Pain and depression in older adults
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Pain and Depression in Older Adults. Stephen Thielke Seattle GRECC. Disclosures. My research is supported in part by a Geriatric Health Outcomes Research Award from the American Geriatric Society Foundation for Health in Aging No other disclosures or conflicts of interest. Overview.

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Pain and depression in older adults l.jpg

Pain and Depression in Older Adults

Stephen Thielke

Seattle GRECC


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Disclosures

My research is supported in part by a Geriatric Health Outcomes Research Award from the American Geriatric Society Foundation for Health in Aging

No other disclosures or conflicts of interest


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Overview

  • Overlap of depression and pain in aging

  • Similarities and differences

  • Depression through the lens of pain

  • Treatment recommendations

Pain

Depression


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Depression and Aging

Thielke, Aging and Mental Health, 2009


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Depression and Aging

Incidence

Persistence

Thielke, Aging and Mental Health, 2009


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Chronic Pain and Aging

2/3 of older adults report chronic pain [lasting 3 months or more] (Gagliese 1997)

Of older adults with pain, 83% report that pain interferes with daily activities and negatively affects quality of life (Herr 2001)

Most frequent pain types in those 65 or older are osteoarthritis of hip or knee (58%) and low back pain (35%) (CDC)

Mean # of pain sites in older adults: 4.3


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Chronic Pain and Aging

Highest prevalence of chronic pain occurs at about age 65, after which there is a slight decline with advancing age, even beyond age 85 (Gibson & Helme 1995)

Pain Intensity not associated with advancing age, but slightly greater intensity of low-level pain (Rustoen 2005)


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Pain and Aging

Many types of chronic pain disorders occur less commonly with advancing age:

Headache

Migraine

Abdominal pain

Chest pain

Low back

 Chronic pain is NOT a “natural part of getting older”


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Depression is Common in Patients with Pain

US Geriatric Population 5%

Ambulatory Medical Patients 5-9%

Medical Inpatients 15-20%

Pain Clinics 10-100% (~50%)

Pain is Common in Patients with Depression

~65%, regardless of treatment setting

Bair et al, Arch Int Med 2003


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Pain Is Strongly Associated with Depression

**

**

**

** p < 0.001

Thielke, HRS, 2008


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Depression and Pain in Older Adults

European 11-country study, Aged in Home Care (AdHOC)

3976 subjects, 65 years and older, receiving home care

Pain: any daily pain over the last week, or pain behaviors

Depression: MDS depression scale

Onder, J Clin Psy 2005


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Depression and Pain

Patients with pain have 2-5 times increased depression incidence

Greater risk of depression with:

Multiple pain complaints

Multiple episodes

Severe pain

Directionality?

Patients with pain and depression have greater:

Pain complaints

Pain intensity

Chronicity



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Neuroimaging Older Adults Studies

Many, but not all, of the same brain areas that are stimulated by physical pain are also stimulated by:

-Induced sadness

-Social exclusion

-Grief

“There is that cliché of a broken heart, but my ribs ached from the pain in my heart. I had to go to the doctor because I thought I was having heart attacks.”


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Psychological and Physical Pain Older Adults

  • “I have suffered from severe, recurrent depression for 40 years. The psychological pain that I felt during my depressed periods was horrible and more severe than my current physical pain associated with metastases in my bones from cancer.”

  • “I woke up in the middle of the night to use the bathroom and forgot that my furniture had been re-arranged. I accidentally tripped over my cocktail table, breaking both of my legs. The pain that I experience from depression is so much worse than the pain associated with my breaking both of my legs.”

Mee et al, J Psychiatric Res2006



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Sleep, Pain, and Depression Older Adults

  • 50-80% of patients with chronic pain have a significant sleep disturbance

  • Sleep disturbance is one of the cardinal symptoms of depression

  • Insomnia predicts depression onset

  • Experimental disruption of slow-wave sleep increases pain sensitivity

  • Sleep deprivation can temporarily relieve depressive symptoms


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Pain Impairs Depression Treatment Response Older Adults

Increasing Pain

% with Depression Response

Baseline Pain Interference Category

Thielke, et al. Am J Geriatric Psych. 2007.


