Pain and Depression in Older Adults With Arthritis

A protocol for a wait list control trial of an intervention to improve pain and depressive symptoms among middle-aged and older African American women

BACKGROUND

Pain and depression frequently co-occur among older adults with comorbidities and can exacerbate one another. The intersection of race, gender and age puts older African American women at high risk of experiencing comorbid pain and depression. The purpose of this study is to test the feasibility and acceptability of a 12-week behavioral activation intervention called DAPPER (Depression and Pain Perseverance through Empowerment and Recovery) that uses non-pharmacological, tailored strategies to target pain and mood symptoms. We will measure pain intensity and depressive symptoms as outcomes, although we are not powered to test differences.

METHODS

We describe the protocol for this study that uses a randomized waitlist control design to examine acceptability and feasibility of an intervention. The study population is comprised of self-identified African American women, 50 years of age or older with chronic pain and who self-report of depressive symptoms. Participants must also be pre-frail or frail and have an ADL or IADL limitation. The intervention consists of eight 1-2-h visits with a nurse interventionist via in-person or virtual telecommunication methods and two visits for non-invasive specimen collection. The primary outcomes include goal attainment, pain and depressive symptoms. Secondary outcomes include stress, frailty, and communication with providers. Follow-up qualitative interviews are conducted with participants to assess intervention acceptability.

DISCUSSION

Findings from this pilot study will provide further evidence supporting the use of non-pharmacological techniques to intervene in the cycle of pain and depression among an at-risk sub-population.

Longitudinal Trajectories of Depressive Symptoms Among Patients With Knee Osteoarthritis: The Role of Pain Intensity

BACKGROUND

Pain is the primary symptom of knee osteoarthritis (KOA), significantly associated with depressive symptoms. Whether the early pain intensity could distinguish different trajectories of depressive symptoms is not well understood among patients with KOA.

AIMS

To identify heterogeneous depressive symptoms trajectories among patients with KOA, and investigate the association between depressive symptoms subgroups and pain intensity.

DESIGN

Secondary analysis of a cohort sample.

SETTING

Three waves of data from the China Health and Retirement Longitudinal Study was collected in 28 provinces across China.

PARTICIPANTS

702 patients with KOA aged ≥ 45 years completed the Center for Epidemiologic Studies Depression Scale biennially from 2011 to 2015.

METHODS

Latent class growth analysis was performed to identify the optimal trajectory shape and number of classes. Multinomial logistic regression analysis was conducted to compare pain intensity across the trajectories.

RESULTS

Four distinct trajectories were identified as follows: no depressive symptoms, highly stable, decreasing, and increasing. In multivariate analysis, compared with the "no depressive symptoms" class, patients in the "highly stable" class and "increasing" class were more likely to report moderate pain (p < 0.05) and severe pain (p < 0.05). In addition, there was no significant difference in pain intensity between "no depressive symptoms" class and "decreasing" class (p > 0.05).

CONCLUSIONS

These results suggest important heterogeneity in depressive symptom trajectories among patients with KOA. Pain intensity could predict different depressive symptom trajectories in patients with KOA. Efforts to improve the depressive symptoms in patients with KOA must incorporate strategies to address pain.

Identifying latent comorbidity patterns in adults with perceived cognitive impairment: Network findings from the behavioral risk factor surveillance system

Background

People with cognitive impairment may be exposed to an increased risk of comorbidities; however, the clustering of comorbidity patterns in these patients is unclear.

Objective

To explore the network structure of chronic comorbidity in a U.S. national sample spanning all 50 U.S. states with more than 170,000 participants reporting perceived cognitive impairment.

Methods

This is a cross-sectional study conducted using Behavioral Risk Factor Surveillance System (BRFSS) secondary data collected in 2019 and covering 49 U.S. states, the District of Columbia, Guam, and the Commonwealth of Puerto Rico. A total of 15,621 non-institutionalized U.S. adult participants who reported "yes" to the subjective cognitive impairment question were considered, of whom 7,045 were men and 8,576 were women. All participants were aged 45 years or older. A statistical graphical model was used that included clustering algorithms and factorization of variables in a multivariate network relationship system [exploratory graphical analysis (EGA)].

Results

The results of the EGA show associations between the comorbid conditions evaluated. These associations favored the clustering of various comorbidity patterns. In fact, three patterns of comorbidities have been identified: (1) arthritis, asthma, respiratory diseases, and depression, (2) obesity, diabetes, blood pressure high, and blood cholesterol high, and (3) heart attack, coronary heart disease, stroke, and kidney disease.

Conclusion

These results suggest the development of interdisciplinary treatment strategies in patients with perceived cognitive impairment, which could help to design an integrated prevention and management of the disease and other related health problems, such as Alzheimer's disease and related dementias.

Association between arthritis and depression risk: a prospective study and meta-analysis

OBJECTIVE

Our research aimed to prospectively evaluate the association between arthritis and depression among middle-aged and elderly Chinese and confirmed this association in other populations.

