Pain and pain medication among home-dwelling older people with and without diabetes

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DISSERTATIONS | MERJA KARJALAINEN | PAIN AND PAIN MEDICATION AMONG HOME-DWELLING... | No 621

MERJA KARJALAINEN

PAIN AND PAIN MEDICATION AMONG HOME-DWELLING OLDER PEOPLE WITH AND WITHOUT DIABETES

Dissertations in Health Sciences

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The number of people with type 2 diabetes is increasing and accumulating in older people. The results of this study showed that older home-dwelling people with and

without diabetes were not substantially different when pain, use of pain medication and kidney function were considered. Older

home-dwelling people with diabetes had a heavier symptom and disease burden, which

emphasizes the need for specific attention to the assessment and planning of their pain

management and pain medication.

MERJA KARJALAINEN

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PAIN AND PAIN MEDICATION AMONG HOME- DWELLING OLDER PEOPLE WITH AND WITHOUT

DIABETES

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Merja Karjalainen

PAIN AND PAIN MEDICATION AMONG HOME- DWELLING OLDER PEOPLE WITH AND WITHOUT

DIABETES

To be presented by permission of the Faculty of Health Sciences,

University of Eastern Finland for public examination in Ca101 Auditorium, Kuopio on June 18^th, 2021, at 12 o’clock noon

Publications of the University of Eastern Finland Dissertations in Health Sciences

No 621

General Practice/Institute of Public Health and Clinical Nutrition/School of Medicine

University of Eastern Finland, Kuopio 2021

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Series Editors

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Professor Tarja Kvist, Ph.D.

Department of Nursing Science Faculty of Health Sciences Professor Ville Leinonen, M.D., Ph.D.

Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences

Professor Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D.

School of Pharmacy Faculty of Health Sciences

Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland

www.uef.fi/kirjasto Grano Oy, 2021

ISBN: 978-952-61-3776-6 (print/nid) ISBN: 978-952-61-3777-3 (PDF)

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Author’s address: General Practice/Institute of Public Health and Clinical

Nutrition/School of Medicine University of Eastern Finland KUOPIO

FINLAND

Doctoral programme: Doctoral program of Clinical Research

Supervisors: Professor Pekka Mäntyselkä, M.D., Ph.D.

General Practice/Institute of Public Health and Clinical Nutrition/School of Medicine

University of Eastern Finland KUOPIO

FINLAND

Docent Miia Tiihonen, Ph.D.

Faculty of Health Sciences/School of Pharmacy University of Eastern Finland

KUOPIO FINLAND

Docent Juha Saltevo, M.D., Ph.D.

University of Eastern Finland KUOPIO

FINLAND

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Reviewers: Professor Pekka Honkanen, M.D., Ph.D.

Center for Life Course Health Research University of Oulu

OULU FINLAND

Docent Kirsi Pietilä, Ph.D.

Faculty ofpharmacy University of Helsinki HELSINKI

FINLAND

Opponent: Docent Merja Laine, M.D., Ph.D.

Department of General Practice and Primary Health Care University of Helsinki

HELSINKI FINLAND

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Karjalainen, Merja

Kuopio: University of Eastern Finland

Publications of the University of Eastern Finland Dissertations in Health Sciences 621. 2021, 114 p.

ISBN: 978-952-61-3776-6 (print) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3777-3(PDF) ISSN: 1798-5714 (PDF)

ABSTRACT

The number of people with type 2 diabetes is increasing in younger and middle- aged people, resulting in a higher prevalence also among older people. People with diabetes have more comorbidities than people without diabetes. As people live longer, the burden of diseases gets bigger. Previously, chronic or frequent pain have been found to be associated with diabetes. However, the prevalence and impact of pain and the use of pain medication among older home-dwelling people with diabetes compared with those without diabetes is not definite. This study investigates pain, self-rated health, the use of pain relieving drugs, kidney function and potentially nephrotoxic drug use in older home-dwelling people with diabetes compared with those without.

Home-dwelling people aged 65 years or older (N=527) with diabetes were identified from the electronic patient record of Inner-Savo primary health care district and age and gender matched control persons (N=890) were identified.

Questionnaires were sent to the participants and 1,084 (76.5%) of them

responded. Frequent pain was perceived as any pain experienced more often than once a week. A Numeric Rating Scale (0-10) was used to assess the interference and intensity of the pain. The participants assessed their health with a Visual Analog Scale and Likert-type scale. 259 randomnly selected people with diabetes and 259 people without diabetes were drawn from those participating in the questionnaire survey and invited to a health examination. Altogether 363 (70%) participated, of which 187 were people with diabetes and 176 people without diabetes. The physician conducted the health examination according to a standard Pain and pain medication among home-dwelling older people with and without diabetes

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protocol. In addition, blood samples were drawn, and the glomerular filtration rate (eGFR) was estimated by using the CKD-EPI equation. Pain medication use and the nephrotoxic medication profile were defined.

In the questionnaire survey, frequent pain was reported by 63% of women with diabetes and 50% of women without diabetes (adjusted, p = 0.22), and in men 47%

and 42% (p=0.58). In women and men, the comorbidity burden and depressive symptoms were associated with frequent pain but not diabetes. Neither pain intensity nor interference were associated with diabetes. Frequent pain was associated with poor self-rated health both when assessed with the Likert scale and VAS (p<0.001). Diabetes was not associated with self-rated health (Likert, p=0.19 and VAS, p=0.070). There was not an interaction between diabetes and pain (p=0.55 and p=0.14).

