BACKGROUND: Patients with dementia are often unable to describe their pain because of memory deficiency and speech problems. This may lead to under-diagnosing and suboptimal pain treatment. The article summarises a thesis on development and testing of a new instrument for pain assessment: Mobilisation-Observation-Behavior-Intensity-Dementia (MOBID-2) pain scale. MATERIAL AND METHODS: 284 nursing home patients (with and without pain), who had been diagnosed with dementia of different types in various stages, were included in the study. Behaviour and intensity of pain was assessed during video-uptakes of clinical examinations and during regular morning care. Psychometric property testing included assessments of reliability, validity and clinical usefulness for the nursing home staff. RESULTS: Observation of pain behaviour during standardised and guided movements, by using the MOBID-2 Pain Scale, provides reliable and valid estimation of intensity of pain associated with the musculoskeletal-system. Pain that is not associated with the musculoskeletal-system is frequently observed, but more challenging to assess. Patients who have severe dementia and/or a combination of Alzheimer's disease and vascular dementia, have a higher risk of suffering from severe and untreated pain than patients without dementia. INTERPRETATION: The MOBID-2 pain scale may help to ensure competent pain treatment, and should be available in all Norwegian nursing homes. A multidisciplinary approach is needed for its implementation and use. Physicians in nursing homes should reconsider the staff's observations, perform additional investigations and find the balance between effects and side effects of pain treatment.

OBJECTIVE. To establish the prevalence of chronic widespread pain and associated symptoms in a general population sample. METHODS. Cross sectional postal survey of 2,034 adults in the north of England. RESULTS. The point prevalence of chronic widespread pain was 11.2%. The symptom was strongly associated with other somatic complaints and with measures of depression and anxiety. CONCLUSION. In the general population, this cardinal symptom of fibromyalgia is common and identifies a group who are more likely also to report symptoms of fatigue and depression.

Impressed with the number of patients whose spells of transient global amnesia were triggered by special circumstances, I have reviewed 78 such cases. Precipitating events were reported in 26 of 85 spells: eight occurred during highly emotional experiences; seven, during sexual intercourse; six, while the patient was in pain; two, while a trigeminal ganglion was being stimulated; and three, during a dip in the cold Atlantic Ocean. These observations suggest an electrophysiologic disturbance. The characteristics of the amnesia, the organization of memory, and behavior during spells were also considered.

It is claimed that a significant percentage of chronic pain patients suffer from drug/alcohol abuse/dependency/addiction. To address this question, 24 articles alluding to chronic pain patient drug/alcohol dependence/addiction were reviewed according to the following criteria: method for drug misuse diagnosis, which drug misuse diagnosis used (abuse, dependence, or addiction), and percentage of patients within each diagnostic category of drug misuse. The result of the review indicated that only seven studies utilized acceptable diagnostic criteria and/or definitions for the drug misuse diagnoses and gave percentages of drug misuse. Within these seven studies, the prevalence percentages for the diagnoses for drug abuse, drug dependence, and drug addiction were in the range of 3.2-18.9%. It is concluded that these diagnoses occur in a significant percentage of chronic pain patients. However, there is little evidence in these studies that addictive behaviors are common within the chronic pain population.

We report here follow-up data on subjects who were examined in two surveys conducted by the United States Center for Health Statistics at an interval of 8 years. The first survey was the 1st National Health and Nutrition Examination Survey (NHANES-1), and the second conducted 8 years later was the National Health and Nutrition Epidemiologic Follow-up Study (NHEFS). From an original sample of 3023 subjects, 153 were known to be deceased, leaving a potential sample of 2870 cases, of whom 2341 were ultimately examined in the NHEFS. The definition of pain used in the NHANES-1 survey identified 15% of the subjects as suffering from persistent pain. Using a different pain definition, in the NHEFS, the frequency of subjects with chronic pain was 32.8%. Applying this second definition, the percentage of subjects with chronic pain in the NHANES-1 had risen from 15 to 20.2. Some subjects (32.5%) who originally had chronic pain were free from pain at the time of follow-up; 59% of the subjects with chronic pain on follow-up did not have it initially. As found originally in the NHANES-1, the group with chronic pain at the NHEFS comprised significantly more females, older people, and people with lower income. On logistic regression analysis the strongest relationship found at the NHEFS between the variables examined was between chronic pain and depression.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVE: To examine the association between self-reported pain and cognitive impairment among frail elderly institution residents. DESIGN: A cross-sectional correlational study. SETTING: A large urban nursing home and congregate apartment complex housing predominantly Jewish elderly. PARTICIPANTS: Seven hundred fifty-eight elderly institution residents (30% in the nursing home, 70% in congregate apartments). The sample was 70% female and averaged 83.3 years of age. MEASUREMENTS: Respondent self-reports tapped pain intensity, number of localized pain complaints, cognitive status, and disability in performance of activities of daily living. Attending physicians or physician assistants rated respondents' health status. MAIN RESULTS: Pain intensity and number of localized pain complaints bore small but significant negative relationships to cognitive impairment. Pain was positively associated with physician-rated ill health and functional disability. The association between pain and cognitive status remained significant even when controlled statistically for effects of physical health and functional disability. Item-by-item examination of localized pain complaints indicated that markedly cognitively impaired individuals were less likely to report pain in the back and joints. However, examination of possible physical causes of reported pain revealed no differences between pain reports of cognitively impaired versus intact individuals in either the presence or the absence of a likely physical cause. CONCLUSIONS: These data provide no evidence for the "masking" of pain complaints by cognitive impairment. They suggest instead that, although cognitively impaired elderly may slightly underreport experienced pain, their self-reports are generally no less valid that those of cognitively intact individuals. Limitations of the research are acknowledged and implications for treatment of cognitively impaired institution residents are discussed.

