Keller, 1994). This measure has also demonstrated good evidence of validity (content, concurrent, criterion, construct, and predictive) and clearly supports the interpretation and meaning of scores (Ware et al., 1993, 1994). The Center for Epidemiological Studies–Depression (CES-D) Scale was used to assess depression. This is a 20-item Likert-type instrument developed to detect major or clinical depression in adolescents and adults (Radloff, 1977). Four components or factors of the CES-D are depressive affect, somatic symptoms, positive affect, and interpersonal relations. Items in the CES-D refer to how an individual has felt and behaved during the last week. Scores range from 0 to 3, with 0 points = rarely or none of the time ( 80%). Hybels and colleagues also demonstrated that the CES-D could reliably identify clinically significant depression in community-dwelling elders. The CES-D short version yielded Cronbach’s alpha of .87 at baseline and .82 at follow-up for a sample of older adults (Zarit, Griffiths, & Berg, 2004). The Older American Resources Service Checklist was used to measure self-report of comorbid conditions. Participants responded to questions about medical conditions they might have been diagnosed with, including cancer. Scores were summed to indicate participants’ number of comorbidities.
DATA ANALYSIS The SPSS Statistics 19.0 (IBM SPSS, Chicago, IL, 2010) was used for all data analysis. Descriptive statistics were used to analyze demographic characteristics as well as the characteristics of pain variables (bodily pain and pain interference), comorbidities (the number of medical diagnosis), and depression. Bivariate statistics using the t test, analysis of variance, and Pearson’s productmoment correlations examined differences among correlations of demographic variables, pain variables, comorbidities, and depression scores.
Results DESCRIPTIVE FINDINGS The study sample consisted of 1,290 women (81.0%) and 302 men (19%), with a mean age of 74.3 years (SD = 5.9 years). The majority were Caucasian (68.8%; n = 1,095), followed by Black (29.4%; n = 468), and other races (1.8%; n = 29). The majority of participants (31.7%; n = 504) reported bodily pain intensity that was moderate and pain interference that was rated a little bit and more (>60%; n = 958) (see Table 1). Participants reported a mean number of medical diagnosis of 3.5 (SD = 1.45), range 1–10, and mild depressive symptoms (M = 5.6, SD = 5.4).
AGE, GENDER, AND RACE ASSOCIATIONS WITH PAIN VARIABLES, DEPRESSION, AND COMORBIDITIES Results of gender and race association with the study variables are shown in Table 2. Analysis showed that women reported slightly more comorbidities (M = 3.56; SD = 1.64) than men (M = 3.22; SD = 1.37). This difference was statistically significant (t = −3.723; p = .001). Women also reported higher level of depression (M = 5.75; SD = 5.42) than men (M = 5.01; SD = 5.01), and this difference was also statistically significant (t = −2.147; p = .03). Compared with men, women also reported significantly more bodily pain and pain interference. There were no significant race differences in bodily pain (F = 0.295; p = .74), pain interference (F = 0.050; p = .95), depression (F = 0.328; p = .72), and number of comorbidities (F = −1.624; p = .20). More advanced age correlated with a higher number of comorbidities (r = .11; p = .001) and worse depression (r = −.10; p = .001).
TABLE 1. CHARACTERISTICS OF PAIN INTENSITY AND PAIN INTERFERENCE SEVERITY Pain Intensity Very mild
Pain Interference Severity
n
%
398
25
None
n
%
603
37.9
Mild
334
21
A little bit
438
27.5
Moderate
504
31.7
Moderate
336
21.1
Severe
145
9.1
Quite a bit
162
10.2
Very severe
28
1.8
Extremely
22
1.4
Note. N = 1,592.
104
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
© 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 104
3/13/14 8:42 AM
INTERCORRELATIONS AMONG PAIN VARIABLES, DEPRESSION, AND COMORBIDITIES
degree of emotional or depressive symptoms that can result from concurrent pain intensity and pain interference and more comorbidities will likely increase (Mavandadi et al., 2007). These adverse outcomes draw significant concern for the large number (52%–61%) of women older than 65 years who are affected by arthritis (Theis, Helmick, & Hootman, 2007). Demographic variables analyzed in the study linked participants with more advanced age to both more depression and comorbidities. Also, women had more comorbidities, more bodily pain, more pain interference, and more depression. High prevalence of multimorbidities was found in studies involving both men and women as their age increased (Fortin, Lapointe, Hudon, & Vanasse, 2005). A significantly higher rate of comorbidities among the female participants of the current study was also supported by evidence that the rate of having two or more medical conditions was 99% among women aged 65 years and older in primary care (Fortin, Bravo, et al., 2005). These findings are confirmed in both crosssectional and longitudinal studies where female gender was implicated as a factor in high prevalence of multimorbidities (Marengoni et al., 2011).
Analysis of intercorrelations among study variables showed that a higher number of comorbidities was significantly correlated with worse depression (r = .11; p = .001), more severe bodily pain (r = .13; p = .001), and more pain interference (r = .16; p = .001). Also, pain interference was correlated with worsening depression scores (r = .30; p = .001). Greater bodily pain was highly correlated with more pain interference (r = .63; p = .001) and correlated with worsening depression scores (r = .23; p = .000).
Discussion Presence of bodily pain and pain interference was high among the study participants. These finding are supported by several published reports of high prevalence of chronic pain (over 50%) and pain interference among community-dwelling older adults that are attributed to arthritis (AGS, 2009; American Pain Foundation, 2009; Brown, Kirkpatrick, Swanson, & McKenzie, 2011; Centers for Disease Control and Prevention, 2013). Equally high prevalence of comorbidities and multimorbidities (over 50%) among the elderly is reported in studies (Caughey, Vitry, Gilbert, & Roughead, 2008; Fortin, Bravo, Hudon, Vanasse, & Lapointe, 2005; Marengoni et al., 2011). These data support the current study finding of 90% prevalence of comorbidities and multimorbidities among study participants. There was a significant positive correlation between the number of comorbidities and depression. This is consistent with the evidence of high prevalence of multiple diseases, which tends to worsen depressive symptoms among older adults with painful musculoskeletal joint disease (Moussavi et al., 2007). An association of depression with chronic comorbid diseases was found to be an important risk factor for worsening health outcomes in a general population of adults around the world (Moussavi et al., 2007), as well as with arthritis in particular (Dunlop et al., 2004). Based on estimates by Centers for Disease Control and Prevention (2006), increases in the rates of arthritis and related pain interferences will occur as more and more people join the ranks of those 65 years and older over the next decade. Therefore, the
IMPLICATIONS The prevalence of pain, comorbidities, and multimorbidities found in this study suggests their importance in planning care for older adults with arthritis. These findings have important clinical implications because of their association with disability, functional decline, poor quality of life, high healthcare cost, and complexity in clinical management decisions. Practitioners, in their clinical assessment of older adults with arthritis, should be cognizant of the high rates of undiagnosed mood disorders among chronic pain sufferers (AgueraOrtiz et al., 2013). Thus, it is important that any plan of care for older adults with multiple chronic conditions consider clinical practice guidelines for multiple problems rather than single problems. Specifically, healthcare practitioners should employ empirical tools in the management of older adults with arthritis to identify the presence and severity of co-occurring conditions to direct effective clinical management to prevent and/or limit adverse pain-related outcomes such as depression.
