- Email: [email protected]
Pain and pain medication use in community-dwelling older adults
The American Journal of Geriatric Pharmacotherapy
P. Sawyer et al.
Brief Report Pain and Pain Medication Use in Community-Dwelling Older Adults Patricia Sawyer, PhDI,2; EricV. Bodner, BS2; Christine S. Ritchie, MDI-3; and Richard M.AIIman, MD I-3 I Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham,Alabama; 2Center for Aging, University of Alabama at Birmingham, Birmingham,Alabama; and 3Birmingham~AtlantaVA Geriatric Research, Education, and Clinical Center, Birmingham,Alabama
ABSTRACT Background: Pain is a common symptom and significant problcm for oldcr adults; up to onc half of communitydwelling older adults have pain that interferes with normal function. Objective: The goal of this study was to investigate the prevalence of pain among a racially and gender-balanced sample of community-dwelling older adults and evaluate sociodemographic factors associated with the reporting of pain. Both nonprescription (over-the-counter [OTC]) and prescription pain medications used by the participants and the sociodemographic factors associated with having medication prescribed were considered. Methods: This was a population-based, prospective, observational study. Subjects were participants in the University of Alabama at Birmingham (UAB) Study of Aging, a stratified random sample of Medicare beneficiaries who completed in-home interviews (1999-2001). Assessments included sociodemographic factors and pain; interviewers listed all prescription and OTC pain medications used. Pain medications were coded as NSAIDs, opiates, and miscellaneous pain medications. A composite ordinal measure reflecting pain severity and frequency ranged from 0 = no pain to 4 = dreadful or agonizing pain >4 times per week. Results: There were 1000 participants in the UAB Study of Aging (mean [SD] age, 75.3 [6.7] years; 50% black; 50% male; 51% rural residence). Seventy-four percent of the subjects reported pain; among these, 52% had daily pain, with 26% reporting dreadful or agonizing pain. Logistic regression controlling for other sociodemographic factors (age, gender, race, education, income, and marital status) found that rural residence (odds ratio [OR], 1.42; 95% CI, 1.1-1.9; P = 0.02) was significantly associated with the reporting of pain. Prescription pain medications were used by 35% of persons with pain and by 17% without pain (P < 0.001); OTC pain medications were used by 52% of persons with pain and by 45% of persons without pain (P = 0.06). Of persons reporting pain, 28% were taking neither prescription nor OTC pain medications; 16% took both and 20% took only prescription pain medications. Logistic regression found that factors associated with taking a prescription pain medication were: unmarried status (OR, 1.56; 95% CI, 1.1-2.2) and pain frequency/severity (OR, 1.39; 95% CI, 1.3-1.6). Taking an OTC pain medication was associated with lower odds of taking a prescription pain medication (OR, 0.50; 95% CI, 0.4-0.7). Age, gender, race, education, rural residence, transportation difficulty, income, and being on Medicaid were not associated with prescription pain medication use. Contusions: Prescription pain medication use was associated with pain frequency/severity after adjusting for sociodemographics and OTC pain medications in this study of community-dwelling older adults, suggesting that even with medications, individuals remained in pain. (Am J Geriatr Pharmacother. 2006;4:316-324) Copyright © 2006 Excerpta Medica, Inc. Key words: pain, pain management, older adults. A preliminary version of this analysis was presented as a poster at the Annual Scientific Meeting of the American Geriatrics Socie~May I ~ 2 I, 2004, Las Vegas, Nevada,
Accepted for publication November 22, 2006. Printed in the USA, Reproduction in whole or part is not permitied,
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P. Sawyer et al.
INTRODUCTION
Pain is a common symptom and significant problem for older adults1; up to one half of community-dwelling adults aged _>65 years have pain that interferes with normal function} ,s It has been suggested that pain is the "fifth vital sign, ''4 6 and pain is a primary reason for seeking medical care. 7 Chronic pain is associated with an elevated perception of burden, even exceeding the burden associated with high levels of acute pain. s An increasing prevalence of pain with age may be due to arthritis, a major source of musculoskeletal pain. 9,1° However, other evidence indicates that older adults either experience less pain or underreport pain, n is perhaps because of an expectation that pain is a natural part of "growing older ''9,14 or an attitude of stoicism leading to a greater reluctance to report pain. n,1<16 Pain among community-dwelling older adults may be less prevalent because those with more pain have been moved to nursing home settings} 2 Although declines in both reports of pain and severity of pain are associated with age _>85 years, 12,1s Herr is cautions that the clinical significance of the decrease may be minimal. In a review by Hunter 17 of research relating demographic factors and pain, there is evidence among working adults that both older age and female gender are associated with pain reporting; however, the results are not conclusive. Women are more likely to report somatic symptoms than men is as well as more disability related to painm; because of the greater proportion of older women and differing disease risk profiles, gender comparisons may be problematic} 7,2° Pickering et al,21 in a matched sample of 42 younger and 42 older adults, found that nociception decreases with age for males, and Cook and Chastain 22 noted that males were likely to accept pain over time. This agrees with findings by Bruno et al 2s that women were more likely to report persistent pain compared with the episodic pain reported by men. In contrast, in a population-based study in Finland (N = 4540; age range, 15-74 years), women were not more likely than men to have chronic pain} 4 There may be cultural differences in pain perception or reporting, 16,2s 2s with ethnic and racial minorities more likely to demonstrate stoicism, having the attitude that pain is to be endured without complaint} 6,29 To our knowledge, there are few studies of gender, race, and age studied in relationship to chronic pain) ° However, Green et a116 noted that blacks reported greater severity and disability from chronic pain than non-Hispanic whites. Evidence about the association of marital status and education with pain is inconclusiveY Living alone and widowhood have been found to be
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associated with pain, particularly for those experiencing recent spousal bereavement) 1 Pain management is a challenge not only because of differing responses to treatments but the various meanings of pain (cognitive, behavioral, and affective) for each individual) 2 It has been noted that pain therapy involves modalities which treat depression and social stresses as well as nociception) s NSAIDs, which provide analgesia similar to the weaker opiates, are a possible treatment option. Adverse effects of NSAIDs include gastric bleeding, and extended use may lead to analgesic nephropathy) 4 0 p i o i d s are effective for pain management, but fear of addiction, respiratory depression, and constipation are associated with their use. 15,s4 Language equating opioids with "narcotics" discourages their use by practitioners as well as patients. The current study investigates the prevalence of pain among a racially and gender-balanced sample of community-dwelling older adults and evaluates sociodemographic factors associated with the reporting of pain. Both nonprescription (over-the-counter [OTC]) and prescription pain medications used by the participants and the sociodcmographic factors associated with having medication prescribed were considered.
