Association between chronic musculoskeletal pain and executive function in community-dwelling older adults

Trajectories of pain and their associations with long-term cognitive decline in older adults: evidence from two longitudinal cohorts

BACKGROUND

Pain is a dynamic experience that varies over time, but it remains unknown whether trajectories of pain are associated with subsequent cognitive decline. The purpose of this study was to identify distinct trajectories of pain presence and activity-limiting pain and investigate their longitudinal associations with the rate of subsequent cognitive decline in older adults.

METHODS

A total of 5685 participants from the English Longitudinal Study of Ageing (ELSA) and 7619 participants from the Health and Retirement Study (HRS) were included. Pain presence trajectories were identified over eight years in the ELSA and 10 years in the HRS, while trajectories of activity-limiting pain were identified over 10 years in the HRS. We utilised linear mixed-effects models to investigate the long-term relationship between pain trajectories and the rate of cognitive decline across various domains, including memory, orientation, executive function and global cognition.

RESULTS

Three pain presence trajectories were identified. Moderate-increasing and high-stable groups exhibited steeper declines in global cognition than the low-stable group. Furthermore, individuals in the moderate-increasing group experienced a more rapid decline in executive function, while the high-stable group showed a faster decline in orientation function. Two trajectories of activity-limiting pain were identified, with the moderate-increasing group experiencing a faster decline in orientation function and global cognition.

CONCLUSIONS

The trajectories of both pain presence and activity-limiting pain are linked to the rate of subsequent cognitive decline among older people. Interventions for specific pain trajectories might help to delay the decline rate of cognition in specific domains.

Chronic pain is specifically associated with updating working memory: a longitudinal twin study

ABSTRACT

Worse executive function (EF) is associated with chronic pain and could mechanistically contribute to pain chronification. It is unclear whether there is overall impairment in EFs or whether there are impairments in specific cognitive domains. Furthermore, the possible genetic risk underlying these associations has not been tested. Participants were from the Colorado Longitudinal Twin study; 786 same-sex twins completed a battery of EF tasks at ages 23 and/or 28 and 634 of these twins self-reported chronic pain at mean age = 28.1; prevalence = 27.76% using the Brief Pain History Questionnaire. The EF tasks were used to define a Common EF factor and 2 factors specific to updating working memory and shifting mental set. We estimated the phenotypic and genetic associations of stable EF variance across ages 23 and 28, as well as EF variance unique to age 28, with pain. With respect to stable EF variance, pain phenotypically correlated with the Updating-specific factor (r = -0.21, P = 0.008) but did not significantly correlate with the Common EF factor (r = -0.06, P = 0.350) nor with the Shifting-specific factor (r = -0.03, P = 0.709). There were no significant phenotypic correlations between pain and EF variance unique to age 28. A twin model indicated that pain and Updating-specific variance share genetic risk (rA = -0.46, P = 0.005) but not environmental risk (rE = 0.05, P = 0.844). Updating working memory shares a phenotypic and genetic relationship with pain in young adults. Impairments in gating or monitoring pain signals may play a mechanistic role in pain development.

Determination of cognitive status and influencing variables in patients with chronic neck pain: A cross-sectional study

OBJECTIVES

This study aimed to evaluate cognitive function in individuals with chronic neck pain (CNP) and investigate the effects of different variables on cognition.

METHODS

The sociodemographic characteristics of the individuals who participated in this study were recorded. Pain intensity of the individuals was evaluated using the Visual Analog Scale, pain-related disability was evaluated with the Neck Disability Index and cognitive function was evaluated using Montreal Cognitive Assessment (MoCA).

RESULTS

For this study, 95 patients with CNP were recruited. The mean age was 45.61 ± 11.14, and the median MoCA score was 24 (20-26), and 64.2% of the patients scored below the original cutoff (<26/30 points). The regression analysis showed that higher age and lower education levels were associated with lower MoCA scores. Education appeared to be the most influential variable. Younger participants (18-45) performed systematically better on naming, attention and language domains than their older counterparts (over 45).

