The effectiveness of psychological treatments for chronic pain in older adults: cautious optimism and an agenda for research

Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: A pilot study

OBJECTIVES

Emotional Awareness and Expression Therapy (EAET) targets trauma and emotional conflict to reduce or eliminate chronic pain, but video telehealth administration is untested. This uncontrolled pilot assessed acceptability, feasibility, and preliminary efficacy of group-based video telehealth EAET (vEAET) for older veterans with chronic musculoskeletal pain.

METHODS

Twenty veterans were screened, and 16 initiated vEAET, delivered as one 60-minute individual session and eight 90-minute group sessions. Veterans completed posttreatment satisfaction ratings and pain severity (primary outcome), pain interference, anxiety, depression, functioning, social connectedness, shame, and anger questionnaires at baseline, posttreatment, and 2-month follow-up.

RESULTS

Satisfaction was high, and veterans attended 7.4 (SD = 0.6) of 8 group sessions; none discontinued treatment. Veterans attained significant, large reductions in pain severity from baseline to posttreatment (p < .001, Hedges' g = -1.54) and follow-up (p < .001, g = -1.20); 14 of 16 achieved clinically significant (≥ 30%) pain reduction, and 3 achieved 90-100% pain reduction. Secondary outcomes demonstrated significant, medium-to-large improvements.

CONCLUSIONS

In this small sample, vEAET produced better attendance, similar benefits, and fewer dropouts than in-person EAET in prior studies. Larger, controlled trials are needed.

CLINICAL IMPLICATIONS

Group vEAET appears feasible and highly effective for older veterans with chronic pain.

Mindfulness-Based Group Therapy for Chronic Pain Management in Older Adults

OBJECTIVES

There were two quality improvement goals for this project: (1) to evaluate the outcomes of an 8-week geriatric-focused mindfulness-based group therapy program for chronic pain management called "Mindfulness-based Chronic Pain Care" offered at a senior community center affiliated with a geriatric primary care clinic, and (2) to obtain feedback from participants to make relevant modifications for future groups.

METHODS

The program consisted of eight 150-minute weekly sessions. Thirteen community-dwelling older adults aged 60 and older participated in the program. The study utilized a non-randomized control-group pretest-posttest design. Participants completed pre- and post-program evaluations measuring pain and related psychosocial outcomes and were also asked to evaluate the importance of the group. Intervention and control groups were compared by t-test, chi-square likelihood ratio, Fischer's exact test, and multivariate analysis of variance with repeated measures.

RESULTS

There were statistically significant improvements in three areas: 1) increased activity level, 2) increased "pain willingness," and 3) decreased generalized anxiety symptoms. Qualitative analysis highlighted how this intervention was important to participants.

CONCLUSIONS

The results of this pilot program indicate promising outcomes for older adults suffering from chronic pain.

CLINICAL IMPLICATIONS

The Mindfulness-based Chronic Pain Care program was a practical, feasible, and acceptable approach for pain management among program participants.

A Randomized Preference Trial Comparing Cognitive-Behavioral Therapy and Yoga for the Treatment of Late-Life Worry: Examination of Impact on Depression, Generalized Anxiety, Fatigue, Pain, Social Participation, and Physical Function

Background

Depression, generalized anxiety, fatigue, diminished physical function, reduced social participation, and pain are common for many older adults and negatively impact quality of life. The purpose of the overall trial was to compare the effects of cognitive-behavioral therapy (CBT) and yoga on late-life worry, anxiety, and sleep; and examine preference and selection effects on these outcomes.

Objective

The present analyses compared effects of the 2 interventions on additional outcomes (depressive symptoms, generalized anxiety symptoms, fatigue, pain interference/intensity, physical function, social participation); and examined whether there are preference and selection effects for these treatments.

