Transcript Pain and Depression in Older Adults

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
1. Overlap of depression and pain in
aging
2. Similarities and differences
3. Depression through the lens of
pain
4. Treatment recommendations
Pain
Depression
Depression and Aging
Thielke, Aging and Mental Health, 2009
Depression and Aging
Incidence
Persistence
Thielke, Aging and Mental Health, 2009
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
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)
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”
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
Pain Is Strongly Associated with Depression
**
**
**
** p < 0.001
Thielke, HRS, 2008
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
Depression
No
depression
Pain
No Pain
19.5%
11.3%
18.7%
80.5%
Pain
No Pain
Depression
71.9%
18.1%
No
Depression
57.5%
42.5%
Onder, J Clin Psy 2005
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
Patients with pain and depression
have greater:
Pain complaints
Pain intensity
Chronicity
Directionality?
Similarities and Differences Between
Pain and Depression in Older Adults
Neuroimaging 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.”
Psychological and Physical Pain
• “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 rearranged. 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
Physical Pain During Depression
Sleep, Pain, and Depression
• 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
Pain Impairs Depression Treatment Response
% with Depression Response
60%
50%
Increasing Pain
40%
30%
20%
Treatment Group
10%
Usual Care
0%
Intervention
Not at all
Moderately
Slightly
Extrem ely
Quite a bit
Baseline Pain Interference Category
Baseline Pain Interference Category
Thielke, et al. Am J Geriatric Psych. 2007.
Treatment Overlap for Pain and
Depression
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
Placebo Response Rates
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
Key Similarities and Differences
Human suffering
Sleep disturbance
High placebo response
Brain areas
Human suffering
Prevalence
Neurotransmitters
Medication effects
Depression Through the Lens of Pain
• 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?
Congenital Analgesia
Depression = Guarding from Social Pain?
Most Patients Do Not Seek Out
Treatment for Pain or for
Depression
The Experience of Pain in Aging
• 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
Evidence-Based Options for
Treating Pain
OTC analgesics
Prescription analgesics
Physical therapy
Exercise
Weight loss
Acupuncture
Massage
Injections
Joint replacement
Supplements
“Taking”  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
Medication-Related Behaviors
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
Willingness to Undertake Risk in Pain
Treatment
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
Fraenkel et al, 2004
Many patients consider medications to be a treatment
of last resort
Ross et al, 2001
Values and Perceived Need
Thrifty
Cautious
Wasteful
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.”
Responses to Pain May Explain
Responses to 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
TREATMENT RECOMMENDATIONS
• 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
TREATMENT RECOMMENDATIONS
• 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”
Be Careful with Opioid 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!
Collaborative Care Interventions for Pain and
Depression Improve Both
IMPACT-DP, n = 13
Collaborative Care Interventions for Pain and
Depression Improve Both
n = 401
Dobscha, S. K. et al. JAMA 2009;301:1242-1252.