CONCLUSIONS

The findings suggest that age and education play an important role in MoCA total and domain scores in these patients. While treating these patients, assessment of cognitive function can be useful for effective pain management.

"Like Peanut Butter and Jelly": A Qualitative Study of Chiropractic Care and Home Exercise Among Older Adults With Spinal Disability

OBJECTIVE

A mixed-methods, randomized controlled trial comparing short- and long-term chiropractic care and exercise therapy for spinal disability in older adults found no between-group differences in the primary outcome. However, those who received long-term management reported greater improvement in neck pain, self-efficacy, function, and balance. This nested qualitative study explored participants' perceptions of the benefits and drawbacks of chiropractic care and exercise for spine-related outcomes, with an emphasis on understanding what makes treatment for spine-related problems worthwhile.

METHODS

Of 171 individual interviews conducted after completing study treatment, 50 participants (25 per treatment group) were randomly selected for this analysis. Qualitative descriptive analysis included dual coding of verbatim transcripts by 2 investigators (MM and SAS), which was further distilled into a consensus-derived codebook of themes and organized using NVIVO software.

RESULTS

Participants described trial interventions as complementary to one another for spine-related disability. Chiropractic care was viewed as improving spinal pain and controlling symptoms, while exercise therapy was noted for its long-term impact on self-efficacy and self-management. These older adults considered changes in pain, global sense of improvement, and improved biomechanical function as making treatment worthwhile.

CONCLUSION

Older adults valued nonpharmacologic treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complementary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.

Comparison of the Impacts of Under-Treated Pain and Opioid Pain Medication on Cognitive Impairment

Purpose: To guide clinicians in balancing the risks and benefits of opioids when treating pain, we conducted two systematic reviews: 1) the impact of pain on cognitive function, and 2) the impact of opioids on cognitive function.

Methods: Part one addressed the impact of pain on cognitive impairment; Part two considered the impact of opioids on cognitive impairment. PubMed was used to search for eligible articles. For part one, 1786 articles were identified, of which 23 met our eligibility criteria. For part two, among 584 articles, 18 were found eligible.

Results: For part one, 16 studies concluded that patients with chronic pain showed impaired cognitive function; six studies found that chronic pain does not worsen cognitive function; one study concluded that the impact of pain on cognitive function differs based on the underlying cognitive status. For part two, 15 studies found that using opioids to control pain did not cause significant cognitive impairment, while three studies concluded the opposite. Studies evaluating older subjects did not observe different results from those in the whole population for both reviews.

Conclusion: The published literature indicates that moderate to severe pain can impair cognitive function, and that careful use of opioid analgesics in such subjects does not necessarily worsen cognition. Although our results are insufficient to support clear guidance due to heterogeneity of cohorts and outcomes, this study may assist primary care providers by rendering explicitly the factors to be considered by providers caring for this population with pain when opioids are considered.

Timeline of pain before dementia diagnosis: a 27-year follow-up study

ABSTRACT

This study examines the importance of length of follow-up on the association between pain and incident dementia. Further objective was to characterize pain trajectories in the 27 years preceding dementia diagnosis and compare them with those among persons free of dementia during the same period. Pain intensity and pain interference (averaged as total pain) were measured on 9 occasions (1991-2016) using the Short-Form 36 Questionnaire amongst 9046 (women = 31.4%) dementia-free adults aged 40 to 64 years in 1991; 567 dementia cases were recorded between 1991 and 2019. Cox regression was used to assess the association between pain measures at different time points and incident dementia and mixed models to assess pain trajectories preceding dementia diagnosis or end point for dementia-free participants. Results from Cox regression showed moderate/severe compared with mild/no total pain, pain intensity, and pain interference not to be associated with dementia when the mean follow-up was 25.0, 19.6, 14.5, or 10.0 years. These associations were evident for a mean follow-up of 6.2 years: for total pain (hazard ratio = 1.72; 95% confidence intervals = 1.28-2.33), pain intensity (1.41; 1.04-1.92), and pain interference (1.80; 1.30-2.49). These associations were stronger when the mean follow-up for incidence of dementia was 3.2 years. Twenty-seven-year pain trajectories differed between dementia cases and noncases with small differences in total pain and pain interference evident 16 years before dementia diagnosis (difference in the total pain score = 1.4, 95% confidence intervals = 0.1-2.7) and rapidly increasing closer to diagnosis. In conclusion, these findings suggest that pain is a correlate or prodromal symptom rather than a cause of dementia.

