The Epidemiology of Pain During the Last 2 Years of Life
Publication: Annals of Internal Medicine
Volume 153, Number 9
Abstract
Background:
The epidemiology of pain during the last years of life has not been well described.
Objective:
To describe the prevalence and correlates of pain during the last 2 years of life.
Design:
Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status.
Setting:
The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006).
Participants:
Older adult decedents.
Measurements:
Clinically significant pain, as indicated by a report that the participant was “often troubled” by pain of at least moderate severity.
Results:
The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195).
Limitation:
Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available.
Conclusion:
Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life.
Primary Funding Source:
National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.
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References
1.
Stewart AL, Teno J, Patrick DL, Lynn J. The concept of quality of life of dying persons in the context of health care. J Pain Symptom Manage. 1999;17:93-108. [PMID: 10069149]
2.
Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. JAMA. 1998;279:1877-82. [PMID: 9634258]
3.
Lloyd-Williams M, Dennis M, Taylor F. A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer. Palliat Med. 2004;18:558-63. [PMID: 15453627]
4.
Steinhauser KE, Christakis , Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284:2476-82. [PMID: 11074777]
5.
Ventafridda V, Ripamonti C, De Conno F, Tamburini M, Cassileth BR. Symptom prevalence and control during cancer patients' last days of life. J Palliat Care. 1990;6:7-11. [PMID: 1700099]
6.
Mercadante S, Casuccio A, Fulfaro F. The course of symptom frequency and intensity in advanced cancer patients followed at home. J Pain Symptom Manage. 2000;20:104-12. [PMID: 10989248]
7.
Conill C, Verger E, Henríquez I, Saiz N, Espier M, Lugo F, et al. Symptom prevalence in the last week of life. J Pain Symptom Manage. 1997;14:328-31. [PMID: 9409097]
8.
Dobratz MC, Wade R, Herbst L, Ryndes T. Pain efficacy in home hospice patients. A longitudinal study. Cancer Nurs. 1991;14:20-6. [PMID: 2013048]
9.
Owens MR, Simmons B, Gibson PS, Weeks D. A longitudinal study of pain in hospice and pre-hospice patients. Am J Hosp Palliat Care. 2001;18:124-8. [PMID: 11407128]
10.
Lynn J, Teno JM, Phillips RS, Wu AW, Desbiens N, Harrold J, et al. Perceptions by family members of the dying experience of older and seriously ill patients. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Ann Intern Med. 1997;126:97-106. [PMID: 9005760]
11.
Teno JM, Clarridge BR, Casey V, Welch LC, Wetle T, Shield R, et al. Family perspectives on end-of-life care at the last place of care. JAMA. 2004;291:88-93. [PMID: 14709580]
12.
Addington-Hall J, McCarthy M. Dying from cancer: results of a national population-based investigation. Palliat Med. 1995;9:295-305. [PMID: 8548091]
13.
McPherson CJ, Addington-Hall JM. Judging the quality of care at the end of life: can proxies provide reliable information? Soc Sci Med. 2003;56:95-109. [PMID: 12435554]
14.
Higginson I, Priest P, McCarthy M. Are bereaved family members a valid proxy for a patient's assessment of dying? Soc Sci Med. 1994;38:553-7. [PMID: 7514313]
15.
Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. JAMA. 2003;289:2387-92. [PMID: 12746362]
16.
Dunlop DD, Manheim LM, Song J, Chang RW. Arthritis prevalence and activity limitations in older adults. Arthritis Rheum. 2001;44:212-21. [PMID: 11212163]
17.
Health and Retirement Study. Survey design. Accessed at hrsonline.isr.umich.edu/sitedocs/surveydesign.pdf on 9 September 2010.
18.
American Geriatrics Society. AGS Clinical Practic Guideline: Pharmacological Management of Persistent Pain in Older Adults. Accessed at www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/persistent_pain_executive_summary on 9 September 2010.
19.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Fort Washington, PA: National Comprehensive Cancer Network; Accessed at www.nccn.org/professionals/physician_gls/PDF/pain.pdf [registration required] on 9 September 2010.
20.
Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. JAMA. 1998;279:1877-82. [PMID: 9634258]
21.
Desbiens , Wu AW, Broste SK, Wenger NS, Connors AF Jr, Lynn J, et al. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatmentm. Crit Care Med. 1996;24:1953-61. [PMID: 8968261]
22.
Silveira MJ, Kabeto MU, Langa KM. Net worth predicts symptom burden at the end of life. J Palliat Med. 2005;8:827-37. [PMID: 16128657]
23.
Hogan C, Lunney J, Gabel J, Lynn J. Medicare beneficiaries' costs of care in the last year of life. Health Aff (Millwood). 2001;20:188-95. [PMID: 11463076]
24.
Lunney JR, Lynn J, Hogan C. Profiles of older medicare decedents. J Am Geriatr Soc. 2002;50:1108-12. [PMID: 12110073]
25.
Archer KJ, Lemeshow S. Goodness-of-fit test for a logistic regression model fitted using survey sample data. Stata J. 2006;6:97-105.
