The Impact of Alzheimer's Disease on the Resting State Functional Connectivity of Brain Regions Modulating Pain: A Cross Sectional Study

Pain and Cognition of Breast Cancer Survivors Treated with Chemotherapy: The Mediating Role of Depression

OBJECTIVES

While chemotherapy is the primary contributor to cancer-related cognitive impairment (CRCI), interindividual differences in CRCI are not well-understood. Studies suggest that breast cancer (BC) survivors who are in pain are more likely to experience depression, which in turn contributes to CRCI, although this hypothesis is not yet tested. Therefore, this study aimed to investigate the relationship between pain and CRCI among BC survivors and the mediation effect of depression on this relationship.

METHODS

As a secondary analysis of a descriptive cross-sectional study investigating fatigue and preferred types of fatigue self-management in BC survivors recruited from five tertiary hospitals in South Korea; of the 229 participants, data on 186 who received chemotherapy were analyzed. Study participants were aged between 20 and 69 years, diagnosed with stage I to III, and treated with chemotherapy and/or radiation therapy. Measurement was done with Korean versions of the Cognitive Failure Questionnaire (to assess CRCI), Brief Pain Inventory (for pain severity and interference on daily functioning), and C-ESD (for depression). To assess bivariate relationships between pain, depression, and CRCI, Pearson correlation was used. A mediation analysis was used to examine the effect of depression on CRCI.

RESULTS

Significant associations were found among pain, depression, and CRCI (all P < 0.01). Furthermore, a mediation effect of depression was found on the association between pain and CRCI (severity, β = 1.26, SE = 0.38, 95% confidence intervals [0.60, 2.08]; interference, β = 1.53, SE = 0.32, 95% confidence intervals [0.95, 2.20]).

CONCLUSION

Findings indicate that among BC survivors, those with higher pain tend to show higher depression and consequently had lower cognitive function.

IMPLICATION FOR NURSING PRACTICE

Oncology nurses may need to identify BC survivors with higher pain, and screening those survivors could be a strategy to identify those at higher risk for CRCI. Also, nurses should focus on managing depression to prevent and/or treat CRCI in BC survivors.

Association between chronic pain and dementia: a systematic review and meta-analysis

PURPOSE

Dementia and chronic pain (CP) are prevalent among older adults. However, no study has systematically reviewed the association between dementia and CP. Therefore, we performed this study to gather evidence about the potential relationship between the two.

METHODS

Two authors independently searched PubMed, Embase, and Web of Science to identify all records published up to 1 September 2022 that explored the association between CP and dementia. The methodological quality of the studies was assessed using the Newcastle Ottawa Scale (NOS). A fixed or random-effects model was used to pool the risk estimates.

RESULTS

Among the initial 3296 articles retrieved, 19 were included in the review (1 cross-sectional, and 18 cohort). The pooled result showed the risk of dementia was 1.42 times higher in CP patients (HR = 1.42, 95% CI 1.23-1.64, P < 0.001). dementia and CP subtypes, gender, and age did not significantly affect the results.

CONCLUSION

Our study shows that people who suffered from CP are at an increased risk of developing dementia, regardless of gender, age, and dementia and CP subtypes.

Gender Differences in Pain Threshold, Unpleasantness, and Descending Pain Modulatory Activation Across the Adult Life Span: A Cross Sectional Study

The neurobiological underpinnings of gender differences in pain perception, and how these differences may be modified by age, are incompletely understood, placing patients at risk of suboptimal pain management. Using functional magnetic resonance imaging, we examined brain responses in the descending pain modulatory system (DPMS, specifically, dorsolateral prefrontal cortex, anterior cingulate cortex, insula, hypothalamus, amygdala, and periaqueductal gray, during an evoked pain task. We investigated the interaction of age and gender in our sample of healthy adults (27 females, 32 males, 30-86 years) on DPMS response. In a perceptually matched thermal pain paradigm, we investigated pain unpleasantness and neural responses for 3 heat pain percepts: just noticeable pain, weak pain, and moderate pain (MP). Females reported just noticeable pain at a lower temperature, but reported less unpleasantness at weak pain and MP percepts, compared to males. There was a significant age-by-gender interaction during moderate pain in the right anterior cingulate cortex and bilateral insula, such that, males had a stronger positive relationship between DPMS response and age compared to females in these regions. Our results indicate that differences in DPMS responses may explain some gender differences in pain perception and that this effect may change across the adult lifespan. PERSPECTIVE: Gender differences in pain have been well-documented but the brain mechanisms for these differences are still unclear. This article describes potential differences in brain functioning during different levels of pain that could explain differences in pain responses between men and women across the adult lifespan.