MATERIALS A N D M E T H O D S Subjects The subjects were participants in the University of Alabama at Birmingham (UAB) Study of Aging, a population-based, prospective, observational study of community-dwelling older adults. Subjects were a random sample of Medicare beneficiaries aged _>65 years living in central Alabama, stratified according to county, race, and gender. Two counties were classified as urban and 3 counties as rural) s This study oversampled blacks, males, and rural residents to provide a balanced sample in terms of race, gender, and urban-rural residence. The study was approved by the UAB Institutional Review Board. Potential subjects were identified and contacted first by mail to solicit their participation in the study. Approximately 2 weeks after receiving the letter, subjeers were contacted by phone to determine their interest in participation. Individuals in nursing homes and persons who were unable to make arrangements for an interview without help from another person were excluded. For interested subjects, an in-home interview was scheduled. Before the interview, written informed consent was obtained. O f 2188 persons contacted by telephone, 52% refused and 2% were ineligible because they did not live in 1 of the study counties, were aged
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<65 years, or were unable to arrange the interview appointment. Recruitment was slightly higher in the rural areas than in the urban counties (51% vs 41%). In-home interviews were conducted by trained interviewers and lasted - 2 hours. The in-home interview (conducted in 1999-2001) included gathering information on sociodemographic factors, a detailed medical history, and list of medications, as well as questions about the frequency and intensity of pain. Measures
$ociodemographic Factors Sociodemographic characteristics included factors that potentially relate to access to health care and affect the availability of medications. Age, gender, race, marital status, education, and income were self-reported. Total combined family income before taxes was reported in 9 categories (<$5000 to >$50,000). Responses indicating perceived income adequacy ("M1 things considered, would you say your income is not enough to make ends meet; gives you just enough to get by on; keeps you comfortable, but permits no luxuries; or allows you to do more or less than what you want?") were used to define an income category for persons with missing responses to reported income. These responses corresponded to income categories of $5000 to $7999, $8000 to $11,999, $16,000 to $19,999, and $30,000 to $39,999, respectively. Education was categorized as 1 = completed sixth grade or less; 2 = completed seventh through eleventh grade; 3 = completed high school or the General Educational Development test; or 4 = any higher education. Transportation resources were assessed by asking, "Over the past 4 weeks, have you had any difficulty getting transportation to where you want to go?" and "Do you limit your activities because you don't have transportation?" Persons responding positively to either question were defined as having transportation difficulty. Participants were asked if they had Medicaid. Disease Burden Participants were asked to report physician diagnoses from a listing of diseases and conditions and to indicate if they were taking any medications for the diseases they reported. Questionnaires were sent to the physician (or clinic) reported as the primary source of care to verify diagnoses. Discharge summaries of the most recent hospitalization were requested if subjects had been hospitalized in the previous 3 years. Diagnoses were considered verified if the participant reported the diagnosis and
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also reported currently using a medication to treat the disease (eg, insulin for diabetes mellitus), or if the diagnosis was confirmed using the physician questionnaire or by a review of a hospital discharge summary. Only verified diagnoses were defined as present for purposes of analyses. A comorbidity index was created giving 1 point for each disease category of the Charlson Comorbidity Index 36 without consideration of severity. Categories included: (1) congestive heart failure; (2) previous heart attack or angina; (3) valvular heart disease; (4) peripheral vascular disease; (5) hypertension; (6) diabetes mellitus; (7) respiratory problems; (8) renal disease; (9) liver disease; (10) cancer other than skin cancer; (11) any neurologic disorder, including stroke, Parkinson's disease, seizures, or Alzheimer's disease; and (12) stomach, bowel, or digestive problems. 36 Because arthritis is a common source of pain among older adults, it was considered separately. Pain Assessment Participants were asked, " H o w frequently over the past 4 weeks have you experienced pain?" (responses coded as not at all, less than once a week, 1-3 times a week, 4-6 times a week, or daily) and " O n a scale of no pain to agonizing pain, which of the following describes the pain you've experienced in the past 4 weeks?" (responses coded as no pain, annoying, uncomfortable, dreadful, or agonizing). Persons were also asked how much their pain interfered with normal work (work both outside the house and housework) over the past 4 weeks. Persons who responded that pain interfered quite a bit or extremely were contrasted to those who said not at all, a little bit, or moderately. A composite ordinal measure was calculated, ranging from 0 = no pain; 1 = annoying or uncomfortable pain up to 3 times per week; 2 = dreadful or agonizing pain up to 3 times per week; 3 = annoying or uncomfortable pain >4 times per week; and 4 = dreadful or agonizing pain >4 times per week. Persons who reported pain were asked if pain limited their activities. Medication Use Participants were asked to show the interviewers all medications, both prescription and nonprescription (OTC), that they were taking at the time of the in-home assessment. These medications were listed by the interviewer and categorized using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification, 37 which classifies central nervous system agents potentially prescribed for pain control as NSAIDs, opiate agonists, opiate partial agonists, miscellaneous analgesics