METHODS

Data from the China Health and Retirement Longitudinal Study were analyzed. Participants were enrolled in this study in 2011-2012 (Wave 1) and followed up in 2013-2014 (Wave 2) and 2015-2016 (Wave 3). Depression was defined as having a score equal to over 10 using the Chinese version of 10-item Center for Epidemiological Studies Depression scale. Arthritis was assessed by self-reported physician diagnosis in Wave 1. Cox proportional hazards regression models were fitted to evaluate prospective associations between baseline arthritis status and incident and persistent depression. Summary effect estimates were pooled from our findings and those reported in literature by applying random effects models.

RESULTS

The study included 7,386 participants aged 58.48 years (standard deviation, 9.59) for final analyses. Individuals with arthritis had a 35% higher risk (multivariable-adjusted hazard ratio [HR]: 1.35; 95% confidence interval [CI]: 1.23, 1.49) and 50% higher risk (HR: 1.50; 95% CI: 1.22, 1.84) of developing incident and persistent depression compared with those without arthritis. The meta-analysis of prospective studies confirmed increased risk of depression in individuals with arthritis (summary HR: 1.42, 95% CI, 1.34, 1.52).

LIMITATIONS

Depression was assessed by a screening tool and arthritis was assessed by self-reported physician diagnosis.

CONCLUSIONS

A positive relationship between arthritis and depression was noted in the middle-aged and elderly Chinese adults and other populations.

The Reciprocal Relationship of Pain and Movement in African American Older Adults With Multi-Joint Osteoarthritis

Pain with movement is a common issue for older adults with osteoarthritis; however, there has been insufficient attention within populations at increased risk for disabling pain, such as African American older adults. Accordingly, using a mixed methods approach, the purpose of the current study is to describe the nature of chronic joint pain and movement and its impact on physical function in African American older adults with symptomatic osteoarthritis. The authors accrued a sample of 110 African American older adults who completed cross-sectional surveys; from this sample, the authors interviewed 18 participants. Findings suggest that patterns of movement are uniquely influenced by pain. Specifically, three dynamic themes emerged: The Impact of Pain on Movement; The Importance and Impact of Movement on Pain; and The Adaptation of Personal Behaviors to Minimize Pain With Movement. Function-focused nursing care rests on addressing challenges and opportunities that African American older adults face in maintaining healthy movement when managing osteoarthritis pain. [Research in Gerontological Nursing, xx(x), xx-xx.].

Pain, Racial Discrimination, and Depressive Symptoms among African American Women

African American women with osteoarthritis (OA) are at high risk of experiencing pain. They report more pain than non-Hispanic White women and men of other racial/ethnic groups. This pain can limit independence and diminish their quality of life. Despite the detrimental effects that pain can have on older African American women with OA, there is a dearth of literature examining factors beyond the OA pathology that are associated with pain outcomes within this population. The purpose of this study was to examine the relationships between racial discrimination and depressive symptoms with pain intensity in African American women with OA. The sample comprised of 120 African American women, aged 50-80 years, with OA, from Texas and New Mexico. The women completed survey booklets to answer study questionnaires. We used multiple linear regression to test associations between racial discrimination, depressive symptoms, and pain intensity. We tested whether depressive symptoms mediated the relationship between racial discrimination and pain intensity by using bootstrapping. Results indicated that racial discrimination was significantly associated with pain intensity and that this relationship was mediated by depressive symptoms, even after controlling for body mass index, years of education, and length of time with OA. Both depressive symptoms and racial discrimination may be modifiable. If these modifiable factors are addressed in this population, there may be decreased pain in middle-aged and older African American women.

Comparison of the Prevalence and Predictors of Depression in Taiwanese and American Older Patients With Arthritis

PURPOSE

To compare the prevalence and predictors of depression in Taiwanese and American older patients with arthritis.

DESIGN AND METHODS

A secondary analysis was conducted to assess 151 Taiwanese and 70 American arthritic patients in Taipei, Taiwan and Chicago, USA.

FINDINGS

The prevalence of depression of Taiwanese and American older arthritic patients was 34% and 40%, respectively. Depression was explained by life satisfaction and functional ability in Taiwanese patients, and by life satisfaction and level of pain in American patients.

PRACTICE IMPLICATIONS

Nurses should assess patients' level of pain and functional ability, as well as their life satisfaction and depression.

Building a Biopsychosocial Conceptual Framework to Explore Pressure Ulcer Pain for Hospitalized Patients

Although pressure ulcers are a prevalent condition, pain associated with pressure ulcers is not fully understood. Indeed, previous studies do not shed light on the association between pressure ulcer stages and the experience of pain. Especially, pain characteristics of suspected deep tissue injury, which is a new category that was recently added by the National Pressure Ulcer Advisory Panel, are yet unknown. This is concerning because the incidence of pressure ulcers in hospitalized patients has increased exponentially over the last two decades, and health care providers are struggling to ensure providing adequate care. Thus, in order to facilitate the development of effective interventions, this paper presents a conceptual framework to explore pressure ulcer pain in hospitalized patients. The concepts were derived from a biopsychosocial model of pain, and the relationships among each concept were identified through a literature review. Major propositions are presented based on the proposed conceptual framework, which integrates previous research on pressure ulcer pain, to ultimately improve understanding of pain in hospitalized patients with pressure ulcers.