Psychophysics of Pain: A Methodological Introduction

For over 100 years, psychophysics ..÷ the scientific study between physical stimuli and sensation ... has been successfully employed in numerous scientific and healthcare disciplines, as an objective measure of sensory phenomena. This manuscript provides an overview of fundamental psychophysical concepts, emphasizing pain and research application..÷defining common terms, methods, and procedures.Psychophysics can provide systematic and objective measures of sensory perception that can be used by nursing scientists to explore complex, subjective phenomena..÷such as pain perception. While there needs to be improved standardization of terms and techniques, psychophysical approaches are diverse and may be tailored to address or augment current research paradigms. The interdisciplinary nature of psychophysics..÷like nursing..÷provides a unique lens for understanding how our perceptions are influenced by measurable sensations. While the quest to understand human perception is far from complete, nursing science has an opportunity to contribute to pain research by using the techniques and methods available through psychophysical procedures.

Chronic pain in Alzheimer's disease: Endocannabinoid system

Chronic pain, one of the most common reasons adults seek medical care, has been linked to restrictions in mobility and daily activities, dependence on opioids, anxiety, depression, sleep deprivation, and reduced quality of life. Alzheimer's disease (AD), a devastating neurodegenerative disorder (characterized by a progressive impairment of cognitive functions) in the elderly, is often co-morbid with chronic pain. AD is one of the most common neurodegenerative disorders in the aged population. The reported prevalence of chronic pain is 45.8% of the 50 million people with AD. As the population ages, the number of older people who experience AD and chronic pain will also increase. The current treatment options for chronic pain are limited, often ineffective, and have associated side effects. This review summarizes the role of the endocannabinoid system in pain, its potential role in chronic pain in AD, and addresses gaps and future directions.

Feasibility, Acceptability, and Efficacy of Home-Based Transcranial Direct Current Stimulation on Pain in Older Adults with Alzheimer's Disease and Related Dementias: A Randomized Sham-Controlled Pilot Clinical Trial

Although transcranial direct current stimulation (tDCS) is emerging as a convenient pain relief modality for several chronic pain conditions, its feasibility, acceptability, and preliminary efficacy on pain in patients with Alzheimer's disease and related dementias (ADRD) have not been investigated. The purpose of this pilot study was to assess the feasibility, acceptability, and preliminary efficacy of 5, 20-min home-based tDCS sessions on chronic pain in older adults with ADRD. We randomly assigned 40 participants to active (n = 20) or sham (n = 20) tDCS. Clinical pain intensity was assessed using a numeric rating scale (NRS) with patients and a proxy measure (MOBID-2) with caregivers. We observed significant reductions of pain intensity for patients in the active tDCS group as reflected by both pain measures (NRS: Cohen's d = 0.69, p-value = 0.02); MOBID-2: Cohen's d = 1.12, p-value = 0.001). Moreover, we found home-based tDCS was feasible and acceptable intervention approach for pain in ADRD. These findings suggest the need for large-scale randomized controlled studies with larger samples and extended versions of tDCS to relieve chronic pain on the long-term for individuals with ADRD.

Increased pain unpleasantness and pain-related fMRI activation in the periaqueductal gray in Alzheimer's disease

Background

Pain continues to be underrecognized and undertreated in people with Alzheimer's disease (AD). The periaqueductal gray (PAG) is essential to pain processing and modulation yet is damaged by AD. While evidence exists of altered neural processing of pain in AD, there has not been a focused investigation of the PAG during pain in people with AD.

Purpose

To investigate the role of the PAG in sensory and affective pain processing for people living with AD.

Methods

Participants from a larger study completed pain psychophysics assessments and then a perceptually-matched heat pain task (warmth, mild, and moderate pain) during a functional MRI scan. In this cross-sectional study, we examined blood oxygenation level-dependent (BOLD) responses in the PAG and other pain-related regions in participants with AD (n = 18) and cognitively intact older adults (age- and sex-matched, n = 18). Associations of BOLD percent signal change and psychophysics were also examined.

Results

There were significant main effects of AD status on the temperature needed to reach each perception of warmth or pain, where people with AD reached higher temperatures. Furthermore, participants with AD rated mild and moderate pain as more unpleasant than controls. PAG BOLD activation was greater in AD relative to controls during warmth and mild pain percepts. No significant differences were found for moderate pain or in other regions of interest. Greater PAG activation during mild pain was associated with higher affective/unpleasantness ratings of mild pain in participants with AD but not in controls.

Conclusion

Results suggest a role for the PAG in altered pain responses in people with AD. The PAG is the primary source of endogenous opioid pain inhibition in the neuroaxis, thus, altered PAG function in AD suggests possible changes in descending pain inhibitory circuits. People with AD may have a greater risk of suffering from pain compared to cognitively intact older adults.

