Elizabeth J. Dansie

Prevalence and impact of pain among older adults in the United States: Findings from the 2011 National Health and Aging Trends Study

Summary Bothersome pain afflicts half of the community‐dwelling US older adult population and is associated with significant reduction in physical function, particularly in those with multisite pain. Abstract This study sought to determine the prevalence and impact of pain in a nationally representative sample of older adults in the United States. Data from the 2011 National Health and Aging Trends Study were analyzed. In‐person interviews were conducted in 7601 adults ages ≥65 years. The response rate was 71.0% and all analyses were weighted to account for the sampling design. The overall prevalence of bothersome pain in the last month was 52.9%, afflicting 18.7 million older adults in the United States. Pain did not vary across age groups (P = 0.21), and this pattern remained unchanged when accounting for cognitive performance, dementia, proxy responses, and residential care living status. Pain prevalence was higher in women and in older adults with obesity, musculoskeletal conditions, and depressive symptoms (P < 0.001). The majority (74.9%) of older adults with pain endorsed multiple sites of pain. Several measures of physical capacity, including grip strength and lower‐extremity physical performance, were associated with pain and multisite pain. For example, self‐reported inability to walk 3 blocks was 72% higher in participants with than without pain (adjusted prevalence ratio 1.72 [95% confidence interval 1.56–1.90]). Participants with 1, 2, 3, and ≥4 sites of pain had gait speeds that were 0.01, 0.03, 0.05, and 0.08 meters per second slower, respectively, than older adults without pain, adjusting for disease burden and other potential confounders (P < 0.001). In summary, bothersome pain in the last month was reported by half of the older adult population of the United States in 2011 and was strongly associated with decreased physical function.

Conditions Comorbid with Chronic Fatigue in a Population-Based Sample

BACKGROUND Chronic fatigue syndrome (CFS) has been found to be comorbid with various medical conditions in clinical samples, but little research has investigated CFS comorbidity in population-based samples. OBJECTIVE This study investigated conditions concurrent with a CFS-like illness among twins in the population-based Mid-Atlantic Twin Registry (MATR), including chronic widespread pain (CWP), irritable bowel syndrome (IBS), and major depressive disorder (MDD). METHOD A survey was mailed to participants in the MATR in 1999. Generalized estimating equations were used to estimate odds ratios to assess associations between CFS-like illness and each comorbid condition. RESULTS A total of 4590 completed surveys were collected. Most participants were female (86.3%); mean age was 44.7 years. Among participants with a CFS-like illness, lifetime prevalences of CWP, IBS, and MDD were 41%, 16%, and 57% respectively. Participants reporting at least one of the three comorbid conditions were about 14 times more likely to have CFS-like illness than those without CWP, IBS, or MDD (95% confidence interval 8.1%-21.3%). Only MDD showed a temporal pattern of presentation during the same year as diagnosis of CFS-like illness. Age, gender, body mass index, age at illness onset, exercise level, self-reported health status, fatigue symptoms, and personality measures did not differ between those reporting CFS-like illness with and without comorbidity. CONCLUSION These results support findings in clinically based samples that CFS-like illness is frequently cormorbid with CWP, IBS, and/or MDD. We found no evidence that CFS-like illnesses with comorbidities are clinically distinct from those without comorbidities.

Redesigning Delivery of Opioids to Optimize Pain Management, Improve Outcomes, and Contain Costs

INTRODUCTION Chronic pain is a public health concern, and in the last decade, there has been a dramatic increase in the use and abuse of prescription opioids for chronic non-cancer pain. METHODS We present an overview of a five-component model of pain management implemented at the University of Washington Division of Pain Medicine designed to facilitate recent state guidelines to reduce the risks associated with long-term use of prescription opioids. RESULTS Central to the model described are guidelines for best clinical practice, a collaborative care approach, telehealth solutions, comprehensive prescription-monitoring, and measurement-based care. DISCUSSION The model presented is a patient-centered, efficient, and cost-effective approach to the management of chronic pain.