Methods

A randomized preference trial of CBT and yoga was conducted in adults ≥60 years who scored ≥26 on the Penn State Worry Questionnaire-Abbreviated (PSWQ-A), recruited from outpatient medical clinics, mailings, and advertisements. Cognitive-behavioral therapy consisted of 10 weekly telephone sessions. Yoga consisted of 20 bi-weekly group yoga classes. Participants were randomized to(1): a randomized controlled trial (RCT) of CBT or yoga (n = 250); or (2) a preference trial in which they selected their treatment (CBT or yoga; n = 250). Outcomes were measured at baseline and post-intervention.

Results

Within the RCT, there were significant between-group differences for both pain interference and intensity. The pain interference score improved more for the CBT group compared with the yoga group [intervention effect of (mean (95% CI) = 2.5 (.5, 4.6), P = .02]. For the pain intensity score, the intervention effect also favored CBT over yoga [.7 (.2, 1.3), P < .01]. Depressive symptoms, generalized anxiety, and fatigue showed clinically meaningful within-group changes in both groups. There were no changes in or difference between physical function or social participation for either group. No preference or selection effects were found.

Conclusion

Both CBT and yoga may be useful for older adults for improving psychological symptoms and fatigue. Cognitive-behavioral therapy may offer even greater benefit than yoga for decreasing pain.

Chronic pain self-management in middle-aged and older adults: A collective intelligence approach to identifying barriers and user needs in eHealth interventions

Objectives

eHealth refers to health services and health information delivered or enhanced through the internet and related technologies. The number of eHealth interventions for chronic pain self-management is increasing. However, little evidence has been found for the overall efficacy of these interventions for older adults. The aim of the current study was to use a Collective Intelligence approach to identify the barriers and specific user needs of middle-aged and older adults using eHealth for chronic pain self-management.

Methods

A Collective Intelligence workshop was conducted with middle-aged and older adults to generate, clarify, select, and structure ideas in relation to barriers to eHealth use and specific design requirements for the purposes of chronic pain self-management. Prior to attending the workshop, participants received a trigger question requesting the identification of five barriers to eHealth use for chronic pain self-management. These barriers were categorised and presented to the group along with barrier-related scenarios and user need prompts, resulting in the generation of a set of ranked barriers and a set of user needs.

Results

A total of 78 barriers were identified, from which six categories emerged: Content, Support, Technological, Personal, Computer Literacy and Accessibility. Additional idea-writing and group reflection in response to these barriers revealed 97 user needs.

Conclusion

This is the first study to use Collective Intelligence methods to investigate barriers to eHealth technology use and the specific user needs of middle-aged and older adults in the context of chronic pain self-management. The results of the current study provide a platform for the design and development of enhanced eHealth interventions for this population.

An Ecological Monitoring and Management App (EMMA) for Older Adults With Chronic Pain: Protocol for a Design and Feasibility Study

Background

Chronic pain is a complex problem for many older adults that affects both physical functioning and psychological well-being. Mobile health (mHealth) technologies have shown promise in supporting older persons in managing chronic conditions. Cognitive behavior therapy is recommended for older people with chronic pain. However, web-based treatment programs for chronic pain are not aimed at the needs of older people and offer standard therapies without providing tailored treatment for this population.

Objective

To address this problem, we aim to develop a psychological web-based intervention for ecological monitoring of daily life experiences with chronic pain called EMMA to support self-management of chronic pain in older adults.

Methods

The key clinical and engagement features of the intervention were established through the integration of evidence-based material from cognitive behavioral therapy for the treatment of chronic pain in older adults. The development process uses a co-design approach and actively involves end-users in the design process by incorporating feedback from focus groups with older adults in order to inform a user-centered intervention design. For the co-design process, we will include 10 older adults with chronic pain, who will discuss the requirements for the app in workshops in order to ensure suitability of the app for older adults with chronic pain. In order to test the feasibility and acceptability of the intervention, we will include a sample of 30 older adults with chronic pain who will test all features of the intervention for a period of 8 consecutive weeks. After the trial period, validated instruments will be used to assess usability and acceptability, as well as influence on pain levels and associated physical and psychological symptoms. Participants will be invited to take part in a semistructured telephone interviews after the trial period to explore their experiences using the app.