Promoting successful participation of people living with Alzheimer's disease and related dementias in pain-related neuroimaging research studies

Recruitment and retention of participants for pain-related neuroimaging research is challenging and becomes increasingly so when research participants have a diagnosis of Alzheimer's disease and related dementias (ADRD). This article shares the authors' recommendations from several years of successful recruitment and completion of pain-related neuroimaging studies of people living with ADRD and includes supportive literature. While not an exhaustive list, this review covers several topics related to recruitment and retention of participants living with ADRD, including community engagement, capacity to consent, dementia diagnostic criteria, pain medication and other study exclusion criteria, participant and caregiver burden, communication concerns, and relationships with neuroimaging facilities. Threaded throughout the paper are important cultural considerations. Additionally, we discuss implications of the coronavirus (COVID-19) pandemic for recruitment. Once tailored to specific research study protocols, these proven strategies may assist researchers with successfully recruiting and retaining participants living with ADRD for pain-related neuroimaging research studies toward improving overall health outcomes.

A Cross-Sectional Study of Pain Sensitivity and Unpleasantness in People with Vascular Dementia

OBJECTIVE

Advanced age holds higher risk of both pain and dementia, with many studies finding dementia often heightens sensitivity to pain. VaD is the second most common type of dementia. Only a few observational or retrospective studies have examined pain responsiveness in VaD, suggesting it may increase pain unpleasantness (i.e., pain affect). This study compared thermal pain psychophysics between a cohort of vascular dementia (VaD) patients and healthy control (HC) subjects.

DESIGN

Single center, cross-sectional, between-subjects design.

SUBJECTS

Verbally communicative, probable VaD patients (N = 23) and age- and sex-matched HC (N = 23).

METHODS

A thermal psychophysics protocol assessed "mild pain" and "moderate pain" thresholds (oC temperature) and associated unpleasantness ratings (0-20 scale) in both VaD and HC groups. Psychophysics were compared between groups by way of a mixed-effects analysis, controlling for depressive symptoms.

RESULTS

There were no significant differences between groups for pain thresholds (main effect p = 0.086, Cohen's d: mild = 0.55, moderate = 0.27). However, unpleasantness ratings were higher in the VaD group compared to HC (main effect p = 0.003; mild pain p = 0.022, Cohen's d = 0.79; moderate pain p = 0.057, Cohen's d = 0.6).

CONCLUSIONS

These results are consistent with prior observational findings suggesting VaD may make patients more susceptible to pain, particularly its affective component.

Pain and Associated Neuropsychiatric Symptoms in Patients Suffering from Dementia: Challenges at Different Levels and Proposal of a Conceptual Framework

Old age is critically associated with multi-morbidity, chronic pain, and high risk for dementia. Recognizing and treating pain is very much dependent on language comprehension and production. Both may be impaired in dementia. Moreover, neuropsychiatric symptoms may interact with pain perception. The main aims of the present article were 1) to identify key areas for future research to elucidate the relation between pain and associated neuropsychiatric symptoms in dementia, and 2) to provide a conceptual framework for ameliorating the clinical process of recognizing, assessing, and managing pain in non-communicating patients with advanced dementia.

Pain processing in older adults with dementia-related cognitive impairment is associated with frontal neurodegeneration

Experimental pain research has shown that pain processing seems to be heightened in dementia. It is unclear which neuropathological changes underlie these alterations. This study examined whether differences in pressure pain sensitivity and endogenous pain inhibition (conditioned pain modulation (CPM)) between individuals with a dementia-related cognitive impairment (N=23) and healthy controls (N=35) are linked to dementia-related neurodegeneration. Pain was assessed via self-report ratings and by analyzing the facial expression of pain using the Facial Action Coding System. We found that cognitively impaired individuals show decreased CPM inhibition as assessed by facial responses compared to healthy controls, which was mediated by decreased gray matter volume in the medial orbitofrontal and anterior cingulate cortex in the patient group. This study confirms previous findings of intensified pain processing in dementia when pain is assessed using non-verbal responses. Our findings suggest that a loss of pain inhibitory functioning caused by structural changes in prefrontal areas might be one of the underlying mechanisms responsible for amplified pain responses in individuals with a dementia-related cognitive impairment.

Chronic pain and cognitive impairment: a cross-sectional study in people living with HIV

Cognitive impairment and chronic pain are amongst the most prevalent neurological sequelae of HIV infection, yet little is understood about the potential bidirectional relationship between the two conditions. Cognitive dysfunction can occur in chronic pain populations whilst those with cognitive impairment can display modified responses to experimentally induced painful stimuli. To date, this has not been explored in HIV cohorts.This study aimed to identify any contribution of chronic pain to cognitive impairment in HIV and to determine differences in pain characteristics between those with and without cognitive dysfunction.This was an observational cohort study involving people living with HIV (n = 148) in the United Kingdom. Participants underwent validated questionnaire-based measurement of pain severity, interference and symptom quality as well as conditioned pain modulation and quantitative sensory testing. All participants completed a computer-based cognitive function assessment.Fifty-seven participants met the criteria for cognitive impairment and 73 for chronic pain. The cognitive impairment group had a higher prevalence of chronic pain (p = 0.004) and reported more neuropathic symptoms (p = 0.001). Those with chronic pain performed less well in emotional recognition and verbal learning domains. The interaction identified between chronic pain and cognitive dysfunction warrants further exploration to identify causal links or shared pathology.