The Role of Fear of Movement in Subacute Whiplash-Associated Disorders Grades I and II

Summary Fear of movement plays and important role in individuals with subacute whiplash‐associated disorders and it should be directly targeted in treatment. ABSTRACT Fear and avoidance of activity may play a role in fostering disability in whiplash‐associated disorders (WAD). This study examined the role of fear after WAD and assessed the effectiveness of 3 treatments targeting fear. People still symptomatic from WAD grade I‐II injuries approximately 3 months previously (n = 191) completed questionnaires (eg, Neck Disability Index [NDI]) and were randomized to 1 of the treatments: (1) informational booklet (IB) describing WAD and the importance of resuming activities, (2) IB + didactic discussions (DD) with clinicians reinforcing the booklet, and (3) IB + imaginal and direct exposure desensitization (ET) to feared activities. DD and ET participants received three 2‐hour treatment sessions. Absolute improvements in NDI were in predicted direction (ET = 14.7, DD = 11.9, IB = 9.9). ETs reported significantly less posttreatment pain severity compared with the IB (Mean = 1.5 vs 2.3, P < .001, d = 0.6) and DD (M = 1.5 vs 2.0, P = .039, d = 0.6) groups. Reduction in fear was the most important predictor of improvement in NDI (β = 0.30, P < .001), followed by reductions in pain (β = 0.20, P = .003) and depression (β = 0.18, P = .004). The mediational analysis confirmed that fear reduction significantly mediated the effect of treatment group on outcome. Results highlight the importance of fear in individuals with subacute WAD and suggest the importance of addressing fear via exposure therapy and/or educational interventions to improve function.

Association of Chronic Widespread Pain With Objectively Measured Physical Activity in Adults: Findings From the National Health and Nutrition Examination Survey

UNLABELLED Chronic widespread pain (CWP) is a common and potentially debilitating disorder. Patterns of physical activity (PA) in adults with CWP have primarily been investigated using subjective, self-report measures. The current study sought to characterize PA among community-dwelling individuals with CWP, chronic regional pain, or no chronic pain using objective measurements obtained via accelerometry in the 2003 to 2004 National Health and Nutrition Examination Survey. Data from 3,952 participants ages 20 and older were analyzed to assess relationships between pain status and objective measurements of PA. Prevalence of CWP was 3.3% and 5.4% in men and women, respectively. In men and women, the average activity counts per minute and time spent in moderate-to-vigorous PA were significantly lower for the CWP group than for the no chronic pain group. Interestingly, time spent in sedentary, light, and lifestyle activities was not associated with pain status. Statistical interaction tests indicated that the effects of chronic pain on counts per minute were stronger in men than in women. Despite recommendations for increased moderate-to-vigorous PA as a pain management strategy for CWP, results from this nationally representative study indicate that adults with CWP participate in less moderate-to-vigorous PA than individuals without chronic pain. PERSPECTIVE Using objective measurement of PA in a nationally representative sample, this study demonstrates that adults with CWP participate in reduced daily and moderate-to-vigorous PA in comparison to people with no chronic pain. Findings indicate that clinicians should emphasize the importance of increasing PA in patients with CWP.

Chronic Fatigue and Personality: A Twin Study of Causal Pathways and Shared Liabilities

BackgroundThe etiology of chronic fatigue syndrome (CFS) remains unknown. Personality traits influence well-being and may play a role in CFS and unexplained chronic fatigue.PurposeThis study aimed to examine the association of emotional instability and extraversion with chronic fatigue and CFS in a genetically informative sample.MethodsWe evaluated 245 twin pairs for two definitions of chronic fatigue. They completed the Neuroticism and Extraversion subscales of the NEO Five Factor Inventory. Using a co-twin control design, we examined the association between personality and chronic fatigue.ResultsHigher emotional instability was associated with both definitions of chronic fatigue and was confounded by shared genetics. Lower extraversion was also associated with both definitions of fatigue, but was not confounded by familial factors.ConclusionsBoth emotional instability and extraversion are related to chronic fatigue and CFS. Whereas emotional instability and chronic fatigue are linked by shared genetic mechanisms, the relationship with extraversion may be causal and bidirectional.

