The therapeutic management of chronic pain in ambulatory care patients aged 65 and over in France: the S.AGES Cohort. Baseline data

Association between car driving and successful ageing. A cross sectional study on the "S.AGES" cohort

BACKGROUND

Assessing successful ageing (SA) is essential to identify modifiable factors in order to enforce health promotion and prevention actions. SA comprises 3 dimensions: an active engagement with life, a low probability of disease and disease-related disability, and a high cognitive and physical functional capacity. Driving seems to be linked to SA as it is a mean to preserve social interactions and requires preserved functional and cognitive status. This study aims to investigate whether driving status can be considered a proxy of SA, by describing determinants associated with driving status in the 65+.

METHODS

This cross-sectional study is ancillary to the S.AGES (Sujets AGÉS-Aged Subjects) study, an observational prospective cohort study which included patients suffering from chronic pain, type-2 diabetes mellitus or atrial fibrillation from 2009 to 2014. SA was defined by the success of three dimensions: physiological comprised of comorbidity and autonomy scores, psychological comprised of cognitive status and emotional state, and a social dimension.

RESULTS

2,098 patients were included of whom 1,226 (58.4%) reported being drivers. 351/2,092 (16.7%) were classified as successful agers: 292/1,266 (23.8%) in the driver group vs. 59/872 (6.8%) in the non-driver group; p < .001. In the final logistic model, after adjustment for relevant variables, SA was associated with driver status OR 1.94 [1.36-2.77].

CONCLUSION

Driving may be considered as a proxy to SA: it reflects elders' independence, cognitive ability and a means to maintain social interactions. To preserve their mobility and enable them to achieve SA, regular screening of driving skills, specific rehabilitation programs are needed. Moreover development and communication on special transports services, communal rides or even driverless car to avoid apprehension around older adults driving could be solutions.

Effects of chronic tramadol administration on cognitive flexibility in mice

RATIONALE

Tramadol is widely used for pain relief especially in seniors. However, long-term use of tramadol has serious adverse effects, including cognitive impairment. Besides its memory effects, already demonstrated in animals, a recent clinical report suggests that tramadol could also affect executive function in seniors. Several studies have hypothesized that the anti-muscarinic properties of tramadol could be responsible for the deleterious effects of tramadol on cognition.

OBJECTIVES

We aimed at investigating the effects of chronic administration of tramadol on cognitive flexibility in adult male mice, as assessed by a visual discrimination reversal task using a touchscreen device. The effects of tramadol were further compared to those of scopolamine, a reference muscarinic antagonist.

RESULTS

We found that, during the early phase of the reversal task, when cognitive flexibility is most in demand, both tramadol-treated mice (20 mg/kg, s.c., twice a day) and scopolamine-treated mice (0.5 mg/kg, s.c., twice a day) needed more correction trials and showed a higher perseveration index than saline-treated mice. Therefore, tramadol affects cognitive flexibility, and its anticholinergic properties could be at least partly involved in these deficits.

CONCLUSIONS

In view of these deleterious cognitive effects of tramadol, physicians should be cautious when prescribing this analgesic, especially in seniors who are more vulnerable to adverse drug events and in which alternative prescription should be preferred whenever possible.

Diagnosis and management of lumbar spinal stenosis in primary care in France: a survey of general practitioners

Background

Lumbar spinal stenosis (LSS) is a common spinal condition and the most frequent indication for spinal surgery in elderly people. General practitioners (GPs) are on the 1^st line for its diagnosis and treatment. We aimed to assess how GPs diagnose and treat people with LSS in France.

Methods

We conducted a cross-sectional survey in a primary care setting. French GPs were selected by a random draw from the French Medical Board. The questionnaire was designed by 3 physicians specialized in physical and rehabilitation medicine and a resident in general practice. A provisional questionnaire was tested in a pilot survey of 11 French GPs. Participants’ feedbacks served to build the final questionnaire. This latter was submitted by e-mail or mail to 330 GPs. GPs were surveyed about the 3 main domains relevant to the management of people with LSS in primary care: 1/ diagnosis, 2/ pharmacological treatments and 3/ non-pharmacological treatments, using self-administered open- and closed-ended questions and visual analog scales.