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and antipyrctics, and opiatc antagonists. No participant was taking a medication classified as an opiate antagonist. Although the other OTC category included acetaminophen and salicylamide, no partidpants used anything but acetaminophen. Ifa medication was a combination, it was coded in multiple categories. Other than informing the interviewer that the medication usage was current, no information was available on the purpose, strength, or scheduling of medication. We considered OTC and prescription medications as NSAIDs, opiates, and miscellaneous pain medications. Statistical Analysis Descriptive statistics were used to identify participants having pain and the pain medications used. To examine differences in pain medication use for those with and without pain, Z2 tests of statistical significance were used. The focus of this analysis was to examine the independent significance of sociodemographic factors both on the presence of pain and the use of prescription pain medications. Therefore, characteristics that potentially overlap were included in the models if they did not present problems of multicolinearity (r 2 > 7). Income and education were the most correlated, with r = 0 . 5 7 7 . At the time of the study, Medicaid was a source of prescription medications and was included as a probable factor associated with prescription medication use. Logistic regression models were used to examine sociodemographic factors associated with persons reporting pain and factors associated with prescription medication use. Statistical testing for all analyses was performed using SPSS software, version 12 (SPSS Inc., Chicago, Illinois). RESULTS Pain Table I shows the baseline characteristics of the 1000 participants (mean [SD] age, 75.3 [6.7] years) in the UAB Study of Aging (50% black; 50% male; 51% rural residence). Seventy-four percent of participants reported some pain; among these, 52% had daily pain, with 26% reporting dreadful or agonizing pain. Activity limitation was reported by 59% of those with any degree of pain. Bivariate analyses indicated that there were significant associations of the presence of pain with female gender (P = 0.023), education less than seventh grade (P = 0.048), income <$8000/y (P = 0.004), rural residence (P = 0.003), receiving Medicaid (P = 0.006), having multiple comorbidities (P = 0.006), and having arthritis (P < 0.001). Multivariable logistic regression of sociode-
The American Journal of Geriatric Pharmacotherapy
Table I. Baseline characteristics of the participants in the University of Alabama at Birmingham Study of Aging (N = I000).
FactorAge >75 years Female Black race Rural residence Married Education less than seventh grade Income <$8000/}/ Transportation difficulty Using Medicaid
No. (%) of Subjects 489 499 500 514
513 204 234 171 88
(49) (50) (50) (51 ) (5 I) (20) (23) (I 7) (9)
mographic factors and pain indicated that only rural residence was significantly and independently associated with the reporting of pain (odds ratio [OR], 1.42; 95% CI, 1.1-1.9; P = 0.02); female gender had a significance value of P = 0.05 (OR, 1.37; 95% CI, 1.0-1.9). After adding comorbidities and arthritis to the model, sociodemographic factors were no longer significantly associated with the presence of pain. These 2 factors remained independently associated with the presence of pain; having a higher comorbidity count had an OR of 1.34 (95% CI, 1.1-1.6; P = 0.005) and having arthritis had an O R o f 2 . 3 5 (95% C.I, 1.7-3.2; P< 0.001). Pain Medication The figure shows the types and number of pain medications taken by participants. Combinations of OTC and prescription pain medications were used by 13% of the sample. Table II compares those with pain versus those without any pain and the types of medication used. Prescription pain medications were used by 35% of persons with pain and by 17% without pain (P < 0.001); OTC pain medications were used by 52% of persons with pain and by 45% of persons without pain (P = 0.06). Only 12% of participants had no pain and were taking no medication for pain. Thirty-two percent of the sample took neither prescription nor OTC medication for pain; of these, 64% reported some level of pain. Those with the most frequent and severe pain took more medications than those with lower levels of pain; however, 17% of subjects with dreadful or agonizing pain >4 times per week took no medication for pain. Prescription pain medications were used by 31% of subjects, and of those, 86% continued to have some
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500 400 -
300
410
-
..o
d Z
200 -
100 -
I
Prescription NSAIDs
I
Opiates
I
Other Prescriptions
I
OTC NSAIDs
I
Other OTC Medications
Types of Pain Medication
500 -
• Combined [] OTC only [] Prescription only
400 -
t~
300
-
~6 6 Z
200 -
100 -
119 I I
I 2
_>3
No. of Pain Medications
Figure. Pain medication use in 1000 participants in the University of Alabama at Birmingham Study of Aging. OTC = over the counter.
Table II. Pain medication use grouped according t o presence of pain in participants from the University of Alabama at Birmingham Study of Aging (N = 1000). Pain Status, No, (%)< None (n Prescription medicationst Over-the counter medications No medicationt *lndividuals may be in both medication categories. tp < 0.001.