The Comorbidity of Self-Reported Chronic Fatigue Syndrome, Post-Traumatic Stress Disorder, and Traumatic Symptoms

BACKGROUND Data from primary care and community samples suggest higher rates of post-traumatic stress disorder (PTSD) among individuals with chronic fatigue syndrome (CFS). OBJECTIVE This study investigated the co-occurrence of CFS, PTSD, and trauma symptoms and assessed the contribution of familial factors to the association of CFS with lifetime PTSD and current traumatic symptoms. METHOD Data on lifetime CFS and PTSD, as measured by self-report of a doctors diagnosis of the disorder, and standardized questionnaire data on traumatic symptoms, using the Impact of Events Scale (IES), were obtained from 8544 female and male twins from the community-based University of Washington Twin Registry. RESULTS Lifetime prevalence of CFS was 2% and lifetime prevalence of PTSD was 4%. Participants who reported a history of PTSD were over eight times more likely to report a history of CFS. Participants with scores ≥ 26 on the IES were over four times more likely to report CFS than those who had scores ≤ 25. These associations were attenuated but remained significant after adjusting for familial factors through within-twin pair analyses. CONCLUSION These results support similar findings that a lifetime diagnosis of CFS is strongly associated with both lifetime PTSD and current traumatic symptoms, although familial factors, such as shared genetic and environmental contributions, played a limited role in the relationship between CFS, PTSD, and traumatic symptoms. These findings suggest that future research should investigate both the familial and the unique environmental factors that may give rise to both CFS and PTSD.

Salivary Cortisol and Cold Pain Sensitivity in Female Twins

BackgroundThere is a dearth of knowledge about the link between cortisol and pain sensitivity.PurposeWe examined the association of salivary cortisol with indices of cold pain sensitivity in 198 female twins and explored the role of familial confounding.MethodsThree-day saliva samples were collected for cortisol levels and a cold pressor test was used to collect pain ratings and time to threshold and tolerance. Linear regression modeling with generalized estimating equations examined the overall and within-pair associations.ResultsLower diurnal variation of cortisol was associated with higher pain ratings at threshold (p = 0.02) and tolerance (p < 0.01). The relationship of diurnal variation with pain ratings at threshold and tolerance was minimally influenced by familial factors (i.e., genetics and common environment).ConclusionsUnderstanding the genetic and non-genetic mechanisms underlying the link between HPA axis dysregulation and pain sensitivity may help to prevent chronic pain development and maintenance.

Genetic and environmental influences on residential location in the US

We used a classical twin design and measures of neighborhood walkability and social deprivation, using each twins street address, to examine genetic and environmental influences on the residential location of 1389 same-sex pairs from a US community-based twin registry. Within-pair correlations and structural equation models estimated these influences on walkability among younger (ages 18-24.9) and older (ages 25+) twins. Adjusting for social deprivation, walkability of residential location was primarily influenced by common environment with lesser contributions of unique environment and genetic factors among younger twins, while unique environment most strongly influenced walkability, with small genetic and common environment effects, among older twins. Thus, minimal variance in walkability was explained by shared genetic effects in younger and older twins, and confirms the importance of environmental factors in walkability of residential locations.

Pain among older hispanics in the United States

BACKGROUND Previous studies suggest that acculturation may influence the experience of pain. STUDY DESIGN We conducted a cross-sectional study to estimate the association between acculturation and the prevalence, intensity, and functional limitations of pain in older Hispanic adults in the United States. METHODS SUBJECTS Participants were English- (HE) and Spanish-speaking (HS) Hispanic and non-Hispanic White (NHW) individuals aged 50 years and older who were interviewed for the Health and Retirement Study during 1998-2008. MEASURES We measured: 1) acculturation as defined by language used in interviews, and 2) the presence, intensity, and functional limitations of pain. ANALYSIS We applied logistic regression using generalized estimating equations, with NHW as the reference category. RESULTS Among 18,593 participants (16,733 NHW, 824 HE, and 1,036 HS), HS had the highest prevalence (odds ratio [OR] = 1.3; 95% confidence interval [CI  = 1.1-1.4) and intensity (OR = 1.6; 95% CI = 1.4-1.9) of pain, but these differences were not significant after adjusting for age, sex, years of education, immigration status (U.S.- vs non-U.S-born), and health status (number of health conditions). Even after adjustment, HS reported the lowest levels of functional limitation (OR = 0.7; 95% CI 0.6-0.9). CONCLUSION Pain prevalence and intensity were not related to acculturation after adjusting for sociodemographic factors, while functional limitation was significantly lower among HS even after adjusting for known risk factors. Future studies should explore the reasons for this difference.