Results

Overall, 90/330 (27.3%) GPs completed the survey. 51/89 (57.3%) GPs were confident with managing people with LSS. Low back pain 51/87 (58.6%), neurogenic claudication 38/87 (43.7%) and paresthesia in the lower limbs 31/87 (35.6%) were the 3 most frequently cited clinical signs leading to the diagnosis of LSS. Improvement with lumbar flexion was mentioned by 9/87 (10.3%) GPs. 85/86 (98.8%) would consider prescribing lumbar imaging, 60/84 (71.4%) corticoid spinal injections and 42/79 (53.2%) would never prescribe lumbar flexion-based endurance training. All GPs would refer people with LSS to another specialist.

Conclusions

French GPs lack confidence with diagnosing LSS and prescribing pharmacological and non-pharmacological treatments for people with LSS.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2782-y) contains supplementary material, which is available to authorized users.

Regular use of acetaminophen or acetaminophen-codeine combinations and prescription of rescue therapy with non-steroidal anti-inflammatory drugs: a population-based study in primary care

OBJECTIVE

There are contrasting positions concerning the benefit-risk ratio of acetaminophen use for osteoarthritis (OA)-related pain. To clarify the effectiveness of acetaminophen or acetaminophen-codeine combinations according to their regimen of use, we evaluated whether being a regular user (adherent) of these medications decreased the occurrence of rescue therapy with non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

Using the Health Search IMS Health Longitudinal Patient Database, we formed a cohort of patients aged ≥18 years and newly treated with acetaminophen or acetaminophen-codeine combinations for OA between 1 January 2001 and 31 December 2013. These patients were followed up for one year in which they were categorized as regular or irregular users of these medications according to a variable medication possession ratio (VMPR) ≥ 50% or lower. We operationally defined the rescue therapy as the use of any NSAIDs prescribed for OA-related pain.

RESULTS

Overall, 40,029 patients (69.5% females; mean age: 68 ± 13.57) treated with acetaminophen or acetaminophen-codeine combinations formed the cohort. After the first year of treatment, regular users showed a statistically significantly lower risk of being prescribed with rescue therapy with NSAIDs (OR = 0.89; 95% CI 0.84-0.96).

CONCLUSION

These findings show that regular use of acetaminophen or acetaminophen-codeine combinations may reduce the need for NSAIDs to treat OA-related pain.

[Primary care pain management in the elderly population: The opening to non-pharmacological interventions. Qualitative study focused on GP experiences]

OBJECTIVES

First of all, understand the management of pain in the elderly population through GP experiences and, secondly, explore their implication to the benefit of well aging.

METHOD

Qualitative study with data collection combining 2 focus groups and 5 in depth interviews centered on the lived experience of 16 GPs in the Languedoc-Roussillon region in southern France. A semiopragmatic phenomenological analysis of the fully transcribed verbatim interviews was used to establish the significant categories in relation with our objectives.

RESULTS

The GPs feel that the pain management still needs improvement even though it has become one of their priorities. GPs often notice iatrogenic effects in the care taking process of multiple pathologies which make them choose for the use of non-pharmacological interventions. The complex nature of pain, which has multiple significations for the elderly population, needs an overall approach by the GPs. They feel that it's their job to manage this because of the proximity and knowledge of the patient and his weaknesses. For them, aging well is a patient experience, they are only a support in this process.

DISCUSSION

GPs think that they are expert in the complex process of pain management. This process has to be seen in a multidimensional approach of an older person with multiple pathologies. Therefore, they make use of non-pharmacological interventions.

CONCLUSION

These interventions need to be developed to improve the quality of life in the elderly population.