26.
Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York: J Wiley; 2000.
27.
Kutner JS, Smith MC, Corbin L, Hemphill L, Benton K, Mellis BK, et al. Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: a randomized trial. Ann Intern Med. 2008;149:369-79. [PMID: 18794556]
28.
Scheetz J, Shell B. Physical therapy in the symptomatic management of pain. Dimens Oncol Nurs. 1988;2:9-13. [PMID: 3266958]
29.
Christakis , Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320:469-72. [PMID: 10678857]
30.
Glare P, Virik K, Jones M, Hudson M, Eychmuller S, Simes J, et al. A systematic review of physicians' survival predictions in terminally ill cancer patients. BMJ. 2003;327:195-8. [PMID: 12881260]
31.
Christakis N. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: Univ Chicago Pr; 2001.
32.
Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994;330:592-6. [PMID: 7508092]
33.
Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “We don't carry that”—failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med. 2000;342:1023-6. [PMID: 10749965]
34.
Du Pen SL, Du Pen AR, Polissar N, Hansberry J, Kraybill BM, Stillman M, et al. Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. J Clin Oncol. 1999;17:361-70. [PMID: 10458255]
35.
Helme RD, Gibson SJ. The epidemiology of pain in elderly people. Clin Geriatr Med. 2001;17:417-31, v. [PMID: 11459713]
36.
Desbiens , Wu AW, Broste SK, Wenger NS, Connors AF Jr, Lynn J, et al. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatmentm. Crit Care Med. 1996;24:1953-61. [PMID: 8968261]
37.
Desbiens , Mueller-Rizner N, Connors AF Jr, Hamel MB, Wenger NS. Pain in the oldest-old during hospitalization and up to one year later. HELP Investigators. Hospitalized Elderly Longitudinal Project. J Am Geriatr Soc. 1997;45:1167-72. [PMID: 9329476]
38.
Harkins SW, Price DD, Martelli M. Effects of age on pain perception: thermonociception. J Gerontol. 1986;41:58-63. [PMID: 3941257]
39.
Bellville JW, Forrest WH Jr, Miller E, Brown BW Jr. Influence of age on pain relief from analgesics. A study of postoperative patients. JAMA. 1971;217:1835-41. [PMID: 5109724]
40.
Reynolds KS, Hanson LC, DeVellis RF, Henderson M, Steinhauser KE. Disparities in pain management between cognitively intact and cognitively impaired nursing home residents. J Pain Symptom Manage. 2008;35:388-96.
41.
Harkins SW, Chapman CR. Detection and decision factors in pain perception in young and elderly men. Pain. 1976;2:253-64.
42.
Woodrow KM, Friedman GD, Siegelaub AB, Collen MF. Pain tolerance: differences according to age, sex and race. Psychosom Med. 1972;34:548-56.
43.
American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57:1331-46. [PMID: 19573219]
44.
Edwards RR, Doleys DM, Fillingim RB, Lowery D. Ethnic differences in pain tolerance: clinical implications in a chronic pain population. Psychosom Med. 2001;63:316-23. [PMID: 11292281]
45.
Schludermann E, Zubek JP. Effect of age on pain sensitivity. Percept Mot Skills. 1962;14:295-301.
46.
A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-8.
47.
Weiss SC, Emanuel LL, Fairclough DL, Emanuel EJ. Understanding the experience of pain in terminally ill patients. Lancet. 2001;357:1311-5. [PMID: 11343734]
48.
Peat G, Thomas E, Handy J, Croft P. Social networks and pain interference with daily activities in middle and old age. Pain. 2004;112:397-405. [PMID: 15561396]
49.
Pappagallo M, eds. The Neurologic Basis of Pain. New York: McGraw-Hill; 2004.
50.
Thomas E, Peat G, Harris L, Wilkie R, Croft PR. The prevalence of pain and pain interference in a general population of older adults: cross-sectional findings from the North Staffordshire Osteoarthritis Project (NorStOP). Pain. 2004;110:361-8. [PMID: 15275787]
51.
Turk DC, Okifuji A, Scharff L. Chronic pain and depression: role of perceived impact and perceived control in different age cohorts. Pain. 1995;61:93-101. [PMID: 7644253]
52.
Dominick KL, Ahern FM, Gold CH, Heller DA. Health-related quality of life among older adults with arthritis. Health Qual Life Outcomes. 2004;2:5. [PMID: 14720300]
Information & Authors
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Published In
Annals of Internal Medicine
Volume 153 • Number 9 • 2 November 2010
Pages: 563 - 569
History
Published online: 2 November 2010
Published in issue: 2 November 2010
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Copyright
© 2010 American College of Physicians.
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The Epidemiology of Pain During the Last 2 Years of Life. Ann Intern Med.2010;153:563-569. [Epub 2 November 2010]. doi:10.7326/0003-4819-153-9-201011020-00005
The Epidemiology of Pain During the Last 2 Years of Life. Ann Intern Med.2010;153:563-569. [Epub 2 November 2010]. doi:10.7326/0003-4819-153-9-201011020-00005
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