The results based on the health examination showed that of people with and without diabetes 66% and 62% used some pain medication (p=0.45). The

respective proportions of regular use were 11% and 13%, and as-needed use was 61% and 56%. Diabetes was not associated with pain medication use. Pain medication was used more as needed than regularly. Accordingly, there were not significant differences between people with and without diabetes in potentially nephrotoxic drug use (1.06 drugs versus 0.97 drugs, p=0.39) and kidney function (80.5 versus 77.5 ml/min/1.73m², p = 0.089).

The results of this study showed that older home-dwelling people with and without diabetes were not significantly different when pain, use of pain medication and kidney function are considered. The way in which self-rated health was

associated with pain was similar in both people with diabetes and without.

However, these results suggest that due to a heavier disease burden, specific attention should be paid to pain management and pain medication in older people with diabetes.

National Library of Medicine Classification: QY 175, WB 176, WJ 300, WK 810, WL 704, WT 101, WT 500

Medical Subject Headings: Aged; Visual Analog Scale; Diabetes Mellitus, Type 2;

Pain Management; Pain; Kidney; Renal Insufficiency, Chronic; Pharmaceutical Preparations

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Karjalainen, Merja

Kipu ja kipulääkkeet iäkkäillä kotona asuvilla diabeetikoilla ja heillä, joilla ei ole diabetesta

Kuopio: Itä-Suomen yliopisto

Publications of the University of Eastern Finland Dissertations in Health Sciences 621. 2021, 114 s.

ISBN: 978-952-61-3776-6 (nid.) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-3777-3 (PDF) ISSN: 1798-5714 (PDF)

TIIVISTELMÄ

Tyypin 2 diabetes lisääntyy sekä nuorilla että keski-ikäisillä, minkä seurauksena sen esiintyvyys kasvaa myös ikääntyneillä. Ihmisten eläessä yhä vanhemmiksi myös sairauksien taakka kasvaa. Krooninen tai usein esiintyvä kipu on yhdistetty diabetekseen. Kivun esiintyvyys, sen vaikutukset ja kipulääkkeitten käyttö ikääntyneillä kotona asuvilla diabeetikoilla ei ole selvää. Tässä väitöskirjassa tutkitaan kipua, itse koettua terveyttä, kipulääkitystä, munuaisten toimintaa ja mahdollista munuaisille haitallista lääkkeitten käyttöä kotona asuvilla ikääntyneillä diabeetikoilla verrattuna ikääntyneisiin, joilla ei ole diabetesta.

Tutkimuksessa tunnistettiin Sisä-Savon sähköisestä potilastietojärjestelmästä 65 vuotta täyttäneet diabeetikot (N=527) ja samanikäiset, samaa sukupuolta olevat verrokihenkilöt (N=890). Osallistujille lähetettiin kyselylomake, johon vastasi 1084 (76.5%) henkilöä. Usein esiintyvä kipu määriteltiin kipuna, jota esiintyi useammin kuin kerran viikossa. Kivun voimakkuus ja häiritsevyys arvioitiin asteikolla 0–10.

Osallistujat arvioivat oman terveytensä Likert-tyyppisellä- ja Visual Analog

asteikolla (VAS). Kyselyihin vastanneista valittiin satunnaistamalla 259 diabeetikkoa ja 259 verrokkia ja heidät kutsuttiin terveystarkastukseen, johon osallistui

yhteensä 363 (70%) kutsutuista. Terveystarkastukseen osallistuneista 187 oli diabeetikkoja ja 176:lla ei ollut diabetesta. Lääkäri teki terveystarkastuksen tietyn protokollan mukaan. Lisäksi otettiin verinäytteet ja glomerulofiltraatio nopeus (eGFR) laskettiin käyttäen CKD-EPI: ä. Määritettiin kipulääkkeiden käyttö ja munuaistoksisen lääkityksen profiili.

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Kyselytutkimuksessa usein esiintyvää kipua oli 63%:lla naisista, joilla oli diabetes ja 50%:lla naisista, joilla ei ollut diabetesta (adjusted, p=0.22). Miehillä vastaavat luvut olivat 47% ja 42% (p=0.58). Sekä naisilla että miehillä kivulla oli yhteys masennusoireisiin ja liitännäissairauksien lukumäärään mutta ei diabetekseen.

Kivun voimakkuudella tai häiritsevyydellä ei myöskään ollut yhteyttä diabetekseen.

Usein esiintyvä kipu oli yhteydessä huonoon itse koettuun terveyteen kun kipua arvioitiin Likert asteikolla ja VAS:lla (p<0.001). Diabeteksella ei ollut yhteyttä itse koettuun terveyteen (Likert, p=0.19 ja VAS, p=0.007). Diabeteksen ja kivun välillä ei ollut yhteyttä (p=0.55 ja p=0.14).

Terveystarkastukseen perustuvat tulokset osoittivat, että 66% diabeetikoista 62% ei-diabeetikoista ja ja käyttivät kipulääkkeitä (p= 0.45). Säännöllisesti

kipulääkkeitä käyttivät 11% diabeetikoista ja 13% ei-diabeetikoista. Kipulääkkeitä käytti tarvittaessa 61% diabeetikoista ja 56% ei-diabeetikoista. Diabetes ei ollut yhteydessä kipulääkkeitten käyttöön. Kipulääkkeitä käytettiin enemmän

tarvittaessa kuin säännöllisesti. Huomattavaa eroa ei ollut myöskään munuaisille haitallisten lääkkeiden käytössä (1.06 lääkettä vs 0.97 lääkettä, p=0.39) eikä munuaisten toiminnassa (80.5 vs 77.5 ml/min/1.73m², p=0.089).