TABLE 2. GENDER AND RACE ASSOCIATIONS WITH PAIN VARIABLES, DEPRESSION, AND COMORBIDITIES Gender Male, M (SD)
Female, M (SD)
Bodily pain intensity
2.77 (1.63); n = 297
Pain interference severity
Study Variables
Race Caucasian, M (SD)
Black, M (SD)
Other Races, M (SD)
.000
3.04 (1.52); n = 1,081
3.099 (1.34); n = 457
−2.684
.007
2.04 (1.28); n = 1,081
5.75 (5.42); n = 1,264
−2.147
.03
3.54 (1.64); n = 1,290
−3.723
.001
t
p
3.12 (1.42); n = 1,270
−3.724
1.86 (1.29); n = 297
2.08 (1.24); n = 1,270
Depression
5.01 (5.01); n = 295
No. of comorbidities
3.22 (1.37); n = 302
F
p
3.10 (1.32); n = 29
0.295
.74
2.04 (1.20); n = 457
1.97 (1.21); n = 29
0.050
.95
5.68 (5.57); n = 1,077
5.44 (4.84); n = 454
5.68 (5.39); n = 28
0.328
.72
3.45 (1.43); n = 1,095
3.59 (1.5); n = 468
3.62 (1.17); n = 29
1.624
.20
Note. N = 1,592. Coding: males = 1; females = 2; Caucasians = 1; Blacks = 2; other races = 3.
© 2014 by National Association of Orthopaedic Nurses
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
105
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 105
3/13/14 8:42 AM
A significantly higher prevalence of multiple chronic conditions including pain among the female study participants has implication for reducing disparities in the healthcare of older adult women and improving their overall health outcomes. Considering a disproportionately higher rate of arthritis in women compared with men, healthcare practitioners should be especially aware of and sensitive to the vulnerabilities of older women to adverse outcomes of comorbid or multiple chronic conditions such as persistent pain, pain interference, and depression in their assessment and planning of care.
LIMITATIONS Secondary data analysis was conducted for this study, which limits control over size and characteristics of the sample. Also, the use of existing data poses a threat to internal or external validity; hence, results of this study are only generalizable to community-dwelling older adults with arthritis. The limitations in the accuracy of self-reported data especially with the report of medical diagnosis are recognized when the strengths of the study results and implications are considered. Participants were recruited as vital older adults and on the average had fewer and less severe manifestations of adverse disease outcomes such as pain, pain interference, and depression at the time of the study measurements. Thus, the effects size of measured variables, although statistically significant, were small.
Conclusion Persistent pain negatively impacts the general health and the emotional and functional status of individuals. Given consistent supporting evidence of the interrelationships of chronic pain, depression, and comorbidities, these are important variables to be considered by healthcare practitioners when caring for older adults with arthritis. A future longitudinal study will be beneficial to determine how the relationships between pain and depression progress over time.
ACKNOWLEDGMENTS The author was a participant in the 2013 NLN Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education and Pocket Nurse. The author thanks Dr. Ruena Norman (Dean of FAMU School of Nursing) whose administrative support through funding and personal encouragement made attendance at the NLN Scholarly Writing Retreat and eventual completion of this manuscript possible.
REFERENCES Adams, N., Plane, M., Fleming, M., Mundt, M., & Saunders, L. (2001). Opioids and the treatment of chronic pain in a primary care sample. Journal of Pain and Symptom Management, 22(3), 791–796. Agüera-Ortiz, L., Failde, I., Cervilla, J., & Mico, J. (2013). Unexplained pain complaints and depression in older people in primary care. Journal of Nutrition, Health & Aging, 17(6), 574–757. doi: 10.1007/s12603-0130012-0.
106
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
American Geriatric Society Expert panel on the Care of Older Adults With Multimorbidity. (2012). Guiding principles for care of older adults with multimorbidity: An approach for clinicians. Journal of American Geriatric Society, 60(10), E1. doi: 10.1111/j.1532-5415. 2012.04188.x American Geriatric Society Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of American Geriatrics Society, 50(s6), S205–S224. American Geriatric Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of American Geriatrics Society, 57, 1331–1346. American Pain Foundation. (2009). A reporter’s guide: Covering pain and its management. Retrieved from http://nationalpress.org/images/uploads/programs/ PAIN_RoweGuide.pdf Brooks, P. (2005). Issues with chronic musculoskeletal pain. Rheumatology, 44, 831–833. Brown, S., Kirkpatrick, M., Swanson, M., & McKenzie, I. (2011). Pain experience of the elderly. Pain Management Nursing, 12(4), 190–196. doi: 10.1016/j.pmn.2010. 05.004. Centers for Disease Control and Prevention. (2006). Prevalence of doctor-diagnosed arthritis and arthritisattributable activity limitation—United States, 2003– 2005. Morbidity and Mortality Weekly Report, 55(40), 1089–1092. Centers for Disease Control and Prevention. (2013). Arthritis. Meeting the challenge of living well. At a glance. Retrieved from http://www.cdc.gov/chronicdisease/ resources/publications/AAG/arthritis.htm Caughey, G., Vitry, A., Gilbert, A., & Roughhead, E. (2008). Prevalence of comorbidity of chronic diseases in Australia. BMC Public Health, 8, 221. doi:10.1186/14712458-8-221. Donald, I. P., & Foy, C. (2004). A longitudinal study of joint pain in older people . Rheumatology , 43 (10), 1256–1260. Dunlop, D., Lyons, J., Manheim, L., Song, J., & Chang, R. (2004). Arthritis and heart disease as risk factors for major depression: The role of functional limitation. Medical Care, 42(6), 502–511. Duong, B., Kerns, R., Towle, V., & Reid, C. (2005). Identifying the activities affected by chronic nonmalignant pain in older veterans receiving primary care. Journal of American Geriatrics Association, 53(4), 687–694. Fortin, M., Bravo, G., Hudon, C., Vanasse, A., & Lapointe, L. (2005). Prevalence of multimorbidity among adults seen in family practice. Annals of Family Medicine, 3(3), 223–228. Fortin, M., Lapointe, L., Hudon, C., & Vanasse, A. (2005). Multimorbidity is common to family practice: Is it commonly researched? Canadian Family Physician, 51, 244–245. Geisser, M., Roth, R., & Robinson, M. (1997). Assessing depression among persons with chronic pain using the Center for Epidemiology Studies–Depression Scale and the Beck Depression Inventory: A comparative analysis . Clinical Journal of Pain, 13 ( 2 ), 163–170. Gonzales, V., Martelli, M., & Baker, J. (2000). Psychological assessment of persons with chronic pain. Neuro Rehabilitation, 14, 69–83. Greenberg, J., & Burns, J. (2003). Pain anxiety among chronic pain patients: Specific phobia or manifestation © 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 106
3/13/14 8:42 AM
