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Factors associated with quality of life of older adults with chronic pain

Factores asociados a la calidad de vida de ancianos con dolor crónico

ABSTRACT

Objective:

To analyze the factors associated with quality of life of the older adults with chronic pain.

Method:

Cross-sectional study conducted with 239 older adults in outpatient care in the state of Goiás, Brazil. The World Health Organization Quality of Life–Old (WHOQOL-OLD) instrument contains six domains and was applied to assess quality of life. Simple and multiple linear regressions were used in the statistical analysis.

Results:

The factors associated with Sensory Abilities were age (β = - 0.52), time spent together (β = - 14.35; - 17.86; - 15.57), and pain intensity (β = - 1, 70). Autonomy was associated with depression (β = - 5.99) and chest pain (β = - 6.17). Social participation related to schooling (β = - 0.64), diabetes mellitus (β = - 8.15), depression (β = - 14.53), pain intensity (β = - 1.43), and lower limb pain (β = - 5.94). Past, present and future activities related to depression (β = - 6.94). Death and dying related to hypertension (β = - 8.40), while Intimacy to depression (β = - 5.99) and headache/face pain (β = - 3.19).

Conclusion:

The time experiencing chronic pain and the location of this experience, as well as depression, diabetes and systemic arterial hypertension were factors that had greater influence on the older adult’s Quality of Life domains.

Descriptors:
Chronic Pain; Quality of Life; Aged; Health Services for the Aged; Geriatric Nursing

RESUMEN

Objetivo:

Analizar los factores asociados a la calidad de vida (CV) de ancianos con dolor crónico.

Método:

Estudio transversal en el cual participaron 239 ancianos en atención ambulatoria en el estado de Goiás, Brasil. Para evaluar la calidad de vida, se aplicó el World Health Organization Quality of Life – Old (WHOQOL-OLD), que presenta seis dominios. Para el análisis estadístico, se utilizó la regresión lineal simple y múltiple.

Resultados:

Los factores asociados con el dominio Funcionamiento sensorial fueron la edad (β = − 0,52), el tiempo de convivencia (β = − 14,35; − 17,86; − 15,57) y la intensidad del dolor (β = − 1,70). El dominio Autonomía se asoció con la depresión (β = − 5,99) y el dolor torácico (β = − 6,17). La Participación social se relacionó con el nivel de estudios (β = − 0,64), diabetes mellitus (β = − 8,15), depresión (β = − 14,53), intensidad del dolor (β = − 1,43) y dolor en miembros inferiores (β = − 5,94). Las actividades pasadas, presentes y futuras se vincularon con la depresión (β = − 6,94). El dominio Muerte y morir se asoció con la hipertensión (β = − 8,40), mientras que el dominio Intimidad se relacionó con la depresión (β = − 5,99) y el dolor de cabeza/en la cara (β = − 3,19).

Conclusión:

El tiempo de convivencia con el dolor crónico y el local de esa experiencia, así como la depresión, diabetes y HAS, fueron los factores que más influyeron en los dominios de CV de los ancianos.

Descriptores:
Dolor Crónico; Calidad de Vida; Anciano; Salud del Anciano; Enfermería Geriátrica

RESUMO

Objetivo:

Analisar os fatores associados à qualidade de vida (QV) em idosos com dor crônica.

Método:

Estudo transversal realizado com 239 idosos em atendimento ambulatorial no estado de Goiás, Brasil. O World Health Organization Quality of Life – Old (WHOQOL-OLD) contém seis domínios e foi aplicado para avaliar a qualidade de vida. Foram utilizadas regressão linear simples e múltipla na análise estatística.

Resultados:

Os fatores associados ao domínio Funcionamento dos sentidos foram idade (β = − 0,52), tempo de convívio (β = − 14,35; − 17,86; − 15,57) e intensidade da dor (β = − 1,70). Ao domínio Autonomia associaram-se a depressão (β = − 5,99) e a dor no tórax (β = − 6,17). A Participação social relacionou-se à escolaridade (β = − 0,64), diabetes mellitus (β = − 8,15), depressão (β = − 14,53), intensidade da dor (β = − 1,43) e à dor em MMII (β = − 5,94). Às Atividades passadas, presentes e futuras associou-se a depressão (β = − 6,94). O domínio Morte e morrer foi associado à hipertensão (β = − 8,40), enquanto o domínio Intimidade foi relacionado à depressão (β = − 5,99) e dor na cabeça/face (β = − 3,19).

Conclusão:

O tempo de convívio com a dor crônica e a localização dessa experiência, assim como a depressão, diabetes e HAS foram fatores que influenciaram com maior magnitude os domínios de QV dos idosos.

Descritores:
Dor Crônica; Qualidade de Vida; Idoso; Saúde do Idoso; Enfermagem Geriátrica

INTRODUCTION

Aging is often accompanied by chronic pain(11 Pereira LV, Vasconcelos PP, Souza LAF, Pereira GA, Nakatani AYK, Bachion MM. Prevalência, intensidade de dor crônica e autopercepção de saúde entre idosos: estudo de base populacional. Rev Latino-Am Enferm. 2014;22(4):662-9. https://doi.org/10.1590/0104-1169.3591.2465
https://doi.org/10.1590/0104-1169.3591.2...
-22 Ruan X, Wu H, Kaye AD. The global burden of pain and disability. Anesth Analg. 2017;124(1):370-1. https://doi.org/10.1213/ANE.0000000000001711
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), imposing a significant social and economic burden(33 Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. J Pain Res. 2016;9(1):457-67. https://doi.org/10.2147/JPR.S105892
https://doi.org/10.2147/JPR.S105892...
) due to increased treatment costs(44 Lazkani A, Delespierre T, Bauduceau B, Pasquier F, Bertin P, Berrut G, et al. Healthcare costs associated with elderly chronic pain patients in primary care. Eur J Clin Pharmacol. 2015;71(1):939-47. https://doi.org/10.1007/s00228-015-1871-6
https://doi.org/10.1007/s00228-015-1871-...
) and losses in quality of life (QOL)(55 Bernfort L, Gerdle B, Rahmqvist M, Husberg M, Levin LA. Severity of chronic pain in an elderly population in Sweden impact on costs and quality of life. Pain. 2015;156(3):521-7. https://doi.org/10.1097/01.j.pain.0000460336.31600.01
https://doi.org/10.1097/01.j.pain.000046...
), which leads to higher morbidity and mortality levels.

