Social & psychological factors associated with oral analgesic use in knee osteoarthritis management.

OBJECTIVE: Determine modifiable social and psychological health factors that are associated with use of oral opioid and non-opioid medications for OA. METHODS: Patients were categorized based on use of the following oral medications: opioids (with/without other oral analgesic treatments), non-opioid analgesics, and no oral analgesic treatment. We used multinomial logistic regression models to estimate adjusted relative risk ratios (RRRs) of using an opioid or a non-opioid analgesic (vs. no oral analgesic treatment), comparing patients by levels of social support (Medical Outcomes Study scale), health literacy ("How confident are you filling out medical forms by yourself?"), and depressive symptoms (Patient Health Questionnaire-8). Models were adjusted for demographic and clinical characteristics. RESULTS: In this sample (mean age 64.2 years, 23.6% women), 30.6% (n = 110) reported taking opioid analgesics for OA, 54.2% (n = 195) reported non-opioid use, and 15.3% (n = 55) reported no oral analgesic use. Opioid users had lower mean social support scores (10.0 vs 10.5 vs 11.9, P = 0.007) and were more likely to have moderate-severe depressive symptoms (42.7% vs 24.1% vs 14.5%, P < 0.001). Health literacy did not differ by treatment group type. Having moderate-severe depression was associated with higher risk of opioid analgesic use compared to no oral analgesic use (RRR 2.96, 95%CI 1.08-8.07) when adjusted for sociodemographic and clinical factors. Neither social support nor health literacy was associated with opioid or non-opioid oral analgesic use in fully adjusted models. CONCLUSIONS: Knee OA patients with more severe depression symptoms, compared to those without, were more likely to report using opioid analgesics for OA.

Advances in understanding the mechanisms and management of persistent pain in older adults.

Older adults with persistent pain are not simply a chronologically older version of younger pain patients. Pain-related disability in older adults may be driven by pain 'homeostenosis', that is, diminished ability to effectively respond to the stress of persistent pain. Some of the comorbidities of ageing that can contribute to pain homeostenosis include cognitive and physical impairments, increased sensitivity to suprathreshold pain stimuli, medical and psychological comorbidities, altered pharmacokinetics and pharmacodynamics, and social isolation. A key distinction between older and younger individuals with persistent pain is the normal and pathological ageing-associated brain changes. These may alter the expression and experience of pain with impaired descending inhibition and dysfunction of pain gating mechanisms. Cognizance of these brain changes is needed to guide appropriate evaluation and treatment approaches. This paper reviews data that support these ageing-associated phenomena. Specifically, we discuss age-related changes in the brain (both normal and pathological) and in pain physiology; changes in experience and expression of pain that occur with dementia and contribute to pain homeostenosis; and unique aspects of age and pain-associated psychological function and their contribution to disability. We also present data demonstrating changes in brain morphology and neuropsychological performance that accompany persistent non-malignant pain in older adults and the treatment implications of these brain changes. Finally, preliminary data are presented on the efficacy of mindfulness meditation, a treatment that has been examined explicitly in older adults and targets optimizing brain function and descending inhibition.

Pain in nursing home residents: management strategies.

Pain is prevalent and undertreated in nursing home residents, despite the existing wide array of effective pharmacological and nonpharmacological treatment modalities. In order to improve the quality of life of these vulnerable individuals, practitioners require education about the correct approach to assessment and management. Assessment should be comprehensive, taking into account the basic underlying pathology (e.g. osteoarthritis, osteoporosis, peripheral neuropathy, fibromyalgia, cancer) as well as other contributory pathology (e.g. muscle spasm, myofascial pain) and modifying comorbidities (e.g. depression, anxiety, fear, sleep disturbance). Pharmacological management should be guided by a stepped-care approach, modelled after that recommended by the World Health Organization for treatment of cancer pain. Nonopioid and opioid analgesics are the cornerstone of pharmacological pain management. Tricyclic antidepressants and anticonvulsants can be very effective for the treatment of certain types of neuropathic pain. In addition to treating the pain per se, attention should be given to prevention of disease progression and exacerbation, as maintaining function is of prime importance. Nursing home residents with severe dementia challenge the practitioner's pain assessment skills; an empirical approach to treatment may sometimes be warranted. The success of treatment should be measured by improvement in pain intensity as well as physical, psychosocial and cognitive function. Effective pain management may impact any or all of these functional domains and, therefore, substantially improve the nursing home resident's quality of life.

Are all older adults with persistent pain created equal? Preliminary evidence for a multiaxial taxonomy.

