Guidance on the management of pain in older people

Comparing Auditory and Visual Distractions for Reducing Pain Severity and Pain Anxiety in Older Outpatients with Burn: A Randomized Controlled Trial

Pain and anxiety are major issues among older patients with burn injuries. Complementary medicine and non-pharmacological methods can relieve pain and anxiety in older people, but comparison of the effects of these methods needs further research. This study aimed to compare the effects of auditory and visual distractions on pain severity and pain anxiety in older outpatients referred to a burn clinic for dressing change. In this randomized controlled clinical trial, older men were randomly assigned to three groups as auditory distraction, visual distraction, and control (n = 45 in each group). The Visual Analogue Scale (VAS) and the Burn Specific Pain Anxiety Scale (BSPAS) were used to asses pain severity and pain anxiety before and immediately after the interventions, and after wound dressing. Reduction in pain severity and pain anxiety after visual distraction was reported. Auditory distraction only reduced pain anxiety. Therefore, visual distraction had a better effect on alleviating pain anxiety compared with auditory distraction. Visual distraction is suggested to be used during dressing changes for older outpatients with burn injuries in outpatient clinics in order to reduce their burn-related suffering and improve their collaboration with the therapeutic regimen.

UK clinical guideline for the prevention and treatment of osteoporosis

The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management.

INTRODUCTION

The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older.

METHODS

Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.

RESULTS

Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement.

CONCLUSION

The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.

Development and testing of a standardized pain interview assessment for use in post-acute care

OBJECTIVES

Pain is highly prevalent among patients in post-acute care (PAC) settings and can affect quality of life, treatment outcomes, and transitions in care. Routine, accurate assessment of pain across settings is important for pain management and care planning; however, existing PAC assessment instruments do not assess patient pain in a standardized manner.

METHODS

We developed and tested a set of pain interview data elements for use across PAC settings (skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, home health agencies) as part of a larger effort undertaken by the Centers for Medicare & Medicaid Services to develop standardized assessment data elements to meet the requirements of the IMPACT Act of 2014. The interview assessed six pain constructs: presence; frequency; interference with sleep; interference with rehabilitation therapies [if applicable]; interference with daily activities; worst pain; and pain relief from treatments/medications). A total of 3031 PAC patients at 143 PAC settings (across 14 U.S. geographic/metropolitan areas in 10 states) participated in a national field test of standardized data elements from November 2017 to August 2018. We assessed item response distributions, time to complete interviews, inter-assessor agreement, and, for a subset of patients, change in responses between admission and discharge assessments. We also conducted focus groups with nurse assessors about their experiences administering the items.

RESULTS

For patients reporting any pain, average time to complete the pain interview was 3.1 min (SD = 1.3), and interrater reliability was excellent for all data elements (kappa range: 0.95-0.99). Findings were similar across types of PAC settings. Qualitative data from nurses emphasized ease of administration and high perceived clinical utility.

CONCLUSION

Findings provide support for feasibility of implementing a standardized pain interview assessment in PAC settings. This tool can support tracking of patient needs across settings and interoperability of data in electronic medical records.

Opioids and Falls Risk in Older Adults: A Narrative Review

Pain treatment is important in older adults but may result in adverse events such as falls. Opioids are effective for nociceptive pain but the evidence for neuropathic pain is weak. Nevertheless, both pain and opioids may increase the risk of falls. This narrative literature review aims to summarize the existing knowledge on the opioid-related fall risk in older adults, including the pharmacokinetics and pharmacodynamics, and assist clinicians in prescribing and deprescribing opioids in older persons. We systematically searched relevant literature on opioid-related fall risk in older adults in PubMed and Scopus in December 2020. We reviewed the literature and evaluated fall-related adverse effects of opioids, explaining how to optimally approach deprescribing of opioids in older adults. Opioid use increases fall risk through drowsiness, (orthostatic) hypotension and also through hyponatremia caused by weak opioids. When prescribing, opioids should be started with low dosages if possible, keeping in mind their metabolic genetic variation. Falls are clinically significant adverse effects of all opioids, and the risk may be dose dependent and highest with strong opioids. The risk is most prominent in older adults prone to falls. To reduce the risk of falls, both pain and the need for opioids should be assessed on a regular basis, and deprescribing or changing to a lower dosage or safer alternative should be considered if the clinical condition allows. Deprescribing should be done by reducing the dosage gradually and by assessing and monitoring the pain and withdrawal symptoms at the same time. Weighing the risks and benefits is necessary before prescribing opioids, especially to older persons at high risk of falls. Clinical decision tools assist prescribers in clinical decisions regarding (de-) prescribing.

The global, regional and national burden of peptic ulcer disease from 1990 to 2019: a population-based study

Background

Peptic ulcer disease (PUD) is a common digestive disorder, of which the prevalence decreased in the past few decades. However, the decreasing tendency has plateaued in recent years due to changes in risk factors associated with the etiology of PUD, such as non-steroidal anti-inflammatory drug use. In this study, we investigated the epidemiological and the sociodemographic characteristics of PUD in 204 countries and territories from 1990 to 2019 based on data from the Global Burden of Disease, Injuries and Risk Factors (GBD) Study.

Methods

Demographic characteristics and annual prevalence, incidence, mortality, disability-adjusted life years (DALYs) and age-standardized death rate (ASR) data associated with PUD were obtained and analyzed. According to the sociodemographic index (SDI), the numbers of patients, ASRs, estimated annual percentage changes and geographical distributions were assessed with a generalized linear model and presented in world maps. All evaluations of numbers and rates were calculated per 100,000 population with 95% uncertainty intervals (UIs).

Results

In 2019, the global prevalence of PUD was approximately 8.09 [95% UI 6.79–9.58] million, representing a 25.82% increase from 1990. The age-standardized prevalence rate was 99.40 (83.86–117.55) per 100,000 population in 2019, representing a decrease of 143.37 (120.54–170.25) per 100,000 population from 1990. The age-standardized DALY rate in 2019 was decreased by 60.64% [74.40 (68.96–81.95) per 100,000 population] compared to that in 1990. In both sexes, the numbers and ASRs of the prevalence, incidence, deaths and DALYs were higher in males than in females over 29 years. Regionally, South Asia had the highest age-standardized prevalence rate [156.62 (130.58–187.05) per 100,000 population] in 2019. A low age-standardized death rate was found in the high-income super-region. Among nations, Kiribati had the highest age-standardized prevalence rate [330.32 (286.98–379.81) per 100,000 population]. Regarding socioeconomic status, positive associations between the age-standardized prevalence, incidence, death rate, DALYs and SDI were observed globally in 2019.

Conclusions

Morbidity and mortality due to PUD decreased significantly from 1990 to 2019, while a gradual upward inclination has been observed in recent 15 years, which might be associated with changes in risk factors for PUD. Attention and efforts by healthcare administrators and society are needed for PUD prevention and control.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02130-2.

Electroacupuncture relieves neuropathic pain by inhibiting degradation of the ecto-nucleotidase PAP in the dorsal root ganglions of CCI mice

BACKGROUND

Although electroacupuncture is widely used in chronic pain management, it is quite controversial due to its unclear mechanism. We hypothesised that EA alleviates pain by inhibiting degradation of the ecto-nucleotidase prostatic acid phosphatase (PAP) and facilitating ATP dephosphorylation in dorsal root ganglions (DRGs).

METHODS

We applied EA in male C57 mice subjected to chronic constriction injury (CCI) and assessed extracellular ATP and 5'-nucleotidease expression in DRGs. Specifically, we used a luminescence assay, quantitative reverse transcriptase-polymerase chain reaction, western blotting, immunohistochemistry and nociceptive-related behavioural changes to gather data, and we tested for effects after PAP expression was inhibited with an adeno-associated virus (AAV). Moreover, membrane PAP degradation was investigated in cultured DRG neurons and the inhibitory effects of EA on this degradation were assessed using immunoprecipitation.

RESULTS

EA treatment alleviated CCI surgery induced mechanical pain hypersensitivity. Furthermore, extracellular ATP decreased significantly in both the DRGs and dorsal horn of EA-treated mice. PAP protein but not mRNA increased in L4-L5 DRGs, and inhibition of PAP expression via AAV microinjection reversed the analgesic effect of EA. Membrane PAP degradation occurred through a clathrin-mediated endocytosis pathway in cultured DRG neurons; EA treatment inhibited the phosphorylation of adaptor protein complex 2, which subsequently reduced the endocytosis of membrane PAP.

CONCLUSIONS

EA treatment alleviated peripheral nerve injury-induced mechanical pain hypersensitivity in mice by inhibiting membrane PAP degradation via reduced endocytosis and subsequently promote ATP dephosphorylation in DRGs.

