Outcomes Associated with Opioid Use in the Treatment of Chronic Noncancer Pain in Older Adults: A Systematic Review and Meta‐Analysis

This systematic review summarizes existing evidence regarding the efficacy, safety, and abuse and misuse potential of opioids as treatment for chronic noncancer pain in older adults. Multiple databases were searched to identify relevant studies published in English (1/1/80–7/1/09) with a mean study population age of 60 and older. Forty‐three articles were identified and retained for review (40 reported safety and efficacy data, the remaining 3 reported misuse or abuse outcome data). The weighted mean subject age was 64.1 (mean age range 60–73). Studies enrolled patients with osteoarthritis (70%), neuropathic pain (13%), and other pain‐producing disorders (17%). The mean duration of treatment studies was 4 weeks (range 1.5?156 weeks), and only five (12%) lasted longer than 12 weeks. In meta‐analyses, effect sizes were ?0.557 (P<.001) for pain reduction, ?0.432 (P<.001) for physical disability reduction, and 0.859 (P=.31) for improved sleep. The effect size for the Medical Outcomes Study 36‐item Health Survey was 0.191 (P=.17) for the physical component score and ?0.220 (P=.04) for the mental component score. Adults aged 65 and older were as likely as those younger than 65 to benefit from treatment. Common adverse events included constipation (median frequency of occurrence 30%), nausea (28%), and dizziness (22%) and prompted opioid discontinuation in 25% of cases. Abuse and misuse behaviors were negatively associated with older age. In older adults with chronic pain and no significant comorbidity, short‐term use of opioids is associated with reduction in pain intensity and better physical functioning but poorer mental health functioning. The long‐term safety, efficacy, and abuse potential of this treatment practice in diverse populations of older persons remain to be determined.     

Self care for chronic illness: Older African Americans and whites

In-person interviews with two hundred and twenty-one older African Americans and whites in Allegheny County, Pennsylvania on their use of self care activities in the care of one of four chronic illnesses (chronic obstructive pulmonary disease (COPD), heart disease, diabetes mellitus, and arthritis, addressed which types of self care they used for each of these illnesses) the similarities and differences between African Americans and whites in their use of self care and how self care is initiated, modified and integrated into a context that includes help from others. The most common response in each of the illnesses was the use of medications or medical treatments by both African Americans and whites. However, there were some differences in the self care practices used by these two groups by illness type. Whites reported monitoring their illness significantly more than African Americans for diabetes and using assistive devices in the management of COPD significantly more than African Americans. While both African Americans and whites practice self care similarly in the management of heart disease, African Americans reported greater use of exercise in their management of arthritis. The amount of assistance provided by others in support of self care varied by illness and by African American and white. The differences in self care usage may be attributed to many factors, among them, differences in cultural experiences with the illness, health beliefs regarding its efficacy and the amount of assistance received from informal supports.     

Appointment-Keeping Behavior is Not Related to Medication Adherence in Hypertensive African Americans

OBJECTIVE The relationship between appointment-keeping behavior, medication adherence (ADH), and systolic and diastolic blood pressure (SBP and DBP) was assessed in 153 hypertensive African Americans followed in a community-based practice. METHODS ADH was assessed with a self-report questionnaire. BP was obtained from electronic medical records and appointment attendance was determined from the log of all appointments made during the 12-month study period. Nonadherence rates were compared across appointment attendance categories with chi-square. Logistic regression was used to assess the relationship between ADH and appointment attendance, whereas multivariate analysis of covariance (MANCOVA) was used to examine the relationship between appointment attendance and BP. RESULTS Twenty-five percent of patients (87% women, mean age 52 years) did not miss any appointments, 44% missed 1–30%, and 31% missed greater than 30%. Adjusted nonadherence rates were similar for all 3 categories (70%, 66%, and 65%, respectively, p = 0.88) as were adjusted mean SBP and DBP in the MANCOVA model, [F (4, 218) = 1.13, p = .34]. Logistic regression analysis did not indicate a significant relationship between appointment attendance and ADH. CONCLUSIONS Appointment-keeping behavior was not related to ADH or BP among hypertensive African Americans. It should not be used as a proxy for ADH in this patient population.     