Results

Digitalization of the pain diary and psychotherapeutic content has started. Recruitment of participants for the co-design workshops will start as soon as we have a functioning prototype of the electronic pain diary and EMMA intervention, which is expected to be in September 2021. The feasibility study will start as soon as the co-design process is finished and required changes have been implemented into the pain diary and the EMMA intervention. We expect to start the feasibility study early in 2022.

Conclusions

Required changes to assure usability and acceptability will be directly implemented in the app. EMMA brings together a strong body of evidence using cognitive behavioral and self-management theory with contemporary mHealth principles, allowing for a cost-effective intervention that can be used to target chronic pain anywhere and anytime by older adults. Given the ubiquity of mHealth interventions for chronic conditions, the results of this study may serve to inform the development of tailored self-management interventions.

International Registered Report Identifier (IRRID)

PRR1-10.2196/26930

The Prevalence and Potential Role of Pain Beliefs When Managing Later-Life Pain

OBJECTIVES

In this study of 154 community-dwelling older adults with chronic noncancer pain, we sought to assess participants' beliefs about pain as well as pain management treatments and to determine the influence of those beliefs on participants' willingness to undertake 3 physician-recommended pain treatments, that is, a pharmacologic, physical, and psychological therapy.

MATERIALS AND METHODS

A 16-item questionnaire was employed to ascertain participants' pain beliefs, divided into 4 subscales representing: (1) negative beliefs about pharmacological treatments, (2) positive beliefs about physical treatment approaches, for example, exercise, (3) positive beliefs about psychological treatments, and (4) fatalistic beliefs about pain. Participants were asked to rate their willingness to undertake a pharmacologic, physical, or psychological therapy if their physician recommended that they do so. Agreement with each belief was measured, and we examined willingness to undertake each treatment as a function of pain belief subscale scores after controlling for relevant covariates.

RESULTS

Positive beliefs about physical treatments (eg, benefits of exercise) were the most strongly endorsed items on the pain beliefs questionnaire. All 3 treatment-focused pain beliefs subscales were significantly associated with willingness to undertake that form of treatment (eg, negative beliefs about pain medication use were associated with decreased willingness to take pain medication). Fatalistic attitudes were significantly associated with a decreased willingness to undertake physical treatments.

DISCUSSION

These results support the notion that patients' beliefs about pain and pain treatments can have important effects on treatment engagement and, if assessed, can help guide clinical management of chronic pain in older adults.

Pain Self-Management: Easier Said than Done? Factors Associated with Early Dropout from Pain Self-Management in a Rural Primary Care Population

OBJECTIVE

To explore whether psychosocial or demographic factors are associated with early dropout from pain self-management in a rural, low-socioeconomic status population.

DESIGN

Secondary analysis of retrospective data.

SETTING

Multidisciplinary pain clinic located in an outer regional area of Australia.

SUBJECTS

One hundred eighty-six people attending a public community health center with chronic noncancer pain (mean age 54.9 years; 58.1% women; 81.7% in receipt of government benefit as their primary source of income).

METHODS

Bivariate analysis and logistic regression, with early dropout as the dependent variable and a range of demographic and psychological independent variables.

RESULTS

Following bivariate analysis, early dropout was significantly associated (P < 0.05) with male gender, younger age, history of substance use, being a past victim of assault/abuse, receiving unemployment or disability benefit, having literacy difficulties, higher pain catastrophizing score, higher daily opioid dose, and not holding a multifactorial belief about the cause of pain. Logistic regression analysis resulted in three significant predictors of dropout: substance use history (P = 0.002), past victim of assault or abuse (P = 0.029), high pain catastrophising score (P = 0.048); and one of engagement: holding a multifactorial belief about pain cause (P = 0.005).

CONCLUSIONS

In a rural, low-socioeconomic status population, addressing social stressors related to lifetime adversity may be important to increasing engagement in pain self-management. Lack of attention to these factors may increase health inequity among those most disabled by chronic pain. Further research into dropout and engagement, especially among disadvantaged populations, is recommended.