Experimentally evoked pain in Alzheimer's disease

BACKGROUND

Pain continues to be underrecognized and undertreated in Alzheimer's disease (AD) while existing guidance about pain assessment and management in dementia is not widespread. Brain regions involved in pain processing and modulation are damaged during AD, and the pain experience in AD is not well understood. Experimental pain studies using psychophysics can further our understanding of the pain experience in AD, which may lead to improved assessment and management of pain in people living with AD.

OBJECTIVE

A systematic review was conducted to explicate the current understanding of experimentally evoked pain in AD from primary research using psychophysical methods.

DATA SOURCES

Peer-reviewed publications were found via PubMed, CINAHL, and PsycINFO. A total of 18 primary research, peer-reviewed full articles that met inclusion criteria were included, representing 929 total participants.

CONCLUSIONS

Experimentally evoked pain in people with AD demonstrates that despite cognitive impairment and a reduced ability to effectively communicate, individuals with AD experience pain similar to or more unpleasant than cognitively intact older adults. This may mean amplified pain unpleasantness in people with AD.

IMPLICATIONS FOR PRACTICE

Our current best practices need to be widely disseminated and put into clinical practice. Self-report of pain continues to be the gold standard, but it is ineffective for noncommunicative patients and those unable to understand pain scales or instructions because of memory/cognitive impairment. Instead, pain treatment should be ethically initiated based on patient reports and behaviors, caregiver/surrogate reports, review of the medical record for painful conditions, analgesic trials, and regular reassessments.

Determining the impact of age and sex on the psychophysical and neurophysiological response to thermal pain across the adult lifespan

AIMS

Determine sex- and age-associated psychophysical and neurophysiological differences in the processing of pain across the adult lifespan.

DESIGN

Preliminary, exploratory, cross-sectional study.

METHODS

Using psychophysics (to measure intensity and unpleasantness) and functional magnetic resonance imaging blood oxygenation level dependent methods (to measure stimulus-evoked brain activation), we will examine sex- and age-associated differences in thermal pain processing and their underlying neurophysiology in a broad range of healthy adults (ages 30-89). We will acquire resting state functional connectivity data for secondary analyses exploring whether resting state connectivity predicts psychophysical and neurophysiological responses to thermal pain. To examine the effects of altered blood flow, we will acquire resting-state arterial spin labeling magnetic resonance imaging data to quantify resting cerebral blood flow. We will interpret findings in the context of a proposed neural model of pain, ageing, and sex. Study funding was received in June of 2014. Ethical approval was obtained from the Vanderbilt University IRB prior to study initiation.

CONCLUSION

Exploring the biological reasons for age- and sex-associated differences in pain processing will increase our understanding of pain in older adults. The paucity of neurobiological evidence to support best practice pain management in older adults places these individuals at risk for poor pain management.

IMPACT

Poorly treated pain in older adults is a critical public health problem associated with a poor quality of life and increased healthcare costs. Understanding how age and sex have an impact on central processing of pain across the lifespan is a critical step toward improving personalized pain medicine.

Policy Implications for Pain in Advanced Alzheimer's Disease

Untreated pain in people with Alzheimer's disease continues to be a serious public health problem. Pain is a subjective and complex experience that becomes increasingly challenging to assess as cognition declines. Our understanding of pain processing is incomplete, particularly for special populations such as people living with Alzheimer's disease, and especially in the advanced stages of the disease. Pain-processing networks in the brain are altered in Alzheimer's disease, yet evidence suggests people living with Alzheimer's disease do not experience less pain. Rather, their pain is not adequately recognized or treated. Although scholarly publications provide important assistance, recent widespread reports and guidelines do not include sufficient guidance, especially as Alzheimer's disease progresses to the last stages. Additionally, current pain measurements may not accurately evaluate pain in this condition, and the existing definitions of pain are not adequate when considering the effects of Alzheimer's disease on pain-processing in the brain. There is a need for new, widespread policies, guidelines, and definitions to help clinicians adequately manage pain in people with Alzheimer's disease. These will need to hinge on continued research because it remains unclear how Alzheimer's disease impacts central pain processing, pain expression, and communication of pain. In the meantime, policies and guidelines need to highlight current best practices as well as the fact that pain continues in Alzheimer's disease.

Could Altered Evoked Pain Responsiveness Be a Phenotypic Biomarker for Alzheimer's Disease Risk? A Cross-Sectional Analysis of Cognitively Healthy Individuals

BACKGROUND

This study evaluated whether the apolipoprotein ɛ4 (APOE4) allele, a genetic marker associated with increased risk of developing late-onset Alzheimer's disease (AD), was associated with differences in evoked pain responsiveness in cognitively healthy subjects.