OBJECTIVE: To determine the prevalence of concomitant disease in individuals with interstitial cystitis and to compare these results to the general population. METHODS: We used a questionnaire-based study evaluating 12 disease processes and a survey of interstitial cystitis characteristics. The population was 2,405 individuals with interstitial cystitis who responded to the initial survey and an additional 277 individuals who were randomly selected and individually contacted. RESULTS: Allergies, irritable bowel syndrome, and sensitive skin were the most common diseases in the interstitial cystitis population. In comparison to the general population, individuals with interstitial cystitis are 100 times more likely to have inflammatory bowel disease and 30 times more likely to have systemic lupus erythematosus. In addition, allergies, irritable bowel syndrome, sensitive skin, and fibromyalgia have an increased association with interstitial cystitis. CONCLUSIONS: Interstitial cystitis has, as yet, an unexplained association with certain other chronic disease and pain syndromes.

Relations among physical illness, functional disability, pain, and symptoms of depression were investigated in a sample of community-residing elderly outpatients. As expected, physical illness, functional disability, and pain were correlated with depressive symptomatology. It was further hypothesized that functional disability (but not physical illness per se) would attenuate the relation between depressed affect and pain. The data supported these predictions by showing that functional disability (but not physical illness) accounted for differences in reported pain between nondepressed subjects and those at risk for developing clinical depression. Additional analyses revealed that functional disability mediated relations between pain and depressed affect and also between illness and depressed affect. These results indicate that both pain and illness are important contributors to functional disability, which in turn contributes to symptoms of depression. Secondary analyses revealed that restriction of certain activities associated with physical mobility and independence were strong individual factors in attenuating the relation between pain and depressed affect. An important implication of this research is that neither pain nor activity restriction should be treated in isolation. Maximal effects are likely to be achieved when both are targeted simultaneously.

PURPOSE: To answer the question whether a single fraction of radiotherapy that is considered more convenient to the patient is as effective as a dose of multiple fractions for palliation of painful bone metastases. Patients: 1171 patients were randomised to receive either 8 Gy x 1 (n = 585) or 4 Gy x 6 (n = 586). The primary tumour was in the breast in 39% of the patients, in the prostate in 23%, in the lung in 25% and in other locations in 13%. Bone metastases were located in the spine (30%), pelvis (36%), femur (10%), ribs (8%), humerus (6%) and other sites (10%). METHOD: Questionnaires were mailed to collect information on pain, analgesics consumption, quality of life and side effects during treatment. The main endpoint was pain measured on a pain scale from 0 (no pain at all) to 10 (worst imaginable pain). Costs per treatment schedule were estimated. RESULTS: On average, patients participated in the study for 4 months. Median survival was 7 months. Response was defined as a decrease of at least two points as compared to the initial pain score. The difference in response between the two treatment groups proved not significant and stayed well within the margin of 10%. Overall, 71% experienced a response at some time during the first year. An analysis of repeated measures confirmed that the two treatment schedules were equivalent in terms of palliation. With regard to pain medication, quality of life and side effects no differences between the two treatment groups were found. The total number of retreatments was 188 (16%). This number was 147 (25%) in the 8 Gy x 1 irradiation group and 41 (7%) in the 4 Gy x 6 group. It was shown that the level of pain was an important reason to retreat. There were also indications that doctors were more willing to retreat patients in the single fraction group because time to retreatment was substantially shorter in this group and the preceding pain score was lower. Unexpectedly, more pathological fractures were observed in the single fraction group, but the absolute percentage was low. In a cost-analysis, the costs of the 4 Gy x 6 and the 8 Gy x 1 treatment schedules were calculated at 2305 and 1734 Euro respectively. Including the costs of retreatment reduced this 25% cost difference to only 8%. The saving of radiotherapy capacity, however, was considered the major economic advantage of the single dose schedule. CONCLUSION: The global analysis of the Dutch study indicates the equality of a single fraction as compared to a 6 fraction treatment in patients with painful bone metastases provided that 4 times more retreatments are accepted in the single dose group. This equality is also shown in long term survivors. A more detailed analysis of the study is in progress.

A study was conducted to examine the role of pain episodes and the role of active and passive pain coping strategies in predicting depression in 287 patients with rheumatoid arthritis (RA). The independent effects of pain and pain coping strategies, as well as the interaction effects between pain and pain coping strategies on depression, were evaluated cross-sectionally and prospectively over a 6-month interval. The cross-sectional findings revealed that pain, passive coping, and the interaction between pain and passive coping contributed independent variance, all accounting for higher depression. Of principal interest was the finding that the frequent use of passive pain coping strategies in the face of high pain contributed to the most severe level of depression over time. These results were obtained after controlling for the potentially confounding effects of prior depression, functional disability, and medication status. These data imply that there may be a potential benefit of developing techniques to reduce the use of passive pain coping strategies to deal with chronic arthritis pain in cognitive-behavioral pain management programs.