Low-dose sublingual fentanyl improves quality of life in patients with breakthrough cancer pain in palliative care

Aim: This subanalysis of the CAVIDIOPAL study evaluated the impact of individualized management of breakthrough cancer pain (BTcP) with fentanyl on the quality of life (QoL) of advanced cancer patients in Spanish palliative care units. Patients & methods: This was a prospective, observational, multicenter study. The European Organization for Research and Treatment of Cancer's QLQ-C30 questionnaire was used at baseline (V0) and visit 28 (V28). Results: Ninety-five patients were mainly treated with 67-133 μg fentanyl, showing a notable reduction in intensity (visual analog scale: 8.0 [V0] to 4.6 [V28]), frequency and duration of BTcP episodes shortly after the first 1-2 weeks of treatment, with significantly improved QoL (global health status: 31.1 [V0] to 53.1 [V28]). Conclusion: Low-dose sublingual fentanyl effectively reduced BTcP in advanced cancer patients in palliative care units, significantly improving QoL. Clinical trial registration: NCT02840500 (ClinicalTrials.gov).

Health-related quality of life among Ebola survivors in Sierra Leone: the role of socio-demographic, health-related and psycho-social factors

Background

Evidence of how social factors affect the health-related quality of life (HRQoL) of Ebola virus disease (EVD) survivors is limited. Our study explores the association between socio-demographic, health-related and psycho-social (stigma) factors and EVD survivors' health-related quality of life (HRQoL) in Sierra Leone.

Methods

We conducted a nationwide cross-sectional study among 358 EVD survivors between January and August 2018. We used a multistage sampling method to recruit EVD survivors, and the RAND 36-Item Health Survey item was used to assess the HRQoL. Data were analysed using descriptive statistics and multiple linear regression.

Results

When comparing by each dimension in relation to their respective summary scores, role limitation physical [0.00 (50.00)] and role limitation emotional [0.00 (33.33)] were the most affected physical health and mental health domains among EVD survivors respectively. EVD survivors who were older (β = − 3.90, 95% CI − 6.47 to − 1.32, p = 0.003), had no formal education (β = − 2.80, 95% CI − 5.16 to − 0.43, p = 0.021), experienced a unit increase in the number of post-Ebola symptoms (β = − 1.08, 95% CI − 1.74 to − 0.43, p < 0.001) and experienced a unit increase in enacted stigma (β = − 2.61, 95% CI − 4.02 to − 1.20, p < 0.001) were more likely to report a decreased level of physical health. EVD survivors who experienced a unit increase in the time spent in the Ebola treatment centre (β = − 0.60, 95% CI − 0.103 to − 0.18, p = 0.006) and those who experienced a unit increase in enacted Stigma were more likely to report decreased levels of mental health (β = − 1.50, 95% CI − 2.67 to − 0.33, p = 0.012).

Conclusion

Sociodemographic, health-related, and psycho-social factors were significantly associated with decrease levels of HRQoL. Our findings improve our understanding of the factors that might influence the HRQoL and suggest the need for EVD survivors to be provided with a comprehensive healthcare package that caters for their physical and mental health needs.

Over-The-Counter Remedies in Older Adults: Patterns of Use, Potential Pitfalls, and Proposed Solutions

Over-the-counter (OTC) products such as pharmaceuticals, dietary supplements, vitamins, and herbal remedies are widely available and copiously used by older adults for health maintenance and symptom management. Owing to physiology, multimorbidity, and polypharmacy, this population is particularly vulnerable to inappropriate use of OTC products, adverse effects, and drug interactions. While OTC pharmaceuticals are bound by FDA-approved standards, dietary supplements are regulated differently, resulting in variable quality and increased possibility for adulteration. Internationally, standards for OTC products vary widely. Accessible educational information, improved provider-patient communication, and revision of regulatory policy could improve safety for older adult users of OTC products.

Advancing Discovery of Snail Mucins Function and Application

Mucins are a highly glycosylated protein family that are secreted by animals for adhesion, hydration, lubrication, and other functions. Despite their ubiquity, animal mucins are largely uncharacterized. Snails produce mucin proteins in their mucous for a wide array of biological functions, including microbial protection, adhesion and lubrication. Recently, snail mucins have also become a lucrative source of innovation with wide ranging applications across chemistry, biology, biotechnology, and biomedicine. Specifically, snail mucuses have been applied as skin care products, wound healing agents, surgical glues, and to combat gastric ulcers. Recent advances in integrated omics (genomic, transcriptomic, proteomic, glycomic) technologies have improved the characterization of gastropod mucins, increasing the generation of novel biomaterials. This perspective describes the current research on secreted snail mucus, highlighting the potential of this biopolymer, and also outlines a research strategy to fulfill the unmet need of examining the hierarchical structures that lead to the enormous biological and chemical diversity of snail mucus genes.

Pharmacological Pain Treatment in 2012 and 2017 Among Older People with Major Neurocognitive Disorder

Background and Objective

Pain is highly prevalent among older people, and treatment is complicated because of comorbidities and polypharmacy. Among people with major neurocognitive disorder additional difficulties might arise. The aim of this study was to describe analgesic drug use in 2012 and 2017 and associated factors among older people with major neurocognitive disorder.

Methods

In this register-based study, the Swedish Dementia Registry and the Swedish Prescribed Drug Register were combined in order to obtain data regarding analgesic drug use among older people with major neurocognitive disorder. One or more filled prescriptions during the timeframe of 6 months (1 July–31 December 2012 and 1 July–31 December 2017) defined drug use during the respective period. A comparison between 2012 and 2017 was made, including a total of 56,101 people (20,889 and 35,212 respectively) with a mean age of 81.9 and 82.7 years, respectively.

Results

The overall use of analgesic drugs increased significantly from 41.6% of individuals to 46.0% between the years 2012 and 2017. Users of opioid analgesics (15.2% vs 17.3%) and paracetamol (37.0% vs 42.3%) increased, while the users of non-steroidal anti-inflammatory drugs (4.9% vs 2.7%) declined between the two data collections. Multiple logistic regression analyses were performed for different drugs and drug classes, and it was found that the use of opioids and paracetamol was associated with older age and a longer time since diagnosis. In contrast, non-steroidal anti-inflammatory drugs were associated with younger age and a shorter time since diagnosis.

Conclusions

The results indicate that on a population level, pharmacological drug treatment has changed in line with guidelines between 2012 and 2017, with an increase in paracetamol and strong opioids and a decrease in non-steroidal anti-inflammatory drugs and tramadol. The relatively high prevalence of opioids warrants concern given the significant risk of adverse effects among older people with major neurocognitive disorder.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00897-9.

Prevalence and characteristics of chronic Pain in the Chinese community-dwelling elderly: a cross-sectional study

BACKGROUND

Chronic pain adversely affects health and daily life in the elderly. Gaining insight into chronic pain that affects the community-dwelling elderly is crucial for pain management in China, which possesses the largest elderly population in the world.

METHODS

This is a cross-sectional design study that followed the STROBE Guideline. A randomized cluster sampling method was used to recruit participants in the Sichuan Province from Dec 2018 to May 2019. In addition, face-to-face interviews were conducted to collect socio-demographic data, characteristics and health-seeking behaviors of chronic pain through a self-designed questionnaire.

RESULTS

A total of 1381 older adults participated in this study. Among these participants, 791 (57.3%) had chronic pain. Here, prevalence and pain intensity were both found to increase from the 60-69 group to the 70-79 group, which then decreased in the ≥80 group with no significant differences in sex (p > 0.05). The most common pain locations were observed in the legs/feet (53.5%), head (23.6) and abdomen/pelvis (21.1%). Among the elderly suffering from chronic pain, 29.4% sought medical help, 59.2% received medication and 59.7% adopted non-drug therapy.

CONCLUSION

Chronic pain is a common health concern in the Chinese community-dwelling elderly, which possesses different characteristics than other countries' populations. Therefore, easier access to medication assistance and provision of scientific guidance for non-drug therapy may serve as satisfactory approaches in improving pain management.

Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Background

Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them.

Objectives

The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes.

Design

This was a mixed-methods study.

Setting

The setting was care homes for older adults in England.

Participants

Care home residents participated.

Results

Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%.

Limitations

No care homes rated as inadequate were recruited to the study.

Conclusions

The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents.

Future work

Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. See the NIHR Journals Library website for further project information.

Prevalence and persistent use of analgesic drugs in older adults receiving domiciliary care at baseline-A longitudinal study

AIMS

To describe the prevalence and persistence of analgesic drug use (opioids and antipyretics [ie, paracetamol and acetylsalicylic acid]) in participants (≥70 years) with and without dementia receiving domiciliary care in the eastern part of Norway. In addition, to explore factors associated with persistent drug use and examine whether drug use has changed after admission to a nursing home.

