Pain and the Montreal Cognitive Assessment (MoCA) in Aging

Does the presence of chronic pain affect scores on cognitive screening tests/brief cognitive measures for dementia? A systematic review and meta-analysis

OBJECTIVE

Cognitive screening tests can identify potential dementia by indicating a concerning level of cognitive impairment. The older populations for whom this is most relevant are more likely to experience chronic pain, which also impairs cognitive function, but pain's impact on cognitive screening tests specifically remains unknown.

METHOD

We conducted a systematic review and meta-analysis (SR/MA) following PRISMA guidelines evaluating cognitive screening scores in studies involving participants with chronic pain compared with a pain-free control group. Our question was whether the presence of chronic pain (self-reported or based on diagnosis) was associated with poorer performance on these screens, and to identify the heterogeneity across groups and screens.

RESULTS

The 51 studies identified yielded 62 effect size estimates. The pooled g was 0.76 (95% confidence interval 0.57 to 0.95). Heterogeneity was high for the full model (= 93.16%) with some reductions in sub-analyses. Around half of the studies were identified as being at a low risk of bias. There was no evidence of publication bias.

CONCLUSIONS

As a whole, this analysis suggests medium to large effect sizes on cognitive screen performance when people are living with chronic pain. We suggest that clinicians should consider the effect of chronic pain when cognitive screens are employed to investigate dementia. Further research could clarify the effect pain has on different screen sub-domains to aid their effective use with these populations.

Greater socioenvironmental risk factors and higher chronic pain stage are associated with thinner bilateral temporal lobes

INTRODUCTION

Previous research indicates ethnic/race group differences in pain and neurodegenerative diseases. Accounting for socioenvironmental factors reduces ethnic/race group differences in clinical and experimental pain. In the current study sample, we previously reported that in individuals with knee pain, ethnic/race group differences were observed in bilateral temporal lobe thickness, areas of the brain associated with risk for Alzheimer's disease, and related dementias. The purpose of the study was to determine if socioenvironmental factors reduce or account for previously observed ethnic/race group differences and explore if a combined effect of socioenvironmental risk and chronic pain severity on temporal lobe cortices is evident.

METHODS

Consistent with the prior study, the sample was comprised of 147 adults (95 women, 52 men), 45-85 years of age, who self-identified as non-Hispanic Black (n = 72) and non-Hispanic White (n = 75), with knee pain with/at risk for osteoarthritis. Measures included demographics, health history, pain questionnaires, cognitive screening, body mass index, individual- and community-level socioenvironmental factors (education, income, household size, marital and insurance status, and area deprivation index), and brain imaging. We computed a summative socioenvironmental risk index.

RESULTS

Regression analyses showed that with the inclusion of socioenvironmental factors, the model was significant (p < .001), and sociodemographic (ethnic/race) group differences were not significant (p = .118). Additionally, findings revealed an additive stress load pattern indicating thinner temporal lobe cortices with greater socioenvironmental risk and chronic pain severity (p = .048).

IMPLICATIONS

Although individual socioenvironmental factors were not independent predictors, when collectively combined in models, ethnic/race group differences in bilateral temporal lobe structures were not replicated. Further, combined socioenvironmental risk factors and higher chronic pain severity were associated with thinner bilateral temporal lobes.

Postoperative serum CHI3L1 level is associated with postoperative cognitive dysfunction in elderly patients after hip fracture surgery: A prospective observational study

Objectives

Postoperative cognitive dysfunction (POCD) is a common postoperative complication in older patients. Chitinase-3-like-1 protein (CHI3L1) is identified as a neuroinflammatory biomarker and impairs cognitive function. This study aimed to evaluate the association between serum levels of CHI3L1 and POCD and explore the levels of interleukin-6 (IL-6), IL-1β and C-reactive protein (CRP) in the elderly after total hip arthroplasty (THA).

Patients and methods

A total of 76 elderly patients undergoing THA were enrolled in the prospective observational study. Serum CHI3L1 levels were measured 1 day before and 1 day after surgery and other perioperative factors were also noted. The correlations between mediators of inflammation in the two groups were compared via Spearman correlation coefficients. The receiver operating characteristic (ROC) curves were implemented to analyze the predictive values of serum CHI3L1 and other inflammatory factors for POCD. And factors associated with POCD were analyzed by univariate and multivariate logistics.

Results

POCD was observed in 31.6% of patients 1 week after surgery. Postoperative serum CHI3L1 levels were higher in POCD patients than in non-POCD patients [1348.26(778.46-1889.77) VS 2322.86(1686.88-2517.35) ng/ml, P < 0.001]. Postoperative serum CHI3L1 level was positively correlated with postoperative IL-6 level (r = 0.284, P = 0.013). Compared with IL-6, IL-1β, and CRP, postoperative CHI3L1 level has the highest predictive value for POCD with the area under the curve (AUC) value of 0.779 according to the ROC curve. By the multivariate logistic regression analysis, elevated postoperative serum CHI3L1 level was found to be an independent risk factor for POCD 1 week after surgery (odds ratio = 1.204, 95% confidence interval = 1.087-1.332, P = 0.001).