Pain characteristics of older persons with medically unexplained symptoms, older persons with medically explained symptoms and older persons with depression

OBJECTIVES

The main objective of the current study is to compare chronic pain characteristics of older patients with Medically Unexplained Symptoms (MUS), to those of patients with Medically Explained Symptoms (MES), and to those of patients with Major Depressive Disorder (MDD).

METHOD

By combining data from the OPUS and NESDO study, we compared pain characteristics of 102 older (>60 years) MUS-patients to 145 older MES-patients and 275 older MDD-patients in a case-control study design. Group differences were analyzed using ANCOVA, adjusted for demographic and physical characteristics. Linear regression was applied to examine the association between pain characteristics and somatization (BSI-53 somatization scale) and health anxiety (Whitely Index).

RESULTS

Older MUS-patients have approximately  two times more chance of having chronic pain when compared to older MES-patients (OR = 2.01; p = .013) but equal chances as opposed to MDD-patients. After adjustments, MUS-patients report higher pain intensity and disability scores and more pain locations when compared to MES-patients, but equal values as MDD-patients. Health anxiety and somatization levels were positively associated with the number of pain sites in MUS-patients, but not with pain severity or disability.

CONCLUSION

Older MUS-patients did not differ from MDD-patients with respect to any of the chronic pain characteristics, but had more intense and disabling pain, and more pain locations when compared to older MES-patients.

Association Between Psychological Interventions and Chronic Pain Outcomes in Older Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Chronic noncancer pain (hereafter referred to as chronic pain) is common among older adults and managed frequently with pharmacotherapies that produce suboptimal outcomes. Psychological treatments are recommended, but little information is available regarding their efficacy in older adults.

OBJECTIVE

To determine the efficacy of psychological interventions in older adults with chronic pain and whether treatment effects vary by participant, intervention, and study characteristics.

DATA SOURCES

MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched from inception to March 29, 2017.

STUDY SELECTION

Analysis included studies that (1) used a randomized trial design, (2) evaluated a psychological intervention that used cognitive behavioral modalities alone or in combination with another strategy, (3) enrolled individuals with chronic pain (pain ≥3 months) with a sample mean age of 60 years or older, and (4) reported preintervention and postintervention quantitative data.

DATA EXTRACTION AND SYNTHESIS

Two of the authors independently extracted data. A mixed-model meta-analysis tested the effects of treatment on outcomes. Analyses were performed to investigate the association between participant (eg, age), intervention (eg, treatment mode delivery), and study (eg, methodologic quality) characteristics with outcomes.

MAIN OUTCOMES AND MEASURES

Pain intensity was the primary outcome; secondary outcomes included pain interference, depressive symptoms, anxiety, catastrophizing beliefs, self-efficacy for managing pain, physical function, and physical health.

RESULTS

Twenty-two studies with 2608 participants (1799 [69.0%] women) were analyzed. Participants' mean (SD) age was 71.9 (7.1) years. Differences of standardized mean differences (dD) at posttreatment were pain intensity (dD = -0.181, P = .006), pain interference (dD = -0.133, P = .12), depressive symptoms (dD = -0.128, P = .14), anxiety (dD = -0.205, P = .09), catastrophizing beliefs (dD = -0.184, P = .046), self-efficacy (dD = 0.193, P = .02), physical function (dD = 0.006, P = .96), and physical health (dD = 0.160, P = .24). There was evidence of effects persisting beyond the posttreatment assessment only for pain (dD = -0.251, P = .002). In moderator analyses, only mode of therapy (group vs individual) demonstrated a consistent effect in favor of group-based therapy.

CONCLUSIONS AND RELEVANCE

Psychological interventions for the treatment of chronic pain in older adults have small benefits, including reducing pain and catastrophizing beliefs and improving pain self-efficacy for managing pain. These results were strongest when delivered using group-based approaches. Research is needed to develop and test strategies that enhance the efficacy of psychological approaches and sustainability of treatment effects among older adults with chronic pain.

Pain severity predicts depressive symptoms over and above individual illnesses and multimorbidity in older adults

BACKGROUND

Multi-morbidity in older adults is commonly associated with depressed mood. Similarly, subjective reports of pain are also associated with both physical illness and increased depressive symptoms. However, whether pain independently contributes to the experience of depression in older people with multi-morbidity has not been studied.