Health-Related Quality of Life and Pain Intensity Among Ethnically Diverse Community-Dwelling Older Adults

Chronic pain is highly prevalent in older adults and often negatively associated with health-related quality of life (HRQoL). This study compared HRQoL, including physical health and mental health, in persons of differing ethnicities, and identified factors associated with pain intensity and HRQoL in ethnically diverse older adults. Older adults with chronic pain from four ethnic groups (African Americans, Afro-Caribbeans, Hispanics, and European Americans) were recruited from the Florida Atlantic University Healthy Aging Research Initiative (HARI) registry. The Medical Outcomes Study Short Form-36 (SF-36) was used to evaluate HRQoL, including functional status, emotional well-being, and social functioning. Of 593 persons in the four ethnic groups in the registry, 174 met the inclusion criteria (pain level of four or higher on an 11-point scale, lasting 3 months or longer). Among these 174, African Americans reported the highest level of pain intensity, followed by Afro-Caribbeans, Hispanics, and European Americans. Hispanics reported the highest physical health scores and the lowest mental health scores. In contrast, African Americans reported the highest mental health scores and the lowest physical health scores. Multivariate linear regression analysis revealed that ethnicity, lower physical health scores, and lower mental health scores were significantly (p ≤ .01) associated with pain intensity. Understanding ethnic variations in response to pain intensity may address gaps in knowledge about HRQoL to reduce disparities in optimal care. Health care providers should consider ethnic norms and cultural diversity to provide optimal interventions for this population.

The Impact of Genetics on Physical Resilience and Successful Aging

Objective: To better understand the impact of genetics on resilience and successful aging, we tested a model of successful aging. Method: This was a descriptive study with a single interview and blood draw done with residents in a continuing care retirement community. Five genes associated with resilience were included in the model. The hypothesis was tested using structural equation modeling. Results: A total of 116 participants completed the survey. Two SNPs from SLC6A4 (rs25533 and rs1042173) and age were the only variables associated with physical resilience and explained 9% of the variance. Cognitive status, age, and depression were directly associated with successful aging; variance in rs25532 or rs1042173, resilience, and pain were indirectly associated with successful aging through depression. Discussion: Continued research to replicate these findings is needed so as to be able to recognize older adults at risk of low physical resilience and implement appropriate interventions.

Practice recommendations for pain assessment by self-report with African American older adults

Despite decades of education and clinical practice guidelines underscoring disparities in pain management, pain continues to be inadequately managed in older African American adults as a result of patient, provider, and systems factors. Critical factors influencing pain assessment in older African American adults has not been extensively examined, contributing to a lack of data to inform health care providers' knowledge on culturally-responsive pain assessment in older African Americans. Assessing pain in older African Americans is unique because differences in language, cultural beliefs, and practices moderate how they report and express pain. This paper presents an overview of patient-provider factors that affect pain assessment in older African Americans with a focus on this population's unique cultural beliefs and practices. Recommendations for best practices for performance of a culturally-responsive pain assessment with older African Americans are provided.

Common patterns of morbidity and multi-morbidity and their impact on health-related quality of life: evidence from a national survey

Background

There is limited evidence about the impact of specific patterns of multi-morbidity on health-related quality of life (HRQoL) from large samples of adult subjects.

Methods

We used data from the English General Practice Patient Survey 2011–2012. We defined multi-morbidity as the presence of two or more of 12 self-reported conditions or another (unspecified) long-term health problem. We investigated differences in HRQoL (EQ-5D scores) associated with combinations of these conditions after adjusting for age, gender, ethnicity, socio-economic deprivation and the presence of a recent illness or injury. Analyses were based on 831,537 responses from patients aged 18 years or older in 8,254 primary care practices in England.

Results

Of respondents, 23 % reported two or more chronic conditions (ranging from 7 % of those under 45 years of age to 51 % of those 65 years or older). Multi-morbidity was more common among women, White individuals and respondents from socio-economically deprived areas. Neurological problems, mental health problems, arthritis and long-term back problem were associated with the greatest HRQoL deficits. The presence of three or more conditions was commonly associated with greater reduction in quality of life than that implied by the sum of the differences associated with the individual conditions. The decline in quality of life associated with an additional condition in people with two and three physical conditions was less for older people than for younger people. Multi-morbidity was associated with a substantially worse HRQoL in diabetes than in other long-term conditions. With the exception of neurological conditions, the presence of a comorbid mental health problem had a more adverse effect on HRQoL than any single comorbid physical condition.

Conclusion

Patients with multi-morbid diabetes, arthritis, neurological, or long-term mental health problems have significantly lower quality of life than other people. People with long-term health conditions require integrated mental and physical healthcare services.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-014-0820-7) contains supplementary material, which is available to authorized users.