320
260)
43 (17) 118 (45) II 5 (44)
Any (n
740)
262 (35) 386 (52) 209 (28)
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pain. Logistic regression (Table III) controlling for sociodemographic factors, comorbidities, arthritis, the severity of pain, and taking OTC pain medications indicated that not being married was significantly associated (P = 0.014) with taking prescription medications for pain, as were a higher number of comorbidities, arthritis, and higher composite pain (all, P < 0.001). Taking OTC pain medications reduced the odds of taking prescription pain medications. The outcome measure included those who used prescription pain medications versus those who did not. The reference group of those who did not take prescription pain medications included those who took neither prescription nor OTC pain medications (n = 324) and those who took only an OTC pain medication (n = 371). DISCUSSION Nearly 75% of these community-dwelling older adults reported some pain and 28% of individuals with pain took no pain medications. Over half of the people with pain said that their pain was such that it limited activity. Although rural residents and females were more likely to report pain, sociodemographic factors were not independently associated with pain after controlling for comorbid conditions and arthritis. This contrasts with studies showing that women, widowed, and those living alone were more likely to report pain, 18,31 as well as studies reviewed by Green et a116 indicating that blacks report more pain.
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Slightly less than one third of the participants used prescription pain medications, indicating that they interacted with the medical system. The only sododemographic factor associated with having a prescription medication was not being married, which could indicate that persons lacking a spouse were more likely to seek professional treatment. Self-management may be the first line of resource for pain control; persons using OTC medications were less likely to use a prescription medication. This study is unique in that it is racially and gender balanced. Additionally, a number of participants were economically disadvantaged, indicated by the lower educational status and the use of Medicaid. Yet these factors were associated neither with the presence of pain nor taking medication for pain. Although previous research suggests ethnic differences both in the experience of pain and the aggressiveness of pain treatment regimens, 16,384° the current study did not find such differences. A discussion of the mechanisms of racial and ethnic differences in pain 41 noted the importance of coping strategies on the pain experience, particularly social support systems, religion, and an attitude of actively confronting difficult situations independently. It is probable that these factors diminish the reporting of pain by blacks, particularly in a southeastern state identified as being in the "Bible Belt," which is noted for high levels of religious participation. These factors--as well as the lowered perception of pain by older adults and underreporting due to a belief that pain is a natural part of
Table III. Multivariable model of prescription pain medication use in the University of Alabama at Birmingham Study of Aging. FactorAge >75 y Black Female Education less than seventh grade Income <$8000/y Rural Not married Transportation difficulty Medicaid Comorbid conditions Arthritis Composite pain measure OTC pain medication OTC
Odds Ratio
95% CI
P
1,12 I, 16 0,83 0,75 I, 18 1,02 1,56 0,78 1,09 1,61 3, 12 1,39 0,50
0,8 1,5 0,8 1,6 0,6 1,2 0,5 I, I 0,8 1,8 0,7 1,4 I,I 2,2 0,6 1,9 0,6 1,9 1,3 2,1 2,3~i,3 1,3 1,6 0,4 0,7
0,463 0,408 0,263 0,181 0,416 0,912 0,014 0,756 0,756 <0,001 <0,00 I <0,001 <0,001
over the counter:
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aging 11 13--may contribute to an attitude shared by both whites and blacks in this study against seeking relief from pain through the formal medical system. Herr 15 suggests a multimodal approach, using both pharmacologic and nonpharmacologic therapies to maximize the older adult's function and quality of life. A limitation of our study is that it is unknown if the medications classified as pain medications were prescribed in response to pain or if participants used other treatment modalities to treat pain. Other limitations include the lack of information about dosage and scheduled use of a medication regimen. Although a composite measure of pain frequency and severity has been used in analyses of pain in nursing homes, it has not been validated elsewhere. 42,43 The study design may not be applicable to the general community in that it oversampled older men and blacks. A longitudinal study would allow the disentangling of symptom, treatment, and response; however, this cross-sectional study still highlights the question of why so many older adults are apparently undertreated for pain when the consequences in everyday life are so considerable. Consequences of poor pain management are multidimensional, affecting not only overall quality of life but specific areas such as appetite, sleep, healing, nutrition, mood, daily functioning and activities, social participation, household tasks, and recreation. 44 50 Additionally, pain and depression often occur concomitantly,51 and a link between pain, cognitive performance, and depression has been shown. 52 It has been suggested that undertreatment of pain in older adults may be a form of elder abuse. 53 In fact, 2 cases in California related to undertreatment of pain were settled favoring the families of the undertreated patients. These cases raise questions of defining abuse and clinical responsibility. 53 Barriers to effective pain treatment include misreporting, lack of adherence, and fears of the potential adverse effects of medicationL15 as well as societal attitudes. A better approach to pain management for older adults is indicated. CONCLUSIONS
Nearly 75% of these community-dwelling older adults reported some level of pain, and more than half of those persons reported having activity limitation due to the pain. After adjusting for sociodemographic factors, only the index of comorbid conditions and arthritis were associated with reporting pain. Prescription pain medication use was associated with pain frequency/ severity after adjusting for sociodemographics and O T C pain medications in this study of community-
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dwelling older adults, suggesting that even with medications, individuals remained in pain. ACKNOWLEDGMENT
This research was funded by the National Institute on Aging (Grant # NIA AG15062), Bethesda, Maryland. REFERENCES
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49. Leveille SG, Ling S, Hochberg MC, et al. Widespread musculoskeletal pain and the progression of disability in older disabled women. A n n Intern Med. 2001;135: 1038-1046. 50. Jones KR, Fink R, Pepper G, et al. Improving nursing home staff knowledge and attitudes about pain. Gerontologist. 2004;44:469~/:78.