In the context of chronic pain, QOL is often impaired in the physical, psychological(66 Niv D, Kreitler S. Pain and quality of life. Pain Pract. 2001;1(2):150-61. https://doi.org/10.1046/j.1533-2500.2001.01016.x
https://doi.org/10.1046/j.1533-2500.2001...
-77 Morete MC, Solano JPC, Boff MS, Filho WJ, Ashmawi HA. Resilience, depression, and quality of life in elderly individuals with chronic pain followed up in an outpatient clinic in the city of São Paulo, Brazil. J Pain Res. 2018;11(1):2561-6. https://doi.org/10.2147/JPR.S166625
https://doi.org/10.2147/JPR.S166625...
), mental, emotional, social, vitality and pain domains,(77 Morete MC, Solano JPC, Boff MS, Filho WJ, Ashmawi HA. Resilience, depression, and quality of life in elderly individuals with chronic pain followed up in an outpatient clinic in the city of São Paulo, Brazil. J Pain Res. 2018;11(1):2561-6. https://doi.org/10.2147/JPR.S166625
https://doi.org/10.2147/JPR.S166625...
) indicating an almost two-fold increase in the likelihood of poor QOL in older adults with chronic pain when compared with older adults without it(88 Wang C, Pu R, Ghose B, Tang S. Chronic musculoskeletal pain, self-reported health and quality of life among older populations in South Africa and Uganda. Int J Environ Res Public Health. 2018;15(12):2806. https://doi.org/10.3390/ijerph15122806
https://doi.org/10.3390/ijerph15122806...
). It directly affects older adult’s health with the imposition of suffering that is often unnecessary.

Some general factors associated with QOL of older adults with chronic pain have been evidenced, such as pain intensity(99 Nasution IK, Lubis NDA, Amelia S, Hocin K. The correlation of pain intensity and quality of life in chronic LBP patients in Adam Malik general hospital. IOP Conf Ser Earth and Environ Sci. 2018;125(1):e012183. https://doi.org/10.1088/1755-1315/125/1/012183
https://doi.org/10.1088/1755-1315/125/1/...
), depression(1010 Sivertsen H, Bjorklof GH, Engedal K, Selbaek G, Helvik AS. Depression and quality of life in older persons: a review. Dement Geriatr Cogn Disord. 2015;40(1):311-39. https://doi.org/10.1159/000437299
https://doi.org/10.1159/000437299...
), age(88 Wang C, Pu R, Ghose B, Tang S. Chronic musculoskeletal pain, self-reported health and quality of life among older populations in South Africa and Uganda. Int J Environ Res Public Health. 2018;15(12):2806. https://doi.org/10.3390/ijerph15122806
https://doi.org/10.3390/ijerph15122806...
), disability, and time experiencing pain(1111 Hong JH, Kim HD, Shin HH, Huh B. Assessment of depression, anxiety, sleep disturbance, and quality of life in patients with chronic low back pain in Korea. Korean J Anesthesiol. 2014;66(6):444-50. https://doi.org/10.4097/kjae.2014.66.6.444
https://doi.org/10.4097/kjae.2014.66.6.4...
). Nevertheless, there are still few investigations focusing on factors that can influence the older adult’s perception of QOL, in view of the domains that compose this construct. The results can contribute to guide future research, with designs sufficiently robust to elaborate high-level scientific evidence that make it possible to confirm the cause-effect relation, leading to a stronger possibility of building a bad QOL predictive model for older adults with chronic pain. Knowing the factors associated with the domains also increases diagnosis, planning and evaluation accuracy of the assistance strategies used to guarantee this population a good QOL.

OBJETIVE

To analyze the factors associated with quality of life of older adults with chronic pain.

METHODS

Ethical aspects

The project was approved by the Research Ethics Committee of the Universidade Federal de Goiás, respecting the principles of CNS Resolution 466/12.

Design, location and study period

This is a cross-sectional, analytical study, designed according to the recommendations of the Strengthening the reporting of observational studies in epidemiology (Strobe) Statement(1212 Malta M, Cardoso LO, Bastos FI, Magnanini MMF, Silva CMFP. Iniciativa STROBE: subsídios para a comunicação de estudos observacionais. Rev Saude Publica. 2010;44(3):559-65. https://doi.org/10.1590/S0034-89102010000300021
https://doi.org/10.1590/S0034-8910201000...
), based on an outline of a larger project entitled “Cross-cultural adaptation, psychometric properties of the Brazilian version of the Chronic pain coping inventory and evaluation of factors related to chronic pain time in an adult outpatient population.” It was developed between the months of November 2016 and December 2017, in waiting rooms of neurology, orthopedics, physiatry and rheumatology outpatient clinics of a federal teaching hospital, in a metropolis in the Central-West region of Brazil.