What are the therapeutic alternatives to dextropropoxyphene in France? A prescribers' survey

About a year after dextropropoxyphene (DXP) withdrawal from the French market, we conducted a survey among members of the French Society of Anesthesia & Intensive Care Medicine (Sfar) and of the French Society of the Study and Treatment of Pain (SFETD) to identify the indications for which this WHO level II analgesic had been prescribed, the prescriber's feedback following withdrawal, and the substitutive analgesics prescribed. DXP had been prescribed by more than 75% of the 430 anaesthesiologists and 230 pain specialists interviewed, mainly for acute and chronic non-cancer pain of moderate intensity. While two thirds of pain specialists were not satisfied with DXP withdrawal, this decision did not affect the majority of anaesthesiologists. In both groups, the main substitutive analgesic was tramadol combined with acetaminophen, while only 24% of prescribers considered acetaminophen alone as a substitute.

Predicting falls in elderly patients with chronic pain and other chronic conditions

BACKGROUND

The aim was to identify fall predictors in elderly suffering from chronic pain (CP) and to test their applicability among patients with other chronic conditions.

METHODS

1,379 non-institutionalized patients aged 65 years and older who were suffering from CP (S.AGE CP sub-cohort) were monitored every 6 months for 1 year. Socio-demographic, clinical and pain data and medication use were assessed at baseline for the association with falls in the following year. Falls were assessed retrospectively at each study visit. Logistic regression analyses were performed to identify fall predictors. The derived model was applied to two additional S.AGE sub-cohorts: atrial fibrillation (AF) (n = 1,072) and type-2 diabetes mellitus (T2DM) (n = 983).

RESULTS

Four factors predicted falls in the CP sub-cohort: fall history (OR: 4.03, 95 % CI 2.79-5.82), dependency in daily activities (OR: 1.81, 95 % CI 1.27-2.59), age ≥75 (OR: 1.53, 95 % CI 1.04-2.25) and living alone (OR: 1.73, 95 % CI 1.24-2.41) (Area Under the Curve: AUC = 0.71, 95 % CI 0.67-0.75). These factors were relevant in AF (AUC = 0.71, 95 % CI 0.66-0.75) and T2DM (AUC = 0.67, 95 % CI 0.59-0.73) sub-cohorts. Fall predicted probability in CP, AF and T2DM sub-cohorts increased from 7, 7 and 6 % in patients with no risk factors to 59, 66 and 45 % respectively, in those with the four predictors. Fall history was the strongest predictor in the three sub-cohorts.

CONCLUSION

Fall history, dependency in daily activities, age ≥75 and living alone are independent fall predictors in CP, AF and T2DM patients.

Primary care management of non-institutionalized elderly diabetic patients: The S.AGES cohort - Baseline data

AIM

S.AGES is a multicenter prospective cohort study of non-institutionalized patients aged 65 and over with atrial fibrillation, type 2 diabetes or chronic pain. Its objective is to describe the medical management in primary care. This article presents the baseline characteristics of subjects in the diabetes subcohort and compares the results to those from cohorts of older diabetic patients.

METHODS

From April 2009 to June 2011, 983 patients were included in the diabetes subcohort by 213 primary care providers. Demographic data, geriatric parameters and the history, characteristics and treatment of the diabetes were recorded at baseline.

RESULTS

The mean age was 76.7 ± 5.9 years. Most patients were living independently, with no cognitive impairment and in relatively good health. The duration of diabetes was 11.3 ± 8.7 years with average HbA1c of 6.9 ± 1.0%. 20% of patients had macrovascular disease, 33% renal failure, 14.6% ocular complication and 7.1% neuropathy. The first-line antidiabetic treatment was metformin (61.2%) and 18% of patients had used insulin. Treatment intensified with the worsening of diabetic symptoms. When compared to those from French and North American cohorts, the results showed increased complications and use of insulin with age, disease duration and severity.

CONCLUSION

Due to the method of recruitment, S.AGES patients were generally healthy with well-controlled diabetes. However, the results were consistent with those from other cohorts. Three-year follow-up is expected to study the management of diabetic patients aged 65 and over in primary care.

Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials

OBJECTIVE

To investigate the efficacy and safety of paracetamol (acetaminophen) in the management of spinal pain and osteoarthritis of the hip or knee.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, AMED, CINAHL, Web of Science, LILACS, International Pharmaceutical Abstracts, and Cochrane Central Register of Controlled Trials from inception to December 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing the efficacy and safety of paracetamol with placebo for spinal pain (neck or low back pain) and osteoarthritis of the hip or knee.

DATA EXTRACTION

Two independent reviewers extracted data on pain, disability, and quality of life. Secondary outcomes were adverse effects, patient adherence, and use of rescue medication. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst possible pain or disability). We calculated weighted mean differences or risk ratios and 95% confidence intervals using a random effects model. The Cochrane Collaboration's tool was used for assessing risk of bias, and the GRADE approach was used to evaluate the quality of evidence and summarise conclusions.

RESULTS

12 reports (13 randomised trials) were included. There was "high quality" evidence that paracetamol is ineffective for reducing pain intensity (weighted mean difference -0.5, 95% confidence interval -2.9 to 1.9) and disability (0.4, -1.7 to 2.5) or improving quality of life (0.4, -0.9 to 1.7) in the short term in people with low back pain. For hip or knee osteoarthritis there was "high quality" evidence that paracetamol provides a significant, although not clinically important, effect on pain (-3.7, -5.5 to -1.9) and disability (-2.9, -4.9 to -0.9) in the short term. The number of patients reporting any adverse event (risk ratio 1.0, 95% confidence interval 0.9 to 1.1), any serious adverse event (1.2, 0.7 to 2.1), or withdrawn from the study because of adverse events (1.2, 0.9 to 1.5) was similar in the paracetamol and placebo groups. Patient adherence to treatment (1.0, 0.9 to 1.1) and use of rescue medication (0.7, 0.4 to 1.3) was also similar between groups. "High quality" evidence showed that patients taking paracetamol are nearly four times more likely to have abnormal results on liver function tests (3.8, 1.9 to 7.4), but the clinical importance of this effect is uncertain.

CONCLUSIONS

Paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis. These results support the reconsideration of recommendations to use paracetamol for patients with low back pain and osteoarthritis of the hip or knee in clinical practice guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42013006367.

Do male and female general practitioners differently prescribe chronic pain drugs to older patients?

OBJECTIVE

The aim of this study was to identify the relationship between general practitioner (GP) gender and prescribing practice of chronic pain drugs in older adults.

DESIGN

Cross-sectional observational study.

SETTING

GPs in private practice throughout France.

SUBJECTS

Two hundred and sixty GPs (80.8% male and 19.2% female) enrolled 1,379 (28.4% male and 71.6% female) noninstitutionalized patients over 65 years of age, suffering from chronic pain.

METHODS

A comparison of prescribing habits between male and female GPs was performed on baseline data with univariate analyses followed by multivariate analyses after taking several confounding factors into account.

RESULTS

No significant differences were found when comparing male and female GPs' prescriptions of World Health Organization step 1, step 2, and step 3 analgesics. Male GPs were more likely than female GPs to prescribe antineuropathic pain drugs (11.3% of patients with male GPs versus 4.8% of patients with female GPs, P = 0.004) and less likely to prescribe symptomatic slow-acting drugs for osteoarthritis (SySADOA) (10.2% of male GPs' patients versus 18.8% of female GPs' patients, P = 0.0003). After adjusting for several confounding factors, male GPs were still more likely to prescribe antineuropathic pain drugs (OR 2.43, 95% CI 1.15-5.14, P = 0.02) and less likely to prescribe symptomatic slow-acting drugs (OR 0.64, 95% CI 0.42-0.97, P = 0.03).

CONCLUSION

Male and female GPs prescribe analgesics in a similar manner. However, male GPs prescribe more antineuropathic pain drugs, but fewer SySADOA.