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Address c o r r e s p o n d e n c e to: Patricia Sawyer, PhD, Center for Aging, CH19-201, University of Alabama at Birmingham, 1530 3rd Avenue South, Birmingham, AL 35294-2041. E-mail: [email protected]
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Brief Report Pain and Pain Medication Use in Community-Dwelling Older Adults Patricia Sawyer, PhDI,2; EricV. Bodner, BS2; Christine S. Ritchie, MDI-3; and Richard M.AIIman, MD I-3 I Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham,Alabama; 2Center for Aging, University of Alabama at Birmingham, Birmingham,Alabama; and 3Birmingham~AtlantaVA Geriatric Research, Education, and Clinical Center, Birmingham,Alabama
ABSTRACT Background: Pain is a common symptom and significant problcm for oldcr adults; up to onc half of communitydwelling older adults have pain that interferes with normal function. Objective: The goal of this study was to investigate the prevalence of pain among a racially and gender-balanced sample of community-dwelling older adults and evaluate sociodemographic factors associated with the reporting of pain. Both nonprescription (over-the-counter [OTC]) and prescription pain medications used by the participants and the sociodemographic factors associated with having medication prescribed were considered. Methods: This was a population-based, prospective, observational study. Subjects were participants in the University of Alabama at Birmingham (UAB) Study of Aging, a stratified random sample of Medicare beneficiaries who completed in-home interviews (1999-2001). Assessments included sociodemographic factors and pain; interviewers listed all prescription and OTC pain medications used. Pain medications were coded as NSAIDs, opiates, and miscellaneous pain medications. A composite ordinal measure reflecting pain severity and frequency ranged from 0 = no pain to 4 = dreadful or agonizing pain >4 times per week. Results: There were 1000 participants in the UAB Study of Aging (mean [SD] age, 75.3 [6.7] years; 50% black; 50% male; 51% rural residence). Seventy-four percent of the subjects reported pain; among these, 52% had daily pain, with 26% reporting dreadful or agonizing pain. Logistic regression controlling for other sociodemographic factors (age, gender, race, education, income, and marital status) found that rural residence (odds ratio [OR], 1.42; 95% CI, 1.1-1.9; P = 0.02) was significantly associated with the reporting of pain. Prescription pain medications were used by 35% of persons with pain and by 17% without pain (P < 0.001); OTC pain medications were used by 52% of persons with pain and by 45% of persons without pain (P = 0.06). Of persons reporting pain, 28% were taking neither prescription nor OTC pain medications; 16% took both and 20% took only prescription pain medications. Logistic regression found that factors associated with taking a prescription pain medication were: unmarried status (OR, 1.56; 95% CI, 1.1-2.2) and pain frequency/severity (OR, 1.39; 95% CI, 1.3-1.6). Taking an OTC pain medication was associated with lower odds of taking a prescription pain medication (OR, 0.50; 95% CI, 0.4-0.7). Age, gender, race, education, rural residence, transportation difficulty, income, and being on Medicaid were not associated with prescription pain medication use. Contusions: Prescription pain medication use was associated with pain frequency/severity after adjusting for sociodemographics and OTC pain medications in this study of community-dwelling older adults, suggesting that even with medications, individuals remained in pain. (Am J Geriatr Pharmacother. 2006;4:316-324) Copyright © 2006 Excerpta Medica, Inc. Key words: pain, pain management, older adults. A preliminary version of this analysis was presented as a poster at the Annual Scientific Meeting of the American Geriatrics Socie~May I ~ 2 I, 2004, Las Vegas, Nevada,
Accepted for publication November 22, 2006. Printed in the USA, Reproduction in whole or part is not permitied,
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INTRODUCTION
Pain is a common symptom and significant problem for older adults1; up to one half of community-dwelling adults aged _>65 years have pain that interferes with normal function} ,s It has been suggested that pain is the "fifth vital sign, ''4 6 and pain is a primary reason for seeking medical care. 7 Chronic pain is associated with an elevated perception of burden, even exceeding the burden associated with high levels of acute pain. s An increasing prevalence of pain with age may be due to arthritis, a major source of musculoskeletal pain. 9,1° However, other evidence indicates that older adults either experience less pain or underreport pain, n is perhaps because of an expectation that pain is a natural part of "growing older ''9,14 or an attitude of stoicism leading to a greater reluctance to report pain. n,1<16 Pain among community-dwelling older adults may be less prevalent because those with more pain have been moved to nursing home settings} 2 Although declines in both reports of pain and severity of pain are associated with age _>85 years, 12,1s Herr is cautions that the clinical significance of the decrease may be minimal. In a review by Hunter 17 of research relating demographic factors and pain, there is evidence among working adults that both older age and female gender are associated with pain reporting; however, the results are not conclusive. Women are more likely to report somatic symptoms than men is as well as more disability related to painm; because of the greater proportion of older women and differing disease risk profiles, gender comparisons may be problematic} 7,2° Pickering et al,21 in a matched sample of 42 younger and 42 older adults, found that nociception decreases with age for males, and Cook and Chastain 22 noted that males were likely to accept pain over time. This agrees with findings by Bruno et al 2s that women were more likely to report persistent pain compared with the episodic pain reported by men. In contrast, in a population-based study in Finland (N = 4540; age range, 15-74 years), women were not more likely than men to have chronic pain} 4 There may be cultural differences in pain perception or reporting, 16,2s 2s with ethnic and racial minorities more likely to demonstrate stoicism, having the attitude that pain is to be endured without complaint} 6,29 To our knowledge, there are few studies of gender, race, and age studied in relationship to chronic pain) ° However, Green et a116 noted that blacks reported greater severity and disability from chronic pain than non-Hispanic whites. Evidence about the association of marital status and education with pain is inconclusiveY Living alone and widowhood have been found to be
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associated with pain, particularly for those experiencing recent spousal bereavement) 1 Pain management is a challenge not only because of differing responses to treatments but the various meanings of pain (cognitive, behavioral, and affective) for each individual) 2 It has been noted that pain therapy involves modalities which treat depression and social stresses as well as nociception) s NSAIDs, which provide analgesia similar to the weaker opiates, are a possible treatment option. Adverse effects of NSAIDs include gastric bleeding, and extended use may lead to analgesic nephropathy) 4 0 p i o i d s are effective for pain management, but fear of addiction, respiratory depression, and constipation are associated with their use. 15,s4 Language equating opioids with "narcotics" discourages their use by practitioners as well as patients. The current study investigates the prevalence of pain among a racially and gender-balanced sample of community-dwelling older adults and evaluates sociodemographic factors associated with the reporting of pain. Both nonprescription (over-the-counter [OTC]) and prescription pain medications used by the participants and the sociodcmographic factors associated with having medication prescribed were considered.