Sample and inclusion and exclusion criteria

A subsample of older adults from the larger project was used (n = 239). Sampling calculation was performed to detect associations between dependent and independent variables. The means of outcomes (QOL domain scores) were compared between the independent variables, considering a 95% confidence level, 80% statistical power and a 5% mean difference for any independent variables investigated in the study in all QOL domains using the World Health Organization Quality of Life - Old (WHOQOL-OLD) instrument, with a 20% refusal rate added to the minimum sample, which totaled a necessary sample of 218 participants(1313 Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian J Psychol Med. 2013;35(2):121-6. https://doi.org/10.4103/0253-7176.116232
https://doi.org/10.4103/0253-7176.116232...
-1414 Dell RB, Holleran S, Ramakrishnan R. Sample size determination. ILAR J. 2002;43(4):207-13. https://doi.org/10.1093/ilar.43.4.207
https://doi.org/10.1093/ilar.43.4.207...
). Sampling was carried out by convenience: patients were approached sequentially after arriving at the clinic and were invited to participate in the study. Older men and women, able to answer research questions and with self-reported chronic pain, were included. Older adults who did not speak, who needed help to provide information or who reached a score ≤ 13 in the Mini Mental State Examination (MMSE)(1515 Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98. https://doi.org/10.1016/0022-3956(75)90026-6
https://doi.org/10.1016/0022-3956(75)900...
) were excluded. The established cutoff point considered that cognitive impairment, combined with lack of schooling, could bias the measures proposed in the study. For individuals with low and medium schooling (one to eight years of study) the cutoff was 18, and for those with schooling > eight years of study, it was 26(1616 Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O mini-exame do estado mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr. 1994;52(1):1-7. https://doi.org/10.1590/S0004-282X1994000100001
https://doi.org/10.1590/S0004-282X199400...
).

Study protocol

The research used the following instruments: sociodemographic characterization questionnaire, MMSE, Brief Pain Inventory (BPI), and WHOQOL-OLD.

Study variables were: outcome – QOL domains (Sensory abilities; Autonomy; Past, present and future activities; Social participation; Death and dying, and Intimacy); exposure – gender; age; marital status; years of schooling; income; self-reported comorbidities with confirmed medical diagnosis; time spent together; chronic pain intensity and location. Chronic pain was considered pain existing for six months or more(1717 Merskey H, Bogduk N, (Eds.). Classification of chronic pain descriptions of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press; 1994.).

To measure pain intensity, the average of the older adult’s responses was used in four items: BPI 3, BPI 4, BPI 5 and BPI 6, using a numerical scale from 0 to 10, with 0 = no pain and 10 = worst possible pain. This instrument also assesses the interference of pain in daily life using a scale from 0 to 10 (in which 0 means “without interference” and 10 “total interference”) which has two sub-dimensions (affective and activity). The instrument also includes a body diagram for pain locations, an open question about the treatment for pain and the relief provided by the treatment(1818 Cleeland CS. The brief pain inventory: user guide. Houston: Anderson Cancer Center; 2009.). In this study, the instrument was used only to measure pain intensity, which was represented by a numerical scale in the categories mild (1-4), moderate (5-6), strong (7-9), and worst possible pain (10).

WHOQOL-OLD module is specific for measuring the older adult’s QOL, valid for the Brazilian population(1919 Chachamovich E, Trentini CM, Fleck MPA, Schmidt S, Power M. Desenvolvimento do instrumento WHOQOL-OLD. In: Fleck MPA, editor. A avaliação de qualidade de vida: guia para profissionais da saúde. Porte Alegre: Artmed; 2008. p. 102-11.). It has six distinct domains (Sensory abilities; Autonomy; Past, present and future activities; Social participation; Death and dying, and Intimacy), with 24 items. Responses are Likert-type, ranging from 1 to 5, where 1 is assigned to words like never, very bad or very dissatisfied, and 5 is given to the words extremely, very satisfied and very good. The score per domain can vary from 0 to 100 points, and it is calculated based on the WHO syntax(1919 Chachamovich E, Trentini CM, Fleck MPA, Schmidt S, Power M. Desenvolvimento do instrumento WHOQOL-OLD. In: Fleck MPA, editor. A avaliação de qualidade de vida: guia para profissionais da saúde. Porte Alegre: Artmed; 2008. p. 102-11.-2020 World Health Organization. The WHOQOL-OLD module: manual. Copenhagen: WHO; 2006.). Higher scores indicate better QOL(2020 World Health Organization. The WHOQOL-OLD module: manual. Copenhagen: WHO; 2006.).

The data were obtained through individual face-to-face interviews, conducted by properly trained observers. The individuals were approached after registering at the outpatient reception desk; those who met the inclusion criteria were invited to participate in the research and then, in an appropriate place, received guidance on the objectives of the investigation. After agreeing, they signed the Informed Consent Term in two copies and then the data collection instruments were applied.

Data analysis

Data record was made by double data entry into Microsoft Excel® spreadsheets. In order to check for inconsistencies, databases were overlaid using Microsoft Excel 2016 software. Non-recoverable data were recorded in the database as missing. Data analysis was performed using Stata software version 15.0. Initially, Kolmogorov-Smirnov test with Lilliefors correction was performed to verify normality, and variables with p-value> 0.05 were considered to have a normal distribution(2121 Ghasemi A, Zahediasl S. Normality tests for statistical analysis: a guide for non-statisticians. Int J Endocrinol Metab. 2012;10(2):486-9. https://doi.org/10.5812/ijem.3505
https://doi.org/10.5812/ijem.3505...
). Then, a descriptive analysis of the sociodemographic variables related to morbidity and pain was performed, expressed in absolute (n) and relative (%), median, interquartile range (IQR), and minimum and maximum values(2222 Spriestersbach A, Rohrig B, Prel JB, Gerhold-Ay A, Blettner M. Descriptive statistics: the specification of statistical measures and their presentation in tables and graphs: part 7 of a series on evaluation of scientific publications. Dtsch Arztebl Int. 2009;106(36):578-83. https://doi.org/10.3238/arztebl.2009.0578
https://doi.org/10.3238/arztebl.2009.057...
). WHOQOL-OLD domains were weighted based on their respective syntax and expressed as mean and standard deviation (SD) values.