of anxiety sensitivity. Behavior Research and Therapy, 41, 223–240. Hall-Lord, M., Johansson, I., Schmidt, I., & Larsson, B. (2003). Family members’ perceptions of pain and distress related to analgesics and psychotropic drugs, and quality of care of elderly nursing home residents. Health and Social Care in the Community, 11(3), 262–274. Harden, N., Weinland, S., Remble, T., Houle, T. T., Colio, S., Steedman, S., & Kee, W. (2005). Medication Quantification Scale Version III: Update in medication classes and revised detriment weights by survey of American Pain Society physicians. The Journal of Pain, 6(6), 364–371. Huber, A., Suman, A. L., Biasi, G., & Carli, G. (2008). Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: two sides of the same coin? Journal of Psychosomatic Research, 64(2), 169–175. doi: 10.1016/j.jpsychores.2007.09.005. Hutt, E., Pepper, G., Vojir, C., Fink, R., & Jones, K. (2006). Assessing the appropriateness of pain medication prescribing practices in nursing homes. Journal of American Geriatrics Society, 54(2), 231–239. Hybels, C., Blazer, D., & Pieper, C. (2001). Toward a threshold for subthreshold depression: An analysis of correlates of depression by severity of symptoms using data from an elderly community sample. The Gerontologist, 41(3), 357–365. Iliffe, S., Kharicha, K., Carmaciu, C., Harari, D., Swift, C., Gillman, G., & Stuck, A. (2009). The relationship between pain intensity and severity and depression in older people: Exploratory study. BMC Family Practice, 10, 54. doi: 10.1186/1471-2296-10-54. Kothe, R., Kohlmann, T., Klink, T., Ruther, W., & Klinger, R. (2006). Impact of back pain on functional limitations, depressed mood and quality of life in patients with rheumatoid arthritis. Pain, 127, 103–108. Leville, S., Cohen-Mansfield, J., & Guranik, J. (2003). The impact of chronic musculoskeletal pain on exercise attitudes, self-efficacy, and physical activity. Journal of Aging and Physical Activity, 11, 275–283. Manning, J., & Jackson, W. (2013). Depression, pain, and comorbid medical conditions. Journal of Clinical Psychiatry, 74(2), e03. doi: 10.4088/JCP.12049vs3c. Mantyselka, P., Turunen, J., Ahonen, R., & Kumpusalo, E. (2003). Chronic pain and poor self-rated health. JAMA, 290(18), 2435–2442. Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., … Fratiglioni, L. (2011). Aging with multiple morbidity: A systematic review of the literature. Ageing Research Review, 10(4), 430–439. doi: 10.1016/j.arr.2011.03.003. Mavandadi, S., Have, T., Katz, I., Durai, U., Krahm, D., Liorente, M. D., … Oslin, D. (2007). Effects of depression treatment on depressive symptoms in older adulthood: The moderating role of pain. Journal of American Geriatric Society, 55(2), 202–211. McCracken, L., Spertus, I., Janeck, A., Sinclair, D. & Wetzel, F. (1999). Behavioral dimensions of adjustment in persons with chronic pain: pain-related anxiety and acceptance. Pain, 80(1-2), 283–289. McHorney, C., Ware, J., Rachel, J., & Sherbourne, C. (1994). The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Medical Care, 32, 40–66. Mossey, J., & Gallagher, R. (2004). The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care © 2014 by National Association of Orthopaedic Nurses
retirement community residents. Pain Medicine, 4, 335–345. Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: Results from the World Health Surveys. Lancet, 370(9590), 851–858. Murphy, L., & Helmick, C. (2012). The impact of osteoarthritis in the United States: A population-health perspective. American Journal of Nursing, 112(3, Suppl. 1), S13–S19. doi: 10.1097/01.NAJ.0000412646.80054.21. Oster, G., Harding, G., Dukes, E., Edelsberg, J., & Cleary, P. (2005). Pain, medication use, health-related quality of life in older persons with postherpetic neuralgia: Results from a population-based survey. The Journal of Pain, 6(6), 356–363. Radloff, L. (1997). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401. doi: 10.1177/014662167700100306. Regan, C., Kearney, P., Savva, G., Cronin, H., & Kenny, R. (2013). Age and sex differences in prevalence and clinical correlates of depression: First results from the Irish Longitudinal Study on Ageing. International Journal of General Psychiatry. Epub ahead of print. doi: 10.1002/gps.3955 Reeuwijk, K., de Rooij, M., van Dijk, G., Veenhof, C., Steultjens, M., & Dekker, J. (2010). Osteoarthritis of the hip or knee: Which coexisting disorders are disabling? Clinical Rheumatology, 29(7), 739–747. doi: 10.1007/s10067-010-1392-8. Reid, C., Williams, C., Concato, J., Tinetti, M., & Thomas, G. (2003). Depressive symptoms as a risk factor for disabling back pain in community-dwelling older persons. Journal of American Geriatrics Society, 51, 1720–1717. Ryan, R., & Frederick, C. (1997). On energy, personality, and health: Subjective vitality as a dynamic reflection of well-being. Journal of Personality, 65(3), 529–565. Sharpe, L., Sensky, T., & Allard, S. (2001). The course of depression in recent onset rheumatoid arthritis. The predictive role of disability, illness perceptions, pain and coping. Journal of Psychosomatic Research, 51, 713–719. Silva, A., Alvarelhao, J., Queiros, A., & Rocha, N. (2013). Pain intensity is associated with self-reported disability for several domains of life in a sample of patients with musculoskeletal pain aged 50 or more. Disability and Health Journal, 6(4), 369–376. doi: 10.1016/j. dhjo.2013.04.007. Silkey, B., Preskorn, S., Goldbeck, A., Shah, R., Neff, M., Jones, T., & Choi, J. (2005). Complexity of medication use in the Veteran’s Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients. Journal of Psychiatric Practice, 11(1), 16–25. Tennstedt, S., Morris, J., Unverzagt, F., Rebok, G., Willis, S., Ball, K., & Marsiske, M. (2010). ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999–2001 [United States]. ICPSR04248-v3. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [Distributor], 2010-06-30. doi:10.3886/ICPSR04248.v3. Theis, K., Helmick, C., & Hootman, J. (2007). Arthritis burden and impact are greater among U.S. women than men: Intervention opportunities. Journal of Women’s Health, 16(4), 441–453. Tsai, C., Bayliss, M., & Ware, J. (1997). SF-36 health survey annotated bibliography (2nd ed.). Boston, MA: New England Medical Center, Health Assessment Lab. van Dijk, G., Veenhof, C., Schellevis, F., Hulsmans, H., Bakker, J., Arwert, H., … Dekker, J. (2008). Comorbidity, Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
107
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 107
3/13/14 8:42 AM
limitations in activities and pain in patients with osteoarthritis of the hip or knee. BMC Musculoskeletal Disorders, 9, 95. doi: 10.1186/1471-2474-9-95. van Dijk, G., Veenhof, C., Spreeuwenberg, P., Coene, N., Burger, B., van Schaardenburg, D., … CARPA Study Group. (2010). Prognosis of limitations in activities in osteoarthritis of the hip or knee: a 3-year cohort study. Archives of Physical Medicine and Rehabilitation, 91(1), 58–66. doi: 10.1016/j.apmr.2009.08.147. Ware, J., Kosinski, M., & Keller, S. (1994). Physical and mental health summary: A user’s manual. Boston, MA: New England Medical Center, Health Assessment Lab.