MATERIALS A N D M E T H O D S Subjects The subjects were participants in the University of Alabama at Birmingham (UAB) Study of Aging, a population-based, prospective, observational study of community-dwelling older adults. Subjects were a random sample of Medicare beneficiaries aged _>65 years living in central Alabama, stratified according to county, race, and gender. Two counties were classified as urban and 3 counties as rural) s This study oversampled blacks, males, and rural residents to provide a balanced sample in terms of race, gender, and urban-rural residence. The study was approved by the UAB Institutional Review Board. Potential subjects were identified and contacted first by mail to solicit their participation in the study. Approximately 2 weeks after receiving the letter, subjeers were contacted by phone to determine their interest in participation. Individuals in nursing homes and persons who were unable to make arrangements for an interview without help from another person were excluded. For interested subjects, an in-home interview was scheduled. Before the interview, written informed consent was obtained. O f 2188 persons contacted by telephone, 52% refused and 2% were ineligible because they did not live in 1 of the study counties, were aged
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<65 years, or were unable to arrange the interview appointment. Recruitment was slightly higher in the rural areas than in the urban counties (51% vs 41%). In-home interviews were conducted by trained interviewers and lasted - 2 hours. The in-home interview (conducted in 1999-2001) included gathering information on sociodemographic factors, a detailed medical history, and list of medications, as well as questions about the frequency and intensity of pain. Measures
$ociodemographic Factors Sociodemographic characteristics included factors that potentially relate to access to health care and affect the availability of medications. Age, gender, race, marital status, education, and income were self-reported. Total combined family income before taxes was reported in 9 categories (<$5000 to >$50,000). Responses indicating perceived income adequacy ("M1 things considered, would you say your income is not enough to make ends meet; gives you just enough to get by on; keeps you comfortable, but permits no luxuries; or allows you to do more or less than what you want?") were used to define an income category for persons with missing responses to reported income. These responses corresponded to income categories of $5000 to $7999, $8000 to $11,999, $16,000 to $19,999, and $30,000 to $39,999, respectively. Education was categorized as 1 = completed sixth grade or less; 2 = completed seventh through eleventh grade; 3 = completed high school or the General Educational Development test; or 4 = any higher education. Transportation resources were assessed by asking, "Over the past 4 weeks, have you had any difficulty getting transportation to where you want to go?" and "Do you limit your activities because you don't have transportation?" Persons responding positively to either question were defined as having transportation difficulty. Participants were asked if they had Medicaid. Disease Burden Participants were asked to report physician diagnoses from a listing of diseases and conditions and to indicate if they were taking any medications for the diseases they reported. Questionnaires were sent to the physician (or clinic) reported as the primary source of care to verify diagnoses. Discharge summaries of the most recent hospitalization were requested if subjects had been hospitalized in the previous 3 years. Diagnoses were considered verified if the participant reported the diagnosis and
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also reported currently using a medication to treat the disease (eg, insulin for diabetes mellitus), or if the diagnosis was confirmed using the physician questionnaire or by a review of a hospital discharge summary. Only verified diagnoses were defined as present for purposes of analyses. A comorbidity index was created giving 1 point for each disease category of the Charlson Comorbidity Index 36 without consideration of severity. Categories included: (1) congestive heart failure; (2) previous heart attack or angina; (3) valvular heart disease; (4) peripheral vascular disease; (5) hypertension; (6) diabetes mellitus; (7) respiratory problems; (8) renal disease; (9) liver disease; (10) cancer other than skin cancer; (11) any neurologic disorder, including stroke, Parkinson's disease, seizures, or Alzheimer's disease; and (12) stomach, bowel, or digestive problems. 36 Because arthritis is a common source of pain among older adults, it was considered separately. Pain Assessment Participants were asked, " H o w frequently over the past 4 weeks have you experienced pain?" (responses coded as not at all, less than once a week, 1-3 times a week, 4-6 times a week, or daily) and " O n a scale of no pain to agonizing pain, which of the following describes the pain you've experienced in the past 4 weeks?" (responses coded as no pain, annoying, uncomfortable, dreadful, or agonizing). Persons were also asked how much their pain interfered with normal work (work both outside the house and housework) over the past 4 weeks. Persons who responded that pain interfered quite a bit or extremely were contrasted to those who said not at all, a little bit, or moderately. A composite ordinal measure was calculated, ranging from 0 = no pain; 1 = annoying or uncomfortable pain up to 3 times per week; 2 = dreadful or agonizing pain up to 3 times per week; 3 = annoying or uncomfortable pain >4 times per week; and 4 = dreadful or agonizing pain >4 times per week. Persons who reported pain were asked if pain limited their activities. Medication Use Participants were asked to show the interviewers all medications, both prescription and nonprescription (OTC), that they were taking at the time of the in-home assessment. These medications were listed by the interviewer and categorized using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification, 37 which classifies central nervous system agents potentially prescribed for pain control as NSAIDs, opiate agonists, opiate partial agonists, miscellaneous analgesics
