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Microsoft PowerPoint - NARI 2008-2.ppt [Read-Only ...

  1. 1. 1 What is different about pain in older persons? Stephen Gibson Deputy Director National Ageing Research Institute, Prof, Department of Medicine, University of Melbourne, email: s.gibson@nari.unimelb.edu.au • Why should we be interested in pain in older persons? • Does age modify the experience of pain? • Age differences in the psychosocial impacts of chronic pain. • Reasons for age differences –Neurophysiology (axon flare, fMRI studies) –Psychological (coping, pain attitudes) –Age associated (social factors)
  2. 2. 2 Age 908070605040302010 50 40 30 20 7-37% 17- 50% 25-65% 25-56% Pain prevalence across the life-span Prevalence of Radiographic OA 0 25 50 75 100 Hands Knees Feet Prevalence(%) 18-24 25-34 35-44 45-54 55-64 65-74 75-79 Age Range (years) NHANES Study 1993
  3. 3. 3 The absence of pain Intensity presenting symptoms of pain Pneumonia (74% vs 45%) ? Arthritis (approx 50%) ? 10% Malignancy (1.5-4.0 less likely) 15% Myocardial (42% vs 18%) 15-20% Studies of age and clinical pain Gibson (2007), Rev Neurotherap., 7, 627-635
  4. 4. 4 Silent Exertional Myocardial Ischemia • Exercise induced 1mm drop in the ST segment of the ECG = myocardial ischemia. • Significant age-related delay in the onset of pain report from the time of ischemia (r = .41). • Intensity of myocardial pain is reduced or muted in very old adults (85+ yrs). Miller et al. 2001, Ambeteya et al. 1994 Studies of age and clinical pain The absence of Intensity pain symptoms of pain Appendicitis (45% vs 5%) ? Gastric Ulcer (33% vs 11%) 15% Post-operative ? 15%-20% Pain Clinic pts N/A 25% Gibson (2007), Rev Neurotherap., 7, 627-635
  5. 5. 5 MPQS MPQA VAS WDS 2 4 6 8 10 12 14 16 18 * * * PainScore 18-39 (n=191) 40-59 y (n=199) 60-79 y (n=250) 80+ y (n=128) Self-rated pain in chronic pain patients Gibson (2003) Proc Pain Manage Res., 10, 433-456. “But Dr, I can’t learn to live with it!”
  6. 6. 6 Age and mood disturbance Depression Anxiety 10 20 30 40 50 18-39 y 40-59 y 60-79 y 80 + y Score * ** ** Yong, Bell, Workman, Gibson (2003), PAIN, 104, 673-681 Age and mood disturbanceAge and mood disturbance Depression Anxiety 10 20 30 40 50 18-39 y 40-59 y 60-79 y 80 + y Score * ** ** Yong, Bell, Workman, Gibson (2003), PAIN, 104, 673-681 40-59 18-39 60-79 80+ Physical Dimension Psychosocial Dimension Score * Age and functional disabilityAge and functional disability 40-59 18-39 60-79 80+ Physical Dimension Psychosocial Dimension Score *
  7. 7. 7 Possible reasons for age differences in pain report and impact • Age differences in pain neurophysiology. • Alterations in pain coping, beliefs and attitudes. • More indirect, secondary age associated influences (eg. comorbidity, bereavement) . EndotheliumEndothelium SP, NKA, CGRP etc.SP, NKA, CGRP etc. releasedreleased Mast CellsMast Cells VDVD PEPE SYMPATHETICSYMPATHETIC NEURONNEURON SPINAL CORDSPINAL CORD SENSORY NEURONSENSORY NEURON SKIN NERVESKIN NERVE ENDINGSENDINGS Axon Reflex Flare Response Tissue Damage
  8. 8. 8 Age-related change in axon flare 1mV 2mV 3mV 20 40 60 80 100 R = .78** Years n = 122 Gibson. Age Aging, 2006, 30, 124-28 Age Differences in Pain CNS Processing Widespread changes in CNS morphology and neurochemistry with advancing age, including areas known to be involved with pain processing (Gibson & Farrell 2004). Two recent MRI studies have shown CNS structural changes in older persons with chronic pain (Oosterman et al. 2006, Buckalew et al. 2008). To date, no studies have examined age differences in CNS pain processing using state of the art neuroimaging techniques. Background
  9. 9. 9 To investigate age differences in supraspinal pain processing using fMRI after correcting for any age- related brain atrophy. Aims… Participants: N (Male/ Female) Age (Mean ± SD ) MMSE# Score /30 (Mean ± SD ) Young 15 (7/8) 26 ± 3 29.42 ± 0.66 Older 15 (6/9) 79 ± 4 29.38± 0.87 * p < .0001 Methods # Folstein’s Mini Mental State Examination Normal score: ≥ 24
  10. 10. 10 Innocuous Pressure Painful Pressure Mechanical Pressure Stimulator Stimulus: Methods (a) Pain Intensity (b) Pain Unpleasantness Methods: Gracely Box Scales 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 WEAK VERY MILD MILD VERY WEAK FAINT NO PAIN SENSATION MODERATE BARELY STRONG SLIGHTLY INTENSE STRONG INTENSE VERY INTENSE EXTREMELY INTENSE 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 NEUTRAL ANNOYING DISTRESSING VERY ANNOYING VERY DISTRESSING INTOLERABLE VERY INTOLERABLE SLIGHTLY UNPLEASANT SLIGHTLY ANNOYING SLIGHTLY DISTRESSING SLIGHTLY INTOLERABLE UNPLEASANT
  11. 11. 11 Mechanical Pain Thresholds Cole et al. Neurobiol of Aging 2008 Pain stimulus Methods Part 2. Functional Brain Imaging
  12. 12. 12 NO WP MP IP 24 54 78 108 132 162 186 216 240 270 294 324 348 378 402 StimulusIntensity Time (Seconds) Run 3 Run 1 Run 2 Methods 2. Functional Brain Imaging NO: no stimulus IP: innocuous pressure WP: weak pain MP: moderate pain Methods 2. Functional Brain Imaging 36 axial slices per brain volume time Slice thickness = 4mm Voxel size 3.5mm 3.5 mm 4mm Acquisition parameters
  13. 13. 13 Prefrontal Cx Insula Insula Primary Motor Cx Putamen SI SII Anterior Cingulate Medial Thalamus Cole et al. Neurobiol of Aging 2008 Age differences in fMRI response Putamen and Caudate Cole et al. Neurobiol of Aging 2008
  14. 14. 14 Results demonstrate a common pain-related CNS activation pattern regardless of age. Older persons showed a significant reduction in striatal activation following painful stimulation. • Impaired coordination of inhibitory motor responses? • Impaired endogenous pain modulation? May help explain observed age differences in pain tolerance and/or increased prevalence of chronic pain in older people. Conclusions Future Directions Need for longitudinal ageing studies. Develop the potential diagnostic and assessment capacity of neuroimaging. Further examination of age differences in pain processing and particularly in pain modulation. Neuroimaging of pathophysiologic pain in older persons (neural plasticity, chronic pain).