Tutkimuksen tulokset osoittivat, että iäkkäillä ei ollut merkittävää eroa

diabeetikkojen ja verrokkihenkilöiden välillä kivussa, kipulääkkeitten käytössä eikä munuaisten toiminnassa. Itse koettu terveys oli yhtälailla yhteydessä kipuun sekä diabeetikoilla että ei-diabeetikoilla. Koska iäkkäillä diabeetikoilla on paljon

sairauksia, heillä pitäisi erityisesti huomioida kivun hoito ja kipulääkitys.

Luokitus: QY 175, WB 176, WJ 300, WK 810, WL 704, WT 101, WT 500 Yleinen suomalainen ontologia: ikääntyneet; aikuistyypin diabetes; kivunhoito;

munuaistaudit; koettu terveys

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ACKNOWLEDGEMENTS

This study was carried out during 2015-2021 at the Institute of Public Health and Clinical Nutrition, University of Eastern Finland. I have had the honor of

working with many fine and one of a kind individuals who I want to thank. I want to acknowledge my main supervisor professor Pekka Mäntyselkä for the opportunity to carry out my Ph.D. study. I am thankful for his time, priceless guidance and support when planning the study and writing the articles. I admire his enormous knowledge and wisdom. I am very grateful to my supervisor docent Miia Tiihonen, for all her valuable advice during the process. Her guidance and feedback was professional and detailed in the field of pharmacy. I admire her wisdom and perseverance and patience. I would like to thank my supervisor and co-author Juha Saltevo, Ph.D., for his comments and constructive feedback on the topic of

diabetes, which I am grateful of. Thanks to the co-authors, Maija Haanpää, Ph.D., and Hannu Kautiainen, Ph.D. for their time and effort during the article writing process. I am grateful for their guidance and constructive feedback concerning the articles and academic writing. Special thanks to the official reviewers of this thesis, docent Kirsi Pietilä and docent Pekka Honkanen for their professional review and constructive comments. Thank you Pia J., for storing the data. I am grateful to Piia and Mikko, who helped me with technical problems. I would like to thank Olli Lappalainen, chief physician of Sisä-Savo health center, for his support to carry out this study. My heartfelt thanks to Katri Hollmen, also colleague and chief physician in Siilinjärvi health center. Warm thanks to all staff in Sisä-Savo for assistance and to public health nurse Tarja for understanding, support, and friendship. I wish to thank North-Savo hospital district, which enabled my work as a researcher and North-Savo Cultural foundation, from where I got research grant. I also want to thank all the participants in this study. I want to thank my children of their love and support during all these years. Susanna, Emmi and Juho, I love you. Warm thanks to my sister Mervi and brother Markku. My dear friends, Anja, Päivi, Sirpa, and Elvira, thank you for your support and taking care of my normal daily life and activities. Finally, my beloved Matti, thank you for your encouragement to start this

thesis and your patience and support during these years.

Kuopio, May 2021

Merja Karjalainen

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LIST OF ORIGINAL PUBLICATIONS

This dissertation is based on the following original publications:

I Karjalainen M, Saltevo J, Tiihonen M, Haanpää M, Kautiainen H, Mäntyselkä P, Frequent pain in older people with and without diabetes – Finnish community based study. BMC Geriatrics 2018, 18: 73

II Karjalainen M, Tiihonen M, Kautiainen H, Saltevo J, Haanpää M, Mäntyselkä P, Pain and self-rated health in older people with and without diabetes.

European Geriatric Medicine 2018, 9 (1), pp. 127-131

III Karjalainen M, SaltevoJ, HaanpääM, KautiainenH, Mäntyselkä P, Tiihonen M, Use of pain relieving drugs in community dwelling older people with and without diabetes. Primary Care Diabetes 2020, 14 pp. 736-740

IV Heinjoki M, Karjalainen M, Saltevo J, Tiihonen M, Haanpää M, Kautiainen H, Mäntyselkä P, Kidney function and nephrotoxic drug use among older home- dwelling persons with or without diabetes in Finland. BMC Nephrology 2020, 21:11

The publications were adapted with the permission of the copyright owners.

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ABBREVIATIONS

ADA American Diabetes Association

AIDS Autoimmune deficiency syndrome

AGS American Geriatric Society BMI Body mass index

BNSP Back, neck and/or shoulder pain

BPI Brief pain inventory CDA Canadian Diabetes

Association

CKD Chronic kidney disease CKD-EPI Chronic kidney disease

Epidemiology Collaboration DM Diabetes mellitus

eGFR Estimated glomelural filtration rate

EMA European Medicines Agency FPG Fasting plasma glucose GADA Glutamate Decarboxylase

Antibody

GDM Gestational diabetes mellitus HbA1C Glycohemoglobin

HIV Human immunodeficiency virus

HRQoL Heath-related quality of life IASP International Association for

the Study of Pain

ICD International Classification of Diseases

IDF International Diabetes Federation

IGT Impaired glucose tolerance IFG Impaired fasting glucose KDIGO Kidney Disease Improving

Global outcomes

MARD Mild age-related diabetes MSC Musculo-skeletal complaint MOD Mild obesity-related diabetes MODY Maturity-onset diabetes of

the young

NRS Numeric Rating Scale (0-10) OGTT Oral glucose tolerance test PIM Potentially inappropriate

medication

PHARAO The Pharmacological Risk Assessment Online system Qol Quality of life

RENBASE Database used to determine detailed drug dosing in renal failure

SAID Severe autoimmune diabetes SIDD Severe insulin-resistant

diabetes

SIGN Scottish Intercollegiate Guidelines network SIRD Severe insulin-resistant

diabetes

SRH Self-rated health

VAS Visual Analog Scale (0-10) WHO World Health Organization

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INTRODUCTION

In Finland, with a total population of 5.5 million people (Official Statistics of Finland 2020), there are over 500,000 people with diabetes. In 2017, 19% of people in Europe were 65 years or older. By 2050, this proportion will be 30% (Eurostat 2020). The corresponding numbers for Finland are almost equal (23% and 30 %). It has been predicted that the number of people aged 65 with diabetes in Europe will rise to 46.3 million by 2045 (International Diabetes Federation 2019). One-half of older adults have prediabetes and one-quarter of older people aged over 65 years have diabetes in the US. (Centers for Disease Control and Prevention 2017), which is expected to increase further.