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and antipyrctics, and opiatc antagonists. No participant was taking a medication classified as an opiate antagonist. Although the other OTC category included acetaminophen and salicylamide, no partidpants used anything but acetaminophen. Ifa medication was a combination, it was coded in multiple categories. Other than informing the interviewer that the medication usage was current, no information was available on the purpose, strength, or scheduling of medication. We considered OTC and prescription medications as NSAIDs, opiates, and miscellaneous pain medications. Statistical Analysis Descriptive statistics were used to identify participants having pain and the pain medications used. To examine differences in pain medication use for those with and without pain, Z2 tests of statistical significance were used. The focus of this analysis was to examine the independent significance of sociodemographic factors both on the presence of pain and the use of prescription pain medications. Therefore, characteristics that potentially overlap were included in the models if they did not present problems of multicolinearity (r 2 > 7). Income and education were the most correlated, with r = 0 . 5 7 7 . At the time of the study, Medicaid was a source of prescription medications and was included as a probable factor associated with prescription medication use. Logistic regression models were used to examine sociodemographic factors associated with persons reporting pain and factors associated with prescription medication use. Statistical testing for all analyses was performed using SPSS software, version 12 (SPSS Inc., Chicago, Illinois). RESULTS Pain Table I shows the baseline characteristics of the 1000 participants (mean [SD] age, 75.3 [6.7] years) in the UAB Study of Aging (50% black; 50% male; 51% rural residence). Seventy-four percent of participants reported some pain; among these, 52% had daily pain, with 26% reporting dreadful or agonizing pain. Activity limitation was reported by 59% of those with any degree of pain. Bivariate analyses indicated that there were significant associations of the presence of pain with female gender (P = 0.023), education less than seventh grade (P = 0.048), income <$8000/y (P = 0.004), rural residence (P = 0.003), receiving Medicaid (P = 0.006), having multiple comorbidities (P = 0.006), and having arthritis (P < 0.001). Multivariable logistic regression of sociode-
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Table I. Baseline characteristics of the participants in the University of Alabama at Birmingham Study of Aging (N = I000).
FactorAge >75 years Female Black race Rural residence Married Education less than seventh grade Income <$8000/}/ Transportation difficulty Using Medicaid
No. (%) of Subjects 489 499 500 514
513 204 234 171 88
(49) (50) (50) (51 ) (5 I) (20) (23) (I 7) (9)
mographic factors and pain indicated that only rural residence was significantly and independently associated with the reporting of pain (odds ratio [OR], 1.42; 95% CI, 1.1-1.9; P = 0.02); female gender had a significance value of P = 0.05 (OR, 1.37; 95% CI, 1.0-1.9). After adding comorbidities and arthritis to the model, sociodemographic factors were no longer significantly associated with the presence of pain. These 2 factors remained independently associated with the presence of pain; having a higher comorbidity count had an OR of 1.34 (95% CI, 1.1-1.6; P = 0.005) and having arthritis had an O R o f 2 . 3 5 (95% C.I, 1.7-3.2; P< 0.001). Pain Medication The figure shows the types and number of pain medications taken by participants. Combinations of OTC and prescription pain medications were used by 13% of the sample. Table II compares those with pain versus those without any pain and the types of medication used. Prescription pain medications were used by 35% of persons with pain and by 17% without pain (P < 0.001); OTC pain medications were used by 52% of persons with pain and by 45% of persons without pain (P = 0.06). Only 12% of participants had no pain and were taking no medication for pain. Thirty-two percent of the sample took neither prescription nor OTC medication for pain; of these, 64% reported some level of pain. Those with the most frequent and severe pain took more medications than those with lower levels of pain; however, 17% of subjects with dreadful or agonizing pain >4 times per week took no medication for pain. Prescription pain medications were used by 31% of subjects, and of those, 86% continued to have some
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500 400 -
300
410
-
..o
d Z
200 -
100 -
I
Prescription NSAIDs
I
Opiates
I
Other Prescriptions
I
OTC NSAIDs
I
Other OTC Medications
Types of Pain Medication
500 -
• Combined [] OTC only [] Prescription only
400 -
t~
300
-
~6 6 Z
200 -
100 -
119 I I
I 2
_>3
No. of Pain Medications
Figure. Pain medication use in 1000 participants in the University of Alabama at Birmingham Study of Aging. OTC = over the counter.
Table II. Pain medication use grouped according t o presence of pain in participants from the University of Alabama at Birmingham Study of Aging (N = 1000). Pain Status, No, (%)< None (n Prescription medicationst Over-the counter medications No medicationt *lndividuals may be in both medication categories. tp < 0.001.