108
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
Ware, J., Snow, K., Kosinski, M., & Gandek, B. (1993). SF-36 health survey: Manual and interpretation guide. Boston, MA: New England Medical Center, The Health Institute. Won, A., Lapane, K., Vallow, S., Schein, J., Morris, J., & Lipsitz, L. (2004). Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. Journal of American Geriatrics Society, 52, 867–874. Zarit, S., Griffiths, P., & Berg, S. (2004). Pain perceptions of the oldest old: A longitudinal study. The Gerontologist, 44(4), 459–468.
© 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 108
3/13/14 8:42 AM
Pain and Depression in Older Adults With Arthritis Uloma D. Onubogu
The experience of chronic pain negatively impacts the general health of individuals. Evidence shows that depression and chronic pain co-occur, and both experiences tend to worsen as the number of comorbidities increases. PURPOSE: The purpose of this study was to examine the relationships between pain and depression as well as the impact of number of comorbidities in older adults with arthritis. METHOD: A cross-sectional analysis of existing data was conducted with a sample of 1,592 community-dwelling older adults (mean age = 74.3 years, SD = 5.9 years). FINDINGS: The majority of participants reported the presence of bodily pain. Mild depressive symptoms and multimorbidities were found. More severe pain correlated with a higher number of comorbidities and worsening depression. IMPLICATIONS: Prevalence and impact of pain and other co-occurring conditions suggest their importance in planning care for the elderly with arthritis. BACKGROUND:
C
hronic pain is a complex, multidimensional experience that can affect individuals physically, socially, emotionally, and psychologically. Chronic musculoskeletal joint disorders such as arthritis are the most common cause of chronic pain and pain-related disability among older adults (American Geriatric Society [AGS], 2009; Brooks, 2005). Individuals with osteoarthritis alone account for more than 10% (27 million) of the U.S. adults with chronic pain, making it a significant healthcare problem (Murphy & Helmick, 2012). This prevalence contributes to the overall problem of chronic pain, which affects more than 50% of older adults (Hall-Lord, Johansson, Schmidt, & Larsson, 2003; Hutt, Pepper, Vojir, Fink, & Jones, 2006; Won et al., 2004). Chronic pain is prevalent among older adults and contributes to an array of adverse consequences that include psychological or emotional symptoms such as depression and anxiety (AGS, 2009; Huber, Suman, Biasi, & Carli, 2008; Leville, Cohen-Mansfield, & Guranik, 2003). A recent study found that more than 90% of persons aged 50 years and older who were assessed for chronic musculoskeletal pain had moderate to severe pain that was always present (Silva, Alvarelhao, Queiros, 102
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
& Rocha, 2013). With associated pain, there is interference in daily activities and functioning. Persistent pain and other forms of physical comorbodities can have adverse effects on depressive symptoms, thereby delaying improvement of symptoms (Mavandadi et al., 2007). Depression and chronic pain commonly co-occur and the risk of depression among older adults with chronic pain increases in the presence of comorbidities. More than 19% of older adults with chronic pain have depressed mood (Iliffe et al., 2009). Multiple chronic conditions (multimorbidity) are reported in as many as 50%–98% of older adults with results that include disability, poor quality of life, increased risk for mortality, and cumulative effects that challenge optimal care (AGS, 2012; Marengoni et al., 2011). The high prevalence of chronic and comorbid diseases contributes to equally high prevalence and complexity of chronic persistent pain experience including depression (AGS, 2009; Harden et al., 2005; Manning & Jackson, 2013). More recent studies found that numerous disorders—musculoskeletal (e.g., chronic back pain) and nonmusculoskeletal (e.g., diabetes)—coexist with arthritis causing disabling limitations (Reeuwijk et al., 2010; van Dijk et al., 2008, 2010). The presence or diagnosis of arthritis was found to be associated with depressed moods in people with persistent pain. This association is attributable to the role of arthritis (attributable risk = 18.1%) in creating functional limitations among the individuals affected (Donald & Fay, 2004; Dunlop, Lyons, Manheim, Song, & Chang, 2004; Duong, Kerns, Towle, & Reid, 2005). The occurrence of depression may exacerbate the pain experience and pain-related interferences (the degree to which pain interferes with normal activities such as house and outside work) as outcomes of negative self-perceived health and functional limitation (Mantyselka, Turunen, Ahonen, & Kumpusalo, 2003; Oster, Harding, Dukes, Edelsberg, & Cleary, 2005; Silkey et al., 2005). With the presence of arthritis and other comorbidities, patients may experience more pain and depression.