OBJECTIVE

The aim was to determine whether individuals at increased risk of late-onset AD based on APOE allele genotype differ phenotypically in their response to experimentally-induced painful stimuli compared to those who do not have at least one copy of the ɛ4 allele.

METHODS

Forty-nine cognitively healthy subjects aged 30-89 years old with the APOE4 allele (n = 12) and without (n = 37) were assessed for group differences in pain thresholds and affective (unpleasantness) responses to experimentally-induced thermal pain stimuli.

RESULTS

Statistically significant main effects of APOE4 status were observed for both the temperature at which three different pain intensity percepts were reached (p = 0.040) and the level of unpleasantness associated with each (p = 0.014). APOE4 positive participants displayed lower overall pain sensitivity than those who were APOE4 negative and also greater overall levels of pain unpleasantness regardless of intensity level.

CONCLUSION

Cognitively healthy APOE4 carriers at increased risk of late-onset AD demonstrated reduced thermal pain sensitivity but greater unpleasantness to thermal pain stimuli relative to individuals at lower risk of late-onset AD. These results suggest that altered evoked pain perception could potentially be used as a phenotypic biomarker of late-onset AD risk prior to disease onset. Additional studies of this issue may be warranted.

Thermal Psychophysics and Associated Brain Activation Patterns Along a Continuum of Healthy Aging

OBJECTIVE

To examine psychophysical and brain activation patterns to innocuous and painful thermal stimulation along a continuum of healthy older adults.

DESIGN

Single center, cross-sectional, within-subjects design.

METHODS

Thermal perceptual psychophysics (warmth, mild, and moderate pain) were tested in 37 healthy older adults (65-97 years, median = 73 years). Percept thresholds (oC) and unpleasantness ratings (0-20 scale) were obtained and then applied during functional magnetic resonance imaging scanning. General linear modeling assessed effects of age on psychophysical results. Multiple linear regressions were used to test the main and interaction effects of brain activation against age and psychophysical reports. Specifically, differential age effects were examined by comparing percent-signal change slopes between those above/below age 73 (a median split).

RESULTS

Advancing age was associated with greater thresholds for thermal perception (z = 2.09, P = 0.037), which was driven by age and warmth detection correlation (r = 0.33, P = 0.048). Greater warmth detection thresholds were associated with reduced hippocampal activation in "older" vs "younger" individuals (>/<73 years; beta < 0.40, P < 0.01). Advancing age, in general, was correlated with greater activation of the middle cingulate gyrus (beta > 0.44, P < 0.01) during mild pain. Differential age effects were found for prefrontal activation during moderate pain. In "older" individuals, higher moderate pain thresholds and greater degrees of moderate pain unpleasantness correlated with lesser prefrontal activation (anterolateral prefrontal cortex and middle-frontal operculum; beta < -0.39, P < 0.009); the opposite pattern was found in "younger" individuals.

CONCLUSIONS

Advancing age may lead to altered thermal sensation and (in some circumstances) altered pain perception secondary to age-related changes in attention/novelty detection and cognitive functions.

Narrative Review of Sensory Changes as a Biomarker for Alzheimer's Disease

Early recognition of Alzheimer's disease (AD) in the prodromal period has not been robust yet will be necessary if effective disease-modifying drugs are to be useful in preventing or delaying the condition. The objective of this narrative review was to describe the current, evidenced based understanding of alterations in sensory data as potential biomarkers for AD. Review of empirical studies that tested senses as biomarkers for AD and were published in English within the past 50 years was completed. Eighteen empirical studies were identified that met the strict criteria for inclusion, with 12 of these studies being related to the olfactory system. Two studies examined auditory, two examined vision, one examined proprioception, and one examined taste. Thus, only olfaction has been studied to any extent, leaving a clear gap in the literature for the use of other senses. A promising area of research has begun to be reported concerning differences in responses to pain stimuli in AD relative to cognitively normal subjects. Pain is not a single sense like the others but integrates several senses and may allow for use as an early biomarker for AD, as it integrates several brain areas and pathways. Unlike the other senses, simple devices can be used to measure changes in pain perception in cognitively normal adults with genetic predispositions for possible AD, making this potentially useful for clinicians in the future.

Pain Management in Home Health Care: Relationship With Dementia and Facility Admissions

BACKGROUND

Pain is common yet under-studied among older Medicare home health (HH) patients with Alzheimer's disease and related dementias (ADRD).

AIMS

Examine (1) the association between ADRD and severe pain in Medicare HH patients; and (2) the impact of severe pain and ADRD on unplanned facility admissions in this population.

DESIGN

Analysis of the Outcome and Assessment Information Set (OASIS) and Medicare claims data.