METHODS

A longitudinal study with 1001 participants (mean [SD] age 83.4 [5.7] years) receiving domiciliary care. Medical information including analgesic drug use was collected at baseline (A1) between August 2008 and December 2010, follow-up assessments after 18 (A2) and 36 months (A3). Analgesic drugs prescribed for regular use were recorded from the participants' medical records. The participants' cognitive and physical health was evaluated at all assessments. Level of care (domiciliary care or nursing home care) was recorded at A2 and A3. Generalized linear mixed models were used to examine the prevalence and persistence of analgesic drug use.

RESULTS

The prevalence of prescribed use of antipyretics and opioids was 13.6% and 9.2%, respectively. Participants with dementia had more frequent use of antipyretics in all assessments and opioids in the last assessment than participants without dementia. Persistent use of both antipyretics and opioids was high between two consecutive assessments, both for participants with and without dementia. Persistent use of analgesics was associated with poorer physical functioning, but not by level of care. Overall, there was no difference between those admitted to a nursing home and those receiving domiciliary care at follow-up, with respect to change in analgesic drug use over time.

CONCLUSION

The prevalence and persistent use of analgesics were high in older adults receiving domiciliary care at baseline and especially in participants with dementia. A holistic approach and interdisciplinary collaboration are essential to effectively assess and treat pain in older adults.

Factors influencing prescription and administration of analgesic medication: A longitudinal study of people with dementia living in care homes

OBJECTIVES

To (1) describe the prescription and administration of regular and 'as required' (pro re nata [PRN]) analgesics in English care homes, (2) investigate individual and care home factors associated with analgesic use.

METHODS

We collected data (2014-2016) at 0-, 4-, and 12-months nested in a longitudinal cohort study of 86 English care homes about residents with diagnosed or probable dementia. We describe analgesics prescribed as regular or PRN medication, by class, and PRN administration. We explored individual differences (sociodemographic; dementia severity [Clinical Dementia Rating]), and care home differences (type; ownership; number of beds; dementia-registered/specialist; Care Quality Commission rating) in prescription and administration using multilevel regression models.

RESULTS

Data were available for 1483 residents. At baseline, 967 residents (67.9%) were prescribed analgesics: 426 residents (28.7%) prescribed regular analgesics and 670 (45.2%) prescribed PRN. Paracetamol was the most prescribed analgesic (56.7%), with PRN prescriptions more common than regular (39.7% vs. 16.6%). Across all study visits, 344 residents (mean = 41.9%) with a PRN prescription did not receive any analgesic in the 2 weeks prior to data collection. Male residents and those with severe dementia received fewer analgesics. Care homes differences in PRN administration were not explained by the modelled variables.

CONCLUSIONS

Pain management in English care homes largely relies on PRN paracetamol that is frequently prescribed but infrequently administered. Care homes differ in how often they administer PRN analgesics. Some care home residents particularly those with more severe dementia are likely to have untreated pain.

Association between malnutrition risk and pain in older hospital patients

OBJECTIVE

To describe the prevalence of malnutrition risk and pain in older hospital patients and characterise the association between these two problems.

RESEARCH METHODS AND PROCEDURES

The study includes a secondary data analysis of data collected in two cross-sectional studies. Data collection was performed in 2017 and 2018 using a standardised and tested questionnaire. The study protocol was approved by an ethical committee.

RESULTS

Data from 3406 patients were analysed. Among the participants, 24.6% of the patients were at risk of malnutrition, and 59.6% of the patients reported feeling pain. A significantly higher number of patients with pain (26.4%) were at risk of malnutrition than patients without pain (22.1%). The multivariate logistic regression analysis showed that patients with severe/very severe or unbearable pain were 1.439 times more likely to develop a risk of malnutrition than patients without pain. Patients with cancer or diseases of the digestive system were twice as likely to develop malnutrition than those without these diseases.

CONCLUSIONS

The results of this study show that older patients with severe pain are at higher risk of developing a risk of malnutrition than those without pain, although the study design (cross-sectional) does not imply causality. Therefore, special efforts should be made to assess pain in these patients to reduce the negative consequences of this pain, such as malnutrition.

Effectiveness of a Peer-Led Pain Management Program in Relieving Chronic Pain and Enhancing Pain Self-Efficacy Among Older Adults: A Clustered Randomized Controlled Trial

Chronic pain is common in nursing home residents, who may have difficulty seeking out pain management strategies. Peer support model show promise as a strategy for managing chronic conditions. This was a clustered randomized controlled trial. A peer-led pain management program was provided for the experimental group. Pain situation, depression, quality of life, non-drug strategies used, and pain knowledge were measured. A total of 262 participants joined the study (146 were allocated as experimental group and 116 as control group). Before our intervention, the mean pain score reported was as high as 6.36 on a 10-point Likert Scale. The high intensity of their pain very much interfered with the daily activities of the participants. Pain interference was high and the participants had poor coping as indicated by the low pain self-efficacy. Depression and a low quality of life score was found. Upon completion of our PAP, there was a significant increase in pain self-efficacy, pain interference as well as quality of life for the participants in the experimental group and not in the control group, and this improvement sustained in 3-month follow up. The present study used a peer support models and proven to be effective in managing pain and pain related situations for nursing home residents with chronic pain. The peer volunteers involved in the pain management program taught relevant pain knowledge and pain management strategies to help our participants.

Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03823495, NCT03823495.

Prevalence of Musculoskeletal Pain and Analgesic Treatment Among Community-Dwelling Older Adults: Changes from 1999 to 2019

Background

Pain is undertreated in older populations. At the same time, increased use of opioids is of concern in the Western world.

Aims

We sought to analyze temporal trends in musculoskeletal pain and prescribed analgesic treatment among community-dwelling people aged 75–95 years using cross-sectional cohort data spanning 20 years.

Methods

The Helsinki Aging Study recruited random samples of people aged 75, 80, 85, 90, and 95 years in 1999, 2009, and 2019. In total, 5707 community-dwelling persons participated in the study. The participants reported their medical diagnoses, regular prescription medications, and the presence of back pain or joint pain within the last 2 weeks (never, sometimes, or daily). We compared analgesic use among participants reporting and not reporting musculoskeletal pain in 1999, 2009, and 2019.

Results

Of the participants, 57–61% reported intermittent or daily musculoskeletal pain. The percentage receiving a prescribed daily analgesic increased from 9% in 1999 to 16% in 2019. The use of non-steroidal anti-inflammatory drugs (NSAIDs) decreased from 1999 to 2019, while the use of paracetamol increased from 2 to 11%. Opioids were taken by 2% in 1999 and 3% in 2019. Of those reporting daily musculoskeletal pain, 20%, 35%, and 32% received regular pain medication in 1999, 2009, and 2019, respectively.

Conclusions

Pain remains undertreated in the community-dwelling older population, although the use of regular prescribed analgesics increased between 1999 and 2019. The use of NSAIDs has decreased, while the use of paracetamol has increased. Daily opioid use has remained modest.

Long-Term Efficacy of a Home-Care Hypnosis Program in Elderly Persons Suffering From Chronic Pain: A 12-Month Follow-Up

BACKGROUND

Pain is a major public health concern in the aging population. However, medication brings about negative effects that compel healthcare professionals to seek alternative management techniques to alleviate pain. Hypnosis has been recognized as an effective technique to manage pain, but its long-term efficacy has yet to be examined in older adults.

AIMS

The aim was to assess the effectiveness, over a 12-month period, of home-care hypnosis in elderly participants suffering from chronic pain.

DESIGN

Real-life retrospective one-arm study with a 12-month follow-up.

SETTINGS

Elderly Persons Suffering From Chronic Pain enrolled in a clinical health care program that offered home medical follow-up.

PARTICIPANTS/SUBJECTS

Fourteen elderly women (mean age 81 years) with chronic pain participated in the home-care hypnosis program. All participants presented chronic pain (≥6 months) with average pain score >4/10.

METHODS

Participants took part in seven 15-minute hypnosis sessions within 12 months. The Brief Pain Inventory questionnaire was used to evaluate pain perception and pain interference at baseline and at 3-, 6-, and 12-month follow-up period.

RESULTS

Hypnosis home-care program significantly decreased pain perception and pain interference compared to baseline after 3 months (-29% and -40%, p < .001), and remained lower at 6 (-31% and -54%, p < .001) and 12 (-31% and -47%, p < .001) months.

