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Explore This IssueApril 2014
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SAN DIEGO—Pain and depression are important to assess and treat in patients with rheumatic diseases. Painful joints may signal underlying disease activity. Pain and depression may impair a patient’s quality of life and physical function, and prompt treatment adjustments. Patients are often at higher risk for poor disease outcomes if their symptoms are not treated properly.
At the 2013 ACR/ARHP Annual Meeting, two experts offered suggestions to clinicians on treating rheumatic diseases in the elderly with dementia or cognitive impairment, and in patients with severe psychiatric disorders. (Editor’s note: This session, ARHP: Rheumatic Disease and Pain Management in Special Needs Populations, was recorded and is available via ACR SessionSelect at www.rheumatology.org.)
Difficulty in Reporting Pain
Pain is common among patients older than 70; dementia and cognitive impairment are also prevalent in this population, creating barriers in patients’ abilities to express or report pain, said Devyani Misra, MD, a rheumatologist at Boston University School of Medicine. Dementia causes impairment in thinking, remembering and reasoning, and dementia patients may also have behavioral problems, Dr. Misra added.
“Pain is probably under-reported and under-recognized in this group, and because it is under-reported and under-recognized, it is undertreated,” said Dr. Misra. Significantly fewer elderly hospital patients with dementia or cognitive impairment receive opioids for their pain, she added. Undertreatment of pain leads to physical problems (e.g., impaired sleep, limited function), and psychosocial problems (e.g., depression).
Dr. Misra said that elders with dementia or cognitive impairment have difficulty with their memory or recall of pain.
Standard approaches to pain assessment include the McGill Pain Questionnaire, the Visual Analog Scale and the Wong-Baker FACES Pain Rating Scale, which uses images of facial expressions of pain to rate intensity. However, self-reporting pain scales are problematic to use in this patient population because of their cognitive impairment. Observational scales may be more useful, according to Dr. Misra.
Two scales have shown favorable results in measuring pain among these patients. Doloplus-2 is a 10-item observational pain scale measuring such factors as somatic complaints, protection of sore areas and mobility. The Pain Assessment Checklist for Seniors with Limited Ability to Communicate comes in both a 24- or 60-item checklist form, and also measures various observations, such as facial expressions of pain and changes in personality or mood. Although these tools are helpful, more accurate measurement tools are greatly needed, Dr. Misra said.
Pharmacologic interventions for managing pain in the elderly population include acetaminophen for mild-to-moderate pain, and opioids for moderate-to-severe pain or when there is evidence of diminished quality of life, Dr. Misra said. Constipation and sedation are potential adverse effects of sustained use of opioids. Corticosteroid injections or topical analgesics may be useful for localized pain. Anticonvulsants and antidepressants are other options, but anticholinergics are not recommended for elderly patients with dementia or cognitive impairment, she noted.
Nonpharmacologic interventions that have shown success in treating pain in this population include support from psychologists, as well as caregivers, she concluded.
Depression Common in RA
At all ages, patients with rheumatic diseases often experience major mood disorders, such as depression, said Lesley Arnold, MD, professor of psychiatry and behavioral neuroscience at the University of Cincinnati School of Medicine, Cincinnati. Prevalence of depression in the general population is about 7%, but 17% of the RA population reports having a major depressive disorder, and 15–48% present with depressive symptoms, Dr. Arnold said.
Depression is a syndrome that may include various emotional and physical symptoms. “If a patient cries in your office, obviously you should screen for depression,” said Dr. Arnold. Patients who are depressed may present with a variety of symptoms. “Anhedonia, especially in men, who sometimes report more emptiness or a lack of feelings, is something to look for.”
Anxiety is intertwined with depression, said Dr. Arnold. “In pain patients, anxiety is actually more common than depression. ‘Can’t turn their minds off at night’ is a common complaint in pain patients.” They may focus on their pain as a symptom of depression, she added. Fatigue and sleep disturbances also are common symptoms of depression. Many women with depression experience increases in their sleep patterns and appetite, while other patients may feel jittery or restless, unable to sleep.
Even depressive symptoms that are subthreshold are important to treat, because they can worsen. “Depression can profoundly impact your patient’s prognosis,” Dr. Arnold said. Depression’s impact on RA patients includes increased pain, fatigue, lower quality of life, increased physical disability, increased healthcare costs, poorer diet, less physical activity and reduced compliance with medications.
A number of screening tools using electronic medical records software may help in diagnosing depression in these patients. These include the Hamilton Rating Scale for Depression, the Hospital Anxiety and Depression Scale, and the Beck Depression Inventory. Some tools are self-reporting questionnaires that patients can complete on laptops or tablet computers at the clinic.
Proper treatment of depression can prevent recurrence, which occurs in 50% of patients who have reported one lifetime episode of the syndrome, as well as improve such symptoms as pain and sleeplessness. Depression is chronic and recurring. “Most people will need to be on therapy for the rest of their lives,” said Dr. Arnold. Although some patients will be referred to a psychiatrist for pharmacologic treatment of their depression, “it might be useful to you, if you have not already done so, to become comfortable using some of these medications in your patients,” she added.
There are many medications available to treat depression and anxiety, including tricyclic antidepressants, selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors, among others. Adverse effects, including anticholinergic effects, weight gain, increased appetite, sexual dysfunction and cardiovascular effects are concerns. It is also important to taper down dosages gradually and to educate patients that full therapeutic effects of many antidepressants may take up to six weeks, Dr. Arnold said. Patients should be maintained on antidepressants for one year after remission of symptoms, she added.
Nonpharmacologic interventions may also help patients who experience pain and depression. Approaches include mindful meditation and emotion-regulation therapy, Dr. Arnold said. “Medications will alleviate symptoms, but will not help people deal with their emotional problems.”
Bipolar disorder (BPD) is another common syndrome, and when it is comorbid with fibromyalgia, there might be increased suicide risk, Dr. Arnold said. Screening tests help identify BPD. “Anytime someone [says] an antidepressant made their mood worse, that is a red flag for bipolar disorder,” she said.
In chronic pain patients, predictors of suicide include poor sleep quality, use of illicit drugs, use of antidepressants, and being unemployed or on disability, Dr. Arnold said. Suicide-screening tests are useful in identifying high risk. “Patients will tell you whether they have suicidal [tendencies] or not.”
Severe mood disorders are common in patients with rheumatic disease, and referral to psychiatric professionals may be necessary, Dr. Arnold concluded. Routine screening will help identify patients who may have comorbid psychiatric disorders, leading to faster treatment to alleviate symptoms and manage the patient’s disease more effectively.
Susan Bernstein is a writer based in Atlanta.