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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)

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Page 1: Microsoft PowerPoint - NARI 2008-2.ppt [Read-Only

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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)

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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

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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

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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

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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!”

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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

*

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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

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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

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� 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

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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

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Mechanical Pain Thresholds

Cole et al. Neurobiol of Aging 2008

Pain

stimulus

Methods

Part 2. Functional Brain Imaging

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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

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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

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�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).

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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

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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.

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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

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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

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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) .

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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.

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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”