As the population ages, diabetes will be more common and accumulate in older people. Moreover, older people commonly have pain and chronic pain is one comorbid condition connected to diabetes (Mäntyselkä et al. 2008, Bair et al.

2010).

Pain is one of the most current reasons for seeking medical treatment (Mäntyselkä et al. 2001, Beehler et al. 2013). Chronic pain is very common in primary care in the adult population (Verhaak et al. 1998, Mäntyselkä et al. 2003, Fayaz et al. 2015). Chronic pain is especially usual among people aged 60 years or older (Niknejad et al. 2018).

People with chronic pain usually have other chronic diseases (Macfarlane et al.

2001, Torrance et al. 2015, Smith et al. 2018). In several studies the burden of comorbidities is found to be independently associated with chronic pain (Butchart et al. 2009, Dominick et al. 2012). Due to physiological changes, comorbidity and polypharmacy, one significant challenge is pharmacological pain management in the group of older people with diabetes and pain.

Previously, it has been found that bothersome pain is markedly more prevalent among adults with diabetes than among those without diabetes (Patel et al. 2013, Pozzobon et al. 2019, Rehling et al. 2019). However, it has also been found that moderate or extreme pain in older people is associated with worse physical functioning and poorer mental health but not with poorer glycemic control (Bair et al. 2010). People with type 2 diabetes often have musculoskeletal complaints, which influence their quality of life extensively (Burner et al. 2009). In older people with diabetes, self-rated health substantially worse compared with those without diabetes (Wexler et al. 2012). Futhermore, persistent pain was related to poor self- rated health independently (Mäntyselkä et al. 2003).

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Based on previous studies, it is possible that older people with diabetes have more pain than those without. Therefore, it can be hypothesized they also use more pain medication. However, this has not been largely studied in primary care settings. Diabetes itself is an important risk factor for decreased kidney function, which can further deteriorate due to pain medication, particularly non-steroidal anti-inflammatory analgesics (NSAID).

The present study is based on a community sample of home-dwelling older people with and without diabetes. It aims to investigate pain, self-rated health, use of pain relieving drugs, kidney function and nephrotoxic drug use among these people, particularly focusing on their relationship with diabetes.

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1 REVIEW OF THE LITERATURE

1.1 OLDER PEOPLE AND MANAGEMENT OF DISEASES IN PRIMARY HEALTH CARE

As a person ages, the body develops molecular and cellular damages which may lead to diseases. These changes develop individually and are partly determined by genes but are also dependent on one’s environment and lifestyle. Because the aging population is growing, there is a large variation in the needs of older people that need to be considered in public health policy and primary health care (World Health Organization 2017).

The older people live, the more chronic diseases they have. Usually, their diseases are managed in primary care. Chronic diseases are associated with disability, poor quality of life and high health care utilization (Marengoni et al.

2011, Parker et al. 2014, Makovski et al. 2019). Moreover, chronic diseases in older people have an influence on clinical management, health outcomes, and increased health costs (Valderas et al. 2009). According to a Swiss study, average cost was 5.5 times higher in people aged 65 or more with at least two chronic diseases

compared with people having less chronic conditions (Bähler 2015).

The American Geriatrics Society (AGS) has developed The AGS Guiding Principles for the Care of Older Adults with Multimorbidity using a systematic literature review and consensus (Boyd et al. 2019). Finnish Current Care Guidelines working group is currently developing the corresponding manual.

1.2 DIABETES

Diabetes is a chronic metabolic disease with metabolic abnormalitis and elevated levels of blood glucose, which causes complications in the heart, blood vessels, kidneys, nerves and eyes in a long term. The most common type of diabetes is type 2 diabetes, accounting for 90-95% of all people with diabetes (American diabetes association 2019). In type 2 diabetes, the body develops insulinresistance or the pancreas does not produce insulin enough. In type 1 diabetes the pancreas does not produce insulin at all or produces it little (World Health Organization 2016). Diabetes type 1 and 2 are extreme types, and between them, there are patients who have characteristics of both main groups. Both type 1 and type 2 diabetes occur in adults and children. Despite the different types of diabetes and

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its progression if hyperglycemia occurs, patients are at risk of having the same complications. Therefore, more important than classification is preventing complications (Skyler et al. 2017).

1.2.1 Pathophysiology and classification of diabetes

The details of pathophysiology are better known in type 1 than in type 2 diabetes.

Based on previous studies, a combination of having first-degree relatives with type 1 diabetes and at least two autoantibodies is a strong predictor of diabetes (Insel et al. 2015). In type 2 diabetes, the demise of β-cells and dysfunction of the pancreas are undefined. Both deficient β-cell insulin secretion and insulin resistance often arise together in type 2 diabetes. In a recent review, genetic studies in general suggest that genes affect the dysfunction of insulin secretion more than insulin sentitivity (Laakso 2019). It is also associated with inflammation and metabolic stress, lifestyle and genetic factors (Insel et al. 2015, Skyler et al.

2017). Furthermore, a BMI ≥25 kg/m2 is regarded as a risk factor for diabetes (American Diabetes Association 2019).