CONCLUSIONS

Seven sessions of 15 minutes allocated throughout a 12-month period produced clinically significant decreases in pain perception and pain interference. Hypnosis could be considered as an optimal additional way for health practitioners to manage chronic pain in an elderly population with long-term efficacy. This study offers a new long-term option to improve chronic pain management at home in elderly populations through a low-cost nonpharmacological intervention.

Paracetamol: A Review of Guideline Recommendations

Musculoskeletal pain conditions are age-related, leading contributors to chronic pain and pain-related disability, which are expected to rise with the rapid global population aging. Current medical treatments provide only partial relief. Furthermore, non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in young and otherwise healthy individuals but are often contraindicated in elderly and frail patients. As a result of its favorable safety and tolerability record, paracetamol has long been the most common drug for treating pain. Strikingly, recent reports questioned its therapeutic value and safety. This review aims to present guideline recommendations. Paracetamol has been assessed in different conditions and demonstrated therapeutic efficacy on both acute and chronic pain. It is active as a single agent and is additive or synergistic with NSAIDs and opioids, improving their efficacy and safety. However, a lack of significant efficacy and hepatic toxicity have also been reported. Fast dissolving formulations of paracetamol provide superior and more extended pain relief that is similar to intravenous paracetamol. A dose reduction is recommended in patients with liver disease or malnourished. Genotyping may improve efficacy and safety. Within the current trend toward the minimization of opioid analgesia, it is consistently included in multimodal, non-opioid, or opioid-sparing therapies. Paracetamol is being recommended by guidelines as a first or second-line drug for acute pain and chronic pain, especially for patients with limited therapeutic options and for the elderly.

A Sham-Controlled Study of Neurofeedback for Pain Management

Background

Neurofeedback (NFB) attempts to alter the brain’s electrophysiological activity and has shown potential as a pain management technique. Existing studies, however, often lack appropriate control groups or fail to assess whether electrophysiological activity has been successfully regulated. The current study is a randomized controlled trial comparing changes in brain activity and pain during NFB with those of a sham-control group.

Methods

An experimental pain paradigm in healthy participants was used to provide optimal control of pain sensation. Twenty four healthy participants were blind randomized to receive either 10 × NFB (with real EEG feedback) or 10 × sham (with false EEG feedback) sessions during noxious cold stimulation. Prior to actual NFB training, training protocols were individually determined for each participant based on a comparison of an initial 32-channel qEEG assessment administered at both baseline and during an experimental pain task. Each individual protocol was based on the electrode site and frequency band that showed the greatest change in amplitude during pain, with alpha or theta up-regulation at various electrode sites (especially Pz) the most common protocols chosen. During the NFB sessions themselves, pain was assessed at multiple times during each session on a 0–10 rating scale, and ANOVA was used to examine changes in pain ratings and EEG amplitude both across and during sessions for both NFB and sham groups.

Results

For pain, ANOVA trend analysis found a significant general linear decrease in pain across the 10 sessions (p = 0.015). However, no significant main or interaction effects of group were observed suggesting decreases in pain occurred independently of NFB. For EEG, there was a significant During Session X Group interaction (p = 0.004), which indicated that EEG amplitude at the training site was significantly closer to the target amplitude for the NFB compared to the sham group during painful stimulation, but this was only the case at the beginning of the cold task.

Conclusion

While these results must be interpreted within the context of an experimental pain model, they underline the importance of including an appropriate comparison group to avoid attributing naturally occurring changes to therapeutic effects.

Implementation of the Multidisciplinary Guideline on Chronic Pain in Vulnerable Nursing Home Residents to Improve Recognition and Treatment: A Qualitative Process Evaluation

The recognition and treatment of pain in nursing home residents presents challenges best addressed by a multidisciplinary approach. This approach is also recommended in the applicable Dutch guideline; however, translating guidelines into practical strategies is often difficult in nursing homes. Nevertheless, a better understanding of guideline implementation is key to improving the quality of care. Here we describe and qualitatively evaluate the implementation process of the multidisciplinary guideline 'Recognition and treatment of chronic pain in vulnerable elderly' in a Dutch nursing home. The researchers used interviews and document analyses to study the nursing home's implementation of the guideline. The project team of the nursing home first filled out an implementation matrix to formulate goals based on preferred knowledge, attitudes, and behaviors for the defined target groups. Together with experts and organizations, pharmacotherapy audit meetings were organized, an expert pain team was appointed, a policy document and policy flowchart were prepared, and 'anchor personnel' were assigned to disseminate knowledge amongst professionals. Implementation was partially successful and resulted in a functioning pain team, a pain policy, the selection of preferred measurement instruments, and pain becoming a fixed topic during multidisciplinary meetings. Nevertheless, relatively few professionals were aware of the implementation process.

Health Costs of Older Opioid Users with Pain and Comorbid Hypercholesterolemia or Hypertension in the United States

This retrospective cross-sectional database study used 2018 Medical Expenditure Panel Survey data to quantify and assess differences in healthcare expenditures between opioid users and non-users among a non-institutionalized sample of older (≥50 years) United States adults with pain in the past four weeks and a diagnosis of comorbid hypercholesterolemia (pain-hypercholesterolemia group) or hypertension (pain-hypertension group). Hierarchical multivariable linear regression models were constructed by using logarithmically transformed positive cost data and adjusting for relevant factors to assess cost differences between groups. Percent difference between opioid users and non-users was calculated by using semi-logarithmic equations. Healthcare costs included inpatient, outpatient, office-based, emergency room, prescription medication, other, and total costs. In adjusted analyses, compared to non-users, opioid users in the pain-hypercholesterolemia and pain-hypertension groups respectively had 66% and 60% greater inpatient expenditure, 46% and 55% greater outpatient expenditure, 67% and 72% greater office-based expenditure, 50% and 60% greater prescription medication expenditure, 24% and 22% greater other healthcare expenditure, and 85% and 93% greater total healthcare expenditure. In conclusion, adjusted total healthcare expenditures were 85-93% greater among opioid users versus non-users in older United States adults with pain and comorbid hypercholesterolemia or hypertension. Future research is needed to identify opioid use predictors among these populations and reduce expenditures.

Integrating Palliative Care Into Heart Failure Management

BACKGROUND

The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families through the prevention and relief of suffering by assessment and treatment of physical, psychosocial, and spiritual problems. Any patient with chronic debilitating disease, including heart failure, is a candidate for interdisciplinary palliative care to manage their complex physical and psychosocial needs.

CLINICAL RELEVANCE

The philosophy of palliative care has evolved to include a vision of holistic care extended to all individuals with serious illness and their families or caregivers that should be integrated throughout the continuum of care, including the acute phase. The critical care nurse will likely encounter patients with heart failure who are receiving or are eligible to receive palliative care at various time points during their illness. Critical care nurses therefore play a pivotal role in symptom palliation affecting the heart failure patient's quality of life.

PURPOSE

To review the models of palliative care and the role that the critical care nurse plays in symptom palliation and preparation of the patient and their family for transition to other levels and settings of care.

CONTENT COVERED

This review addresses the principles and models of palliative care along with how to integrate these principles into all phases of the heart failure disease continuum. Also included are recommendations for palliation of symptoms specific to heart failure patients as well as a discussion of the role of the critical care nurse and the importance of shared decision-making.

Evaluation of the Pain Impact Index for Community-Dwelling Older Adults Through the Application of Rasch Modelling

OBJECTIVE

Evaluate the Pain Impact Index, a simple, brief, easy-to-use, and novel tool to assess the impact of chronic pain in community-dwelling older adults.

METHODS

A Rasch modelling analysis was undertaken in Stata using a partial credit model suited to the Likert-type items that comprised the Index. The Index was evaluated for ordering of category thresholds, unidimensionality, overall fit to the Rasch model, measurement bias (Differential Item Functioning, DIF), targeting, and construct validity.

RESULTS

The four-item Pain Impact Index was self-completed by 6454 community-dwelling Australians who were aged at least 70 years and experienced pain on most days. Two items showed evidence of threshold disordering, and this was resolved by collapsing response categories (from 5 to 3) for all items. The rescored Index conformed to the unidimensionality assumption and had satisfactory fit with the Rasch model (analyses conducted on a reduced sample size to mitigate the potential for overpowering: n = 377, P > 0.0125, power > 77%). When considering uniform DIF, the most frequent sources of measurement bias were age, knee pain, and upper back pain. When considering nonuniform DIF, the most frequent source of measurement bias was knee pain. The Index had good ability to differentiate between respondents with different levels of pain impact and had highest measurement precision for respondents located around the average level of pain impact in the study sample. Both convergent and discriminant validity of the Index were supported.