Bivariate and multiple analyzes were used to ascertain the factors associated with QOL domains. In the bivariate analysis, simple linear regression was performed to verify the association between independent variables and domains (dependent variables). Then, variables with p-value ≤ 0.20 in the bivariate analysis were included in the multiple linear regression model for confounding variables adjustment(2323 Schneider A, Hommel G, Blettner M. Linear regression analysis: part 14 of a series on evaluation of scientific publications. Dtsch Arztebl Int. 2010;107(44):776-82. https://doi.org/10.3238/arztebl.2010.0776
https://doi.org/10.3238/arztebl.2010.077...
). Variables entry method was employed in a single step. The magnitude of the associations was presented in an unadjusted regression coefficient (β) with the respective 95% CI. The models were evaluated and validated according to the following assumptions of linear regression: (i) multicollinearity by the variance inflation factor (VIF) - the absence of multicollinearity was defined as mean FIV <5.0(2424 Kim JH. Multicollinearity and misleading statistical results. Korean J Anesthesiol. 2019;72(6):558-69. https://doi.org/10.4097/kja.19087
https://doi.org/10.4097/kja.19087...
); normality of residues by K-S test, adopting test p values> 0.05(2121 Ghasemi A, Zahediasl S. Normality tests for statistical analysis: a guide for non-statisticians. Int J Endocrinol Metab. 2012;10(2):486-9. https://doi.org/10.5812/ijem.3505
https://doi.org/10.5812/ijem.3505...
); (iii) homoscedasticity, assessed by Breusch-Pagan/Cook-Weisberg test - the homoscedasticity of the models was confirmed when p value> 0.05(2525 Daye ZJ, Chen J, Li H. High-dimensional heteroscedastic regression with an application to eQTL Data Analysis. Biometrics. 2012;68(1):316-26. https://doi.org/10.1111/j.1541-0420.2011.01652.x
https://doi.org/10.1111/j.1541-0420.2011...
), and (iv) linearity analyzed by graphical visualization(2626 Kroll MH, Emancipator K. A theoretical evaluation of linearity. Clin Chem [Internet]. 1993 [cited 2020 Sep 9];39(3):405-13. Available from: https://pubmed.ncbi.nlm.nih.gov/8448849/
https://pubmed.ncbi.nlm.nih.gov/8448849/...
).

In all analyzes, p values <0.05 were considered statistically significant.

RESULTS

Sociodemographic, economic, comorbidity and chronic pain characteristics are described in Table 1. There was a prevalence of women (70.3%) and 60-69 years age group (66.5%).

Table 1
Distribution of older adults with chronic pain (N = 239) according to sociodemographic, economic, comorbidity and chronic pain characteristics, Goiânia, Brazil 2016-2017

In WHOQOL-OLD, Autonomy (M = 61.8) and Social Participation (M = 63.5) domains achieved the lowest mean score. QOL average total score was 66.5 (Table 2).

Table 2
Descriptive measures of WHOQOL-OLD domains, Goiânia, Brazil 2016-2017

Table 3 shows the results of the multiple regression analysis of the factors associated with each QOL domain, that is, those that reached p <0.20 in the bivariate analysis. It is observed that, among the two domains with lower mean scores in QOL, the Autonomy domain was influenced by depression and chest pain, explaining 16.4% of QOL of this sample; the Social Participation domain was negatively influenced by diabetes mellitus, depression, greater pain intensity and headache/face pain, explaining 22.4% of QOL. Other factors negatively associated with the Sensory abilities domain included the time experiencing pain and pain intensity. Systemic arterial hypertension also negatively influenced the Death and dying domain; and depression and headache/face pain affected the Intimacy domain.

Table 3
Multiple regression by domain of the potential factors associated with the perception of QOL of older adults people with chronic pain, Goiânia, Brazil 2016-2017

DISCUSSION

The results show that the Autonomy and Social Participation domains have the lowest average scores when compared with the others, which indicates a greater negative influence on the QOL of older adults with chronic pain, corroborating the findings of other studies(2727 Ferretti F, Castanha AC, Padoan ER, Lutinski J, Silva MR. Quality of life in the elderly with and without chronic pain. BrJP. 2018;1(2):111-5. https://doi.org/10.5935/2595-0118.20180022
https://doi.org/10.5935/2595-0118.201800...
-2828 Paiva FTF, Lima LR, Funez MI, Volpe CRG, Funguetto SS, Stiva MM. The influence of pain on elderly diabetics' quality of life. Rev Enferm UERJ. 2019;27:e31517. https://doi.org/10.12957/reuerj.2019.31517
https://doi.org/10.12957/reuerj.2019.315...
). Additionally, these were the most explicative domains related to QOL in this sample.