Table 1 shows the classification of diabetes According to The American Diabetes Association (ADA 2019). The Finnish Diabetes Current Care Guidelines uses the same classification.

Table 1. Classification of diabetes (ADA 2019)

Type 1 diabetes

due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency

Type 2 diabetes

due to a progressive loss of β-cell insulin secretion frequently in the background of insulin resistance

Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy and was not clearly overt diabetes prior to gestation

Specific types of diabetes due to other causes,

1. monogenic diabetes syndromes such as neonatal diabetes and maturity-onset diabetes of the young [MODY]

2. diseases of the exocrine pancreas such as cystic fibrosis and pancreatitis

3. drug- or chemical-induced diabetes such as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ transplantation

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In a new classification of diabetes type 2 there are five different subgroups (Ahlqvist et al 2018). In severe autoimmune diabetes (SAID) there are glutamate decarboxylase antibodies (GADA), insulin deficiency and poor metabolic control. In severe insulin-deficient diabetes (SIDD) there are deficiency of insulin and poor metabolic control but no GADA. Severe insulin-resistant diabetes (SIRD)is characterized by insulin resistance and obesity. In mild obesity-related diabetes (MOD), in spite of a high BMI there is no insulin resistance. Mild age-related diabetes (MARD) occurs in older people and has only plain metabolic derangements.

1.2.2 Diagnosis of diabetes

A diagnosis of diabetes is based on either the fasting plasma glucose (FPG) value or the 2-h plasma glucose (2-h PG) value during a 75 g oral glucose tolerance test (OGTT), or A1C criteria (International Expert Committee 2009, American Diabetes Association 2019). These tests may be used to both diagnose diabetes and to screen for prediabetes (American Diabetes Association 2019).

Normal fasting plasma glucose is ≤ 5.5 mmol/l (American Diabetes Association 2019) or ≤6,0 (World Health Organization 2016). In impaired glucose tolerance, values are 5.6-6.9mmol/l (American Diabetes Association 2019) and 6.1-6.9mmol/l (World Health Organization 2016). Diabetes can be diagnosed if fasting plasma glucose is ≥ 7.0mmol/l. 2-hour values less than 7.8mmol/l are normal in the oral glucose tolerance test and values of 7.8-11.0mmol/l means impaired glucose tolerance. Diabetes is diagnosed when 2-hour plasma glucose is over 11.0mmol/l.

Normal Hba1C is ≤ 42.0 mmol/mol and a Hba1C of ≥ 48.0 mmol/mol or ≥ 6.5%

means diabetes (American Diabetes Association 2019, World Health Organization 2016).

Finland uses the same criteria as WHO. Impaired glucose tolerance (IGT) and fasting glucose (IFG) are considered prediabetes. Abnormal glucose value should be checked and measured in different days if the patient does not have symptoms (thirst, polyuria, weight loss). In the event the patient has symptoms, a diabetes diagnosis can be based on one fasting glucose value, provided that it is ˃11.0 mmol/l (Diabetes: Finnish Current Care Guidelines 2020).

1.2.3 Prevalence of diabetes

The prevalence of diabetes worldwide has increased evently for the past three decades, doubling since 1980 to 422 million adults (8.5% of the adults aged 18 or

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older) in 2014 (NCD Risk factor collaboration 2016). The causes are complex. The increasing prevalence of diabetes is related to increased numbers of people with excess weight and obesity, and decreasing physical activity.

In Finland, the prevalence of diabetes is assessed to be 11%, consisting mostly (89%) of type 2 diabetes (Laakso et al. 2016). The number of people with diabetes receiving reimbursement for the cost of diabetes medication increased 20%

between the years 2011-2016 and at the end of 2018 the number of people receiving reimbursement was 346,929 (Kela 2018).

1.2.4 Management of diabetes

The target for most adults with type 2 diabetes treated with oral diabetes medication alone is <7% (Hba1C 53 mmol/mol)( American Diabetes Association 2019). Tighter Hba1C targets such as <6.5% (HbA1C≤48mmol/mol) may be proper for spesific individuals if this can be attained without adverse effects of treatment or significant hypoglycemia. This more stringent target applies to those who have had diabetes for a short time and have better β-cell function and patients treated with metformin or lifestyle only and who attain significant weight progress (American Diabetes Association 2019). The target of fasting glucose is below 7 mmol/l, and below 10 mmol/l after two hours of eating. Low density lipoprotein (LDL) should be below 2.5mmol/l in all people with diabetes and below 1.8mmol/l in people with diabetes and high cardiovascular risk or a cardiovascular event. The recommended blood pressure is below 140/80 mmHg (Diabetes: Finnish Current Care Guidelines, 2020).

To prevent complications in people with diabetes it is important to control risk factors such as hyperglycemia, high blood pressure, smoking, dyslipidemia, and excess weight. Medication and individual support are important, and should take into account the patient´s knowledge, psychological, social and economic

resources (Peeples et al. 2007, Canadian Diabetes Association 2013, American Diabetes Association 2019, diabetes: Finnish Current Care Guidelines 2020).

In The ADA ´s annual major updates of 2019, the focus is on the tailored care of the individual, cardiovascular disease (CVD) in people with diabetes, and diabetes technology for older adults. Moreover, the guidelines now include a section of lifestyle management (American Diabetes Association 2019). There is a target to halt the rise in diabetes and obesity by 2025 globally (World Health Organization 2016).

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1.2.5 Diabetes in older people

In older people the incidence of diabetes increases until approximately 65 years, after which both prevalence and incidence appear to stabilize. The prevalence of diabetes in adults over 65 years varies from 22% to 33% (Kirkman et al. 2012). In this group of adults the number of diagnosed diabetes may increase by 4.5-fold in 2005-2050 while the increase is 3-fold in the total population (Narayan et al. 2006).

