Debra K. Weiner

An interdisciplinary expert consensus statement on assessment of pain in older persons

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study.

&NA; The objectives of this pilot study were to assess the feasibility of recruitment and adherence to an eight‐session mindfulness meditation program for community‐dwelling older adults with chronic low back pain (CLBP) and to develop initial estimates of treatment effects. It was designed as a randomized, controlled clinical trial. Participants were 37 community‐dwelling older adults aged 65 years and older with CLBP of moderate intensity occurring daily or almost every day. Participants were randomized to an 8‐week mindfulness‐based meditation program or to a wait‐list control group. Baseline, 8‐week and 3‐month follow‐up measures of pain, physical function, and quality of life were assessed. Eighty‐nine older adults were screened and 37 found to be eligible and randomized within a 6‐month period. The mean age of the sample was 74.9 years, 21/37 (57%) of participants were female and 33/37 (89%) were white. At the end of the intervention 30/37 (81%) participants completed 8‐week assessments. Average class attendance of the intervention arm was 6.7 out of 8. They meditated an average of 4.3 days a week and the average minutes per day was 31.6. Compared to the control group, the intervention group displayed significant improvement in the Chronic Pain Acceptance Questionnaire Total Score and Activities Engagement subscale (P = .008, P = .004) and SF‐36 Physical Function (P = .03). An 8‐week mindfulness‐based meditation program is feasible for older adults with CLBP. The program may lead to improvement in pain acceptance and physical function.

Functional reach: a marker of physical frailty.

To establish the concurrent validity of our new balance instrument, functional reach (FR = maximal safe standing forward reach), as a marker of physical frailty compared with other clinical measures of physical performance.

The impact of chronic low back pain on older adults: A comparative study of patients and controls

Abstract Chronic low back pain (CLBP) is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. Many older adults remain quite functional despite CLBP, and because age‐related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain‐free. Three hundred twenty cognitively intact participants (162 with ⩾moderate pain for ⩾3 months, and 158 pain‐free) underwent comprehensive assessment of pain severity, medical comorbidity (illnesses, body mass index, medications), severity of degenerative disc and facet disease, lumbar flexion, psychological constructs (self‐efficacy, mood, overall mental health), and self‐reported as well as performance‐based physical function. Significant differences were ascertained for all 22 measures. Discriminant function analysis revealed that eight measures uniquely maximized the separation between the two groups (self‐reported function with the Functional Status Index and the SF‐36, performance‐based function with repetitive trunk rotation and functional reach, mood with the Geriatric Depression Scale, comorbidity with the Cumulative Illness Rating Scale and BMI, and severity of degenerative disc disease). These results should help to guide investigators that perform studies of CLBP in older adults and practitioners that want an easily adaptable battery for use in clinical settings.

“I felt like a new person.” The effects of mindfulness meditation on older adults with chronic pain: qualitative narrative analysis of diary entries

UNLABELLED To identify the effects of mindfulness meditation on older adults with chronic low back pain (CLBP), we conducted a qualitative study based on grounded theory and used content analysis of diary entries from older adults who had participated in a clinical trial of an 8-week mindfulness meditation program. Participants were 27 adults > or = 65 years of age with CLBP of at least moderate severity and of at least 3 months duration. We found several themes reflecting the beneficial effects of mindfulness meditation on pain, attention, sleep, and achieving well-being. Various methods of pain reduction were used, including distraction, increased body awareness leading to behavior change, better pain coping, and direct pain reduction through meditation. Participants described improved attention skills. A number of participants reported improved sleep latency as well as quality of sleep. Participants described achieving well-being during and after a meditation session that had immediate effects on mood elevation but also long-term global effects on improved quality of life. Several themes were identified related to pain reduction, improved attention, improved sleep, and achieving well-being resulting from mindfulness meditation that suggest it has promising potential as a nonpharmacologic treatment of chronic pain for older adults. PERSPECTIVE Community-dwelling older adults with chronic low back pain experience numerous benefits from mindfulness meditation including less pain, improved attention, better sleep, enhanced well-being, and improved quality of life. Additional research is needed to determine how mindfulness meditation works and how it might help with other chronic illnesses.

Effects of Central Nervous System Polypharmacy on Falls Liability in Community-Dwelling Elderly

Background: While central nervous system (CNS) active medications such as psychotropics and narcotic analgesics have been implicated in contributing to falls in older adults, the combined effect of multiple CNS-active medications has not been investigated. The purpose of this study was to examine the influence, in community-dwelling elderly, of (1) taking multiple CNS-active medications on fall liability and (2) individual classes of CNS-active medications (using discrete drug classification) on the risk of falls after controlling for important confounders – age, mobility, cognition and depression. Methods: 305 community-dwelling male veterans (age: 70–104) were screened at study entry for mobility, cognition and depression. CNS-active medications were categorized as benzodiazepines, other sedative-hypnotics, neuroleptics, tricyclic antidepressants, and opioid analgesics. Subjects were prospectively followed for 6 months to monitor falls; at the end of this time period, subjects were classified as fallers (at least one fall) or nonfallers. The relationship between CNS-active drug use and falls was examined using multivariable analyses. Results: The risk of falls was significantly greater in CNS-active medication users as compared with nonusers. Adjusted odds ratio for one CNS-active drug was 1.54 (95% confidence interval 1.07–2.22) and for two or more agents 2.37 (95% confidence interval 1.14–4.94). Conclusions: In community-dwelling elderly, the use of multiple CNS-active medications is associated with enhanced falls liability, over and above the use of one CNS-active drug alone. This apparent dose-response relationship provides support for causality.