Productive Activities and Perceived Well-Being in an African American Older Adult Urban Sample

Few studies have examined the relationship between productive activities and well-being among urban lower-income African American older adults. The purpose of this study was to examine (1) the pattern and prevalence of types and specific kinds of productive activities and (2) the association among sociodemographic data, individual capacity, kinds and levels of productive activity, and well-being at the individual level. Approximately 12% of 531 respondents participated in employment, whereas 20% participated in volunteer activities. The majority of the respondents (99.4%) joined in leisure activities. More than 75% engaged in religious activities. The respondents also reported that they participated in various kinds of productive activities. Age, physical health status, perceived social support, and perceived neighborhood satisfaction were the most important regression predictors of perceived well-being. Higher levels of involvement in religious activities and leisure activities were related to a greater perceived well-being.     

Medication and Behavioral Adherence Among HIV+ Older Adults

The purpose of this investigation was to explore HIV medication adherence among older adults. In Study 1, 44 HIV+ adults were recruited from the University of Pennsylvania Center for AIDS Research and interviewed about their health behaviors, including medication adherence. In Study 2, 40 HIV+ adults were surveyed about their communication with their physician and HIV medication and behavioral recommendations. Both studies found that a considerable percentage of participants were not completely adherent to their HIV medications. Furthermore, the majority of participants reported good communication with their physician. The findings of these studies have implications for intervention efforts aimed at increasing adherence to both medications and recommended behaviors among HIV+ older adults.     

Gout in African Americans

Purpose

African Americans have a substantially higher prevalence of risk factors for gout than Caucasians. The aim of the present study was to compare the risk for incident gout among African Americans and Caucasians.

Methods

Incidence rates of physician-diagnosed gout among 11,559 Caucasian men and 931 African American men aged 35 to 57 years and at high cardiovascular risk, observed for 7 years as a part of the Multiple Risk Factor Intervention Trial, were analyzed. Cox regression models were used to account for potential confounding by age, body mass index, diuretic use, hypertension and diabetes status, aspirin and alcohol consumption, and kidney disease.

Results

At baseline, after accounting for risk factors, African Americans had a 14% lower prevalence of hyperuricemia than Caucasians. Incidence of gout increased with increasing prevalence of risk factors in both Caucasians and African Americans. Ethnic disparities in incidence rates were most apparent among those without other risk factors for gout. In separate Cox regression models, after accounting for risk factors, African American ethnicity was associated with a hazard ratio of 0.78 (95% confidence interval [CI], 0.66-0.93) for physician-diagnosed gout and 0.88 (95% CI, 0.85-0.90) for incident hyperuricemia. Significant interactions were observed; the association was the strongest (hazard ratio 0.47; 0.37-0.60). These associations were unaffected by addition of serum urate as a covariate or by using alternate case definitions for gout.

Conclusions

After accounting for the higher prevalence of risk factors, African American ethnicity is associated with a significantly lower risk for gout and hyperuricemia compared with Caucasian ethnicity.     

Foot Pain,Plantar Pressures,and Falls in Older People: A Prospective Study

OBJECTIVES: To determine whether foot pain and plantar pressure are associated with falls in community‐dwelling older adults. DESIGN: Community‐based cohort study with 12‐month prospective falls follow‐up. SETTING: Sydney and Illawarra statistical regions of New South Wales, Australia. PARTICIPANTS: Randomly recruited, community‐dwelling adults (158 men and 154 women) aged 60 and older. MEASUREMENTS: Manchester Foot Pain and Disability Index to establish baseline foot pain and dynamic plantar pressures. Participants were then classified as fallers (n=107) or nonfallers (n=196) based on their falls incidence over the following 12 months. RESULTS: Fallers had a significantly higher prevalence of foot pain than nonfallers (57.9% vs 42.1%; chi‐square=4.0; P=.04). Fallers also generated a significantly higher peak pressure and pressure‐time integral under the foot than non‐fallers. In addition, individuals with foot pain had a significantly higher peak pressure and pressure‐time integral under the foot than those without foot pain. CONCLUSION: High plantar pressures generated during gait may contribute to foot pain and risk of falls. Providing interventions to older people with foot pain and high plantar pressures may play a role in reducing their falls risk.     