METHODS

In this study, participants were 1281 consecutive older adults presenting to one of 19 primary care services in Australia (recruitment rate = 75%). Participants were asked to indicate the presence of a number of common chronic illnesses, to rate their current pain severity and to complete the Geriatric Depression Scale.

RESULTS

Results confirmed that the number of medical illnesses reported was strongly associated with depressive symptoms. Twenty-six percent of participants with multi-morbidity scored in the clinical range for depressive symptoms in comparison to 15% of participants with no illnesses or a single illness. In regression analyses, the presence of chronic pain (t = 5.969, p < 0.0005), diabetes (t = 4.309, p < 0.0005), respiratory (t = 3.720, p < 0.0005) or neurological illness (t = 2.701, p = 0.007) were all independent contributors to depressive symptoms. Even when controlling for each individual illness, and the overall number of illnesses (t = 2.207, p = 0.028), pain severity remained an independent predictor of depressed mood (F change = 28.866, p < 0.0005, t = 5.373, p < 0.0005).

CONCLUSIONS

Physicians should consider screening for mood problems amongst those with multi-morbidity, particularly those who experience pain.

Implementing a Pain Self-Management Protocol in Home Care: A Cluster-Randomized Pragmatic Trial

OBJECTIVES

To determine the effectiveness of a cognitive-behavioral pain self-management (CBPSM) protocol delivered by physical therapists (PTs) for use by older adults with activity-limiting pain receiving home care.

DESIGN

A randomized pragmatic trial comparing delivery of the intervention plus usual care with usual care alone.

SETTING

Community.

PARTICIPANTS

Individuals aged 55 and older admitted with orders for physical therapy who endorsed activity-limiting pain and reported pain scores of 3 or greater on a scale from 0 to 10 (N = 588).

INTERVENTION

A CBPSM protocol delivered by PTs.

MEASUREMENTS

Primary outcomes were assessed at 60 days using validated measures of pain-related disability, pain intensity, gait speed, and number of activity of daily living (ADL) deficits.

RESULTS

Of 588 participants, 285 received care from a PT randomized to the intervention and 303 from a PT randomized to the usual care group. Both groups had significant reductions in pain-related disability, pain intensity, and ADL limitations and improved gait speed. No significant treatment differences were identified. There were no consistent treatment differences when interactions and subgroups were examined.

CONCLUSION

This real-world pragmatic trial found no effect of implementation of a pain self-management intervention in a home care setting. Despite the lack of positive findings, future studies are indicated to determine how similar protocols that have been found to be effective in efficacy studies can be successfully implemented in routine clinical care.

The determinants of coping with pain in chronically ill geriatric patients - the role of a sense of coherence

BACKGROUND

Given the rising population of the elderly in modern societies, the concern for their good functioning poses a challenge for the 21st century medicine and social services. Senior citizens are at an increased risk of developing chronic conditions, which in turn increase discomfort associated with physiological processes of aging. Sensations of pain have a particular influence on the mentioned discomfort, and pain is prevalent among older people. Therefore, from the perspective of an elderly person and senior care, it is crucial to identify determinants of effective coping with chronic pain.

OBJECTIVES

The aim of the research was to assess the relationship between a sense of coherence (SOC) and pain-coping strategies in chronically ill seniors. A total number of 188 individuals were included in the study, of whom 117 were female subjects and 71 were male subjects, with a mean age of 68.38 (standard deviation [SD] =6.35) years in the studied group. Subjects were sampled based on a diagnosis of a chronic medical illness with chronic pain as one of the major symptoms.

METHODS

The Polish adaptation of the Orientation to Life Questionnaire (SOC-29) to assess an SOC, the Coping Strategies Questionnaire (CSQ) to assess pain-coping strategies, and the visual analog scale (VAS) to assess pain intensity were used in the study.