Because of aging, people are prone to increasing insuline resistance and impaired pancreatic islet function and therefore having type 2 diabetes. In older people, insulin resistance is associated with sarcopenia, adiposity, and physical inactivity (Amati et al. 2009).

The alignment of treatment goals is similar among the ADA, diabetes specialists in Europe and in Finland (American Diabetes Association 2019, Hambling et al.

2019, Diabetes: Finnish Current Care Guidelines 2020).

The minimum goal of treatment is to be asymptomatic (no tiredness, polyuria, thirst, losing weight, delirium or sensitivity to infections). Hypoglycemia should be avoided. In an otherwise healthy person under 75 years of age, the glycemic goals are the same as for younger people. If there is a possibility of hypoglycemia, the goal of HbA1c can be 58-69 mmol/mol. For older persons consideration should be given to comorbidities, function and quality of life. In people 75 or older, glycemic targets are individualized and the most important issues to be considered are having the best possible quality of life and being independent and asymptomatic.

The new five-cluster classification of type 2 diabetes can identify patients who are at high risk of diabetic complications, and moreover gives information about the disease mechanism (Ahlqvist et al 2018).

1.2.6 Comorbidities among older people with diabetes

Compared with people without diabetes, older people with diabetes have an increased prevalence and incidence of pain, polypharmacy, low body mass index, cognitive impairment, falls, dizziness, incontinence, vision and hearing impairment, (Cigolle et al. 2010) (table 2). In addition, older people with diabetes have more premature deaths, functional disability, hypertension, depressive symptoms and coronary heart disease (Forssas et al. 2010, Kamradt et al. 2017, Jing et al. 2018) (table 2). In a Finnish study, people with type 2 diabetes had almost double the mortality rate compared with the control population (Forssas et al. 2010).

In a Finnish study made in northern Finland with older people, there is an association of depressive symptoms between both prediabetes and diabetes

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(Perkkiö et al. 2019). Earlier it was found that people with diabetes aged 45-74 had more depressive symptoms than people without diabetes or impaired glucose tolerance (Mäntyselkä et al. 2011). In two longitudinal studies, older people with depressive symptoms had a 1.6-2.5-fold risk of developing diabetes (Carnethon et al 2003, Demakakos et al. 2010, Park et al 2014). Depression increased

substantially (60%) the risk of type 2 diabetes (Mezuk et al. 2008).

All these conditions and comorbidities may affect the self-management of diabetes (Kirkman et al. 2012, World Health Organization 2016, Centers for Disease Control and Prevention 2017). These conditions are associated with lower HRQoL (Yang et al. 2019), and they can worsen their self-management either directly or indirectly. Dementia and advanced heart failure can directly influence diabetes self-management (Piette et al. 2006). Chronic pain and depression can indirectly limit diabetes self-management, decreasing daily activities and regular exercise (Krein et al. 2005).

Table 2. Conditions associated with diabetes in older people

Common conditions among older people with diabetes

Other conditions with diabetes

Pain, polypharmacy, low body mass index, cognitive impairment, falls, dizziness, incontinence, vision impairment, hearing

impairment

Premature deaths, depression, functional disability, hypertension and coronary heart

disease Cigolle et al. 2010, Forssas et al. 2010, Kamradt et al. 2017, Jing et al. 2018.

1.3 CHRONIC OR FREQUENT PAIN

Chronic pain is a considerable health care problem in Europe and in the whole world (Breivik et al. 2013). Chronic pain causes suffering, distress and makes daily functioning more difficult. According to the International Association for the Study of Pain (IASP) the revised definition of pain is “an unpleasant sensory and

emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Raja et al. 2020). The transition from acute to chronic pain means a change from inflammation and peripheral tissue damage to more significant central sensitization and central nervous system mechanisms

(Schneiderhan et al. 2017). Chronic pain is an individual sensory and emotional

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experience, which depends on meaning of the pain and the mental state of the person (Bushnell et al. 2013).

The latest systematic classification of the International Classification of Diseases (ICD 10) for chronic pain was developed by the IASP (Treede et al. 2019). In

collaboration with the WHO, an IASP Working Group has renewed the

classification, in which chronic pain is defined as pain that recurs or persists for more than three months. Chronic pain is divided into seven subgroups. One subgroup is “chronic primary pain”, where chronic pain may be considered a disease in its own right. Such conditions include fibromyalgia and non-specific low- back pain, among others. In the six other subgroups, pain is secondary as a symptom to a disease. These conditions are called chronic secondary pain:

“chronic cancer-related pain, chronic neuropathic pain, chronic secondary visceral pain, chronic post-traumatic and postsurgical pain, chronic secondary headache and orofacial pain, and chronic secondary musculoskeletal pain” (Treede et al.

2019).

In older people, pain is usually frequent, due to osteoarthritis, spine problems or neuropathic pain, for instance. Frequent pain can be defined as pain

experienced once or twice a week to daily (Helme and Gibson 1999).

1.3.1 Prevalence of chronic or frequent pain

The estimated worldwide prevalence of chronic pain was 10% in adults in a systematic review from 1990 to 2017 (Andrews et al. 2018). In another review in the UK, the prevalence varied from 35-51% (Fayaz et al. 2015). In some studies the prevalence of chronic pain increases to 62-74% in the over 75 age group (Fayaz et al. 2015, Karttunen et al. 2015, Rottenberg et al. 2015). Of the ‘oldest of the old’

aged 85 years and over, 28% experienced pain (Carmaciu et al. 2007).

