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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: [email protected]
• 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
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
Pre
vale
nce
(%
)
18-24 25-34 35-44 45-54 55-64 65-74 75-79
Age Range (years)
NHANES Study 1993
3
The absence of pain Intensitypresenting 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
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 Intensitypain 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
MPQS MPQA VAS WDS
2
4
6
8
10
12
14
16
18
* *
*
Pain Score
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
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
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
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
� 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
Older15
(6/9)79 ± 4 29.38± 0.87
* p < .0001
Methods
# Folstein’s Mini Mental State Examination
Normal score: ≥ 24
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
Mechanical Pain Thresholds
Cole et al. Neurobiol of Aging 2008
Pain
stimulus
Methods
Part 2. Functional Brain Imaging
12
NO
WP
MP
IP
24 54 78 108 132 162 186 216 240 270 294 324 348 378 402
Stimulus Intensity
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
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
�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
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
Age differences in coping strategy use
**
Corran & Gibson 1994
* P < 0.01 (N = 297)
PAIN CLINIC RESEARCHPAIN CLINIC RESEARCH
COPING STRATEGIESCOPING STRATEGIES
* 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
Pain attitudes and age
Pain Attitudes Questionnaire
STOICISM
FortitudeGet on with life despite pain
No good complaining
Concealment:Keep pain to self
Hide pain from others
SuperiorityI control my pain better than others
I can tolerate more pain
CAUTIOUSNESS
Self doubtI don’t trust myself to make pain
judgements
I lack confidence in labelling pain sensations
Reluctance to label as painI 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
Age and pain attitudes
* *
Fortitude Concealment Superiority Self-doubt Reluctance1.5
2.0
2.5
3.0
3.5
4.0
4.5
< 40yrs
40-59yrs
60-79yrs
80+yrs*
*
Stoicism and Cautiousness Subscales
MeanPAQ-R scores
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
Effect of age versus PAQ on pain adjustment
• MPQ-SAge -.242 **
• Stoic-Fortitude -.265 ** Age -.072 NS
Depression Age -.366 ***
• Stoic-Fortitude -.415 *** Stoic-Concealment .231 * Age -.206 *
DisabilityAge -.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
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
Path analysis of spousal bereavement-
depression-pain severity nexus
Bradbeer et al. Clin J. Pain, (2003), 19, 247-254.
Spousal
bereavementPain severity
Depression
.17**
Spousal
bereavementPain severity
Depression
-.01
Never try to teach a pig to
sing!
“.....it wastes your time,
and it annoys the pig”