In the multiple analysis, factors negatively associated with the QOL Autonomy domain included depression, greater pain intensity and chest pain. In the Social participation domain, there was a negative association with schooling, diabetes mellitus, depression, pain intensity and lower limb pain. In this sense, it is worth mentioning that, among the older adults, an association of depression with autonomy was evidenced(2929 Gonçalves FB, Araújo APS, Júnior JRAN, Oliveira DV. Qualidade de vida e indicativos de depressão em idosas praticantes de exercícios físicos em academias da terceira idade da cidade de Maringá (PR). Saude Pesqui. 2015;8(3):557-67. https://doi.org/10.17765/2176-9206.2015v8n3p557-567
https://doi.org/10.17765/2176-9206.2015v...
). Another study(3030 Kuss K, Laekeman M. Activating physiotherapy for chronic pain in elderly patients: recommendations, barriers and resources. Schmerz. 2015;29(4):402-10. https://doi.org/10.1007/s00482-015-0037-x
https://doi.org/10.1007/s00482-015-0037-...
) showed that there is a loss of autonomy among older adults with chronic pain, which leads the authors to argue that depression in older adults suffering from chronic pain should be diagnosed and treated as soon as possible to avoid further losses in QOL. The biggest concern is that these morbidities (depression and chronic pain) have been experienced concurrently by the participants in this study. It is known that the genesis of chronic pain and depression is related to common mechanisms, such as the activation of specific centers in the central nervous system(3131 Zis P, Daskalaki A, Bountouni I, Sykioti P, Varrassi G, Paladini A. Depression and chronic pain in the elderly: links and management challenges. Clin Interv Aging. 2017;12:709-20. https://doi.org/10.2147/CIA.S113576
https://doi.org/10.2147/CIA.S113576...
). In this context, older adults with chronic pain may be more likely to develop depression and vice versa. Losses in autonomy lead to dysfunctional interpersonal relationships, withdrawal from recreation and leisure activities, absence of health care in general and social isolation(1010 Sivertsen H, Bjorklof GH, Engedal K, Selbaek G, Helvik AS. Depression and quality of life in older persons: a review. Dement Geriatr Cogn Disord. 2015;40(1):311-39. https://doi.org/10.1159/000437299
https://doi.org/10.1159/000437299...
,1919 Chachamovich E, Trentini CM, Fleck MPA, Schmidt S, Power M. Desenvolvimento do instrumento WHOQOL-OLD. In: Fleck MPA, editor. A avaliação de qualidade de vida: guia para profissionais da saúde. Porte Alegre: Artmed; 2008. p. 102-11.,3232 Boyle G. The role of autonomy in explaining mental ill-health and depression among older people in long-term care settings. Ageing Soc. 2005;25(5):731-48. https://doi.org/10.1017/S0144686X05003703
https://doi.org/10.1017/S0144686X0500370...
), which can negatively influence these people’s QOL.

Additionally, chest pain influences the low scores found in the Autonomy domain. No research was found investigating pain location as a factor associated with the Autonomy domain in older adults with chronic pain, which limited comparison of findings. However, it is worth remembering that 84.1% of the participants in this study reported moderate intensity pain/worst possible pain, clinically significant and reason for important losses in people’s lives, showing a relevant association with poor QOL(99 Nasution IK, Lubis NDA, Amelia S, Hocin K. The correlation of pain intensity and quality of life in chronic LBP patients in Adam Malik general hospital. IOP Conf Ser Earth and Environ Sci. 2018;125(1):e012183. https://doi.org/10.1088/1755-1315/125/1/012183
https://doi.org/10.1088/1755-1315/125/1/...
,3333 Geelen CC, Kindermans HP, Bergh JP, Verbunt JA. Perceived physical activity decline as a mediator in the relationship between pain catastrophizing, disability, and quality of life in patients with painful diabetic neuropathy. Pain Pract. 2016;17(3):320-8. https://doi.org/10.1111/papr.12449
https://doi.org/10.1111/papr.12449...
). It is important to consider that individuals who suffer from chronic pain tends to isolate themselves and avoid participating in daily and community activities(3434 Karayannis NV, Baumann I, Sturgeon JA, Melloh M, Mackey SC. The impact of social isolation on pain interference: a longitudinal study. Ann Behav Med. 2019;53(1):65-74. https://doi.org/10.1093/abm/kay017
https://doi.org/10.1093/abm/kay017...
).

Chest pain can be associated with cardiovascular diseases, such as coronary syndromes(3535 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. https://doi.org/10.1016/S0140-6736(18)32279-7
https://doi.org/10.1016/S0140-6736(18)32...
-3636 Vargas RA, Riegel F, Oliveira Junior N, Siqueira DS, Crossetti MGO. Qualidade de vida de pacientes pós-infarto do miocárdio: revisão integrativa da literatura. Rev Enferm UFPE. 2017;11(7):2803-9. https://doi.org/10.5205/reuol.10939-97553-1-RV.1107201721
https://doi.org/10.5205/reuol.10939-9755...
). Sometimes, the stigma that accompanies localized pain may cause the older adult to withdraw from their activities for fear of greater damage to their health. Losses in autonomy can also be associated with cardiovascular changes that generate disability(3535 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. https://doi.org/10.1016/S0140-6736(18)32279-7
https://doi.org/10.1016/S0140-6736(18)32...
) and can impair decision making, freedom and the activities they would like to do throughout their lives, directly impacting QOL.