CONCLUSION

The Pain Impact Index showed evidence of unidimensionality, was able to successfully differentiate between levels of pain impact, and had good evidence of construct validity.

Viscosupplementation for the treatment of osteoarthritis. The contribution of EUROVISCO group

Viscosupplementation (VS) is a symptomatic treatment for knee and other joint osteoarthritis (OA). Despite a long history of use, conflicting opinions remain on the best clinical indications and the most appropriate patients to be treated with intra-articular hyaluronic acid (IA-HA), the optimal dosing regimen and the modalities of retreatment. A multidisciplinary committee of European experts on OA (EUROVISCO) was constituted to formulate recommendations, aimed at helping physicians in the decision-making and the optimal achievement of VS. Before each session members were tasked to collate an exhaustive literature review. Level of evidence and strength of recommendation were based on the level of agreement for each item according to the Delphi method. In 2015, a consensus position was proposed for 24 statements. Among those that obtained a consensual agreement, the working group stressed that VS is effective in mild/moderate knee OA but is not an alternative to surgery in advanced OA, and that dosing regimen must be supported by controlled trials. In 2018, two decision algorithms for the retreatment with IA-HA in knee OA were published. Among the key recommendations, the experts recommended to re-treat every year patients with high risk of OA progression, even if not symptomatic. In 2020, EUROVISCO published two sets of recommendations for the design of clinical trials on the disease-modifying effect of VS and for optimizing the results of VS. The working group underlined that an accurate analysis of radiological features and symptoms and a careful clinical examination may improve the chances of success of VS, as well as good technique of injection and the use of imaging guidance. Based on the exhaustive analysis of the literature and their own clinical experience, the EUROVISCO experts offer a wide range of recommendations intended to help practitioners, particularly in certain cases where the specific characteristics of the patients make the therapeutic decision difficult.

European clinical practice recommendations on opioids for chronic noncancer pain - Part 2: Special situations

BACKGROUND

Opioid use for chronic non-cancer pain (CNCP) is under debate. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).

METHODS

The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.

RESULTS

The European Clinical Practice Recommendations give guidance for combination with other medications, the management of frequent (e.g. nausea, constipation) and rare (e.g. hyperalgesia) side effects, for special clinical populations (e.g. children and adolescents, pregnancy) and for special situations (e.g. liver cirrhosis).

CONCLUSION

If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively.

SIGNIFICANCE

If a trial with opioids for chronic noncancer pain is conducted, detailed knowledge and experience are needed to adapt the opioid treatment to a special patient group and/or clinical situation and to manage side effects effectively. A collaboration of medical specialties and of all health care professionals is needed for some special populations and clinical situations.

Predictors of development and persistence of musculoskeletal pain in community-dwelling older people: A two-year longitudinal study

AIM

The aim of this prospective cohort study was to identify the predictors of the development and persistence of musculoskeletal pain (MSKP) in older people.

METHODS

Participants comprised 431 community-dwelling older people aged 70+ years. Demographic, anthropometric, balance, mobility, cognitive function, psychological status and physical activity level measures were obtained at baseline. Participants were asked about the presence of MSKP in the neck/back, hip, knee/leg and/or feet at baseline and two-year follow-up. Logistic regression analyses were performed to identify predictors of the development and persistence of MSKP at two-year follow-up.

RESULTS

Of 179 participants who reported no MSKP at baseline, 84 (46.9%) reported MSKP at two-year follow-up, which was associated with a higher body mass index (odds ratio (OR) 1.10, 95% confidence interval (CI) 1.02-1.18), more reported depressive symptoms (OR 1.30, 95% CI 1.05-1.61) and lower physical activity levels (OR 0.92, 95% CI 0.84-1.00) at baseline. Of 252 participants who reported MSKP at baseline, 202 (80.2%) reported MSKP at follow-up, which was associated with a slower 6-m walking time (OR 1.27, 95% CI 1.08-1.49) and more reported depressive symptoms (OR 1.39, 95% CI 1.09-1.78). These associations remained significant after adjusting for age, sex, comorbidities and medication use.

CONCLUSIONS

This study suggests that higher body mass index, more depressive symptoms and less physical activity are predictors of developing MSKP, whereas slow gait speed and depressive symptoms are predictors of the persistence of MSKP among older people. The results highlight the importance of weight control, strategies to improve mental wellbeing and an active lifestyle for pain management among older people. Geriatr Gerontol Int 2021; 21: 519-524.

Bibliometric Analysis of Research Articles on Pain in the Elderly Published from 2000 to 2019

Background

Given the rapid growth of the global aging population, pain has become an unneglectable concern amongst the elderly. The quantity of scientific research outputs on pain in the elderly has increased over time, but only a small number of studies have used bibliometric methods to analyze scientific research in this field. This paper aimed to analyze scientific research on pain in the elderly published from 2000 to 2019 in a systematic manner using bibliometric methods.

Methods

Articles on pain in the elderly published from 2000 to 2019 were retrieved from the Web of Science (WoS). Abstracts were coded on the basis of predetermined items (eg, type of article, topic, type of subjects, pain characteristics), and relevant information on the first author, citation scores, and article keywords were collected.

Results

A total of 2105 articles were included in this study. Statistical analysis revealed that the publication of articles on pain in the elderly increased in frequency over time (P<0.001). Most of the publications were original articles. Amongst the countries identified, the United States published the largest number of papers on this topic. Pain characteristics (50.21%), pain intervention (35.68%), and pain assessment (9.69%) were the main topics of research on geriatric pain. Back pain (12.30%) appeared to be the most popular pain type described in the included papers.

Conclusion

This work provides researchers with an in-depth understanding of pain in the elderly by evaluating relevant publications in the past two decades. Researchers in this field are warranted to explore future directions on geriatric pain such as the transition from acute pain to chronic pain and the underlying mechanisms of pain in the elderly.

Developing guidelines to support injured workers who live and work with chronic pain

BACKGROUND

Living and working with chronic pain requires persons to alter lifestyles and have the knowledge as well as support to manage unforeseen challenges. Knowledge for persons living with pain who want to participate in meaningful paid and unpaid work is not easily accessible. While there is literature on chronic pain management, work transitions and return to work, less emphasis has been placed on the complexity of living and working with chronic pain. The Creating a Way Forward Project was envisioned to address this gap and to identify the informational needs of workers with pain, health/helping professionals (workers' advisors, return to work specialists, legal representatives), and stakeholders. The overarching aim of the project was to use evidence and experiential knowledge to inform the development of a foundation for educational guides and toolkits to support workers with pain to achieve their outcomes for remaining at work.

METHODS

Phase one of the project involved a scoping review of chronic pain and work. Phase two involved stakeholder consultations, a focus group and knowledge integration of the literature and experiential insights. Knowledge synthesis drew on a Template Analysis of multiple sources of data.

RESULTS

Knowledge domains and key components were identified for persons with pain and for the health/helping professions.

CONCLUSION

These domains reflect a foundation for knowledge in practical training and the development of curriculum for education in self-management program and in inter professional health profession education. These knowledge domains provide a basis for future research in integrated approaches and knowledge use toward improving transitions for persons living with chronic pain who want to participate in productive paid and unpaid work. Ongoing research in knowledge domains that health providers and persons with pain need will expand the potential for improving health outcomes in living with and managing pain.

Why Being Physically Active or Inactive Affects Older Women's Physical Role?

Background

Active aging is aimed at promoting quality of life in older adults. Nevertheless, the relationship between physical role and the practice of physical activity (PA) can be influenced by bodily pain feeling and by a low level of health-related quality of life (HRQoL). Passive and active strategies are susceptible to being modified and constitute an important psychological predictor of adaptation to pain. This cross-sectional study (1) analyzed the differences between inactive/active older adult women in terms of clinical and sociodemographic characteristics, pain coping strategies, and HRQoL; (2) studied the associations between pain coping strategies, the dimensions of the HRQoL questionnaire, and physical role; and (3) determined if passive strategies, bodily pain, physical function, and general health were significant mediators in the link between being inactive/active and physical role.

Methods

Participants of the present cross-sectional study completed measures of clinical and sociodemographic characteristics, HRQoL using the Short-Form Health Survey-36, and active and passive strategies using the Vanderbilt Pain Management Inventory (VPMI).

Results

A total of 157 inactive (69.9 ± 7.1 years) and 183 active (68.8 ± 5.3 years) women from rural areas were included in the study. Both groups significantly differed in the majority of the clinical and sociodemographic characteristics measured, pain coping strategies, and HRQoL. Bodily pain, physical function, and general health predicted physical role. Moreover, passive strategies, bodily pain, physical function, and general health mediated the link between inactive/active participants and physical role.