Degenerative Lumbar Disc and Facet Disease in Older Adults: Prevalence and Clinical Correlates

Study Design. A case-control study of older adults with and without chronic low back pain (CLBP). Objective. Compare and describe the radiographic severity of degenerative disc and facet disease in the lumbosacral spine of community-dwelling older adults with and without CLBP and to examine the relationship between spinal pathology and pain. Summary of Background Data. Degenerative spinal pathology is often implicated as the primary reason for CLBP in older adults. Despite evidence that spinal pathology may be ubiquitous in older adults regardless of pain status, radiography continues to be heavily used in the diagnostic process. Methods. Participants in this case-control study included 162 older adults (≥65) with CLBP and an age and gender matched pain-free group of 158 people. CLBP was characterized as pain of at least moderate intensity occurring daily or almost everyday for at least 3 months. Radiographic severity of disc and facet disease was graded using a reliable and valid system. Results. Results demonstrated that the presence of degenerative disc and facet pathology in older adults is ubiquitous, regardless of clinical status, with greater than 90% demonstrating some level of degeneration. Higher radiographic severity scores were associated with the presence of CLBP. In fact, presence of severe disc pathology was associated with 2-fold greater odds of having CLBP. But, radiographic severity of disc and facet disease was not associated with pain severity among those with CLBP. Conclusion. From a research perspective, radiographic evaluation of spinal pathology provides additional information about older adults with CLBP compared to pain-free individuals, but its clinical utility for diagnostic purposes is still in question.

Does functional reach improve with rehabilitation

Functional reach (FR, maximal safe standing forward reach) is a precise, reliable, clinically accessible, age-sensitive measure of balance that approximates center of pressure excursion and validly estimates physical frailty. We now test its ability to detect improvement in balance over time. Twenty-eight inpatient male veterans (age 40 to 105, mean, 67.3) undergoing physical rehabilitation and 13 nonrehabilitation controls were evaluated at baseline and every 4 weeks using FR (yardstick method), 10-foot walking time (WT), the Duke hierarchical mobility skills protocol (HMS) and a portion of the Functional Independence Measure (FIM). Their sensitivity to change was determined using the responsiveness index (RI). FR as well as the other physical performance instruments tested were found to be sensitive to change (RI for FR = 0.97, WT = 11.26, HMS = 4.63, FIM = 4.93) and therefore, appropriate measures for use in prospective clinical trials.

Chronic Pain Is Associated with Brain Volume Loss in Older Adults: Preliminary Evidence

OBJECTIVES The primary aim of this pilot investigation was to identify structural brain differences in older adults with chronic low back pain (CLBP) as compared with pain-free individuals. DESIGN Cross-sectional, case-control. PARTICIPANTS Sixteen cognitively intact older adults, eight with CLBP and eight pain-free; excluded if with psychiatric or neurological disorders, substance abuse, opioid use, diabetes mellitus, and/or hypertension. METHODS Brain magnetic resonance imaging (MRI) and tests of neuropsychological performance (digit span, digit symbol substitution, letter-number sequencing, trail making) were administered to all participants. Gray matter (GM), white matter (WM), cerebrospinal fluid, and corpus callosum (CC) volumes were measured as a percentage of total supratentorial intracranial volume. Voxel-based morphometry analysis of GM and WM assessed regional differences. RESULTS Between-groups analysis revealed a non-significant trend toward decreased middle CC volume in the CLBP group (1.43E-03 +/- 2.67E-04, 1.63E-03 +/- 2.00E-04: P = 0.09). Regional analysis in the CLBP group demonstrated significantly decreased GM volume (P < 0.001) in the posterior parietal cortex and middle cingulate WM volume (P < 0.001) of the left hemisphere. CLBP participants performed significantly worse on digit span forward (P = 0.03). CONCLUSIONS Older adults with CLBP have structural brain changes in the middle CC, middle cingulate WM, and the GM of the posterior parietal cortex as well as impaired attention and mental flexibility. Additional investigation is needed to corroborate and extend these findings and more clearly elucidate their relationship to physical function and the risk of disability.

Pain in nursing home residents: management strategies.

Pain is prevalent and undertreated in nursing home residents, despite the existing wide array of effective pharmacological and nonpharmacological treatment modalities. In order to improve the quality of life of these vulnerable individuals, practitioners require education about the correct approach to assessment and management. Assessment should be comprehensive, taking into account the basic underlying pathology (e.g. osteoarthritis, osteoporosis, peripheral neuropathy, fibromyalgia, cancer) as well as other contributory pathology (e.g. muscle spasm, myofascial pain) and modifying comorbidities (e.g. depression, anxiety, fear, sleep disturbance). Pharmacological management should be guided by a stepped-care approach, modelled after that recommended by the World Health Organization for treatment of cancer pain. Nonopioid and opioid analgesics are the cornerstone of pharmacological pain management. Tricyclic antidepressants and anticonvulsants can be very effective for the treatment of certain types of neuropathic pain. In addition to treating the pain per se, attention should be given to prevention of disease progression and exacerbation, as maintaining function is of prime importance. Nursing home residents with severe dementia challenge the practitioner’s pain assessment skills; an empirical approach to treatment may sometimes be warranted. The success of treatment should be measured by improvement in pain intensity as well as physical, psychosocial and cognitive function. Effective pain management may impact any or all of these functional domains and, therefore, substantially improve the nursing home resident’s quality of life.