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260)
43 (17) 118 (45) II 5 (44)
Any (n
740)
262 (35) 386 (52) 209 (28)
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pain. Logistic regression (Table III) controlling for sociodemographic factors, comorbidities, arthritis, the severity of pain, and taking OTC pain medications indicated that not being married was significantly associated (P = 0.014) with taking prescription medications for pain, as were a higher number of comorbidities, arthritis, and higher composite pain (all, P < 0.001). Taking OTC pain medications reduced the odds of taking prescription pain medications. The outcome measure included those who used prescription pain medications versus those who did not. The reference group of those who did not take prescription pain medications included those who took neither prescription nor OTC pain medications (n = 324) and those who took only an OTC pain medication (n = 371). DISCUSSION Nearly 75% of these community-dwelling older adults reported some pain and 28% of individuals with pain took no pain medications. Over half of the people with pain said that their pain was such that it limited activity. Although rural residents and females were more likely to report pain, sociodemographic factors were not independently associated with pain after controlling for comorbid conditions and arthritis. This contrasts with studies showing that women, widowed, and those living alone were more likely to report pain, 18,31 as well as studies reviewed by Green et a116 indicating that blacks report more pain.
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Slightly less than one third of the participants used prescription pain medications, indicating that they interacted with the medical system. The only sododemographic factor associated with having a prescription medication was not being married, which could indicate that persons lacking a spouse were more likely to seek professional treatment. Self-management may be the first line of resource for pain control; persons using OTC medications were less likely to use a prescription medication. This study is unique in that it is racially and gender balanced. Additionally, a number of participants were economically disadvantaged, indicated by the lower educational status and the use of Medicaid. Yet these factors were associated neither with the presence of pain nor taking medication for pain. Although previous research suggests ethnic differences both in the experience of pain and the aggressiveness of pain treatment regimens, 16,384° the current study did not find such differences. A discussion of the mechanisms of racial and ethnic differences in pain 41 noted the importance of coping strategies on the pain experience, particularly social support systems, religion, and an attitude of actively confronting difficult situations independently. It is probable that these factors diminish the reporting of pain by blacks, particularly in a southeastern state identified as being in the "Bible Belt," which is noted for high levels of religious participation. These factors--as well as the lowered perception of pain by older adults and underreporting due to a belief that pain is a natural part of
Table III. Multivariable model of prescription pain medication use in the University of Alabama at Birmingham Study of Aging. FactorAge >75 y Black Female Education less than seventh grade Income <$8000/y Rural Not married Transportation difficulty Medicaid Comorbid conditions Arthritis Composite pain measure OTC pain medication OTC
Odds Ratio
95% CI
P
1,12 I, 16 0,83 0,75 I, 18 1,02 1,56 0,78 1,09 1,61 3, 12 1,39 0,50
0,8 1,5 0,8 1,6 0,6 1,2 0,5 I, I 0,8 1,8 0,7 1,4 I,I 2,2 0,6 1,9 0,6 1,9 1,3 2,1 2,3~i,3 1,3 1,6 0,4 0,7
0,463 0,408 0,263 0,181 0,416 0,912 0,014 0,756 0,756 <0,001 <0,00 I <0,001 <0,001
over the counter:
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aging 11 13--may contribute to an attitude shared by both whites and blacks in this study against seeking relief from pain through the formal medical system. Herr 15 suggests a multimodal approach, using both pharmacologic and nonpharmacologic therapies to maximize the older adult's function and quality of life. A limitation of our study is that it is unknown if the medications classified as pain medications were prescribed in response to pain or if participants used other treatment modalities to treat pain. Other limitations include the lack of information about dosage and scheduled use of a medication regimen. Although a composite measure of pain frequency and severity has been used in analyses of pain in nursing homes, it has not been validated elsewhere. 42,43 The study design may not be applicable to the general community in that it oversampled older men and blacks. A longitudinal study would allow the disentangling of symptom, treatment, and response; however, this cross-sectional study still highlights the question of why so many older adults are apparently undertreated for pain when the consequences in everyday life are so considerable. Consequences of poor pain management are multidimensional, affecting not only overall quality of life but specific areas such as appetite, sleep, healing, nutrition, mood, daily functioning and activities, social participation, household tasks, and recreation. 44 50 Additionally, pain and depression often occur concomitantly,51 and a link between pain, cognitive performance, and depression has been shown. 52 It has been suggested that undertreatment of pain in older adults may be a form of elder abuse. 53 In fact, 2 cases in California related to undertreatment of pain were settled favoring the families of the undertreated patients. These cases raise questions of defining abuse and clinical responsibility. 53 Barriers to effective pain treatment include misreporting, lack of adherence, and fears of the potential adverse effects of medicationL15 as well as societal attitudes. A better approach to pain management for older adults is indicated. CONCLUSIONS
Nearly 75% of these community-dwelling older adults reported some level of pain, and more than half of those persons reported having activity limitation due to the pain. After adjusting for sociodemographic factors, only the index of comorbid conditions and arthritis were associated with reporting pain. Prescription pain medication use was associated with pain frequency/ severity after adjusting for sociodemographics and O T C pain medications in this study of community-
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dwelling older adults, suggesting that even with medications, individuals remained in pain. ACKNOWLEDGMENT
This research was funded by the National Institute on Aging (Grant # NIA AG15062), Bethesda, Maryland. REFERENCES
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Address c o r r e s p o n d e n c e to: Patricia Sawyer, PhD, Center for Aging, CH19-201, University of Alabama at Birmingham, 1530 3rd Avenue South, Birmingham, AL 35294-2041. E-mail: [email protected]
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