BACKGROUND: Persistent pain is grossly undertreated in older adult sufferers, despite its high prevalence in this age group. Because of its multidimensional impacts, including depression, sleep disruption and physical disability, patients with persistent pain often benefit from interdisciplinary pain clinic treatment. This treatment is expensive, however, and may not be required by all patients. The Multiaxial Assessment of Pain (MAP) has demonstrated value in predicting response to treatment in younger adults with persistent pain. OBJECTIVE: To examine the feasibility of a MAP taxonomy for community-dwelling adults age 65 years or older. PARTICIPANTS AND PROCEDURES: One hundred eight subjects with persistent pain (mean age 73.8 years, SD=8.4 years) were interviewed and data collected on demographics, pain intensity, depressive symptoms, sleep disruption, pain interference with performance of basic and instrumental activities of daily living, frequency of engagement in advanced activities of daily living, cognitive function and comorbidity. A subset of these subjects underwent physical capacities testing, including maximal isometric lift strength, dynamic lifting endurance, timed chair rise and balance. RESULTS: Analyses derived three primary clusters of patients. Cluster 1 (24%) reported less intense pain, less depression and sleep disruption, and higher activity levels. Cluster 3 (30%) suffered from more pain and were more functionally disabled. Cluster 2 (46%) had characteristics of cluster 1 and cluster 3, but with some characteristics that were clearly unique. CONCLUSIONS: While these results are preliminary and require further validation, they indicate that older adults are heterogeneous in their response to persistent pain. Future studies should be performed to examine whether the MAP taxonomy is applicable to older adults regardless of medical diagnosis. Ultimately, this information may have meaning with regard to both treatment prescribing, and the design and interpretation of intervention studies.

Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly.

BACKGROUND: While central nervous system (CNS) active medications such as psychotropics and narcotic analgesics have been implicated in contributing to falls in older adults, the combined effect of multiple CNS-active medications has not been investigated. The purpose of this study was to examine the influence, in community-dwelling elderly, of (1) taking multiple CNS-active medications on fall liability and (2) individual classes of CNS-active medications (using discrete drug classification) on the risk of falls after controlling for important confounders--age, mobility, cognition and depression. METHODS: 305 community-dwelling male veterans (age: 70-104) were screened at study entry for mobility, cognition and depression. CNS-active medications were categorized as benzodiazepines, other sedative-hypnotics, neuroleptics, tricyclic antidepressants, and opioid analgesics. Subjects were prospectively followed for 6 months to monitor falls; at the end of this time period, subjects were classified as fallers (at least one fall) or nonfallers. The relationship between CNS-active drug use and falls was examined using multivariable analyses. RESULTS: The risk of falls was significantly greater in CNS-active medication users as compared with nonusers. Adjusted odds ratio for one CNS-active drug was 1.54 (95% confidence interval 1.07-2.22) and for two or more agents 2.37 (95% confidence interval 1.14-4.94). CONCLUSIONS: In community-dwelling elderly, the use of multiple CNS-active medications is associated with enhanced falls liability, over and above the use of one CNS-active drug alone. This apparent dose-response relationship provides support for causality.

Predictors of pain self-report in nursing home residents.

The purpose of this study was to examine the influence of cognitive function and other biopsychosocial factors on test-retest agreement, four-week variability, and intensity of self-reported pain using the verbal 0 to 10 scale and a pain thermometer in 115 nursing home residents over four weeks. Pain was assessed twice on three days during week 1, and once each during weeks 2, 3 and 4. A forward stepwise regression procedure was used to examine the influence of biopsychosocial parameters (age, race, gender, educational status, marital status, comorbidity, cognitive function, depression, social support, physical function and self-rated health) on pain intensity, test-retest agreement and variability. There was a quadratic association between cognitive function and test-retest agreement with the 0-10 scale; residents with Folstein scores of 22-26 were more likely to show disagreement (50% of 34) than residents with scores < 22 or > 26 (7% of 71). Higher Folstein scores were also associated with greater pain intensity for both pain scales (p < 0.001). Baseline pain intensity was significantly related to pain variability (0-10 scale only). The clinician should be cognizant of these relationships when interpreting verbalizations of pain in long-term care facilities.

Factors that disturb sleep in nursing home residents.

The purpose of this cross-sectional survey was to examine subjective sleep quality, and identify factors that disturb sleep in cognitively intact nursing home (NH) residents. We interviewed 51 cognitively intact NH residents using a validated instrument, the Pittsburgh Sleep Quality Index (PSQI). Questions regarding the environment, symptoms suggestive of restless leg syndrome, and periodic leg movements were also asked. Three individuals were unable to answer all the questions and, therefore, analyses were performed on 48 subjects. Seventy-three percent of the subjects were identified as "poor" sleepers based upon a total PSQI score > 5. Factors that disturbed the residents' sleep three or more times a week were: nocturia (71%), environment-related noise or light (38%), pain (33%), feeling too hot (6%) and leg cramps (6%). On multiple regression analysis, poor sleep correlated with depressive symptoms and comorbidity, not with age or gender. Poor sleep quality is common among cognitively intact NH residents. In our study, nocturia, environmental factors and pain were the most commonly perceived causes of sleep disturbance. Poor sleep independently correlated with depressive symptoms and comorbidity. These findings should be kept in mind when evaluating sleep complaints in the nursing home.

