Stephanie S. Leone

Pain, not chronic disease, is associated with the recurrence of depressive and anxiety disorders

BackgroundStudies suggest that poor physical health might be associated with increased depression and anxiety recurrence. The objectives of this study were to determine whether specific chronic diseases and pain characteristics are associated with depression and anxiety recurrence and to examine whether such associations are mediated by subthreshold depressive or anxiety symptoms.Methods1122 individuals with remitted depressive or anxiety disorder (Netherlands Study of Depression and Anxiety) were followed up for a period of four years. The impact of specific chronic diseases and pain characteristics on recurrence was assessed using Cox regression and mediation analyses.ResultsChronic diseases were not associated with recurrence. Neck (HR 1.45, p < .01), chest (HR 1.65, p < .01), abdominal (HR 1.52, p < .01) pain, an increase in the number of pain locations (HR 1.10, p < .01) and pain severity (HR 1.18, p = .01) were associated with an increased risk of depression recurrence but not anxiety. Subthreshold depressive symptoms mediated the associations between pain and depression recurrence.ConclusionsPain, not chronic disease, increases the likelihood of depression recurrence, largely through its association with aggravated subthreshold depressive symptoms. These findings support the idea of the existence of a mutually reinforcing mechanism between pain and depression and are indicative of the importance of shedding light on neurobiological links in order to optimize pain and depression management.

Functional outcome in older adults with joint pain and comorbidity: design of a prospective cohort study

BackgroundJoint pain is a highly prevalent condition in the older population. Only a minority of the older adults consult the general practitioner for joint pain, and during consultation joint pain is often poorly recognized and treated, especially when other co-existing chronic conditions are involved. Therefore, older adults with joint pain and comorbidity may have a higher risk of poor functional outcome and decreased quality of life (QoL), and possibly need more attention in primary care. The main purpose of the study is to explore functioning in older adults with joint pain and comorbidity, in terms of mobility, functional independence and participation and to identify possible predictors of poor functional outcome. The study will also identify predictors of decreased QoL. The results will be used to develop prediction models for the early identification of subgroups at high risk of poor functional outcome and decreased QoL. This may contribute to better targeting of treatment and to more effective health care in this population.Methods/DesignThe study has been designed as a prospective cohort study, with measurements at baseline and after 6, 12 and 18 months. For the recruitment of 450 patients, 25 general practices will be approached. Patients are eligible for participation if they are 65 years or older, have at least two chronic conditions and report joint pain on most days. Data will be collected using various methods (i.e. questionnaires, physical tests, patient interviews and focus groups). We will measure different aspects of functioning (e.g. mobility, functional independence and participation) and QoL. Other measurements concern possible predictors of functioning and QoL (e.g. pain, co-existing chronic conditions, markers for frailty, physical performance, psychological factors, environmental factors and individual factors). Furthermore, health care utilization, health care needs and the meaning and impact of joint pain will be investigated from an older persons perspective.DiscussionIn this paper, we describe the protocol of a prospective cohort study in Dutch older adults with joint pain and comorbidity and discuss the potential strengths and limitations of the study.

The longitudinal association of cognitive appraisals and coping strategies with physical functioning in older adults with joint pain and comorbidity: a cohort study

BackgroundSubstantial variation exists in physical functioning (PF) among patients with comparable pain severity, which may be partly explained by underlying psychological processes, like cognitive appraisal of pain and coping with pain. It remains unclear to what extent such determinants contribute to changes in PF over time, especially in older populations. Therefore, we examined longitudinal associations of cognitive appraisals and coping strategies with PF, in older adults with joint pain and comorbidity.MethodsA prospective cohort study among 407 older adults with joint pain and comorbidity provided data over 18 months, with 6 month time-intervals. We measured PF (RAND-36), five cognitive appraisals (consequences, concerns, emotional representations, self-efficacy, catastrophizing), four coping strategies (ignoring pain, positive self-statement, increasing activity levels, activity avoidance) and three time-dependent covariates; pain intensity, anxiety and depressive symptoms. Longitudinal associations were analyzed with Generalized Estimated Equations (GEE), by testing auto-regressive models, adjusted for covariates.ResultsMore negative thoughts about consequences of pain (β = -0.54, 95 % CI = -1.02; -0.06), more catastrophizing (β = -0.67, 95 % CI = -1.26; -0.07) and more activity avoidance (β = -0.32, 95 % CI = -0.57; -0.08) were significantly associated with subsequent deterioration in PF, whereas higher perceived self-efficacy (β = 0.22, 95 % CI = 0.12; 0.31) was associated with subsequent improvement in PF. Neither concerns, emotional representations, ignoring pain, positive self-statement nor increasing activity levels were longitudinally related to PF.ConclusionsMore negative thoughts about consequences of pain, more catastrophizing and more activity avoidance contributed to deteriorated PF, whereas higher perceived self-efficacy contributed to improved PF. This knowledge may contribute to future management of functional limitations in older adults with joint pain and comorbidity.