Conclusions

Being physically active or inactive contributes to a better understanding of the link between PA, pain coping strategies, and physical role in older women.

Characteristics and treatment of geriatric patients in an osteopathic neuromusculoskeletal medicine clinic

CONTEXT

Osteopathic manipulative medicine (OMM) is an adjunctive treatment approach available to geriatric patients, but few studies provide details about presenting conditions, treatments, and response to osteopathic manipulative treatment (OMT) in that patient population.

OBJECTIVES

To provide descriptive data on the presentation and management of geriatric patients receiving OMT at an outpatient osteopathic neuromusculoskeletal medicine (ONMM) clinic.

METHODS

Data were retrospectively collected from electronic health records (EHR) at a single outpatient clinic for clinical encounters with patients over 60 years of age who were treated with OMT between July 1, 2016, and June 30, 2019. Records were reviewed for demographic information, insurance type, presenting concerns, assessments, regions treated, OMT techniques used, and treatment response.

RESULTS

There were 9,155 total clinical encounters with 1,238 unique patients found during the study period. More women than men were represented for overall encounters (6,910 [75.4%] vs. 2,254 [24.6%]) and unique patients (850 [68.7%] vs. 388 [31.3%]; both p<0.001). The mean (standard deviation, SD) number of encounters per patient per year was 4.5 (4.0) and increased with increasing age by decade (p<0.001). Medicare was the most common primary insurance (7,246 [79.2%]), with private insurance the most common secondary insurance (8,440 [92.2%]). The total number of presenting concerns was 12,020, and back concerns were most common (6,406 [53.3%]). The total number of assessments was 18,290; most were neuromusculoskeletal (17,271 [94.5%]) and in the thoracolumbar region (7,109 [38.9%]). The mean (SD) number of somatic dysfunction assessments per encounter was 5 (1.7); the thoracic region was the most documented and treated (7,263 [15.8%]). With up to 19 technique types per encounter, the total number of OMT techniques documented across all encounters was 43,862, and muscle energy (7,203 [16.4%]) was the most documented. The use of high-velocity, low-amplitude (HVLA) declined as age increased (p<0.001). The overall treatment response was documented in 7,316 (79.9%) encounters, and most indicated improvement (7,290 [99.6%]).

CONCLUSIONS

Our results showed that geriatric patients receiving OMT at our clinic were predominately presenting for neuromusculoskeletal concerns associated with back, neck, and extremity conditions, consistent with national epidemiological data for this population. The most common OMT techniques were also consistent with those used nationally by osteopathic medical students and practicing physicians. Future longitudinal studies are needed to determine the length of time improvement persists and the overall health impact experienced by geriatric patients receiving OMT.

Analgesic purchases among older adults - a population-based study

Background

Pain is a frequent and inevitable factor affecting the quality of life among older people. Several studies have highlighted the ineffectiveness of treating chronic pain among the aged population, and little is known about the prevalence of analgesics administration among community-dwelling older adults. The objective was to examine older adults’ prescription analgesic purchases in relation to SF-36 pain in a population-based setting.

Methods

One thousand four hundred twenty community-dwelling citizens aged 62–86 years self-reported SF-36 bodily pain (pain intensity and pain-related interference) scores for the previous 4 weeks. The Social Insurance Institution of Finland register data on analgesic purchases for 6 months prior to and 6 months after the questionnaire data collection were considered. Special interest was focused on factors related to opioid purchases.

Results

Of all participants, 84% had purchased prescription analgesics during 1 year. NSAIDs were most frequently purchased (77%), while 41% had purchased paracetamol, 32% opioids, 17% gabapentinoids, and 7% tricyclic antidepressants. Age made no marked difference in purchasing prevalence. The number of morbidities was independently associated with analgesic purchases in all subjects and metabolic syndrome also with opioid purchases in subjects who had not reported any pain.

Discussion

Substantial NSAID and opioid purchases emerged. The importance of proper pain assessment and individual deliberation in terms of analgesic contraindications and pain quality, as well as non-pharmacological pain management, need to be highlighted in order to optimize older adults’ pain management.

Pain Characteristics and Quality of Life in Older People at High Risk of Future Hospitalization

This study deals with how pain characteristics in conjunction with other factors affect quality of life (QoL) in a vulnerable primary care population. We recruited vulnerable older people (75+, n = 825) living in south-eastern Sweden. A postal questionnaire included pain aspects, QoL (EQ-5D-3L, RAND-36 physical functioning, attitudes toward own aging, and life satisfaction), functional status, social networks, and basic demographic information. Pain extent and localization was obtained by digitalization of pain drawings reported on standard body charts. Most respondents were experiencing pain longer than 3 months (88.8%). Pain frequency varied mostly between occasionally (33.8%) and every day (34.8%). A minority reported high pain intensity (13.6%). The lower back and lower legs were the most frequently reported pain locations (>25%). Multiple linear regression model revealed three characteristics of pain (intensity, frequency, and extent) remained inversely associated with the EQ-5D-3L index score (R² = 0.57). Individually, each of these pain characteristics showed a negative impact on the other three dimensions of QoL (R² = 0.23–0.59). Different features of pain had impact on different dimensions of QoL in this aging population. A global pain assessment is useful to facilitate individual treatment and rehabilitation strategies in primary care.

Effectiveness of ibuprofen plus paracetamol combination on persistence of acute musculoskeletal disorders in primary care patients

Background General practitioners often deal with patients suffering acute musculoskeletal disorders. Paracetamol, non-steroidal anti-inflammatory drugs, and opioids are the most prescribed medications, according to pain intensity and patient's features. Combinations of different analgesics can be adopted to enhance pain relief, but only one fixed-dose combination has been recently launched to treat acute musculoskeletal pain. Objective This study aimed to investigate the effectiveness of ibuprofen plus paracetamol (fixed-dose) combination compared to other analgesics in preventing musculoskeletal pain persistence. Setting Italian outpatients' data extracted from a national general practice database. Method A retrospective cohort study was conducted on the Health Search Database. Patients prescribed with analgesics for acute musculoskeletal painful conditions were considered (i.e., non-chronic painful conditions, identified using a query validated by two expert General Practitioners (GPs)). For each patient, the first prescription of an analgesic was defined as index date. A new GP's visit related to musculoskeletal disorders in the first 3 months following the index date was defined as "pain persistence". Main outcome measure Risk of pain persistence among users of the ibuprofen plus paracetamol combination compared to other systemic analgesics. Results Overall, 102,216 patients were treated with systemic analgesics for acute musculoskeletal disorders. Most patients were middle-aged or elderly women. 939 (0.92%) patients were prescribed with the fixed-dose ibuprofen plus paracetamol combination for a mean duration of 7.23 ± 2.68 days, mainly for low back pain and cervicalgia. Musculoskeletal pain persistence was found in 22,125 (21.65%) patients. Compared to other systemic analgesics, the ibuprofen plus paracetamol combination resulted significantly more effective in preventing pain persistence (adjusted hazard ratio 0.72, 95% confidence interval 0.61-0.85). Conclusion These findings suggest that the fixed-dose ibuprofen plus paracetamol combination might be effective in controlling musculoskeletal pain persistence.

Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study

PURPOSE

The main aim of the study was to assess the impact of individualized management of breakthrough cancer pain (BTcP) on quality of life (QoL) of patients with advanced cancer in clinical practice.

METHODS

A prospective, observational, multicenter study was conducted in patients with advanced cancer that were assisted by palliative care units. QoL was assessed with the EORTC QLQ-C30 questionnaire at baseline (V0) and after 28 days (V28) of individualized BTcP therapy. Data on background pain, BTcP, comorbidities, and frailty were also recorded.

RESULTS

Ninety-three patients completed the study. Intensity, duration, and number of BTcP episodes were reduced (p < 0.001) at V28 with individualized therapy. Transmucosal fentanyl was used in 93.8% of patients, mainly by sublingual route. Fentanyl titration was initiated at low doses (78.3% of patients received doses of 67 μg, 100 μg, or 133 μg) according to physician evaluation. At V28, mean perception of global health status had increased from 31.1 to 53.1 (p < 0.001). All scales of EORTC QLQ-C30 significantly improved (p < 0.001) except physical functioning, diarrhea, and financial difficulties. Pain scale improved from 73.6 ± 22.6 to 35.7 ± 22.3 (p < 0.001). Moreover, 85.9% of patients reported pain improvement. Probability of no ≥ 25% improvement in QoL was significantly higher in patients ≥ 65 years old (OR 1.39; 95% CI 1.001-1.079) and patients hospitalized at baseline (OR 4.126; 95% CI 1.227-13.873).