Depression was negatively associated with the Social participation domain, as well as schooling, diabetes mellitus, pain intensity and lower limb pain. Ferretti et al.(2727 Ferretti F, Castanha AC, Padoan ER, Lutinski J, Silva MR. Quality of life in the elderly with and without chronic pain. BrJP. 2018;1(2):111-5. https://doi.org/10.5935/2595-0118.20180022
https://doi.org/10.5935/2595-0118.201800...
) showed a difference in the mean score of the Social participation domain (3.73 ± 0.59) between older adults with and without chronic pain (3.96 ± 0.56)(2727 Ferretti F, Castanha AC, Padoan ER, Lutinski J, Silva MR. Quality of life in the elderly with and without chronic pain. BrJP. 2018;1(2):111-5. https://doi.org/10.5935/2595-0118.20180022
https://doi.org/10.5935/2595-0118.201800...
). A study review identified depression as a factor of decreased social participation among older adults(3737 Pinto JM, Neri AL. Trajectories of social participation in old age: a systematic literature review. Rev Bras Geriatr Gerontol. 2017;20(2):260-73. https://doi.org/10.1590/1981-22562017020.160077
https://doi.org/10.1590/1981-22562017020...
), social withdrawal and abandonment of community activities(1010 Sivertsen H, Bjorklof GH, Engedal K, Selbaek G, Helvik AS. Depression and quality of life in older persons: a review. Dement Geriatr Cogn Disord. 2015;40(1):311-39. https://doi.org/10.1159/000437299
https://doi.org/10.1159/000437299...
). In this regard, cultural aspects, available resources, habits and beliefs(3737 Pinto JM, Neri AL. Trajectories of social participation in old age: a systematic literature review. Rev Bras Geriatr Gerontol. 2017;20(2):260-73. https://doi.org/10.1590/1981-22562017020.160077
https://doi.org/10.1590/1981-22562017020...
) are evaluated, which can also explain a negative association with morbidities as diabetes mellitus and arterial hypertension, since erroneous habits and beliefs increase the probability of occurrence and the adequate treatment of these comorbidities. Recent research conducted with community older adults with diabetes mellitus and with and without chronic pain showed that those who suffered from chronic pain had a lower mean score (59.84 ± 19.01) in the Social participation domain when compared with those without it (61, 83 ± 20.95)(2828 Paiva FTF, Lima LR, Funez MI, Volpe CRG, Funguetto SS, Stiva MM. The influence of pain on elderly diabetics' quality of life. Rev Enferm UERJ. 2019;27:e31517. https://doi.org/10.12957/reuerj.2019.31517
https://doi.org/10.12957/reuerj.2019.315...
).

Pain intensity was also a factor associated with this domain. In this sense, it is worth remembering that diabetes is related to neuropathies, especially the sensory-motor ones, physical complications and high-intensity pain that generate disability(3535 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. https://doi.org/10.1016/S0140-6736(18)32279-7
https://doi.org/10.1016/S0140-6736(18)32...
). Lower limb pain prevailed among the community older adult with chronic pain(11 Pereira LV, Vasconcelos PP, Souza LAF, Pereira GA, Nakatani AYK, Bachion MM. Prevalência, intensidade de dor crônica e autopercepção de saúde entre idosos: estudo de base populacional. Rev Latino-Am Enferm. 2014;22(4):662-9. https://doi.org/10.1590/0104-1169.3591.2465
https://doi.org/10.1590/0104-1169.3591.2...
), indicating a possible relation with disability(22 Ruan X, Wu H, Kaye AD. The global burden of pain and disability. Anesth Analg. 2017;124(1):370-1. https://doi.org/10.1213/ANE.0000000000001711
https://doi.org/10.1213/ANE.000000000000...
,3838 Aguiar BM, Silva PO, Vieira MA, Costa FM, Carneiro JA. Evaluation of functional disability and associated factores in the elderly. Rev Bras Geriatr Gerontol. 2019;22(2):e180163. https://doi.org/10.1590/1981-22562019022.180163
https://doi.org/10.1590/1981-22562019022...
), which affects functional, social, physical and psychological activities(3838 Aguiar BM, Silva PO, Vieira MA, Costa FM, Carneiro JA. Evaluation of functional disability and associated factores in the elderly. Rev Bras Geriatr Gerontol. 2019;22(2):e180163. https://doi.org/10.1590/1981-22562019022.180163
https://doi.org/10.1590/1981-22562019022...
). Chronic pain reduces mobility, directly or indirectly, imposes limitations on mobility and on performing basic and instrumental activities of daily living, affecting social participation(11 Pereira LV, Vasconcelos PP, Souza LAF, Pereira GA, Nakatani AYK, Bachion MM. Prevalência, intensidade de dor crônica e autopercepção de saúde entre idosos: estudo de base populacional. Rev Latino-Am Enferm. 2014;22(4):662-9. https://doi.org/10.1590/0104-1169.3591.2465
https://doi.org/10.1590/0104-1169.3591.2...
-22 Ruan X, Wu H, Kaye AD. The global burden of pain and disability. Anesth Analg. 2017;124(1):370-1. https://doi.org/10.1213/ANE.0000000000001711
https://doi.org/10.1213/ANE.000000000000...
,3434 Karayannis NV, Baumann I, Sturgeon JA, Melloh M, Mackey SC. The impact of social isolation on pain interference: a longitudinal study. Ann Behav Med. 2019;53(1):65-74. https://doi.org/10.1093/abm/kay017
https://doi.org/10.1093/abm/kay017...
). One agrees with the authors’ statements about high-intensity pain contributing to isolation, worsening professional and leisure activities, and changing family life(99 Nasution IK, Lubis NDA, Amelia S, Hocin K. The correlation of pain intensity and quality of life in chronic LBP patients in Adam Malik general hospital. IOP Conf Ser Earth and Environ Sci. 2018;125(1):e012183. https://doi.org/10.1088/1755-1315/125/1/012183
https://doi.org/10.1088/1755-1315/125/1/...
,2727 Ferretti F, Castanha AC, Padoan ER, Lutinski J, Silva MR. Quality of life in the elderly with and without chronic pain. BrJP. 2018;1(2):111-5. https://doi.org/10.5935/2595-0118.20180022
https://doi.org/10.5935/2595-0118.201800...
,3434 Karayannis NV, Baumann I, Sturgeon JA, Melloh M, Mackey SC. The impact of social isolation on pain interference: a longitudinal study. Ann Behav Med. 2019;53(1):65-74. https://doi.org/10.1093/abm/kay017
https://doi.org/10.1093/abm/kay017...
).