In a Finnish population-based study the prevalence of daily chronic pain was 14% among adults aged 20-74 years (Mäntyselkä et al. 2003). A third of the older population has been found to suffer from frequent pain (Helme and Gibson 1999).

One community-based study of home-dwelling people aged 75 years or older found that a third (38 %) had daily pain (Mäntyselkä et al. 2004). In another Finnish study one quarter of the study population aged 62-86 years had experienced moderate to very severe pain intensity during the previous month; the prevalence of moderate to very severe pain-related interference was 20% (Marttinen et al.

2019).

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1.3.2 Association of chronic or frequent pain and comorbidities with self- rated health in people with diabetes

Self-rated health (SRH) is a subjective measure in which people rate their health with an instrument. One instrument to measure SRH is a question of the SF-36 (Scogging et al. 2009): ‘‘In general, would you say that your health is excellent, very good, good, fair, or poor?’’

Chronic pain has an independent effect on disability, SRH and quality of life (Mäntyselkä et al. 2003, McDaid et al. 2013, Karttunen et al. 2015). It has been shown that SRH is independently and significantly associated with people having at least two chronic diseases (Ishizaki et al. 2019). HRQoL is recommended as a key factor when assessing pain management outcomes (Borsook et al. 2013).

Systematic reviews found an association between chronic pain and low health related quality of life (HRQoL) (Leadly et al. 2013, Nygaard et al. 2014). In Ireland it was found that each chronic condition studied (diabetes, cardiovascular disease, respiratory disease or chronic pain) had an independent effect on disability, SRH and QoL (McDaid et al. 2013).

Older patients in primary care who have poorer glycemic control, have lower HRQoLand functional capacity, especially regarding mobility and self-care

(Kamarul et al. 2010, Aro et al. 2018). If comorbidities are ignored, it can weaken a patient´s functioning, quality of life and mortality risk (Piette et al. 2006). A

systematic review with eighteen studies showed that physical exercise and glucose checks were frequently positive factors, while complications, hypertension, the duration of diabetes, and depression were negative factors associating with the quality of life of type 2 diabetes patients (Jing et al. 2018). Increased distress in people with diabetes, chronic pain, impaired ability to move, female gender, lower education and increased BMI seem to have a negative impact on the HrQol in patients with two or more chronic conditions (Kamradt et al. 2017)

In a Finnish study, frequent chronic pain was associated with SRH independently and even more strongly than chronic diseases including diabetes (Mäntyselkä et al.

2003). There are a few studies that show trends in SRH over time. A Finnish follow- up study aimed at analyzing changes in SRH, disabilities, comorbidities and

psychological wellbeing. These studies were conducted among people aged 75-85 years living in their homes. SHR improved in the 20 years follow-up time depite of the increased comorbidities (Karppinen et al. 2017)

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1.3.3 The predictive importance of pain characteristics in quality of life, mood, cost and health care use

In a study from Australia, psychological factors mediated the relatioship between chronic pain and physical disability. The authors also concluded that chronic pain, interfering and severe pain were associated with physical disability (Hairi et al.

2013). In a study from Germany, researchers examined the association of pain and depression in community-dwelling older adults. The participants were asked about pain quality, severity, frequency, duration and location. The conclusion was that multisite pain and the number of painful body areas, pain frequency and severity were the best predictors of depression (Denkinger et al. 2014).

It has been shown that the more interfering pain is, the more older people use healthcare resources (Blyth et al. 2004, Kennedy et al. 2017). A swedish

population-based study found that chronic pain and its severity in people 65 and older was associated with increased costs to the community and a low quality of life (Bernfort et al. 2015).

1.3.4 Chronic or frequent pain in older people with diabetes

A few studies were found concerning pain in older people with and without diabetes (table 3). Most of them were interview studies (McCarthy et al. 2009, Sudore et al. 2012, Mcdaid et al. 2013) or based on questionnaires (Pico-Espinosa et al. 2017) or both (Baker et al. 2017). One of them was based on record data (Caughey et al. 2010). Although every study involved older people with diabetes, the comparison between people with and without diabetes was made only in half of the studies (McCarthy et al. 2009, McDaid et al. 2013, Pico-Espinosa et al. 2017).

In several studies, pain seems to be present in 20-35% of older people with diabetes (McCarthy et al. 2009, Caughey et al. 2010, Sudore et al. 2012). There was an association between diabetes and chronic pain (McDaid et al. 2013, Pico- Espinosa et al. 2017) except in one study (McCarthy et al. 2009), which was conducted in a restricted area of New York, which may explain the difference between it and the other studies (McCarthy et al. 2009). In one population-based study, people with diabetes had pain more often than those without diabetes (OR 1.43; 95% CI 1.17-1.75) (McDaid et al. 2017). In another study diabetes also seemed to predict frequent back, neck and/or shoulder pain (RR 1.65, 95% CI 1.23-2.18) (Pico-Espinosa et al. 2017).

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Table 3. Frequent and chronic pain in older people with and without diabetes.

Summary of studies. * Refe-

rence

Study design Pain indicator

Data Dia-

betes N

No Dia- betes

N

Pain in people with diabetes

N (%)

Pain in people without diabetes N (%) McCarthy

et al. 2009 New York

Telephone interview cohort, pain in previous 3

months

N=840, community based, aged 70

and over

170 670 95(22) 341(41)

Caughey et al. 2010

Australia

cross-sectional record data, pain lasting at least 3 months

18.968 independent or not aged 65 and

over

18.968 - 3794(20) -

Sudore et al. 2012 California

cross-sectional telephone interview,

medical report chronic pain in

the last 6 months

N=13.171 home-dwelling

people with diabetes aged 30-

70

13171 - 4571(35) -

McDaid et al. 2013

Ireland

cross-sectional, interview, pain lasting at least

three months

N=6159 data from two population- representative

studies of health aged over 50

256 5904 N=1540(35) in the whole dataset, odds ratio 1.43(95%

confidence interval 1.17 to 1.75) in people

with diabetes having pain vs controls Baker et

al. 2017 US

cross-sectional, telephone interview after posting a letter asking about pain

frequency (over the past four weeks) from 0 to

4 and severity from 0 to 4.