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Treatment Overlap for Pain and Depression Older Adults

Pain

Depression

“Opium cure” for depression never worked

ECT not effective for chronic pain

Antidepressant response:

-Depression response usually 6-8 weeks

-Pain response usually 3-4 weeks

Noradrenergic drugs have direct analgesic properties

Pure serotonergic drugs have no direct effect on pain

Doses for pain are roughly ½ of those for depression


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Placebo Response Rates Older Adults

Brief Pain Inventory - Severity

Depression trials show ~30% placebo response

Only 48% of placebo-controlled trials of antidepressants showed superiority to placebo

Khan & Bhat, J Clin Psy, 2008


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Key Older AdultsSimilarities and Differences

Human suffering

Sleep disturbance

High placebo response

Brain areas

Human suffering

Prevalence

Neurotransmitters

Medication effects

Pain and depression often occur together

“Psychic Pain” and “Physical Pain” are different

 Pain and depression are a bad combination


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Depression Through the Lens of Pain Older Adults

  • Why do we need physical pain?

  • What would happen if we didn’t have pain?

  • Why don’t people treat their pain?

  • What does psychological pain do for us?

  • Why don’t more people treat their depression?


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Congenital Analgesia Older Adults

Depression = Guarding from Social Pain?



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The Experience of Pain in Aging Depression

  • Belief that pain is “just a part of getting older”

  • “Many [osteoarthritis patients] were unwilling to use medication. For these individuals, treating pain with medication was seen as masking rather than curing symptoms, and was seen as potentially harmful because of an increased risk of unwanted side effects.”

Gignac, Hawker et al 2006


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Evidence-Based Options for Treating Pain Depression

OTC analgesics

Prescription analgesics

Physical therapy

Exercise

Weight loss

Acupuncture

Massage

Injections

Joint replacement

Supplements


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“Taking” Depression Taking Effectively

19 older adults with osteoarthritis pain

Qualitative interview

4/19 (21%) taking medications as prescribed or directed

Others use lower doses than prescribed or less often than directed

None using analgesics in advance of activities

Sale, Gignac, Hawker 2006


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Medication-Related Behaviors Depression

Filling Percodan prescription and throwing the whole bottle away

Filling higher-dose bottle with lower-dose pills

Rationing pain medications to refill far less than allowed

Not telling family members about using less than prescribed

Adhering to pain medications differently than to other medications

Sale, Gignac, Hawker 2006


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Willingness to Undertake Risk in Pain Treatment Depression

Preference for topical treatments such as capsaicin over oral agents; pills preferred only if they were reported as being three times as effective as capsaicin

All the patients switched their preferences when offered a safer but less effective treatment option

20% of older patients are unwilling to accept any additional risk for reductions in pain

Many patients consider medications to be a treatment of last resort

Fraenkel et al, 2004

Ross et al, 2001


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Values and Perceived Need Depression

Thrifty Wasteful

Cautious Rash

Stoical Hedonistic

Patient Hurried

Selfless Selfish

“I don’t need to treat this. I’ll hold out.”

“I need to take something to feel better now.”


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Responses to Pain May Explain Responses to Depression Depression

  • Depression as a form of “social pain”?

  • Social comparison as the cause of depression in older adults? (Blazer 2008)

  • Patients resist NEEDING a treatment for pain or depression

  • Suffering the symptom often feels like the right thing to do

  • Suffering the symptom often seems safer than risking something unknown just to placate it


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TREATMENT RECOMMENDATIONS Depression

  • Ask about pain and about depression

  • Ask about pain and depression treatments

  • Work to understand effects of mental health on use of pain treatments

  • Do not assume that one problem is causing the other

  • Do not assume that addressing one problem will fix the other


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TREATMENT RECOMMENDATIONS Depression

  • The realistic goal is to make the depression go away, but not to make the pain go away

  • Consider antidepressants for pain and for depression, but do not expect them to fix the problem

  • Placebo response is large in both depression and pain: use this to your advantage

  • Understand patient’s sense of “as needed”


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Be Careful with DepressionOpioid Analgesics

  • Accidental deaths in US from prescription opioids exceed deaths from heroin & cocaine

  • More deaths in Washington State last year from prescription opioids than from traffic fatalities!



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Collaborative Care Interventions for Pain and Depression Improve Both

n = 401

Dobscha, S. K. et al. JAMA 2009;301:1242-1252.


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