Religious coping in the nursing home: a biopsychosocial model.

OBJECTIVE: To examine psychosocial and physical health correlates of religious coping in medically ill chronically institutionalized older adults. Religious coping is defined as the extent to which persons use religious beliefs and practices to help them to cope. METHOD: This is a cross-sectional cohort study conducted in a 120 bed VA-affiliated and a 125 bed university affiliated community-based nursing home in Durham, North Carolina. Participants were 115 chronic care nursing home residents; mean age of the sample was seventy-nine years, 44 percent were women, and 17 percent were African Americans. Subjects were enrolled for a one-month period during which comprehensive psychosocial and health assessments were performed, including evaluation of cognitive function (Mini-Mental State Exam), physical function (Barthel index), severity of medical comorbidity (Cumulative Illness Rating Scale), self-reported physical pain (vertical verbal descriptor scale), depressive symptoms (Geriatric Depression Scale), social support (social network), and religious coping (Religious Coping Index). RESULTS: Over 43 percent of the sample scored in the depressed range of the Geriatric Depression Scale. Almost 60 percent reported they used religion at least to a large extent when coping with their problems; 34 percent said that it was the most important factor that enabled them to cope. Patients who used religion to cope had greater social support (p = .01), more severe medical illness (p = .04), and better cognitive functioning (p = .02). CONCLUSIONS: Religious beliefs and practices are frequently used by chronically institutionalized older adults to help them to cope. Religious coping is associated with more severe medical illness, higher social support, and better cognitive functioning.

Does radiographic osteoarthritis correlate with flexibility of the lumbar spine?

OBJECTIVES: To examine the association between radiographic lumbosacral (LS) osteoarthritis (OA) and lumbar flexibility in elders without back pain or known spinal pathology and to develop a reliable grading system for osteoarthritis of the lumbosacral spine. DESIGN: Cross-sectional study. SETTING: Durham VA and Duke University Medical Center Department of Radiology. PARTICIPANTS: 35 volunteers aged 64-90 (nursing home residents and community dwellers). Exclusion criteria were known spinal pathology, back pain, inability to stand independently for 1 minute, and > 150% of ideal body weight. INTERVENTIONS: All subjects underwent LS spine radiographs and flexibility measures (forward flexion, extension, lateral flexion, and axial rotation). MAIN OUTCOME MEASURES: Reliability of ordinal OA X-ray grading system, tested using intraclass correlations (ICCs); stability of flexibility measures, using ICCs; and association of disc or facet summary scores (sum of all levels, T12 thru S1) with flexibility measures, using Pearson correlations. RESULTS: ICCs for interest flexibility measures ranged from 0.72 to 0.94. ICCs for interobserver X-ray scores were 0.85 for facet disease and 0.93 for disc disease. The correlation of facet disease with forward lumbar flexion was 0.29. The correlation of disc disease with flexibility showed modest correlation for forward (r = 0.34), right lateral (r = 0.36), and left lateral (r = 0.35) flexion. None of the correlations was influenced by age. CONCLUSIONS: We have developed a reliable radiographic scoring instrument for assessing radiographic OA of the LS spine. It appears that painless LS disc OA is one factor that influences spinal motion.

Chair rise strategies in the elderly.

The elderly often have difficulty with rising from a chair. The purpose of this study was to characterize their rising strategies. A group of 22 elderly adults with a range of functional impairments was asked to rise from chairs of varying heights. Videotape motion analysis was used to identify strategies, estimate centre of mass, and measure time to rise. Three movement strategies were identified, "momentum transfer", "stabilization", and "combined" based on the velocity of trunk movement and base of support rearrangement. "Momentum transfer" uses horizontal momentum developed in the trunk to rise; "stabilization" uses centre of mass and base of support repositioning but very little momentum; "combined" uses elements of both momentum transfer and stabilization. Differences in the time to rise and the centre of mass to base of support separation between the momentum transfer and stabilization strategies were significant at each chair height. The momentum transfer, combined, and stabilization may form a continuum of chair rise strategies.

Does functional reach improve with rehabilitation?