Frequency, severity and determinants of functional limitations in older adults with joint pain and comorbidity: Results of a cross-sectional study

Older adults with joint pain and comorbidity are especially at risk of becoming functionally impaired. Therefore, we studied the frequency and severity of functional limitations and identified potential modifiable determinants that may reduce functional limitations. A prospective cohort study of older adults (≥65 years) with joint pain and comorbidity provided cross-sectional baseline data (n=407). Based on the International Classification of Functioning, Disability and Health (ICF) model, we measured Physical Functioning; PF, (Instrumental) Activities of Daily Living; (I)ADL, and participation. Apart from examining the frequency and severity, we identified determinants of functional limitations with multivariate regression analyses, by adding determinants in two steps: (1) only physical determinants, (2) physical and psychosocial determinants. Limitations in PF, ADL, IADL and participation were present in 66%, 31%, 61% and 47% of the participants, respectively. About 22% reported limitations on all four measures. Of the physical determinants, especially frailty and higher pain intensity were related to functional limitations. Remarkably, adding psychosocial determinants to the model weakened some of these relations. The psychosocial determinants were especially related to poor PF (i.e. anxiety symptoms, activity avoidance and poor general health perception) and participation restrictions (i.e. depressive symptoms, less social support). An inverse relation was present between self-efficacy and both outcomes. In conclusion, our sample reported substantial levels of functional limitations. More depressive symptoms, more activity avoidance and less social support were indicative of more functional limitations, whereas higher perceived self-efficacy was indicative of better functioning. Such psychosocial determinants should receive more attention in research.

Social participation in older adults with joint pain and comorbidity; testing the measurement properties of the Dutch Keele Assessment of Participation

Objective The Keele Assessment of Participation (KAP) questionnaire measures person-perceived participation in 11 aspects of life. Participation allows fulfilment of valued life activities and social roles, which are important to older adults. Since we aimed to use the KAP in a larger Dutch cohort, we examined the measurement properties of KAP in a Dutch sample of older adults with joint pain and comorbidity. Design Cohort study. Setting A community-based sample in Amsterdam, the Netherlands and North Staffordshire, UK. Participants Participants were aged 65 years and over, had at least two chronic diseases (identified through general practice consultation) and reported joint pain on most days (questionnaire). The Dutch cohort provided baseline data (n=407), follow-up data at 6 months (n=364) and test–retest data 2 weeks after 6 months (n=122). The UK cohort provided comparable data (n=404). Outcome measures The primary outcome was person-perceived participation, as measured with the KAP. The measurement properties examined were the following: structural validity (factor analysis), internal consistency (Cronbachs α), reliability (intraclass correlation coefficients; ICC), construct validity (hypothesis testing), responsiveness (hypothesis testing and area under the curve) and cross-cultural validity (differential item functioning; DIF). Results Factor analysis revealed two domains: KAPd1: ‘participation in basic activities’ and KAPd2: ‘participation in complex activities’, with Cronbachs α of 0.74 and 0.57 and moderate test–retest reliability: ICC of 0.63 and 0.57, respectively. Further analyses of KAPd1 showed poor construct validity and responsiveness. Despite the uniform DIF in item ‘interpersonal relations’, the total KAPd1 score seemed comparable between the Dutch and UK sample. Conclusions Only KAP domain ‘participation in basic activities’ showed good internal consistency and sufficient reliability. KAPd2 lacks sufficient measurement properties for application in studies, although items may be used as single items. Further development of the concept ‘participation’ may help the development and validation of instruments to measure participation.

Explaining fatigue: An examination of patient causal attributions and their (in)congruence with family doctors’ initial causal attributions

Abstract Background: General practitioners (GPs) and patients can have different ideas about the causes of fatigue, which may hinder management of fatigue. Objective: To investigate the causal attributions of patients and their GPs for fatigue, their level of agreement, and the association between patients’ attributions, and fatigue characteristics and other illness perceptions. Methods: Baseline data, collected between 2004 and 2006, of a prospective cohort study among 642 adult patients presenting to Dutch primary care practices (n = 147) with a main symptom of fatigue, were used. Patient causal attributions and illness perceptions were measured using the revised illness perception questionnaire (fatigue version). GP causal attributions were measured with an open question included in the form that was completed at the end of the patients visit. Fatigue severity was measured using the checklist individual strength. Results: Psychosocial causes were among the most often reported causal attributions by both patients and GPs. In 33% of 519 cases, the GP had no idea about the cause whereas the patient did. Overall, the agreement between the first reported causal attribution of patients and GPs was low. Qualitative differences in the labelling of causes were also found. Type of attribution (physical vs psychosocial/psychological) was associated with duration of fatigue (40 vs 25 months), and personal control (score 17.4 vs. 18.9). Conclusion: Most patients and GPs had ideas about the causes of fatigue, but differences were found in the first reported causes and the labelling of causes. The findings may provide leads for optimizing communication about fatigue.

Self-perceived care needs in older adults with joint pain and comorbidity

BackgroundThe aim of this study was to explore self-perceived care needs and determinants of identified needs in older adults with joint pain and comorbidity.MethodsThis is a cross-sectional study using baseline data from a cohort study of older adults in the Netherlands (≥65 years) with joint pain and comorbidity (n = 407). We used the Camberwell Assessment of Need for the Elderly (CANE) to assess self-perceived care needs. Regression analyses were conducted to examine the associations between needs and sociodemographic factors (age, gender, partner status and educational level), physical factors (pain intensity, comorbidity, frailty and physical functioning) and psychosocial factors (anxiety, depression and social support).ResultsOlder adults with joint pain and comorbidity reported on average 4.0 care needs out of 13 CANE items, of which 0.3 were unmet. High levels of environmental and physical needs were reported, such as needs with regard to physical illness (91%), household (61%) and mobility/falls (53%). However, most of these needs were met. Only few people reported psychosocial needs, but a large proportion of these needs was unmet, especially regarding company (66.7%) and daytime activities (37%). Psychosocial needs were more often present in frail participants (OR 2.40, 95% CI 1.25–4.61), and those with less perceived social support (OR 1.05, 95% CI 1.01–1.08) and more depressive symptoms (OR 1.17, 95% CI 1.07–1.26).Discussion/ConclusionsUnmet needs are mainly present in the psychosocial domain. Specific attention targeted at these unmet needs may improve psychosocial well-being of older adults with joint pain and comorbidity.