CONCLUSION

Individualized BTcP therapy improved QoL of patients with advanced cancer. Transmucosal fentanyl at low doses was the most used drug.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov database (NCT02840500) on July 19, 2016.

A Contextual Analysis to Explore Barriers and Facilitators of Pain Management in Swiss Nursing Homes

PURPOSE

As part of a contextual analysis, this study aimed to generate a comprehensive understanding of barriers and facilitators to pain management in nursing homes to identify potential leverage points for future implementation studies.

DESIGN

An explanatory sequential mixed-methods study embedded in a cross-sectional study in 20 Swiss nursing homes (data collection: July-December 2016).

METHODS

Quantitative data were collected via care worker questionnaire surveys comprising 20 items assessing perceptions of barriers to pain management. Descriptive statistics were computed. In the subsequent qualitative strand we conducted four focus group discussions with care workers (registered nurses, licensed practical nurses, and nursing aides) using a knowledge-mapping approach. Findings of both strands were merged and mapped onto domains of the Capability, Opportunity, and Motivation determine Behavior (COM-B) system, a model for behavior, to identify determinants for behavior change.

FINDINGS

Data from 343 completed care worker surveys (response rate 67.3%) and four focus groups with care workers were analyzed. Items rated most problematic were as follows: lack of availability of nonpharmacological treatment (60.9%), lack of application of nonpharmacological treatment (53.6%), reluctance of residents to report pain (51.1%), and lack of time for a comprehensive pain assessment (50.5%). Focus groups partly corroborated quantitative findings and complemented them with facilitators, such as close collaboration with physicians and further barriers (e.g., organizational factors such as high turnover and a lack of established routines in pain management).

CONCLUSIONS

Our approach using a behavioral model highlighted a need for implementation strategies that improve pain management knowledge and focus on motivational aspects to establish new routines and habits related to pain management among care workers.

CLINICAL RELEVANCE

Our findings suggest that future approaches to improve pain management in nursing homes should go beyond provision of education and training. To establish new practices or adapt existing ones, a more complex approach (e.g., introduction of external or internal facilitators) is necessary to influence motivation and ultimately change behavior.

Association between frailty and chronic pain among older adults: a systematic review and meta-analysis

PURPOSE

Frailty and chronic pain are prevalent among older adults. However, no study has systematically reviewed the association between frailty and chronic pain in older adults. Therefore, we aimed to estimate the prevalence of frailty and prefrailty among older adults with chronic pain and review the longitudinal association between frailty status and chronic pain.

METHODS

Embase, Medline, Pubmed, and Cochrane library were searched from inception to March 2020. The methodological quality of the studies was assessed using the Newcastle Ottawa Scale. Random effect models and Mantel-Haenszel weighting were adopted to synthesize the estimates.

RESULTS

Among the initial 846 articles retrieved, 24 were included in the review (12 cross-sectional, and 12 longitudinal). The pooled prevalence in persons with chronic pain was 18% (95% CI 14-23%; I2 = 98.7%) for frailty and 43% (95% CI 36-51%; I2 = 98.2%) for prefrailty. The pooled prevalence of chronic pain was 50% (95% CI 45-55%; I2 = 88.3%) for individuals with frailty and 37% (95% CI 31-42%; I2 = 97.1%) for individuals with prefrailty. Persons with chronic pain were 1.85 (95% CI 1.49-2.28; I2 = 93.2%) times more likely to develop frailty after an average follow-up of 5.8 years compared to those without.

CONCLUSION

Frailty and prefrailty are common in persons with chronic pain. Chronic pain among non-frail older persons significantly predicts the incidence of frailty after an average follow-up of 5.8 years. Future studies should explore the efficacy of different pain management strategies in reducing physical frailty and clarify the association of other types of frailty (cognitive, social and psychological) with chronic pain.

Association Between Serum 25-Hydroxyvitamin D Concentrations and Chronic Pain: Effects of Drinking Habits

Purpose

Although the explanation for inconsistencies in the reported association between serum 25-hydroxyvitamin D [25(OH)D] levels and chronic pain (CP) has not yet been determined, understanding this discrepancy is necessary for the development of vitamin D supplementation as an effective treatment for CP. The aim of this cross-sectional study was to examine the relationship between 25(OH)D concentrations and CP according to drinking habits in Japanese subjects.

Patients and Methods

We distributed invitation letters to 2314 individuals older than 40 years in Shika town, a rural area in Japan, and 724 subjects (386 females; mean age: 63.9 ± 10.4 years) were recruited. CP was defined as persistent pain lasting at least 3 months in any part of the body. Serum concentrations of 25(OH)D, a biomarker of the vitamin D status, were measured using a radioimmunoassay. A serum 25(OH)D level <20 ng/mL was defined as serum 25(OH)D deficiency. Drinking habits were assessed using a self-administered questionnaire. There were three choices, “rarely drink”, “sometimes” and “everyday”. Respondents who answered “rarely drink” were labelled as non-drinkers and the others as drinkers.

Results

The prevalence of CP was 40.6%. A significant interaction between CP and drinking habits on 25(OH)D concentrations was observed (p = 0.098). A one-way analysis of covariance was performed to compare 25(OH)D concentrations between the subjects with and without CP in each drinking group, and the serum 25(OH)D levels of subjects with CP were significantly lower than those without CP among drinkers (p = 0.007). A logistic regression analysis revealed a correlation between serum 25(OH)D deficiency and CP in drinkers after adjustments for several confounding factors (odds ratio: 0.499; 95% confidence interval: 0.268 − 0.927; p = 0.028).

Conclusion

The present results suggest that low serum 25(OH)D concentrations are associated with the development of CP in drinkers.

Pain in Older Adults With Dementia: A Survey in Spain

The risk of suffering pain increases significantly throughout life, reaching the highest levels in its latest years. Prevalence of pain in nursing homes is estimated to range from 40 to 80% of residents, most of them old adults affected with dementia. It is already known that pain is under-diagnosed and under-treated in patients with severe cognitive impairment and poor/absent verbal communication, resulting in a serious impact on their quality of life, psychosocial, and physical functioning. Under-treated pain is commonly the cause of behavioral symptoms, which can lead to misuse of antipsychotic treatments. Here, we present two Regional and National Surveys in Spain (2015–2017) on the current practices, use of observational tools for pain assessment, guidelines, and policies. Results, discussed as compared to the survey across central/north Europe, confirm the professional concerns on pain in severe dementia, due to poor standardization and lack of guidelines/recommendations. In Spain, observational tools are scarcely used because of their difficulty and low reliability in severe dementia, since the poor/absent verbal communication and comprehension are considered limiting factors. Behavioral observation tools should be used while attending the patients, in a situation including rest and movement, should be short (3–5 min) and scored using a numeric scale. Among the pain items to score, “Facial expression” and “Verbalization” were considered essential and very useful, respectively. This was in contrast to “Body movements” and “Vocalizations,” respectively, according to the survey in central/north Europe. Scarce time availability for pain assessment and monitoring, together with low feasible and time-consuming tools, can make pain assessment a challenge. The presence of confounding factors, the low awareness and poor knowledge/education of specific tools for this population are worrisome. These complaints draw future directions to improve pain assessment. More time available, awareness, and involvement of the teams would also benefit pain assessment and management in cognitive impairment. The experiences and opinions recorded in these surveys in Spain and other E.U. countries were considered sources of knowledge for designing the “PAIC-15 scale,” a new internationally agreed-on meta-tool for Pain Assessment in Impaired Cognition and the “Observational pain assessment” in older persons with dementia.

Opioid prescribing and risk of drug-opioid interactions in older discharged patients with polypharmacy in Australia

Background Opioids are commonly prescribed to managing chronic pain in older persons. However, these patients are often at risk of drug-opioid interactions due to polypharmacy. Objectives To identify the prevalence of opioid prescribing and drug-opioid interactions in poly-medicated older patients and factors associated with opioid prescribing. Setting Patients were included if they were admitted to the Royal Adelaide Hospital between September 2015 and August 2016, aged ≥ 75 years and took ≥ 5 medications at discharge. Methods After ethics approval, data of were retrospectively collected from case notes. The Charlson Comorbidity Index and Drug Burden Index were determined and opioids were classified as strong or weak. The association between opioid use and concurrent medications was computed using logistic regression and the results presented as odds ratios (OR) and 95% confidence intervals (95% CI), adjusted for age, sex, Charlson Comorbidity Index, number of prescribed medications and modified-Drug Burden Index. Main outcome measure Association between concurrent medications and opioid prescribing. Results 15,000 geriatric admissions were identified, of which 1192 were included. A total of 283 (23.7%) patients were prescribed opioids, with oxycodone accounting for 56% of these prescriptions. Opioid users were prescribed more medications (11.2 vs. 9.0, P < 0.001) and had higher Drug Burden Index (1.2 vs. 0.14, P < 0.001) compared to non-users. Opioid use was associated with concurrent prescription of antiepileptics (OR = 1.7, 95% CI 1.1-2.6), and negatively associated with Charlson Comorbidity Index (OR = 0.9, 95% CI 0.8-0.98) and concurrent use of antipsychotics (OR = 0.5, 95% CI 0.3-0.9) and beta blocking agents (OR = 0.4, 95% CI 0.3-0.6). Conclusions Strong opioids were prescribed more often than weak opioids and opioid users presented with characteristics and concurrent medications which increased the risk of opioid related adverse drug effects.