SETTINGS/PARTICIPANTS

6,153 patients ≥65 years receiving care from a nonprofit HH agency in 2017.

METHODS

Study outcomes included presence of severe pain and time-to-event measures of unplanned facility admissions (hospital, nursing home, or rehabilitation facilities). ADRD was identified using ICD-10 diagnosis codes and cognitive impairment symptoms. Logistic regression and Cox proportional hazard models were used to examine, respectively, the association between ADRD and severe pain, and the independent and interaction effects of severe pain and ADRD on unplanned facility admission.

RESULTS

Patients with ADRD (n = 1,525, 24.8%) were less likely to have recorded severe pain than others (16.4% vs. 23.6%, p < .001). Adjusting for demographics, comorbidities, mental and physical functional status, and use of HH services, having severe pain was related to a 35% increase (hazard ratio [HR] = 1.35, p = .002) in the risk of unplanned facility admission, but the increase in such risk was the same whether or not the patient had ADRD.

CONCLUSIONS

HH patients with ADRD may have under-recognized pain. Severe pain is a significant independent predictor of unplanned facility admissions among HH patients.

Age-Related Changes in Pain Perception Are Associated With Altered Functional Connectivity During Resting State

Aging affects pain experience and brain functioning. However, how aging leads to changes in pain perception and brain functional connectivity has not yet been completely understood. To investigate resting-state and pain perception changes in old and young participants, this study employed region of interest (ROI) to ROI resting-state functional connectivity (rsFC) analysis of imaging data by using regions implicated in sensory and affective dimensions of pain, descending pain modulation, and the default-mode networks (DMNs). Thirty-seven older (66.86 ± 4.04 years; 16 males) and 38 younger healthy participants (20.74 ± 4.15 years; 19 males) underwent 10 min’ eyes-closed resting-state scanning. We examined the relationship between rsFC parameters with pressure pain thresholds. Older participants showed higher pain thresholds than younger. Regarding rsFC, older adults displayed increased connectivity of pain-related sensory brain regions in comparison to younger participants: increased rsFC between bilateral primary somatosensory area (SI) and anterior cingulate cortex (ACC), and between SI(L) and secondary somatosensory area (SII)-(R) and dorsolateral prefrontal cortex (PFC). Moreover, decreased connectivity in the older compared to the younger group was found among descending pain modulatory regions: between the amygdala(R) and bilateral insula(R), thalamus(R), ACC, and amygdala(L); between the amygdala(L) and insula(R) and bilateral thalamus; between ACC and bilateral insula, and between periaqueductal gray (PAG) and bilateral thalamus. Regarding the DMN, the posterior parietal cortex and lateral parietal (LP; R) were more strongly connected in the older group than in the younger group. Correlational analyses also showed that SI(L)-SII(R) rsFC was positively associated with pressure pain thresholds in older participants. In conclusion, these findings suggest a compensatory mechanism for the sensory changes that typically accompanies aging. Furthermore, older participants showed reduced functional connectivity between key nodes of the descending pain inhibitory pathway.

Neuroimaging Methods for Nursing Science

BACKGROUND

Since the inception of magnetic resonance imaging, thousands of studies have appeared in the literature reporting on multiple imaging techniques. However, there is a paucity of neuroimaging research programs developed by nurse scientists.

OBJECTIVES

The purpose of this article is to introduce the nurse scientist to complex neuroimaging methods with the ultimate goal of creating impetus for future use of brain imaging in nursing research.

METHODS

This article reviews common neuroimaging methods, presents vocabulary frequently used in neuroimaging work, provides information on access to resources in neuroimaging education, and discusses considerations for use of neuroimaging in research.

RESULTS

Ten imaging modalities are reviewed, including structural and functional magnetic resonance imaging, computed tomography, positron emission tomography, and encephalography.

DISCUSSION

Choosing an imaging modality for research depends on the nature of the research question, needs of the patient population of interest, and resources available to the novice and seasoned nurse scientist. Neuroimaging has the potential to innovate the study of symptom science and encourage interdisciplinary collaboration in research.

Do Warmed Blankets Change Pain, Agitation, Mood or Analgesic Use Among Nursing Home Residents?

BACKGROUND

Pain, agitation, and thermal discomfort are common symptoms of older adults residing in nursing homes. Nonpharmacologic interventions are recognized as a best practice strategy for people living in nursing homes because of their low adverse effect profile and increased evidence of effectiveness. Warmed blankets have not been empirically tested for use in long-term care.

AIMS

The purpose of this quality improvement project was to describe the use of warmed blankets in a nursing home setting and determine if use was associated with changes in pain, agitation, mood, or analgesic use.

DESIGN

A pretest posttest design was used along with a comparison of intact groups.

SETTINGS

The setting was one 160-bed skilled long-term care facility.