Uloma D. Onubogu, PhD, MSN, MSEd, APRN-BC, Associate Professor, Florida A&M University, Tallahassee, FL. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/NOR.0000000000000035 © 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 102
3/13/14 8:42 AM
Chronic Pain and Comorbidities Depression is well documented as a correlate of persistent pain as well as a major indicator of emotional distress among patients with chronic pain (AGS, 2009; Greenberg & Burns, 2003). Depression is also known to initiate, exacerbate, and maintain the pain experience (McCracken, Spertus, Janeck, Sinclair, & Wetzel, 1999). Among a sample (N = 209) of individuals 60 years and older with reported persistent joint pain, 36% were diagnosed with depression (Adams, Plane, Fleming, Mundt, & Saunders, 2001). A higher prevalence of depression was reported by more than 50% of a general population of older adults with persistent pain (Mossey & Gallagher, 2004). More depressive symptoms in persons with persistent pain may be attributed to physical illness (Regan, Kearney, Savva, Cronin, & Kenny, 2013) or to their response to distressful stimuli—both sensory and emotional (AGS, 2002; Gonzales, Martelli, & Baker, 2000; Harden et al., 2005). For example, Ryan and Frederick (1997) found that vitality (indicator of affective well-being or disposition) was lower among older adults with chronic pain, especially if they perceive their pain to be disabling or frightening. This further contributes to their emotional distress. When assessed longitudinally at 6 points over a period of 21 months, Sharpe, Sensky, and Allard (2001) found that pain intensity was one of two variables that consistently predicted level of depression in a population of older adults. Recent study findings that show a high (80.5%) prevalence of undiagnosed mood disorder among older adults with comorbid chronic pain (Agüera-Ortiz, Failde, Cervilla, & Mico, 2013) raise concern about the extent of the problem. Following another longitudinal study of the relationships between pain severity, pain interference, and change in depressive symptoms in older adults at baseline and 3, 6, and 12 months, Mavandadi and colleagues (2007) found that at higher pain intensity levels, improvements in depressive symptoms of persons surveyed were blunted. However, when pain interference was considered in addition to pain intensity, the authors found that the extent to which pain interfered with functioning had a negative impact on the individual’s recovery from depression. Clearly, depressive symptoms in older adults with chronic pain have remained prevalent, despite ongoing research and awareness of the psychosocial impact of chronic pain, and advances in pain management. Thus, in older adults with arthritis who have a significant persistent pain experience, research is needed to evaluate the clinical consequences of comorbidities and adverse pain-related outcomes such as depression. The purpose of this study was to examine the relationships between pain and depression as well as the impact of the number of comorbidities in older adults with arthritis. Demographic differences (gender and race) were also examined. The following specific questions were addressed: 1. Are age, gender, and race associated with bodily pain intensity, pain interference severity, depression, and comorbidities among older adults with arthritis? © 2014 by National Association of Orthopaedic Nurses
2. What are the intercorrelations among the study variables (bodily pain, pain interference, depression, and comorbidities)?
Methods DESIGN AND SUBJECTS This study design was descriptive correlational. A crosssectional secondary analysis of data was conducted using data obtained from the Advanced Cognitive Training for Independent Vital Elderly (ACTIVE) trial (Tennstedt et al. 2010) through the Interuniversity Consortium for Political and Social Research (ICSPR). ACTIVE data accessed for this study are in the public domain (ICSPR #04248). Condition for access of data and the terms of agreement stipulated by ICSPR were satisfied. The ACTIVE study is a large National Institutes of Health–funded randomized and controlled 5-year clinical trial that was conducted by researchers in universities located in six U.S. metropolitan areas to determine the effects of cognitive training on memory and functioning. The ACTIVE study involved 2,802 independent living, cognitively intact (Mini-mental State Examination [MMSE] scores ≥22), older adults aged 65 years and older who had no diagnosis of terminal illness (e.g., cancers) or conditions causing functional decline (e.g., stroke or dementia). Participation in the ACTIVE study was voluntary, and persons were excluded from the study if they had two or more activities-of-daily-living disabilities (score on the self-rated activities-of-dailyliving/instrument activities of daily living [IADL] checklist), or verbally reported medical conditions associated with imminent functional decline or death (such as stroke or cancer); and/or exhibited severe loss of vision, hearing, or poor verbal communication. Study volunteers had to pass an initial first-level screening via a telephone interview and additional inperson cognitive testing to be eligible. Eligible participants were randomized into three groups to receive specific cognitive training or one control group to receive no training. Study assessments were conducted at baseline, immediately after intervention, and annually for 5 years. This study included only a subsample of 1,592 participants at baseline who reported a diagnosis of arthritis on the Older American Resources Service Checklist.
MEASURES Self-reported bodily pain (pain severity) and pain interference (extent to which pain interfered with normal work such as housework and outside work) were measured on the Medical Outcomes Short Form-36 (SF-36) Bodily Pain subscale (Ware, Snow, Kosinski, & Gandek, 1993). The SF-36 evaluates general health, the relative burden of diseases and symptoms such as pain, and the benefits of health interventions (Ware et al., 1993). Participants reported severity of bodily pain experienced during the past 4 weeks on a 6-point verbal descriptor scale from 1 (none) to 6 (very severe). Pain interference in the past 4 weeks was scored on a 5-point verbal descriptor scale as 1 (not at all) to 5 (extremely). The SF-36 Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
103
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 103
3/13/14 8:42 AM
demonstrates good overall reliability on both internal consistency and test-retest methods that have exceeded the minimum standard of 0.70 in many studies (McHorney Ware, Rachel, & Sherbourne, 1994; Tsai, Bayliss, & Ware, 1997; Ware et al., 1993; Ware, Kosinski, & Keller, 1994). This measure has also demonstrated good evidence of validity (content, concurrent, criterion, construct, and predictive) and clearly supports the interpretation and meaning of scores (Ware et al., 1993, 1994). The Center for Epidemiological Studies–Depression (CES-D) Scale was used to assess depression. This is a 20-item Likert-type instrument developed to detect major or clinical depression in adolescents and adults (Radloff, 1977). Four components or factors of the CES-D are depressive affect, somatic symptoms, positive affect, and interpersonal relations. Items in the CES-D refer to how an individual has felt and behaved during the last week. Scores range from 0 to 3, with 0 points = rarely or none of the time ( 80%). Hybels and colleagues also demonstrated that the CES-D could reliably identify clinically significant depression in community-dwelling elders. The CES-D short version yielded Cronbach’s alpha of .87 at baseline and .82 at follow-up for a sample of older adults (Zarit, Griffiths, & Berg, 2004). The Older American Resources Service Checklist was used to measure self-report of comorbid conditions. Participants responded to questions about medical conditions they might have been diagnosed with, including cancer. Scores were summed to indicate participants’ number of comorbidities.
DATA ANALYSIS The SPSS Statistics 19.0 (IBM SPSS, Chicago, IL, 2010) was used for all data analysis. Descriptive statistics were used to analyze demographic characteristics as well as the characteristics of pain variables (bodily pain and pain interference), comorbidities (the number of medical diagnosis), and depression. Bivariate statistics using the t test, analysis of variance, and Pearson’s productmoment correlations examined differences among correlations of demographic variables, pain variables, comorbidities, and depression scores.
Results DESCRIPTIVE FINDINGS The study sample consisted of 1,290 women (81.0%) and 302 men (19%), with a mean age of 74.3 years (SD = 5.9 years). The majority were Caucasian (68.8%; n = 1,095), followed by Black (29.4%; n = 468), and other races (1.8%; n = 29). The majority of participants (31.7%; n = 504) reported bodily pain intensity that was moderate and pain interference that was rated a little bit and more (>60%; n = 958) (see Table 1). Participants reported a mean number of medical diagnosis of 3.5 (SD = 1.45), range 1–10, and mild depressive symptoms (M = 5.6, SD = 5.4).