The association between obesity and chronic pain among community-dwelling older adults: a systematic review and meta-analysis

OBJECTIVES

To systematically review studies and explore the association between obesity and chronic pain among community-dwelling older adults.

METHODS

A comprehensive literature search was conducted in 9 databases and the Pubmed search engine from their inception to March 19, 2020. Studies that investigated the associations between overweight/obesity and chronic pain among older people were obtained. Comprehensive Meta-analysis was used to meta-analyze the eligible studies.

RESULTS

Totally 14 studies with 40,999 participants were included in this review, and 8 of these studies were meta-analyzed. The meta-analyses showed that both overweight (pooled OR = 1.166, 95% CI: 1.104-1.232, p < 0.01) and obesity (pooled OR = 1.786, 95% CI: 1.530-2.085, p < 0.01) had significant associations with chronic pain among older adults.

CONCLUSIONS

Overweight and obesity are both associated with chronic pain among older adults. It is suggested that body weight control strategies might be incorporated into the pain management program for older adults with obesity.

Inflammation, HIV, and Immune Quiescence: Leveraging on Immunomodulatory Products to Reduce HIV Susceptibility

The relationship between inflammation and HIV has been a focus of research over the last decade. In HIV-infected individuals, increased HIV-associated immune activation significantly correlated to disease progression. While genital inflammation (GI) has been shown to significantly increase the risk of HIV acquisition and transmission, immune correlates for reduced risk remain limited. In certain HIV-exposed seronegative individuals, an immune quiescent phenotype characterized reduced risk. Immune quiescence is defined by specific, targeted, highly regulated immune responses that hinder overt inflammation or immune activation. Targeted management of inflammation, therefore, is a plausible strategy to mitigate HIV risk and slow disease progression. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as hydroxychloroquine and aspirin have shown encouraging preliminary results in low-risk women by reducing systemic and genital immune activation. A topical NSAID, containing ibuprofen, is effective in treating vulvovaginal inflammation. Additionally, the glucocorticoids (GCs), prednisolone, and dexamethasone are used to treat HIV-associated immune activation. Collectively, these data inform on immune-modulating drugs to reduce HIV risk. However, the prolonged use of these pharmaceutical drugs is associated with adverse effects, both systemically and to a lesser extent topically. Natural products with their reduced side effects coupled with anti-inflammatory properties render them viable options. Lactic acid (LA) has immunomodulatory properties. LA regulates the genital microbiome by facilitating the growth of Lactobacillus species, while simultaneously limiting bacterial species that cause microbial dysbiosis and GI. Glycerol monolaurate, besides being anti-inflammatory, also inhibited SIV infections in rhesus macaques. The proposed pharmaceutical and natural products could be used in combination with either antiretrovirals for treatment or preexposure prophylaxis for HIV prevention. This review provides a summary on the associations between inflammation, HIV risk, and disease progression. Furthermore, we use the knowledge from immune quiescence to exploit the use of pharmaceutical and natural products as strategic interventions to manage inflammation, toward mitigating HIV infections.

Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis

BACKGROUND

Among Canadian residents living in long-term care (LTC) facilities, and especially among those with limited ability to communicate due to dementia, pain remains underassessed and undermanaged. Although evidence-based clinical guidelines for the assessment and management of pain exist, these clinical guidelines are not widely implemented in LTC facilities. A relatively unexplored avenue for change is the influence that statutes and regulations could exert on pain practices within LTC. This review is therefore aimed at identifying the current landscape of policy levers used across Canada to assess and manage pain among LTC residents and to evaluate the extent to which they are concordant with evidence-based clinical guidelines proposed by an international consensus group consisting of both geriatric pain and public policy experts.

METHODS

Using scoping review methodology, a search for peer-reviewed journal articles and government documents pertaining to pain in Canadian LTC facilities was carried out. This scoping review was complemented by an in-depth case analysis of Alberta, Saskatchewan, and Ontario statutes and regulations.

RESULTS

Across provinces, pain was highly prevalent and was associated with adverse consequences among LTC residents. The considerable benefits of using a standardized pain assessment protocol, along with the barriers in implementing such a protocol, were identified. For most provinces, pain assessment and management in LTC residents was not specifically addressed in their statutes or regulations. In Alberta, Saskatchewan, and Ontario, regulations mandate the use of the interRAI suite of assessment tools for the assessment and reporting of pain.

CONCLUSION

The prevalence of pain and the benefits of implementing standardized pain assessment protocols has been reported in the research literature. Despite occasional references to pain, however, existing regulations do not recommend assessments of pain at the frequency specified by experts. Insufficient direction on the use of specialized pain assessment tools (especially in the case of those with limited ability to communicate) that minimize reliance on subjective judgements was also identified in current regulations. Existing policies therefore fail to adequately address the underassessment and undermanagement of pain in older adults residing in LTC facilities in ways that are aligned with expert consensus.

Predicting Pain-Related 30-Day Emergency Department Return Visits in Middle-Aged and Older Adults

OBJECTIVE

The objective of this study was to determine predictive factors for pain-related emergency department returns in middle-aged and older adults. Design, Setting, and Subjects. This was a subanalysis of patients > 55 years of age enrolled in a prospective observational study of adult patients presenting within 30 days of an index visit to a large, urban, academic center.

METHODS

Demographic and clinical data were collected and compared to determine significant differences between patients who returned for pain and those who did not. Multiple logistic regressions were used to determine significant predictive variables for return visits.

RESULTS

The majority of the 130 enrolled patients > 55 years of age returned for pain (57%), were African American (78%), were younger (55-64 years old, 67%), had a high emergency department acuity level (level 1 or 2) at their index visit (56%), had low health literacy (Rapid Estimate of Adult Literacy in Medicine [REALM] score, 62%), lived in an area of extreme deprivation (69%), and were admitted (61%) during their index visit. Age (odds ratio [OR] = 0.9, 95% CI = 0.8-0.9, P = 0.047), health literacy (REALM scores; OR = 3.1, 95% CI = 1.3-7.5, P = 0.011), and index visit pain scores (OR = 1.1, 95% CI = 1.0-1.2, P = 0.004) were predictive of emergency department returns for pain in middle-aged and older adults.

CONCLUSIONS

The likelihood of emergency department return visits for pain in middle-aged and older adults decreased with older age, increased with higher health literacy (REALM scores), and increased with increase in pain scores.

Synthesis, structural determination, in vitro and in silico biological evaluation of divalent or trivalent cobalt complexes with indomethacin

The interaction of cobalt chloride with the non-steroidal anti-inflammatory drug indomethacin (Hindo) led to the formation of the polymeric complex [Co(indo-O)2(H2O)2(μ-Cl)]n·n(MeOH·H2O) bearing one chlorido bridge between the cobalt atoms. The presence of the nitrogen-donor co-ligands 2,2'-bipyridine (bipy), 2,2'-bipyridylamine (bipyam), 1,10-phenanthroline (phen) or 1H-imidazole (Himi) resulted in the isolation of complexes [Co2(μ-indo-O,O')2(indo-O)2(bipy)2(μ-H2O)]·3.3MeOH, [Co(indo-O,O')2(bipyam)]·0.9MeOH·0.2H2O, [Co(indo-O,O')2(phen)] (4) and [Co(indo-O)2(Himi)2] (5), respectively, where the indomethacin ligands were coordinated in diverse manners. The study of the affinity of the complexes for calf-thymus DNA revealed their intercalation between the DNA-bases. The binding of the complexes to albumins was also examined and the corresponding binding constants and binding subdomain were determined. The free radical scavenging activity of the compounds was evaluated towards 1,1-diphenyl-picrylhydrazyl and 2,2'-azinobis(3-ethylbenzothiazoline-6-sulfonic acid). Molecular modeling calculations may usually provide a molecular basis for the understanding of both the impairment of DNA by its binding with the studied complexes and the ability of these compounds to transportation through serum albumin proteins. This study can provide information for the elucidation of the mechanism of action of the compounds in a molecular level.