PARTICIPANTS/SUBJECTS

There were 141 residents eligible since they did not have a condition that could be worsened by superficial heat.

METHODS

Warmed blankets were unfolded and placed over residents with pain, agitation, or thermal discomfort. Short-term pain measures included use of the Revised FACES Pain Scale, the PAINAD (Pain Assessment in Advanced Dementia) scale, and the Brief Agitation Rating Scale. Long-term measures were taken from the electronic medical record.

RESULTS

Of the 141 eligible residents, 24.1% (n = 34) received a warmed blanket over the 1- month study period. There were statistically significant decreases in both pain level and agitation among baseline, 20 minutes after application, and the subsequent shift assessments (p < .001). There were also long-term changes in the number of pain complaints (p = .040), severity of pain complaints (p = .009), and as-needed analgesic use (p = .011). There were no statistically significant differences between the treated group and comparison group on any long-term measures.

CONCLUSIONS

Warmed blankets are a low-cost intervention with a high potential for bringing comfort to nursing home residents.

The silent epidemic of chronic pain in older adults

Chronic pain is highly prevalent among older adults where it is associated with significant suffering, disability, social isolation, and greater costs and burden to health care systems. Pharmaceutical treatment of chronic pain in older adults is usually only partially effective and is often limited by side effects including urinary retention, constipation, sedation, cognitive impairment, and increased risk of falls. Since older adults are underrepresented in clinical trials testing treatments for chronic pain, the potential impacts of polypharmacy and frailty on reported outcomes and side effect profiles are largely unknown. Thus, for current treatments, providers and patients must balance anticipated benefits of pain reduction with the known and unknown risks of treatment. Chronic pain is also a risk factor for premature death as well as accelerated cognitive decline, suggesting potential shared mechanisms between persistent pain (or its treatment) and dementia. Cognitive decline and dementia may also impact pain perception and the ability to report pain, complicating treatment decisions. Associations between persistent pain and the risks of premature death and accelerated cognitive decline make estimates for chronic pain in these populations particularly challenging. Future research is needed to improve estimates for chronic pain in older adults, to elucidate underlying mechanisms of pain with aging, and to develop and advance safer, more effective treatment options for chronic pain in older adults.

Structural Brain Changes in Delirium: An Integrative Review

Delirium is a serious complication of acute illness. Little is known, however, regarding the neurobiology of delirium, largely due to challenges in studying the complex inpatient population. Neuroimaging is one noninvasive method that can be used to study structural and functional brain abnormalities associated with delirium. The purpose of this integrative literature review was to examine the content and quality of current structural neuroimaging evidence in delirium. After meeting inclusion criteria, 11 articles were included in the review. Commonly noted structural abnormalities were impaired white matter integrity, brain atrophy, ischemic lesions, edema, and inflammation. Findings demonstrated widespread alterations in several brain structures. Limitations of the studies in this review included small sample sizes, inappropriate or questionable delirium measurements, and failure to consider confounding variables. This review provides insight into possible structural changes responsible for the signs and symptoms seen in patients with delirium, but more high-quality studies are needed.

Sex Differences in Associations of Cognitive Function with Perceptions of Pain in Older Adults

BACKGROUND

Sex differences in pain have been shown to exist in older adults with normal cognition and people with Alzheimer's disease. It is unknown if sex differences in pain in older adults exist in a range of communicative older adults with varying cognitive ability from no impairment to moderately severe cognitive impairment.

OBJECTIVE

This study proposes to compare the association between psychophysical responses to experimental thermal pain between males and females to determine if sex differences in pain exist across the cognitive spectrum.

METHODS

We conducted a secondary analysis of data from an age- and sex-matched between-groups cross-sectional study examining the psychophysical response to contact heat in people with and without dementia.

RESULTS

Median age of males (n = 38) and females (n = 38) was 73 (range: 68-87) with similar distributions of Mini-Mental State Examination (MMSE) scores (range: 11-30). Findings revealed inverse statistically significant associations with the threshold temperature of warmth (females: r = -0.41, p = 0.010; males: r = -0.33, p = 0.044). There was an apparent divergent pattern of MMSE associations with unpleasantness ratings between the groups. At the moderate pain threshold, that difference became statistically significant (p = 0.033). Females demonstrated a positive association of MMSE with unpleasantness (r = 0.30, p = 0.072), while males demonstrated an inverse association at that respective threshold (r = -0.20, p = 0.221).

CONCLUSIONS

Between-group findings suggest that patterns of responses to thermal stimulus intensity may differ between males and females with worsening cognition with females reporting significantly less unpleasantness with the percept of moderate pain and males reporting significantly higher unpleasantness with moderate pain perception.