Neurocognitive functioning in symptomatic adults with sickle cell disease: A description and comparison with unaffected siblings

Children and adults with sickle cell disease (SCD) are at risk for neuropsychological deficits; however, the neurocognitive functioning of adults with SCD and related comorbidities has not been widely reported in the literature. We examined specific cognitive domains in symptomatic adults with SCD and compared them with their unaffected siblings. We also examined relationships between cognitive scores, patient-reported outcomes (PROs), and medical/laboratory values. Thirty patient-sibling pairs (M patient age = 32.5 years, M sibling age = 32.1 years) completed evaluations as part of a medical clinical trial (NCT00061568). All patient and sibling neurocognitive test scores were within normal limits. Patients scored significantly lower (M = 91.0 ± 11.3) than their siblings (M = 100.6 ± 12.3; t = -3.5, p < .01) on the Wechsler Processing Speed Index. They also indicated more problems than siblings on an executive functioning questionnaire, although these differences were nonsignificant after accounting for depressive symptoms. Higher fetal hemoglobin and lower creatinine correlated with better scores on particular cognitive and PRO measures. In summary, our sample of adults with symptomatic SCD demonstrated worse processing speed and experience more executive challenges than their siblings, despite treatment with hydroxyurea. These relative weakness likely relate to disease processes but the specific physiological mechanism is unclear.

Musculoskeletal Pain in Older Adults: A Clinical Review

Persistent pain in older adults is a widely prevalent and disabling condition that is the manifestation of multiple contributing physical, mental, social, and age-related factors. To effectively treat pain, the clinician must assess and address contributing factors using a comprehensive approach that includes pharmacologic and nonpharmacologic therapies within the context of a strong therapeutic relationship among the patient, caregivers, and a multidisciplinary team. This article reviews the current understanding of persistent pain in older adults and suggests a general approach to its assessment and management, followed by specific considerations for musculoskeletal pain conditions commonly seen in older adults.

Falls in Community-Dwelling Older Adults with Lower Back or Knee Pain Are Associated with Cognitive and Emotional Factors

(1) Background: The present study aimed to examine physical, cognitive and emotional factors affecting falls in community-dwelling older adults with and without pain; (2) Methods: Data from 789 older adults who participated in a community-based health survey were analyzed. Participants completed questionnaires on the presence of pain and previous falls. Muscle weakness (handgrip strength < 26.0 kg for men and < 18.0 kg for women) and low skeletal muscle mass (appendicular skeletal muscle mass index < 7.0 kg/m2 for men and < 5.7 kg/m2 for women) were determined. Mild cognitive impairment (MCI) and depressive symptoms were assessed using the National Center for Geriatrics and Gerontology-Functional Assessment Tool and 15-item geriatric depression scale (GDS-15), respectively; (3) Results: In participants with pain, MCI and GDS-15 were associated with previous falls after adjusting for age, sex, education and medication use. In participants without pain, muscle weakness and low skeletal muscle mass were associated with previous falls when adjusting for the above covariates; (4) Conclusions: Falls in participants with pain were associated with cognitive and emotional factors, whereas falls in those without pain were associated with physical factors. Fall prevention interventions for older adults with pain may require tailored strategies to address cognitive and emotional factors.

Executive Functions and Pain

Abstract. A growing body of literature suggests that chronic-pain patients suffer from problems in various neuropsychological domains, including executive functioning. In order to better understand which components of executive functioning (inhibition, shifting and/or updating) might be especially affected by pain and which mechanisms might underlie this association, we conducted a systematic review, including both chronic-pain studies as well as experimental-pain studies. The chronic-pain studies (N = 57) show that pain is associated with poorer executive functioning. The findings of experimental-pain studies (N = 28) suggest that this might be a bidirectional relationship: Pain can disrupt executive functioning, but poorer executive functioning might also be a risk factor for higher vulnerability to pain.