  15. 15. 15 Possible reasons for age differences in pain report and impact • Age differences in pain neurophysiology. • Alterations in pain coping, beliefs and attitudes. • More indirect, secondary age associated influences (eg. comorbidity, bereavement) . Coping Strategies Questionnaire • Self coping statements I see it as a challenge and I can beat this. • Ignoring sensation I tell myself it doesn’t hurt. • Diverting attention I think of things I enjoy doing. • Praying and hoping I rely on my faith in God. • Increasing behavioural activities I do something active, like household chores. • Catastrophising It is awful and I feel that it overwhelms me. • Reinterpreting the sensation I think of it as some other sensation, like numbness. Rosenstiel & Keefe 1983
  16. 16. 16 Age differences in coping strategy use ** Corran & Gibson 1994 * P < 0.01 (N = 297) PAINCLINICRESEARCHPAINCLINICRESEARCH COPINGSTRATEGIESCOPINGSTRATEGIES * P < 0.01 (N= 297) 18 - 49 40 - 59 60 - 79 80+ Ignoring Pain Sensation Praying and Hoping ** Relationship between coping strategy use and levels of pain, mood and disability Young Older (60+) -ve Catastrophising (15-30%) Catastrophising (12-30%) Reinterpreting (3-5%) Diverting attention (4%) +ve Ignoring (2-4%) Coping statements (5-9%) High self efficacy (9%) High self efficacy (11%) Corran & Gibson Prog Pain Res Manag 1994, 2, 895-906.
  17. 17. 17 Pain attitudes and age Pain Attitudes Questionnaire STOICISM Fortitude Get on with life despite pain No good complaining Concealment: Keep pain to self Hide pain from others Superiority I control my pain better than others I can tolerate more pain CAUTIOUSNESS Self doubt I don’t trust myself to make pain judgements I lack confidence in labelling pain sensations Reluctance to label as pain I am often reluctant to call something painful I need to be certain before reporting pain Yong, Bell, Workman, Gibson (2003), Pain, 104, 673-681
  18. 18. 18 Age and pain attitudes * * Fortitude Concealment Superiority Self-doubt Reluctance 1.5 2.0 2.5 3.0 3.5 4.0 4.5 < 40yrs 40-59yrs 60-79yrs 80+yrs* * Stoicism and Cautiousness Subscales MeanPAQ-Rscores Relationship between PAQ attitudes and the levels of pain, mood and disability MPQ-S MPQ-A Depress Anxiety Disability Stoic: -Fortitude -.29** -.14* -.51** -.39** -.18* -Concealment -.07 -.01 .27 ** .27 ** -.01 -Superiority -.04 -.04 -.11 -.18 * -.02 Cautious: -Self-doubt -.06 -.03 -.04 .10 .05 -Reluctance -.03 -.04 -.02 .08 .03
  19. 19. 19 Effect of age versus PAQ on pain adjustment • MPQ-S Age -.242 ** • Stoic-Fortitude -.265 ** Age -.072 NS Depression Age -.366 *** • Stoic-Fortitude -.415 *** Stoic-Concealment .231 * Age -.206 * Disability Age -.085 NS • Stoic-Fortitude -.274 ** Age -.001 NS * p<.05 ** p<.01 *** p<.001 Possible reasons for age differences in pain report and impact • Age differences in pain neurophysiology. • Alterations in pain coping, beliefs and attitudes. • More indirect, secondary age associated influences (eg. comorbidity, bereavement) .
  20. 20. 20 Spousal support Age-related social factors and pain Socio-demographic factors Odds ratio Report of any pain Activity limiting pain Moderate-severe pain Female Living alone Widow(er) Widow(er) 1.3 (1.0-1.7) 1.5 (1.1-1.9) 1.5 (1.1-1.9) 3.4 (1.6-5.8) Other non-significant factors in the logistic regression include: educational level, living status, social support, income. Bradbeer et al. Clin J. Pain, (2003), 19, 247-254.
  21. 21. 21 Path analysis of spousal bereavement- depression-pain severity nexus Bradbeer et al. Clin J. Pain, (2003), 19, 247-254. Spousal bereavement Pain severity Depression .17** Spousal bereavement Pain severity Depression -.01 Never try to teach a pig to sing! “.....it wastes your time, and it annoys the pig”

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