AGE, GENDER, AND RACE ASSOCIATIONS WITH PAIN VARIABLES, DEPRESSION, AND COMORBIDITIES Results of gender and race association with the study variables are shown in Table 2. Analysis showed that women reported slightly more comorbidities (M = 3.56; SD = 1.64) than men (M = 3.22; SD = 1.37). This difference was statistically significant (t = −3.723; p = .001). Women also reported higher level of depression (M = 5.75; SD = 5.42) than men (M = 5.01; SD = 5.01), and this difference was also statistically significant (t = −2.147; p = .03). Compared with men, women also reported significantly more bodily pain and pain interference. There were no significant race differences in bodily pain (F = 0.295; p = .74), pain interference (F = 0.050; p = .95), depression (F = 0.328; p = .72), and number of comorbidities (F = −1.624; p = .20). More advanced age correlated with a higher number of comorbidities (r = .11; p = .001) and worse depression (r = −.10; p = .001).
TABLE 1. CHARACTERISTICS OF PAIN INTENSITY AND PAIN INTERFERENCE SEVERITY Pain Intensity Very mild
Pain Interference Severity
n
%
398
25
None
n
%
603
37.9
Mild
334
21
A little bit
438
27.5
Moderate
504
31.7
Moderate
336
21.1
Severe
145
9.1
Quite a bit
162
10.2
Very severe
28
1.8
Extremely
22
1.4
Note. N = 1,592.
104
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
© 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 104
3/13/14 8:42 AM
INTERCORRELATIONS AMONG PAIN VARIABLES, DEPRESSION, AND COMORBIDITIES
degree of emotional or depressive symptoms that can result from concurrent pain intensity and pain interference and more comorbidities will likely increase (Mavandadi et al., 2007). These adverse outcomes draw significant concern for the large number (52%–61%) of women older than 65 years who are affected by arthritis (Theis, Helmick, & Hootman, 2007). Demographic variables analyzed in the study linked participants with more advanced age to both more depression and comorbidities. Also, women had more comorbidities, more bodily pain, more pain interference, and more depression. High prevalence of multimorbidities was found in studies involving both men and women as their age increased (Fortin, Lapointe, Hudon, & Vanasse, 2005). A significantly higher rate of comorbidities among the female participants of the current study was also supported by evidence that the rate of having two or more medical conditions was 99% among women aged 65 years and older in primary care (Fortin, Bravo, et al., 2005). These findings are confirmed in both crosssectional and longitudinal studies where female gender was implicated as a factor in high prevalence of multimorbidities (Marengoni et al., 2011).
Analysis of intercorrelations among study variables showed that a higher number of comorbidities was significantly correlated with worse depression (r = .11; p = .001), more severe bodily pain (r = .13; p = .001), and more pain interference (r = .16; p = .001). Also, pain interference was correlated with worsening depression scores (r = .30; p = .001). Greater bodily pain was highly correlated with more pain interference (r = .63; p = .001) and correlated with worsening depression scores (r = .23; p = .000).
Discussion Presence of bodily pain and pain interference was high among the study participants. These finding are supported by several published reports of high prevalence of chronic pain (over 50%) and pain interference among community-dwelling older adults that are attributed to arthritis (AGS, 2009; American Pain Foundation, 2009; Brown, Kirkpatrick, Swanson, & McKenzie, 2011; Centers for Disease Control and Prevention, 2013). Equally high prevalence of comorbidities and multimorbidities (over 50%) among the elderly is reported in studies (Caughey, Vitry, Gilbert, & Roughead, 2008; Fortin, Bravo, Hudon, Vanasse, & Lapointe, 2005; Marengoni et al., 2011). These data support the current study finding of 90% prevalence of comorbidities and multimorbidities among study participants. There was a significant positive correlation between the number of comorbidities and depression. This is consistent with the evidence of high prevalence of multiple diseases, which tends to worsen depressive symptoms among older adults with painful musculoskeletal joint disease (Moussavi et al., 2007). An association of depression with chronic comorbid diseases was found to be an important risk factor for worsening health outcomes in a general population of adults around the world (Moussavi et al., 2007), as well as with arthritis in particular (Dunlop et al., 2004). Based on estimates by Centers for Disease Control and Prevention (2006), increases in the rates of arthritis and related pain interferences will occur as more and more people join the ranks of those 65 years and older over the next decade. Therefore, the
IMPLICATIONS The prevalence of pain, comorbidities, and multimorbidities found in this study suggests their importance in planning care for older adults with arthritis. These findings have important clinical implications because of their association with disability, functional decline, poor quality of life, high healthcare cost, and complexity in clinical management decisions. Practitioners, in their clinical assessment of older adults with arthritis, should be cognizant of the high rates of undiagnosed mood disorders among chronic pain sufferers (AgueraOrtiz et al., 2013). Thus, it is important that any plan of care for older adults with multiple chronic conditions consider clinical practice guidelines for multiple problems rather than single problems. Specifically, healthcare practitioners should employ empirical tools in the management of older adults with arthritis to identify the presence and severity of co-occurring conditions to direct effective clinical management to prevent and/or limit adverse pain-related outcomes such as depression.
TABLE 2. GENDER AND RACE ASSOCIATIONS WITH PAIN VARIABLES, DEPRESSION, AND COMORBIDITIES Gender Male, M (SD)
Female, M (SD)
Bodily pain intensity
2.77 (1.63); n = 297
Pain interference severity
Study Variables
Race Caucasian, M (SD)
Black, M (SD)
Other Races, M (SD)
.000
3.04 (1.52); n = 1,081
3.099 (1.34); n = 457
−2.684
.007
2.04 (1.28); n = 1,081
5.75 (5.42); n = 1,264
−2.147
.03
3.54 (1.64); n = 1,290
−3.723
.001
t
p
3.12 (1.42); n = 1,270
−3.724
1.86 (1.29); n = 297
2.08 (1.24); n = 1,270
Depression
5.01 (5.01); n = 295
No. of comorbidities
3.22 (1.37); n = 302
F
p
3.10 (1.32); n = 29
0.295
.74
2.04 (1.20); n = 457
1.97 (1.21); n = 29
0.050
.95
5.68 (5.57); n = 1,077
5.44 (4.84); n = 454
5.68 (5.39); n = 28
0.328
.72
3.45 (1.43); n = 1,095
3.59 (1.5); n = 468
3.62 (1.17); n = 29
1.624
.20
Note. N = 1,592. Coding: males = 1; females = 2; Caucasians = 1; Blacks = 2; other races = 3.