Conclusion

Postoperative elevated serum CHI3L1 level was significantly associated with the incident of POCD, and positively correlated with postoperative IL-6 level in the elderly after THA. This biomarker may have potential utility for further elucidating the etiology of POCD.

The Relationship Between Chronic Pain and Cognitive Impairment in the Elderly: A Review of Current Evidence

Chronic pain and cognitive impairment are prevalent geriatric syndromes in the population of older adults, and they are the main cause of disability in people over sixty-five years of age. As the global population continues to age, chronic pain and cognitive impairment will affect an increasing number of older adults. While numerous studies in recent years have shown that chronic pain is associated with cognitive decline, the exact mechanisms linking the two remain unclear. In this review, we aim to present the available evidence on the connection between chronic pain and cognitive impairment and to discuss the potential mechanisms by which chronic pain affects cognitive function. In addition, we review potential therapeutic interventions targeting psychological factors, microglia activation, and altered gut flora that may improve and prevent cognitive decline in people with chronic pain.

Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes

BACKGROUND

Postoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures.

METHODS

Among 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses.

RESULTS

A Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02).

CONCLUSION

Postoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.

Self-reported pain and fatigue are associated with physical and cognitive function in middle to older-aged adults

Persistent fatigue is often reported in those with chronic musculoskeletal pain. Separately, both chronic pain and chronic fatigue contribute to physical and cognitive decline in older adults. Concurrent pain and fatigue symptoms may increase disability and diminish quality of life, though little data exist to show this. The purpose of this study was to examine associations between self-reported pain and fatigue, both independently and combined, with cognitive and physical function in middle-older-aged adults with chronic knee pain. Using a cross-sectional study design participants (n = 206, age 58.0 ± 8.3) completed questionnaires on pain and fatigue, a physical performance battery to assess physical function, and the Montreal Cognitive Assessment. Hierarchical regressions and moderation analyses were used to assess the relationship between the variables of interest. Pain and fatigue both predicted physical function (β = -0.305, p < 0.001; β = -0.219, p = 0.003, respectively), however only pain significantly predicted cognitive function (β = -0.295, p <0.001). A centered pain*fatigue interaction was a significant predictor of both cognitive function (β = -0.137, p = 0.049) and physical function (β = -0.146, p = 0.048). These findings indicate that self-reported fatigue may contribute primarily to decline in physical function among individuals with chronic pain, and less so to decline in cognitive function. Future studies should examine the impact of both cognitive and physical function decline together on overall disability and health.

Predictors of the Health-Related Quality of Life (HRQOL) in SF-36 in Knee Osteoarthritis Patients: A Multimodal Model With Moderators and Mediators

Purpose

The study aimed to examine associations between the 36-item short form health survey (SF-36) in clinical and neurophysiological measures to identify its predictors in patients with knee osteoarthritis (KOA) in a rehabilitation program.

Methods

We analyzed data from our cohort study (DEFINE cohort). We analyzed data from our KOA arm, with 107 patients, including clinical assessments, demographic data, pain scales, motor function (Timed Up and Go Test (TUG), 10 meters walk test, and 6-minute walk), balance (BBS), sleepiness (ESS), and Transcranial Magnetic Stimulation (TMS) and Electroencephalography (EEG).

Results

Our results showed 83.19% of patients were female with an average age of 68.6 years and an average number of days of pain was 96 days; around 31.86% were using more than five medications per day. Regarding the multimodal model to explain SF-36, the main variables relevant to the quality of life (QoL) were related to emotional aspects, such as anxiety and depression. Moreover, our study added findings with polymorphism (OPRM1/rs1799971) predicting mental aspects. Cognitive variables were important in predicting the mental health, emotional, and social support dimensions of the SF-36. In the physical domain, pain-related variables predominantly predicted QoL in these relationships. The domain of vitality significantly predicted all dimensions studied, except for mental and general health.

Conclusion

The results help in understanding the aspects that contribute to QoL and are discussed considering the general literature on physical rehabilitation and specific to this clinical group. Furthermore, the statistical methods allowed us to explore and effectively understand the dimensions related to QoL.

Comparison of Montreal Cognitive Assessment in Korean Version for Predicting Mild Cognitive Assessment in 65-Year and Over Individuals

Objectives

The purpose of this study was to compare the validity and reliability of the two Korean versions of the MoCA for individuals aged ≥65 years.

Methods

A total of 185 participants aged ≥65 years were included in this cross-sectional study. This study investigated the reliability of the two Korean versions of the MoCA (the MoCA-K and MoCA-K2) by having each participant complete both assessments twice and comparing them to their Korean version of the Mini-Mental State Exam (MMSE-K) scores. The participants either completed the tests in order A (MoCA-K2 before MoCA-K) then B (MoCA-K before MoCA-K2) or vice versa. The tests were then completed in the opposite order. This study conducted all experiments at 3-day intervals.

