NIA supports research on pain in older people
“Tell me where it hurts.”
“It hurts when I try to lift my arm.”
“I was in so much pain I didn’t want to move a muscle.”
“I can’t walk across the room without my knees hurting.”
“It doesn’t hurt that much and I don’t want people to think I’m a complainer, but when I take the medication, I feel a lot better.”
Geriatricians frequently hear these and similar statements from their patients.
Pain is a significant problem for older adults, who tend to have more pain than younger people. They have it more often and in more places in their bodies. It’s also often more difficult to diagnose and treat pain in an older person than in a younger one.
The topic of pain in older people is an area of increasing interest in research. It cuts across all areas of study, from cellular and neurological mechanisms of pain to the prevalence of pain in the population and the ways of measuring and treating it. Recognizing the cross-cutting nature of the topic, the NIA established a Working Group on Pain, chaired by Dr. Wen Chen, program director for the Sensory/Motor Disorders of Aging in the Division of Neuroscience, in 2010 to coordinate and strategize multidisciplinary research programs and initiatives on pain in aging across three NIA extramural research divisions.
Findings from the National Health and Aging Trends Study
The importance of attention to pain in older people is increasingly apparent. A recent analysis of data from the National Health and Aging Trends Study by NIA grantee Kushang Patel and colleagues found that more than half (53 percent) of the older adults surveyed reported having bothersome pain in the last month; three-quarters of them reported having pain in more than one body location. Bothersome pain, particularly in multiple locations, was also associated with decreased physical capacity.
The percentage of people reporting pain was similar across age groups from 65 to 90+ years, but women reported having pain more often than men, and people with less education reported more pain than those with more education. Back, knee, and shoulder were the most prevalent sites of pain.
Data from SAGE on the prevalence of pain
Data from the Study of Global Ageing and Adult Health conducted by the World Health Organization and supported in part by NIA, echoed this analysis. Of the six countries in the SAGE survey—China, Ghana, India, Mexico, Russia, and South Africa—all but Mexico reported an increase in the prevalence of pain with increased age and more pain in women than in men.
“These are solid epidemiological data,” said Dr. Basil Eldadah, chief of the Geriatrics Branch in NIA’s Division of Geriatrics and Clinical Gerontology. “Still, we know that pain tends to be underreported and undertreated among older adults. There is an expectation among many providers, caregivers, and older people themselves that pain is just a natural part of aging. As a result, many older people often don’t report the extent or degree of their pain.
“Cognitive impairment is also a major cause of underreporting of pain in older adults,” he continued. “When older individuals cannot clearly communicate that they’re in pain, we rely on indirect measures like behavioral observations and reports from family members or other proxy responders; nevertheless, people with cognitive impairment are still susceptible to being undertreated for pain.”
Pain in older adults with chronic conditions
Treating pain in older people also is complicated by the fact that 75 percent of people 65 and older have two or more chronic conditions—such as heart disease, diabetes, chronic lung disease, or arthritis. Medications for these conditions can interact with pain medications, and pain often goes untreated or undertreated as a result.
“A major research challenges is to identify and develop the most suitable pain management strategies for older adults, particularly those with painful chronic conditions,” said Dr. Chen. “Research in the neuroscience of pain has helped us understand that the experience of pain involves the participation from many parts of the body as well as many parts of the nervous system. The brain regions that detect painful stimuli are connected to the brain regions that recognize and interpret what we sense and how we feel. Many of these regions undergo profound changes as we get older, but we don’t know much about how these age-related changes affect our sense of pain and our treatment paradigms.”
“Managing pain is not just about pain,” noted Dr. Eldadah. “That is to say, the physical sensation of pain is not the only factor. An important goal of geriatric pain management is also maintaining function, which is particularly important for older people who may have a disability or who may be at risk of developing one. The question is not ‘can we eliminate your pain?’ Rather, it’s ‘can we reduce your pain enough so you can do the things you want to do?’”
A trans-NIH effort
The NIH Pain Consortium, comprised of 21 Institutes and Centers (ICs) and five offices in the Office of the NIH Director, is a focal point for coordinating pain research support across NIH. NIA is a member of the Consortium, which sponsors annual widely-attended symposia in Bethesda, MD, on specific pain-related topics and leads the Interagency Pain Research Coordinating Committee.
