ORLANDO — Pain is a comorbid condition too often overlooked in the setting of geriatric psychiatry, despite the potential for better mental health outcomes when it is treated, Dr. Jordan F. Karp said at the annual meeting of the American Association for Geriatric Psychiatry.
“I don't think enough attention is paid to assessing, diagnosing, and managing pain by many psychiatrists and other physicians who treat older adults,” he said in an interview. “I highly doubt that clinicians are aware of the effects of pain on cognition.”
Because pain has reached “epidemic” proportions among the elderly and can significantly worsen cognition and depression, it should be assessed and treated routinely as part of the psychiatric management of this population, said Dr. Karp, medical director of geriatric psychiatry at one of the referral pain clinics at the University of Pittsburgh Medical Center.
Studies suggest that up to 50% of community-dwelling seniors experience pain that interferes with normal functioning, and up to 80% of nursing home patients live with undertreated pain—the source of which can be musculoskeletal, neuropathic, visceral, metabolic, or other. (See box.)
It is well known that persistent pain limits mobility, increases the risk of falls, and can lead to social isolation, but it is not always appreciated that pain can also increase anxiety, depression, and cognitive impairment, said Dr. Karp, who has a clinical and research focus on both pain and affective disorders in older adults. He disclosed his advisory role with Eli Lilly & Co. and Myriad Genetics Inc.
In a recent survey of 56 patients in an older adult pain management program, he showed that higher pain severity was associated with poorer performance on a test of number/letter switching (Pain Med. 2006;7:444–52).
In another study of older adults (mean age 73 years), different investigators demonstrated lower neuropsychological function among 163 subjects with chronic low back pain (CLBP), compared with 163 who were pain free (Pain Med. 2006;7:60–70). Recent preliminary evidence also suggests reduced brain volume among eight seniors with CLBP, compared with eight who were pain free (Pain Med. 2008;9:240–8).
The comorbidity of pain and depression is a vicious circle, Dr. Thomas Meeks of the University of California, San Diego, said in a separate presentation at the meeting.
A link between depression and immune system dysfunction has been described, and both pain and weakened immunity have been associated with an increase in inflammatory cytokines. Inflammatory cytokines are also associated with anorexia, sleep disturbance, and fatigue and have been shown to negatively affect brain chemicals such as serotonin and norepinephrine, suggesting “there may be a role of inflammatory cytokines in late-life depression,” he said.
Since the rise in inflammatory cytokines seen with acute pain can persist long after the source of the pain has been corrected, prompt diagnosis and treatment of pain is important to reduce the risk of persistent pain and chronic depression, Dr. Meeks said.
“We need to keep pain in mind and ask our patients about it,” said Dr. Karp. In addition to various visual or verbal rating scales that can be used to inquire about pain, he said, certain direct questions might be helpful:
▸ Are you in pain now, or if not now, do you hurt more often than not?
▸ Where do you hurt?
▸ How has pain interfered with your life?
▸ Does pain interfere with your sleep?
“Insomnia is ubiquitous in this group,” he said. “It has been associated with a decreased pain threshold, and it decreases patients' ability to actively cope with their pain problem.”
Preliminary analysis from some of his pilot work has shown that insomnia and fatigue among older patients are associated with passive rather than active coping skills. “Passive skills are less effective and involve things like catastrophizing, praying, or hoping the pain will stop, whereas more active coping involves increasing behavioral activities and using coping self-statements like 'I will get through this,' 'the pain will pass,' or 'the pain will not kill me,'” he said.
When direct questioning is not useful or patients are nonverbal, behavioral observation can reveal a great deal about the pain an individual may be experiencing. “They may be grimacing or sighing; they may be irritable, disruptive, or verbally abusive; their body position may be rigid or guarded; or they might show their discomfort by fidgeting,” said Dr. Karp.
The recently validated Elderly Pain Caring Assessment 2 provides further insight into nonverbal cues (Pain 2007;133:87–98). “It's unlikely that we are going to be able to introduce another assessment into our nursing homes, but informing staff about some of these probes may be useful,” he said.