© 2014 by National Association of Orthopaedic Nurses
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
105
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 105
3/13/14 8:42 AM
A significantly higher prevalence of multiple chronic conditions including pain among the female study participants has implication for reducing disparities in the healthcare of older adult women and improving their overall health outcomes. Considering a disproportionately higher rate of arthritis in women compared with men, healthcare practitioners should be especially aware of and sensitive to the vulnerabilities of older women to adverse outcomes of comorbid or multiple chronic conditions such as persistent pain, pain interference, and depression in their assessment and planning of care.
LIMITATIONS Secondary data analysis was conducted for this study, which limits control over size and characteristics of the sample. Also, the use of existing data poses a threat to internal or external validity; hence, results of this study are only generalizable to community-dwelling older adults with arthritis. The limitations in the accuracy of self-reported data especially with the report of medical diagnosis are recognized when the strengths of the study results and implications are considered. Participants were recruited as vital older adults and on the average had fewer and less severe manifestations of adverse disease outcomes such as pain, pain interference, and depression at the time of the study measurements. Thus, the effects size of measured variables, although statistically significant, were small.
Conclusion Persistent pain negatively impacts the general health and the emotional and functional status of individuals. Given consistent supporting evidence of the interrelationships of chronic pain, depression, and comorbidities, these are important variables to be considered by healthcare practitioners when caring for older adults with arthritis. A future longitudinal study will be beneficial to determine how the relationships between pain and depression progress over time.
ACKNOWLEDGMENTS The author was a participant in the 2013 NLN Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education and Pocket Nurse. The author thanks Dr. Ruena Norman (Dean of FAMU School of Nursing) whose administrative support through funding and personal encouragement made attendance at the NLN Scholarly Writing Retreat and eventual completion of this manuscript possible.
REFERENCES Adams, N., Plane, M., Fleming, M., Mundt, M., & Saunders, L. (2001). Opioids and the treatment of chronic pain in a primary care sample. Journal of Pain and Symptom Management, 22(3), 791–796. Agüera-Ortiz, L., Failde, I., Cervilla, J., & Mico, J. (2013). Unexplained pain complaints and depression in older people in primary care. Journal of Nutrition, Health & Aging, 17(6), 574–757. doi: 10.1007/s12603-0130012-0.
106
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
American Geriatric Society Expert panel on the Care of Older Adults With Multimorbidity. (2012). Guiding principles for care of older adults with multimorbidity: An approach for clinicians. Journal of American Geriatric Society, 60(10), E1. doi: 10.1111/j.1532-5415. 2012.04188.x American Geriatric Society Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of American Geriatrics Society, 50(s6), S205–S224. American Geriatric Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of American Geriatrics Society, 57, 1331–1346. American Pain Foundation. (2009). A reporter’s guide: Covering pain and its management. Retrieved from http://nationalpress.org/images/uploads/programs/ PAIN_RoweGuide.pdf Brooks, P. (2005). Issues with chronic musculoskeletal pain. Rheumatology, 44, 831–833. Brown, S., Kirkpatrick, M., Swanson, M., & McKenzie, I. (2011). Pain experience of the elderly. Pain Management Nursing, 12(4), 190–196. doi: 10.1016/j.pmn.2010. 05.004. Centers for Disease Control and Prevention. (2006). Prevalence of doctor-diagnosed arthritis and arthritisattributable activity limitation—United States, 2003– 2005. Morbidity and Mortality Weekly Report, 55(40), 1089–1092. Centers for Disease Control and Prevention. (2013). Arthritis. Meeting the challenge of living well. At a glance. Retrieved from http://www.cdc.gov/chronicdisease/ resources/publications/AAG/arthritis.htm Caughey, G., Vitry, A., Gilbert, A., & Roughhead, E. (2008). Prevalence of comorbidity of chronic diseases in Australia. BMC Public Health, 8, 221. doi:10.1186/14712458-8-221. Donald, I. P., & Foy, C. (2004). A longitudinal study of joint pain in older people . Rheumatology , 43 (10), 1256–1260. Dunlop, D., Lyons, J., Manheim, L., Song, J., & Chang, R. (2004). Arthritis and heart disease as risk factors for major depression: The role of functional limitation. Medical Care, 42(6), 502–511. Duong, B., Kerns, R., Towle, V., & Reid, C. (2005). Identifying the activities affected by chronic nonmalignant pain in older veterans receiving primary care. Journal of American Geriatrics Association, 53(4), 687–694. Fortin, M., Bravo, G., Hudon, C., Vanasse, A., & Lapointe, L. (2005). Prevalence of multimorbidity among adults seen in family practice. Annals of Family Medicine, 3(3), 223–228. Fortin, M., Lapointe, L., Hudon, C., & Vanasse, A. (2005). Multimorbidity is common to family practice: Is it commonly researched? Canadian Family Physician, 51, 244–245. Geisser, M., Roth, R., & Robinson, M. (1997). Assessing depression among persons with chronic pain using the Center for Epidemiology Studies–Depression Scale and the Beck Depression Inventory: A comparative analysis . Clinical Journal of Pain, 13 ( 2 ), 163–170. Gonzales, V., Martelli, M., & Baker, J. (2000). Psychological assessment of persons with chronic pain. Neuro Rehabilitation, 14, 69–83. Greenberg, J., & Burns, J. (2003). Pain anxiety among chronic pain patients: Specific phobia or manifestation © 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 106
3/13/14 8:42 AM