RESULTS AND CONCLUSION

The mean score of respondents' SOC was 133.44 (SD =24.35). Among most common pain-coping strategies used by the respondents were prayer and hope, and the declaration of coping with pain while redefining pain was the least often used coping strategy in the studied group. Individuals with stronger SOC were less prone to catastrophizing and more often declared that they were coping with and could control and reduce pain.

Psychological Approaches to Coping with Pain in Later Life

A psychological model of coping with the demands of aging is outlined. Chronic pain is conceptualized as a challenge to normal aging, because it threatens identity, risks affective disorder (depression), and interferes with action. The sparse evidence for psychological interventions is reviewed, and a case is made for the types of interventions that should be developed to address the specific presentation of geriatric pain management.

The effect of pain on presence and severity of depressive disorders in older persons: The role of perceived control as mediator

BACKGROUND

The relation between pain and depression is reported repeatedly. It is suggested that pain by itself is not sufficient for the development of depression. We aim to study the role of perceived control as mediating factor in the relation between pain and depressive disorders at old age.

METHODS

Baseline data of the Netherlands Study of Depression in Older Persons (NESDO) were used, including 345 persons with DSM-IV depressive disorders (CIDI) and 125 control persons without depressive disorders, aged 60 years and over. Measures included severity of depression (Inventory of Depressive Symptomatology), presence and intensity of pain and pain-related disability (Chronic Graded Pain scale), and a general measure of perceived control over life (Pearlin Mastery Scale). In mediation analyses direct and indirect effects were estimated.

RESULTS

Older persons with depressive disorders reported pain more frequently with higher intensity than controls. After controlling for confounding, the direct effect of pain intensity and the indirect effect through perceived control on depression were OR=1.10 (CI 95% .98;1.25) and OR=1.24 (1.15;1.35). For pain-related disability these were OR=1.14 (1.02;1.29) and OR=1.21 (1.13;1.29). In depressed persons there was a strong direct effect of pain intensity and disability and a smaller indirect effect through perceived control on severity of depressive symptoms.

LIMITATIONS

This cross-sectional study cannot give evidence on causal direction.

CONCLUSIONS

Perceived control plays an important role as mediator in the association between pain and presence of depression. In depressed persons however, the direct role of pain seems more important in the association with depression severity.

Chronic Pain in Irish Prison Officers: Profile and Predictors of Pain-Related Disability and Depression

OBJECTIVE

International research has consistently found increased risk for physical health and psychological difficulties among prison officers including elevated risk of assault resulting in acute pain. This study represented an exploratory examination of the experience of chronic pain conditions among Irish prison officers with particular reference to the psychosocial predictors of pain severity, pain interference, and depression.

DESIGN

A questionnaire battery was completed by 152 Irish prison officers. The questionnaires measured pain severity and interference, anxiety, depression, social support, coping strategies, and resilience.

RESULTS

Results showed that 48% of participants reported chronic pain based on the International Association for the Study of Pain definition. Psychological distress was high among respondents reporting chronic pain, with 38% of participants meeting the criteria for "probable depression" while 51% met the criteria for "probable anxiety disorder." In regression analyses, depression emerged as a significant predictor of both pain severity and pain interference while anxiety and pain interference emerged as significant predictors of depression.

CONCLUSION

Chronic pain appears to be prevalent in prison officers and is associated with both physical and psychological impairment. Health care staff in correctional facilities should be aware that these health difficulties are prevalent in the prison work environment.

Chronic Pain in Older Adults

This review summarizes existing evidence relevant to the epidemiology of chronic pain in older adults, age-related differences relevant to pain, pain assessment, and important considerations regarding pain management in later life. Features unique to pain assessment in older adults include the likelihood of multiple diagnoses contributing to chronic pain, the ability of older adults to self-report, including those with mild to moderate cognitive impairment, and recognition that some older adults with cognitive impairment may demonstrate various behaviors to communicate pain. Management is best accomplished through a multimodal approach, including pharmacologic and nonpharmacologic treatments, physical rehabilitation, and psychological therapies. Interventional pain therapies may be appropriate in select older adults, which may reduce the need for pharmacologic treatments.