Functional reach (FR, maximal safe standing forward reach) is a precise, reliable, clinically accessible, age-sensitive measure of balance that approximates center of pressure excursion and validly estimates physical frailty. We now test its ability to detect improvement in balance over time. Twenty-eight inpatient male veterans (age 40 to 105, mean, 67.3) undergoing physical rehabilitation and 13 nonrehabilitation controls were evaluated at baseline and every 4 weeks using FR (yardstick method), 10-foot walking time (WT), the Duke hierarchical mobility skills protocol (HMS) and a portion of the Functional Independence Measure (FIM). Their sensitivity to change was determined using the responsiveness index (RI). FR as well as the other physical performance instruments tested were found to be sensitive to change (RI for FR = 0.97, WT = 11.26, HMS = 4.63, FIM = 4.93) and therefore, appropriate measures for use in prospective clinical trials.

When older adults face the chair-rise challenge. A study of chair height availability and height-modified chair-rise performance in the elderly.

OBJECTIVE: Define the range of community seating heights available for use by older adults; test whether raising chair height by small increments facilitates chair-rise performance; and heighten physician and furniture industry awareness of discrepancies that may exist between actual and acceptable chair heights for older adults. DESIGN: Phase 1: Survey of commercially available chair heights. Phase 2: Cross-sectional descriptive study of chair-rise ability. SETTING: Phase 1: Local furniture stores, physician offices, hospital waiting areas, and nursing homes. Phase 2: Postural Control Lab. PARTICIPANTS: Twenty-two volunteers (nursing home residents and community dwellers). EXCLUSION CRITERIA: inability to stand independently and inability to bear full weight on the lower extremities in the standing position. MEASUREMENTS: Chair rise success at six heights (17-22 inches), self-reported difficulty (visual analogue scale), change in minimum hip angle and maximum shoulder angle during rise, using motion analysis. RESULTS: Phase 1: Community chair heights ranged from 12 to 18 inches, with a mean of 16.3 in physician offices, 16.6 in nursing homes, 16.4 in hospitals, 17.3 in "kitchens" and 15 in "living rooms." Phase 2: As chair height increased from 17 to 22 inches, chair rise effort decreased, as shown by near doubling of percent successful rises, decline in mean self-reported difficulty score, increase in mean minimum hip angle, and decrease in mean maximum shoulder angle. CONCLUSIONS: Seating height may need to be more closely scrutinized in areas frequented by frail elders. Augmentation of seat height by small increments facilitates chair rise performance.

Functional reach: a marker of physical frailty.

OBJECTIVE: To establish the concurrent validity of our new balance instrument, functional reach (FR = maximal safe standing forward reach), as a marker of physical frailty compared with other clinical measures of physical performance. DESIGN, SETTING AND PARTICIPANTS: 45 community-dwelling persons age 66-104 were evaluated at one point in time using (1) FR (yardstick method), (2) Physical and Instrumental Activities of Daily Living (PADL, IADL), (3) Life Space, a 3-point measure of social mobility, (4) 10-item hierarchical mobility skills protocol, (5) 10-foot walking speed, (6) one-footed standing, and (7) tandem walking. Data analysis employed Spearman correlations. Partial r's were also calculated after controlling for age. RESULTS: The FR performance range was broad (4.3-16.5 inches, mean 10.9, SD 3.1). Except for PADL, the association of FR with the other physical performance measures was strong, with r's ranging from 0.64-0.71; the association of FR with PADL was 0.48. After controlling for age in the regression analysis, partial r's ranged from 0.52-0.63. The association of FR with age was -0.50. CONCLUSIONS: Based on cross-sectional data, FR is a practical instrument that correlates with physical frailty even more than with age.

Large vessel vasculitis of the central nervous system in systemic lupus erythematosus: report and review of the literature.

Large vessel vasculitis rarely involves the central nervous system in patients with systemic lupus erythematosus. We describe an exemplary case, along with its dramatic cerebral angiogram, and review the literature on this unusual entity.

Functional reach: a new clinical measure of balance.

A new clinically accessible measure of balance, functional reach (FR), is the difference between arm's length and maximal forward reach, using a fixed base of support. The purposes of this study were to (a) establish FR as a measure of the margin of stability versus the laboratory measure, center of pressure excursion (COPE); (b) test reliability and precision, and (c) determine factors that influence FR, including age and anthropometrics. We evaluated FR in 128 volunteers (age 21-87 years). FR was determined with a precise electronic device and a simple clinical apparatus (yardstick). FR correlates with COPE (Pearson r = .71) and is precise (coefficient of variation = 2.5%) and stable (intraclass correlation coefficient across days = .81). Age and height influence FR. FR is portable, inexpensive, reliable, precise, and a reasonable clinical approximator of the margin of stability. FR may be useful for detecting balance impairment, change in balance performance over time, and in the design of modified environments for impaired older persons.