No studies were found with samples of older adults with chronic pain that investigated an association between schooling and the Social participation domain. However, research that assessed QOL of people in general showed a divergent result(3939 Alberte JSP, Ruscalleda RMI, Guariento ME. Qualidade de vida e variáveis associadas ao envelhecimento patológico. Rev Soc Bras Clin Med [Internet]. 2015 [cited 2020 Jan 23];13(1):32-9. Available from: http://files.bvs.br/upload/S/1679-1010/2015/v13n1/a4766.pdf
http://files.bvs.br/upload/S/1679-1010/2...
-4040 Inouye K, Pedrazzani ES. Nível de instrução, status socioeconômico e avaliação de algumas dimensões da qualidade de vida de octogenários. Rev Latino-Am Enfermagem. 2007;15(1):742-7. https://doi.org/10.1590/S0104-11692007000700005
https://doi.org/10.1590/S0104-1169200700...
), that is, a higher schooling level seemed to increase the chance of a better QOL. In this sense, the authors understand that new research should be carried out to confirm the findings of this study or to refute them.

An interesting finding was the negative association between the Sensory abilities domain and time experiencing pain (over one year), and a greater intensity of this pain suggests the need to systematically assess long-lived patients with chronic pain, as their QOL, and perhaps their cognitive capacity, can be impaired, since chronic pain, regardless of its location and etiology, can cause brain abnormalities and contribute to the reduction of gray matter volume(4141 Fritz HC, McAuley JH, Wittfeld K, Hegenscheid K, Schmidt CO, Langner S, et al. Chronic back pain is associated with decreased prefrontal and anterior insular gray matter: results from a population-based cohort study. J Pain. 2016;17(1):111-8. https://doi.org/10.1016/j.jpain.2015.10.003
https://doi.org/10.1016/j.jpain.2015.10....
), exacerbating cognitive losses and pain. A study conducted in the older adult with chronic back pain showed a negative correlation (r = - 0.326; p = 0.026) between time experiencing pain (over three months) and QOL(1111 Hong JH, Kim HD, Shin HH, Huh B. Assessment of depression, anxiety, sleep disturbance, and quality of life in patients with chronic low back pain in Korea. Korean J Anesthesiol. 2014;66(6):444-50. https://doi.org/10.4097/kjae.2014.66.6.444
https://doi.org/10.4097/kjae.2014.66.6.4...
).

Moreover, aging brings with it losses in vision, hearing, taste(4242 Neumann L, Schauren BC, Adami FS. Taste sensitivity of adults and elderly persons. Rev Bras Geriatr Gerontol. 2016;19(5):797-808. https://doi.org/10.1590/1809-98232016019.150218
https://doi.org/10.1590/1809-98232016019...

43 Ottaviano G, Frasson G, Nardello E, Martini A. Olfaction deterioration in cognitive disorders in the elderly. Aging Clin Exp Res. 2016;28(1):37-45. https://doi.org/10.1007/s40520-015-0380-x
https://doi.org/10.1007/s40520-015-0380-...
-4444 Costa-Guarisco LP, Dalpubel D, Labanca L, Chagas MHN. Perception of hearing loss: use of the subjective faces scale to screen hearing among the elderly. Cienc Saude Colet. 2017;22(11):3579-88. https://doi.org/10.1590/1413-812320172211.277872016
https://doi.org/10.1590/1413-81232017221...
) and other sensory abilities. Previous research(4545 Lemos BO, Cunha AMR, Cesarino CB, Martins MRI. The impact of chronic pain on functionality and quality of life of the elderly. BrJP. 2019;2(3):237-41. https://doi.org/10.5935/2595-0118.20190042
https://doi.org/10.5935/2595-0118.201900...
) showed that the mean score of the Sensory abilities domain was lower (40.0) than in this study and, in this sense, it is believed that the divergence may be related to the average pain intensity that, in our study, was lower.

In the Intimacy domain, which addresses the older adult’s intimate and personal relationship(1919 Chachamovich E, Trentini CM, Fleck MPA, Schmidt S, Power M. Desenvolvimento do instrumento WHOQOL-OLD. In: Fleck MPA, editor. A avaliação de qualidade de vida: guia para profissionais da saúde. Porte Alegre: Artmed; 2008. p. 102-11.), depression and headache were the negatively associated factors. Older adults with depression have a tendency towards isolation, which damages personal bonds(4646 Ahangar AA, Hosseini SR, Kheirkhah F, Karimi M, Saadat P, Bijani A, et al. Association between chronic pain and depression among the elderly of Amirkola City, Northern Iran. Elderly Health J[Internet]. 2017 [cited 2018 Dec 29];3(2):74-9. Available from: http://ehj.ssu.ac.ir/article-1-99-en.pdf
http://ehj.ssu.ac.ir/article-1-99-en.pdf...
). No studies investigating factors associated with this domain in older adults with chronic pain were found. However, the study that compared the scores attributed by the older adult in the Intimacy domain showed that the average score among those with depression was lower (11.0 ± 1.9) than among the older adult without depression (14.4 ± 1.7)(4747 Gonçalves VC, Andrade KL. Prevalência de depressão em idosos atendidos em ambulatório de geriatria da região nordeste do Brasil (São Luís-MA). Rev Bras Geriatr Gerontol. 2010;13(2):289-99. https://doi.org/10.1590/S1809-98232010000200013
https://doi.org/10.1590/S1809-9823201000...
), indicating an influence on quality of life.