Results

Of the 185 total participants analyzed, 95 indicated cognitive impairment, while 90 had normal in MoCA-K scores; 50 demonstrated cognitive impairment, while 135 had normal in MMSE-K scores; and 101 and 84 participants showed cognitive impairment and normal in MoCA-K2 scores, respectively. Cronbach's α values were 0.929 for the MoCA-K, 0.774 for the MMSE-K, and 0.919 for the MoCA-K2. The mean scores were 22.37, 25.29, and 21.96 points for the MoCA-K, MMSE-K, and MoCA-K2, respectively. The sensitivity and the specificity of the MoCA-K were 77.0% and 78.0%, respectively, while those of the MoCA-K2 were 68.9% and 80.0%, respectively.

Conclusions

These results suggest that both the MoCA-K and MoCA-K2 are suitable and reliable evaluation tools for MCI screening; however, the MoCA-K had better overall sensitivity and specificity.

Brain gamma-aminobutyric acid, but not glutamine and glutamate levels are lower in older adults with chronic musculoskeletal pain: considerations by sex and brain location

INTRODUCTION AND OBJECTIVES

GABAergic and glutamatergic neurotransmitter systems are central to the pathophysiology of chronic pain and are equally affected by aging processes. We measured levels of frontal gamma-aminobutyric acid (GABA) and the combined resonance of glutamate and glutamine (Glx) in vivo using proton magnetic resonance spectroscopy (1H-MRS) to elucidate age-specific and pain-specific associations with clinical and experimental pain in older adults.

METHODS

Younger (18-24, n = 24) and older (60-94, n = 41) individuals part of a larger study (Neuromodulatory Examination of Pain and Mobility Across the Lifespan [NEPAL]) underwent questionnaires, quantitative sensory testing, and 1H-MRS Mescher-Garwood point-resolved spectroscopy to measure GABA and Glx levels in prefrontal and sensorimotor brain regions.

RESULTS

Older participants had significantly lower sensorimotor, but not prefrontal, GABA and Glx levels, compared with younger controls (P's < 0.05). Younger controls had significantly higher prefrontal and sensorimotor GABA, but not Glx, levels compared with older controls and older adults with chronic pain (P's < 0.05). Older males with chronic pain had significantly lower prefrontal GABA compared with older and younger male controls (P's < 0.05). Prefrontal GABA, but not Glx, was significantly associated with self-reported and experimental pain measures (P's < 0.05). Our results are the first to focus exclusively on age and pain differences in GABA and Glx including younger and older controls to elucidate aging and pain contributions to brain GABAergic and glutamatergic processes.

CONCLUSION

Evaluation of both the neuroinhibitory and neuroexcitatory mechanisms provide promising potential for improving both our understanding of the mechanisms of chronic pain in aging and opportunities for effective, individualized treatments.

Chronic Pain is Associated With Reduced Sympathetic Nervous System Reactivity During Simple and Complex Walking Tasks: Potential Cerebral Mechanisms

BACKGROUND

Autonomic dysregulation may lead to blunted sympathetic reactivity in chronic pain states. Autonomic responses are controlled by the central autonomic network (CAN). Little research has examined sympathetic reactivity and associations with brain CAN structures in the presence of chronic pain; thus, the present study aims to investigate how chronic pain influences sympathetic reactivity and associations with CAN brain region volumes.

METHODS

Sympathetic reactivity was measured as change in skin conductance level (ΔSCL) between a resting reference period and walking periods for typical and complex walking tasks (obstacle and dual-task). Participants included 31 people with (n = 19) and without (n = 12) chronic musculoskeletal pain. Structural 3 T MRI was used to determine gray matter volume associations with ΔSCL in regions of the CAN (i.e., brainstem, amygdala, insula, and anterior cingulate cortex).

RESULTS

ΔSCL varied across walking tasks (main effect p = 0.036), with lower ΔSCL in chronic pain participants compared to controls across trials 2 and 3 under the obstacle walking condition. ΔSCL during typical walking was associated with multiple CAN gray matter volumes, including brainstem, bilateral insula, amygdala, and right caudal anterior cingulate cortex (p's < 0.05). The difference in ΔSCL from typical-to-obstacle walking were associated with volumes of the midbrain segment of the brainstem and anterior segment of the circular sulcus of the insula (p's < 0.05), with no other significant associations. The difference in ΔSCL from typical-to-dual task walking was associated with the bilateral caudal anterior cingulate cortex, and left rostral cingulate cortex (p's < 0.05).

CONCLUSIONS

Sympathetic reactivity is blunted during typical and complex walking tasks in persons with chronic pain. Additionally, blunted sympathetic reactivity is associated with CAN brain structure, with direction of association dependent on brain region. These results support the idea that chronic pain may negatively impact typical autonomic responses needed for walking performance via its potential impact on the brain.