The ICs comprising the Pain Consortium support research on a wide range of pain-related issues, including chronic lower back pain; pain and co-morbid conditions in military personnel, veterans, and their families; the neurobiology of migraine pain; and non-pharmacological approaches to pain management, among others. Several ICs in the Consortium also jointly support 12 NIH Centers of Excellence in Pain Education.
“NIA has significantly increased our pain research in the last few years,” said Dr. Chen, who represents NIA at the Pain Consortium. In FY 2007, NIA supported only five pain grants. Now, NIA funds 58 grants related to pain, including 22 R01s.
The planning for this line of research has been deliberate and collaborative, Dr. Chen noted. Following an exploratory workshop led by the NIA under the aegis of the NIH Pain Consortium in the summer of 2008, the institute issued its first broad program announcement for pain research in 2009. In September 2010, a second workshop included participation from AHRQ, FDA, and VA, as well as from NIH, and led to a published conference summary in Pain Medicine. In 2011, NIA sponsored an RFA focused on using existing data or ongoing studies to study pain treatment outcomes in older adults.
In December 2012, the Pain in Aging Program Announcement was reissued, with fellow Consortium members NIDA, NIAAA, and NCCAM. There was a good response, and NIA and the Consortium expects more, as the announcement remains open until January 8, 2016, and covers a wide range of research areas, with possible topics including genetics and neurobiology of pain, the interaction of pain management with normal psychological function, and understanding health disparities in the progression and severity of pain in older people. To highlight the importance of pain in aging, NIA inaugurated its scientific symposium series at the annual Gerontological Society of America meeting in November 2013 with a session focused on pain research.
The Division of Behavioral and Social Research (BSR) also supports the Pain in Aging program announcement and is interested in furthering understanding of pain. BSR’s focus, explained Dr. Lis Nielsen, chief of BSR’s Individual Behavioral Processes Branch, focuses on quality of life, function, and disparities in the experience and treatment of painful conditions in older adults. She pointed to a recent National Academy of Sciences report on subjective well-being, which featured the presence or absence of pain as one of the key factors by which well-being is measured. Also, NIA’s Health and Retirement Study and the English Longitudinal Study of Ageing, which NIA supports in part, include measures of pain in their interviews, asking which activities are painful and which activities are constrained due to pain.
“These large databases provide opportunities for analyses of prevalence and severity of pain nationally and cross-nationally, as well as investigation of the causes of national and international differences in the experience and treatment of pain,” Dr. Nielsen said. “We’re looking at a combination of self-report and biomarkers in a number of BSR-supported studies, as well as exploring the potential of behavioral, non-pharmacological approaches to treat pain and address the challenges faced by older adults living with chronic pain.”
Palliative care can help people with chronic conditions
On the clinical side, NIA is very interested in geriatric palliative care. “When people think of palliative care, they usually think of care to relieve pain at the end of life,” said Dr. Eldadah. “But, a lot of older people who are not at the end of their lives, particularly those with multiple chronic conditions, could benefit from treatment to relieve pain and other disabling symptoms associated with their underlying conditions.”
NIA, along with NCCAM and NINR, are sponsoring the Program Announcements, “Advancing the Science of Geriatric Palliative Care,” which support R01, R03, and R21 awards and are open until January 8, 2017. The initiative is focused on the development of more effective approaches to symptom management, how to identify risk factors that predispose people to complications from treatment, and how to improve symptom assessment, particularly among patients with cognitive impairment. In addition, research could explore treatment regimens with non-pharmacological elements that might reduce or eliminate the need for medications, among other things.
An important aspect of the palliative care program announcements is that applications are being sought for research in a variety of settings—for example, home, hospital, and short- and long-term care facilities—as well as transitions across these settings. End-of-life and hospice care are intentionally excluded because palliative care for older people at earlier points in their illnesses has not received much research attention.
“I believe that geriatrics and palliative care are a natural marriage,” Dr. Eldadah said. “They are both patient-centered approaches to treatment to improve optimal function. But, palliative care is more than pain relief; it’s a treatment philosophy that involves delivering multidisciplinary care to older people through a patient-centered approach to relieve symptoms and improve quality of life for patients and their caregivers. We’re interested in finding out how best to do that.”