Headache/facial pain has a high prevalence in older adults and affects about 65.0% of this population(4848 Starling AJ. Diagnosis and management of headache in older adults. Mayo Clin Proc. 2018;93(2):252-62. https://doi.org/10.1016/j.mayocp.2017.12.002
https://doi.org/10.1016/j.mayocp.2017.12...
), besides being one of the factors responsible for the years of disability experienced(3535 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. https://doi.org/10.1016/S0140-6736(18)32279-7
https://doi.org/10.1016/S0140-6736(18)32...
). Investigations in the area of headache and craniofacial pain point to isolation as a psychosocial consequence, possibly justified by low self-esteem, irritability, physical discomfort, hostility and feeling of helplessness, aspects associated with environmental stimuli that previously did not generate pain and which then start to be referred to as a cause of pain (lighting and noise, for example)(3535 GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. https://doi.org/10.1016/S0140-6736(18)32279-7
https://doi.org/10.1016/S0140-6736(18)32...
,4848 Starling AJ. Diagnosis and management of headache in older adults. Mayo Clin Proc. 2018;93(2):252-62. https://doi.org/10.1016/j.mayocp.2017.12.002
https://doi.org/10.1016/j.mayocp.2017.12...
).

In the Past, present and future activities domain, a negative association with depression was found. Fleck(1919 Chachamovich E, Trentini CM, Fleck MPA, Schmidt S, Power M. Desenvolvimento do instrumento WHOQOL-OLD. In: Fleck MPA, editor. A avaliação de qualidade de vida: guia para profissionais da saúde. Porte Alegre: Artmed; 2008. p. 102-11.) shows that in this domain issues related to personal satisfaction, recognition and achievements are addressed, moving in the direction of the statements by Silvertsen et al(1010 Sivertsen H, Bjorklof GH, Engedal K, Selbaek G, Helvik AS. Depression and quality of life in older persons: a review. Dement Geriatr Cogn Disord. 2015;40(1):311-39. https://doi.org/10.1159/000437299
https://doi.org/10.1159/000437299...
). That is, older adults, in general, have different aspirations throughout their lives, like to be recognized for their achievements, and are proud of them. When in a depressed state, they lose expectations, become frustrated, isolate themselves and maintain a negative view, becoming melancholy and sad, which directly interferes with quality of life.

Finally, systemic arterial hypertension was negatively associated with the Death and dying domain. No similar studies were found comparing these data. However, it is known that hypertension generates functional and structural changes in target organs, and that it prevails in the older adult population, compromising QOL and reducing this population’s life expectancy(4949 Francisco PMSB, Segri NJ, Borim FSA, Malta DC. Prevalence of concomitant hypertension and diabetes in Brazilian older adults: individual and contextual inequalities. Cienc Saude Coletiva. 2018;23(11):3829-40. https://doi.org/10.1590/1413-812320182311.29662016
https://doi.org/10.1590/1413-81232018231...
). Systemic arterial hypertension generates losses in the aging process, which possibly justifies the scores attributed in the Death and dying domain. Borges et al.(5050 Borges JES, Camelier AA, Oliveira LVF, Brandão GS. Quality of life of elderly hypertensive and diabetics of the community: an observational study. J Physiother Res. 2019;9(1):74-84. https://doi.org/10.17267/2238-2704rpf.v9i1.2249
https://doi.org/10.17267/2238-2704rpf.v9...
) showed a low mean score (12.4) in this domain when investigating a sample of older adults with hypertension.

Study limitations

A limitation for this study is related to the moment when older adults were approached for data collection, since they could be anxious about waiting for medical appointments. Another limitation may be linked to the fact that the sample was obtained for convenience. In addition, participants with severe disabilities that prevented them from attending the services in which the study was conducted may have been excluded. However, the findings were obtained using a sample calculated in a probabilistic way. These are innovative results, with the potential to contribute to the care of the older adult with chronic pain.

Contributions to the area of Nursing

This research examines, per domain, the factors associated with the QOL of older adults with chronic pain, aiming to contribute to the diagnosis, planning and implementation of nursing care strategies that collaborate to enabling this population’s QOL. Knowing the factors that influence this construct can help develop a proposal for a predictive QOL model, directing the nurses’ action to prevent harm and unnecessary suffering.

CONCLUSIONS

The findings of this study show that the characteristics of chronic pain, especially the time experiencing pain and the location of this experience, as well as depression and diabetes, are the factors that influence the Sensory abilities, Autonomy, Social participation, Intimacy and Past, present and future activities domains. This result shows the importance of the proper management of comorbidities, which are often underdiagnosed and undertreated in the older adult and/or mistakenly understood as typical of senility, such as chronic pain.

In addition, systemic arterial hypertension also strongly influences the domain Death and dying, indicating the importance of prevention and continuous and supervised treatment of this comorbidity in the older adult with chronic pain.

The factors investigated in each domain were not able to fully explain the quality of life of older adults with chronic pain. However, it was possible to identify that the Autonomy and Social participation domain, which explain the construct the most, are strongly influenced by factors such as depression, pain location and diabetes.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho
ASSOCIATE EDITOR: Álvaro Sousa

Publication Dates

  • Publication in this collection
    21 May 2021
  • Date of issue
    2021

History

  • Received
    28 June 2020
  • Accepted
    20 Oct 2020
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