Willingness of Older Korean‐American Adults to Use Hospice

Responding to an urgent need for more research on end‐of‐life concerns of racial and ethnic minorities, the present study explored predictors of willingness of older Korean‐American adults (N=675) to use hospice. Guided by Andersen's behavioral health model, the study considered predisposing factors (age, sex, marital status, education), potential health needs (chronic conditions, functional disability), and enabling factors (health insurance, acculturation, prior awareness of hospice). Nearly three‐quarters of the sample answered yes to the following statement and question, “Hospice is a program that helps people who are dying by making them feel comfortable and free of pain when they can no longer be cured of their disease. If you needed hospice services, would you use them?” A greater willingness was observed in younger persons (odds ratio (OR)=0.96, 95% confidence interval (CI)=0.93–0.98) and those with higher levels of education (OR=1.67, 95% CI=1.12–2.48), more chronic conditions (OR=1.23, 95% CI=1.05–1.44), health insurance (OR=0.59, 95% CI=0.37–0.94), higher levels of acculturation (OR=1.07, 95% CI=1.03–1.10), and prior awareness of hospice (OR=4.43, 95% CI=2.85–6.90). The present study highlights the role of prior awareness in shaping individuals' attitudes toward services, calling attention to a need for community education and outreach programs for racial and ethnic minorities, with specific emphasis on dissemination of information and greater awareness of hospice services.     

The meaning of healthy and not healthy: Older African Americans and whites with chronic illness

Qualitative in-person interviews with 114 olderAfrican Americans and whites with chronic illness wereconducted to assess whether they thought of themselvesas healthy or not healthy and the meanings associatedwith that assessment. The first and most frequentlyassigned attribute of healthy was the presence offunctional capacities; for not healthy it was thepresence of medical conditions or physical symptoms. While both African Americans and whites respondedsimilarly regarding the assessment of whether theywere healthy or not healthy, African Americansdescribed the attributes associated with healthy ornot healthy somewhat differently than whites. Also,both groups reported more varied meanings to theconcept of `healthy' than to `not healthy', suggestingthat `healthy' may be a multidimensional constructmore connected to ones' total life experiences than is`not healthy'. This study concludes that social andcultural factors such as race, ethnicity or healthexperiences may influence how individuals perceive anddescribe their health status and the processes used inmaking these assessments.     

Predictors of unstable anticoagulation in African Americans

Objective We sought to identify contributors to unstable anticoagulation in African Americans. Patients and methods Sixty African Americans on warfarin were enrolled. Cytochrome P450 2C9 and vitamin K epoxide reductase genotypes and vitamin K intake were assessed, and clinical and dietary data during the 12 months prior to enrollment were collected. Data were compared between stable and unstable patients, classified based on the proportion of international normalized ratio (INR) values outside the therapeutic range. Results The median proportion of out-of-range INRs among study participants was 44%; 28 patients had a higher proportion of INRs out-of-range and were included in the unstable group, with the remaining constituting the stable group. The median (IQR) number of clinic visits/year was higher among unstable versus stable patients [18 (15–22) vs. 16 (13–19); P = 0.03]. Higher warfarin doses, lower adherence, vomiting or diarrhea, and use of antiinfective agents were more common among unstable patients. Genotype was not associated with anticoagulation stability. After regression analysis, only poor adherence and gastrointestinal illness remained predictive of unstable anticoagulation. In a control group of Caucasians of similar age and sex distribution, poor adherence, but not gastrointestinal illness, was associated with unstable anticoagulation. Conclusion We conclude that poor warfarin adherence and gastrointestinal illness are major contributors to unstable anticoagulation in African Americans. Our data suggest that, similar to Caucasians, improving warfarin adherence rates may be an important mean to improve anticoagulation control in African Americans. In addition, close monitoring during acute illness may be particularly important in this population.     