Pain, aging and dementia: Towards a biopsychosocial model

Dementia is a progressive disease associated with irreversible impairment and loss of cognitive abilities. About half of older people with dementia experience pain. In this paper, we propose that pain in older people with dementia can be conceptualized as the final result of the interaction of three heterogeneous phenomena, pain, aging, and dementia, which are created and influenced by the interactions of predisposing, lifelong, and current biopsychosocial factors. We review pain assessment in people with dementia using both self-report and observational/behavioral measures. We then review the biological/sensory, psychological (cognitive and affective) and social dimensions of pain in dementia. The available data suggest that dementia does not impact pain threshold or tolerance. To date, there is little research on the social dimension of pain in dementia. Changes in the affective domain in response to experimental pain have been contradictory with evidence supporting both increased and decreased unpleasantness and emotional responsiveness in people with dementia compared to healthy controls. Clinically, depression is a significant burden for older people with dementia and chronic pain. The relationship between pain and other neuropsychiatric symptoms is controversial, and there is insufficient evidence on which to base conclusions. Some of the most important dementia-related changes may arise in the cognitive domain, including impairments of semantic and episodic memory for pain, executive function, and pain anticipation. Changes in brain activation and interconnectivity support many of these conclusions. Despite methodological limitations, we conclude there are compelling preliminary data to support a biopsychosocial framework of pain and dementia. Future research directions, especially the need for improved assessment tools, are highlighted.

Association of Comorbid Burden and Patient Outcomes of Residents With Dementia in Jordanian Nursing Homes

Medical and psychiatric comorbidity in individuals with dementia is often associated with serious adverse health outcomes. Using a convenience sample of 76 residents with dementia in Jordanian nursing homes, the current study aimed to examine the relationship among comorbid burden, ability to verbally self-report symptoms, severity of dementia, and patient outcomes of pain and agitation. Comorbid burden and ability to verbally self-report symptoms were found to be significant predictors of patient outcomes of pain and agitation. However, the ability to verbally self-report symptoms did not explain the relationship between comorbid burden and patient outcomes. Nurses must understand the impact of comorbid burden and the ability to verbally self-report symptoms regarding pain and agitation in individuals with dementia. [Journal of Gerontological Nursing, 44(7), 50-58.].

Sex Differences in the Psychophysical Response to Contact Heat in Moderate Cognitive Impairment Alzheimer's Disease: A Cross-Sectional Brief Report

Background:

People with Alzheimer’s disease (AD) report pain less frequently and receive less pain medication than people without AD. Recent studies have begun to elucidate how pain may be altered in those with AD. However, potential sex differences in pain responsiveness have never been explored in these patients. It is unclear whether sex differences found in prior studies of healthy young and older individuals extend to people with AD.

Objective:

The purpose of this study was to examine sex differences in the psychophysical response to experimental thermal pain in people with AD.

Methods:

Cross-sectional analysis of 14 male and 14 female age-matched (≥65 years of age, median = 74) and AD severity-matched (Mini-Mental State Exam score <24, median = 16) communicative people who completed thermal psychophysics.

Results:

There was a statistically significant main effect of sex for both temperature and unpleasantness ratings that persisted after controlling for average and current pain (mixed-effects general liner model: temperature: p = 0.004, unpleasantness: p < 0.001). Females reported sensing mild pain and moderate pain percepts at markedly lower temperatures than did males (mild: Cohen’s d = 0.72, p = 0.051, moderate: Cohen’s d = 0.80, p = 0.036). By contrast, males rated mild and moderate thermal pain stimuli as more unpleasant than did females (mild: Cohen’s d = 0.80, p = 0.072, moderate: Cohen’s d = 1.32, p = 0.006). There were no statistically significant correlations of temperature with perceived unpleasantness for mild or moderate pain (r_s = 0.29 and r_s = 0.20 respectively, p > 0.05).

Conclusions:

Results suggest experimental pain-related sex differences persist in older adults with AD in a different manner than those previously demonstrated in cognitively intact older adults. These findings could potentially aid in developing targeted pain management approaches in this vulnerable population. Further studies are warranted to replicate the findings from this pilot work.

Certified Nursing Assistants' Understanding of Nursing Home Residents' Pain

Pain is a significant problem for nursing home residents, yet its assessment is complex. Certified nursing assistants (CNAs) spend significant time with residents, but their role in understanding residents' pain is largely unexplored. The current qualitative grounded theory study analyzed interviews with 16 CNAs who described their experiences caring for residents in pain. Findings revealed how CNAs understood, recognized, interpreted, and responded to residents' pain. CNAs were found to differentiate between pain that they considered normal (everyday pain) and new pain judged significant enough to report to licensed nurses. CNAs exhibited a holistic understanding of pain, knowledge of strategies to identify and interpret pain, and actions to independently mitigate and report pain. Although additional confirmatory data are needed, the differentiation made between everyday and reportable pain may have important clinical implications suggesting that CNAs should always report to a licensed nurse when they perceive or suspect that residents have pain. [Journal of Gerontological Nursing, 44(4), 29-36.].