Are Functional Brain Alterations Present in Low Back Pain? A Systematic Review of EEG Studies

This systematic review analyzed available literature on functional brain alterations in low back pain (LBP) measured with electroencephalography (EEG), as until now evidence thereof was unclear. Four electronic databases were systematically searched the 10th of March 2018, resulting in 12 included studies. Studies showed a risk of bias of 37.5 to 75% using the Newcastle-Ottawa Scale for case-control studies. Limited evidence reported higher amplitudes of balance-related potentials and early components of somatosensory evoked potentials (SEP) to noxious stimuli, and altered feedback-related negativity and P300 potentials during decision-making in chronic LBP (CLBP). These findings suggest postural strategies requiring a higher cortical attention-demand, increased sensory-discriminative processing of noxious input, and altered decision-making in CLBP. However, further research is warranted as these inferences were based on single studies. Moderate evidence for unaltered amplitude of late-phase SEPs to noxious stimuli and auditory evoked potentials in LBP implies that the affective-emotional processing of stimuli might be unaffected in LBP. Furthermore, moderate evidence indicated disturbed habituation of somatosensory stimuli in LBP. Most studies examined nonspecific or mixed CLBP populations, hence EEG-quantified brain activity in (sub)acute or recurrent LBP still needs to be explored. PERSPECTIVE: This review presents an overview of the current understanding of the functional LBP brain measured with EEG. The limited evidence in current research suggests altered cortical function regarding balance control, somatosensory processing, and decision making in LBP, and highlights opportunities for future EEG-research.

Pain characteristics and incidence of functional disability among community-dwelling older adults

This study examined the association between pain characteristics and the incidence of functional disability among community-dwelling older adults. This prospective cohort study included 4,365 older adults (mean age 74.7 years, 53.5% female) living in community settings. Pain characteristics, including severity and duration of pain, were assessed in participants who also underwent monthly follow-up assessment of functional disability for 24 months based on the national long-term care insurance system. Among the 4,365 participants, 2,149 (48.7%) reported pain, regardless of severity and duration. Of the 2,149 participants with pain, 950 (44.2%) reported moderate to severe pain and 1,680 (78.2%) reported chronic pain. Based on the univariate analyses, participants with moderate (hazard ratio [95% confidence interval]: 1.48 [1.05–2.09]) or severe (2.84 [1.89–4.27]) pain and chronic pain (1.50 [1.15–1.95]) showed significantly higher risk of disability incidence than did those without pain. After adjusting for covariates, severe pain remained a significant predictor (hazard ratio [95% confidence interval]: 1.66 [1.05–2.62]), but moderate (1.00 [0.69–1.47]) and chronic pain (1.04 [0.77–1.40]) did not. Our results established that moderate to severe pain or chronic pain affects functional disability; in particular, severe pain was independently associated with the incidence of disability. Subjective complaints of pain do not always correspond to physical causes; however, simplified questions regarding pain characteristics could be useful predictors of functional disability in community-dwelling older people.

Effect of Pain Severity on Executive Function Decline in Community-Dwelling Older Adults

Objective: The purpose of this study was to explore the reciprocal relationship between pain severity and executive function in community-dwelling older adults. Method: In this prospective cohort study, 64 Japanese community-dwelling older adults aged 60 years or older (mean age 72.8 years; women, 68.8%) were analyzed. Pain severity was assessed by self-reported questionnaire while executive function was assessed by the Trail Making Test at baseline and at 1-year follow-up assessment. A mixed effect model was conducted to analyze the effect of baseline executive function on change in pain severity and effect of baseline pain severity on change in executive function. Results: The effect of baseline Trail Making Test on change in pain severity was not significant. On the contrary, the effect of high baseline pain severity on the decline in set shifting (Trail Making Test Part B) was significant even after adjustment with age, sex, years of education, depressive symptoms, and analgesic drug use. Conclusion: Higher baseline pain severity was associated with greater executive function decline in community-dwelling older adults. Executive function decline due to severe pain should be considered as well as pain itself.