of anxiety sensitivity. Behavior Research and Therapy, 41, 223–240. Hall-Lord, M., Johansson, I., Schmidt, I., & Larsson, B. (2003). Family members’ perceptions of pain and distress related to analgesics and psychotropic drugs, and quality of care of elderly nursing home residents. Health and Social Care in the Community, 11(3), 262–274. Harden, N., Weinland, S., Remble, T., Houle, T. T., Colio, S., Steedman, S., & Kee, W. (2005). Medication Quantification Scale Version III: Update in medication classes and revised detriment weights by survey of American Pain Society physicians. The Journal of Pain, 6(6), 364–371. Huber, A., Suman, A. L., Biasi, G., & Carli, G. (2008). Predictors of psychological distress and well-being in women with chronic musculoskeletal pain: two sides of the same coin? Journal of Psychosomatic Research, 64(2), 169–175. doi: 10.1016/j.jpsychores.2007.09.005. Hutt, E., Pepper, G., Vojir, C., Fink, R., & Jones, K. (2006). Assessing the appropriateness of pain medication prescribing practices in nursing homes. Journal of American Geriatrics Society, 54(2), 231–239. Hybels, C., Blazer, D., & Pieper, C. (2001). Toward a threshold for subthreshold depression: An analysis of correlates of depression by severity of symptoms using data from an elderly community sample. The Gerontologist, 41(3), 357–365. Iliffe, S., Kharicha, K., Carmaciu, C., Harari, D., Swift, C., Gillman, G., & Stuck, A. (2009). The relationship between pain intensity and severity and depression in older people: Exploratory study. BMC Family Practice, 10, 54. doi: 10.1186/1471-2296-10-54. Kothe, R., Kohlmann, T., Klink, T., Ruther, W., & Klinger, R. (2006). Impact of back pain on functional limitations, depressed mood and quality of life in patients with rheumatoid arthritis. Pain, 127, 103–108. Leville, S., Cohen-Mansfield, J., & Guranik, J. (2003). The impact of chronic musculoskeletal pain on exercise attitudes, self-efficacy, and physical activity. Journal of Aging and Physical Activity, 11, 275–283. Manning, J., & Jackson, W. (2013). Depression, pain, and comorbid medical conditions. Journal of Clinical Psychiatry, 74(2), e03. doi: 10.4088/JCP.12049vs3c. Mantyselka, P., Turunen, J., Ahonen, R., & Kumpusalo, E. (2003). Chronic pain and poor self-rated health. JAMA, 290(18), 2435–2442. Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., … Fratiglioni, L. (2011). Aging with multiple morbidity: A systematic review of the literature. Ageing Research Review, 10(4), 430–439. doi: 10.1016/j.arr.2011.03.003. Mavandadi, S., Have, T., Katz, I., Durai, U., Krahm, D., Liorente, M. D., … Oslin, D. (2007). Effects of depression treatment on depressive symptoms in older adulthood: The moderating role of pain. Journal of American Geriatric Society, 55(2), 202–211. McCracken, L., Spertus, I., Janeck, A., Sinclair, D. & Wetzel, F. (1999). Behavioral dimensions of adjustment in persons with chronic pain: pain-related anxiety and acceptance. Pain, 80(1-2), 283–289. McHorney, C., Ware, J., Rachel, J., & Sherbourne, C. (1994). The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Medical Care, 32, 40–66. Mossey, J., & Gallagher, R. (2004). The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care © 2014 by National Association of Orthopaedic Nurses
retirement community residents. Pain Medicine, 4, 335–345. Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression, chronic diseases, and decrements in health: Results from the World Health Surveys. Lancet, 370(9590), 851–858. Murphy, L., & Helmick, C. (2012). The impact of osteoarthritis in the United States: A population-health perspective. American Journal of Nursing, 112(3, Suppl. 1), S13–S19. doi: 10.1097/01.NAJ.0000412646.80054.21. Oster, G., Harding, G., Dukes, E., Edelsberg, J., & Cleary, P. (2005). Pain, medication use, health-related quality of life in older persons with postherpetic neuralgia: Results from a population-based survey. The Journal of Pain, 6(6), 356–363. Radloff, L. (1997). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1(3), 385–401. doi: 10.1177/014662167700100306. Regan, C., Kearney, P., Savva, G., Cronin, H., & Kenny, R. (2013). Age and sex differences in prevalence and clinical correlates of depression: First results from the Irish Longitudinal Study on Ageing. International Journal of General Psychiatry. Epub ahead of print. doi: 10.1002/gps.3955 Reeuwijk, K., de Rooij, M., van Dijk, G., Veenhof, C., Steultjens, M., & Dekker, J. (2010). Osteoarthritis of the hip or knee: Which coexisting disorders are disabling? Clinical Rheumatology, 29(7), 739–747. doi: 10.1007/s10067-010-1392-8. Reid, C., Williams, C., Concato, J., Tinetti, M., & Thomas, G. (2003). Depressive symptoms as a risk factor for disabling back pain in community-dwelling older persons. Journal of American Geriatrics Society, 51, 1720–1717. Ryan, R., & Frederick, C. (1997). On energy, personality, and health: Subjective vitality as a dynamic reflection of well-being. Journal of Personality, 65(3), 529–565. Sharpe, L., Sensky, T., & Allard, S. (2001). The course of depression in recent onset rheumatoid arthritis. The predictive role of disability, illness perceptions, pain and coping. Journal of Psychosomatic Research, 51, 713–719. Silva, A., Alvarelhao, J., Queiros, A., & Rocha, N. (2013). Pain intensity is associated with self-reported disability for several domains of life in a sample of patients with musculoskeletal pain aged 50 or more. Disability and Health Journal, 6(4), 369–376. doi: 10.1016/j. dhjo.2013.04.007. Silkey, B., Preskorn, S., Goldbeck, A., Shah, R., Neff, M., Jones, T., & Choi, J. (2005). Complexity of medication use in the Veteran’s Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients. Journal of Psychiatric Practice, 11(1), 16–25. Tennstedt, S., Morris, J., Unverzagt, F., Rebok, G., Willis, S., Ball, K., & Marsiske, M. (2010). ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly), 1999–2001 [United States]. ICPSR04248-v3. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [Distributor], 2010-06-30. doi:10.3886/ICPSR04248.v3. Theis, K., Helmick, C., & Hootman, J. (2007). Arthritis burden and impact are greater among U.S. women than men: Intervention opportunities. Journal of Women’s Health, 16(4), 441–453. Tsai, C., Bayliss, M., & Ware, J. (1997). SF-36 health survey annotated bibliography (2nd ed.). Boston, MA: New England Medical Center, Health Assessment Lab. van Dijk, G., Veenhof, C., Schellevis, F., Hulsmans, H., Bakker, J., Arwert, H., … Dekker, J. (2008). Comorbidity, Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
107
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 107
3/13/14 8:42 AM
limitations in activities and pain in patients with osteoarthritis of the hip or knee. BMC Musculoskeletal Disorders, 9, 95. doi: 10.1186/1471-2474-9-95. van Dijk, G., Veenhof, C., Spreeuwenberg, P., Coene, N., Burger, B., van Schaardenburg, D., … CARPA Study Group. (2010). Prognosis of limitations in activities in osteoarthritis of the hip or knee: a 3-year cohort study. Archives of Physical Medicine and Rehabilitation, 91(1), 58–66. doi: 10.1016/j.apmr.2009.08.147. Ware, J., Kosinski, M., & Keller, S. (1994). Physical and mental health summary: A user’s manual. Boston, MA: New England Medical Center, Health Assessment Lab.
108
Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
Ware, J., Snow, K., Kosinski, M., & Gandek, B. (1993). SF-36 health survey: Manual and interpretation guide. Boston, MA: New England Medical Center, The Health Institute. Won, A., Lapane, K., Vallow, S., Schein, J., Morris, J., & Lipsitz, L. (2004). Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. Journal of American Geriatrics Society, 52, 867–874. Zarit, S., Griffiths, P., & Berg, S. (2004). Pain perceptions of the oldest old: A longitudinal study. The Gerontologist, 44(4), 459–468.
© 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ599R1.indd 108
3/13/14 8:42 AM