Health status of older Asian Americans in California

Given the paucity of research on differences between older adults representing the many Asian-American subcategories, the present study explored physical and mental health status in five subcategories of Asian Americans aged 60 and older: Chinese, Japanese, Korean, Vietnamese, and Filipino. Data were drawn from the 2007 California Health Interview Survey (CHIS). Background characteristics and physical and mental health conditions were compared, with results showing differences cross the five subcategories of older Asian Americans. Specific patterns were identified in chronic diseases, disease comorbidity, and disability rates. Vietnamese and Filipinos tended to have poorer physical health than Chinese, Japanese, and Koreans. The poorest self-rated health and the highest disability rate were found in the older Vietnamese. Filipinos also exhibited the greatest number of chronic diseases, including the highest rates of asthma, high blood pressure, and heart disease. Although Koreans had the fewest self-reported chronic diseases and the least evidence of disease comorbidity, they also had the highest psychological distress. The lowest psychological distress was found in older Japanese. Findings suggest that generalizing findings from one particular Asian category or from an aggregate Asian category may be problematic and may not reflect an accurate picture of the burden of health in specific Asian categories. Being aware of these differences in background and health characteristics may help providers to better serve older Asian clients.     

Daily Variations in Objective Nighttime Sleep and Subjective Morning Pain in Older Adults with Insomnia: Evidence of Covariation over Time

OBJECTIVES: To examine the relationship between objectively measured nocturnal sleep and subjective report of morning pain in older adults with insomnia; to examine not only the difference between persons in the association between sleep and pain (mean level over 14 days), but also the within‐person, day‐to‐day association. DESIGN: Cross‐sectional. SETTING: North‐central Florida. PARTICIPANTS: Fifty community‐dwelling older adults (mean age±standard deviation 69.1±7.0, range 60–90) with insomnia. MEASUREMENTS: Daily home‐based assessment using nightly actigraphic measurement of sleep and daily self‐report of pain over 14 consecutive days. RESULTS: Between persons, average sleep over 14 days was not associated with average levels of rated pain, but after a night in which an older adult with insomnia experienced above‐average total sleep time he or she subsequently reported below‐average pain ratings. The model explained approximately 24% of the within‐person and 8% of the between‐person variance in pain ratings. CONCLUSIONS: Sleep and pain show day‐to‐day associations (i.e., covary over time) in older adults with insomnia. Such associations may suggest that common physiological systems underlie the experience of insomnia and pain. Future research should examine the crossover effects of sleep treatment on pain and of pain treatment on sleep.     

Treating hepatitis C in African Americans

Background: The epidemiology, natural history and response to therapy of chronic hepatitis C differs significantly between African Americans and other ethnic populations. The reasons for these differences are not entirely clear but include mode of transmission, viral kinetics, immune responsiveness, and demographics. Objective: Review of the peer‐reviewed literature and expert opinion from 1990 to 2005 regarding features of hepatitis C virus (HCV) infection in African Americans, differences in presentation and response to therapy, and treatment recommendations. Results: The epidemiology of HCV infection in African Americans appears to be predominantly associated with socio‐economic status and high‐risk behaviors. However, disease course, response to treatment, and virologic outcome may be a function of race. African Americans may clear HCV less efficiently than other ethnic groups, although impaired immune responsivity may also lead to decreased necro‐inflammatory activity and progression to cirrhosis. Therapy‐naive African Americans have lower sustained virologic response rates to this treatment than other populations. Conclusions: Strategies to improve outcomes in African Americans include higher doses of current medications, medications with fewer adverse events, and new experimental molecular therapies.     

Attitudes of older Korean Americans toward mental health services

Given the increasing evidence that older ethnic minorities underuse mental health services, the present study assessed determinants of attitudes toward mental health services with a sample of older Korean Americans (N=472). Adapting Andersen's behavioral health model, predisposing factors (age, sex, marital status, education, length of residence in the United States), mental health needs (anxiety, suicidal ideation, depressive symptoms), and enabling factors (personal experiences and beliefs) were considered as potential predictors. Shorter residence in the United States and higher levels of depressive symptoms were associated with more-negative attitudes toward mental health services. Culture-influenced personal beliefs (knowledge about mental illness and stigmatism) were found to play a substantial role in shaping individuals' attitudes toward mental health services. Findings call attention to the need to investigate how culture influences the response to mental health needs and to develop community education and outreach programs to close the gaps between mental health needs and service utilization in older ethnic minority populations.