N=236 community- dwelling people

with diabetes aged over 65

236 - frequency

mean 2.2 severity

mean 1.5 -

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Pico- Espinosa et al.2017,

Sweden

follow-up in 2006 and 2010, questionnaires,

weekly pain in last 6 months in back, neck and/or

shoulder/arms pain

in the beginning N=8,666, all participants free

from pain, in follow-up N=6846, home- dwelling aged 45-

84

451 8215 adjusted risk ratio (RR) for occurrence of pain and compared to

people without

diabetes in men 1.64 (95%Cl:

1.23-2.18) in women 0.92 (95%Cl:0.6-1.14)

*Databases and search terms: PubMed 2001- 13.8.2019: diabetes, neuropathic pain, chronic pain, frequent pain, older people; Scopus 1993-13.8.2019: TITLE-ABS (diabetes* AND ((chronic OR frequent*) W/4 pain) AND (aged OR elder* OR "old person*" OR "old people"

OR "older person*" OR "older people" OR "old adult*" OR "older adult*"))

1.4 MANAGEMENT OF CHRONIC AND FREQUENT PAIN

It is estimated that 40–60 % of the people with chronic pain have deficient management of their pain (Breivik et al. 2006, Karttunen et al. 2014). In a

telephone interview survey of 15 countries in Europe, 40% of patients thought that their physician did not consider their pain as a problem. This study stated that specialist services were unavailable to a majority of people having chronic pain (Breivik et al. 2006). In Finland, a 3-year follow-up interview study a substantial proportion of patients hoped that their pain management would be payd more attention by their physician (Karttunen et al. 2014).

In managing chronic pain, the main goal is to improve or restore functioning and to get the best possible quality of life rather than to achieve the cure (Mills et al. 2016). The Scottish Intercollegiate Guidelines Network (SIGN) has yielded evidence-based guidelines to optimize information for clinical practice. The SIGN guidelines´ methodology and objectivity are internationally recognized and have an effect on healthcare worldwide. In December 2013 the SIGN produced a new guideline on Chronic Pain management. This guideline is aimed at the assessment and management of adults with chronic non-malignant pain by non-specialists. In this guideline it is recommended to identify the type of pain in order to assess and plan care and to optimize treatment. Self-management can be used with support.

Pharmacological therapies require at least an annual assessment. Furthermore, a psychologically-based intervention should be considered. Physical therapies and exercise are recommended and complementary therapies such as acupuncture should be considered for osteoarthritis or chronic low back pain for short-term relief (Blair et al. 2014).

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1.4.1 Pharmacological pain management in older people

The American Geriatric Society (AGS) Panel on the Pharmacological Management of Persistent Pain in Older Persons provides guidelines for the pharmacological management of persistent pain in older persons (AGS 2009). The aim of pain management is to avoid the adverse effects (gastrointestinal, cardiovascular and renal) of analgesics (AGS 2009, 2019). The British Geriatric Society recommends paracetamol as the first line pain relieving drug because of its safety profile (Abdulla et al. 2013). The British Geriatric Society and the AGS´s clinical practice guidelines recommend the use of oral non-steroidal anti-inflammatory (NSAID) use with extreme caution and for short periods if paracetamol is not efficient enough (Abdulla et al. 2013, Connelly 2015). NSAIDs are not effective in chronic pain (Bjordal et al. 2004).

Opioids may be preferred for patients who are at risk of NSAID-related events.

It has been shown that short-time use of opioids has decreased pain intensity and increased physical functioning but worsened mental functioning in older people (Papaleontiou et al. 2010). When opioids are used in older people, chronic diseases and polypharmacy must be considered because of the adverse events such as anticholinergic cognitive burden, falls, sedation and constipation (Smith et al. 2010, Ziegler and Fonseca 2015, Roitto et al. 2019) and drug-drug interactions (Smith H et al. 2010).

Older people in general have more pain than younger people. For older people in particular, many factors must be taken into account in pharmacokinetics and pharmacodynamics. In normal aging, the muscles atrophy, total body water volume decreases, and body fat increases, which affects plasma concentration, volume distribution and elimination of drugs. The function of organs, such as the kidneys, gastrointestinal tract, hepatic and central nervous system, changes and general metabolism slows down.

Individual physiological and disease-specific changes and responses must be observed individually in pharmacological pain management (Miller et al. 2009, Abdulla et al. 2013). The major challenges in the pain management of older people include chronic diseases, polypharmacy, body aging and cognitive decline (Paladini et al. 2015).

1.4.2 Pharmacological pain management and impaired kidney function Normal aging causes a loss of nephrons and people aged 70-75 have half of their

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Because of these normal changes and the burden of diseases, older people are prone to drug-induced renal impairment and at the same time the

pharmacokinetics and pharmacodynamics of the drugs change with decreased kidney function (Aymanns et al. 2010, Auvinen et al. 2018, Schmidt-Mende et al.

2019). Renal, gastrointestinal effects and hypertension should be monitored because of the risk of adverse events especially when using NSAIDs (Caughey et al.

2009). The simultaneous use of antihypertensive drugs and NSAIDs may weaken the antihypertensive effect (Fournier et al. 2012). Moreover, in older people the simultaneous use of NSAIDs and ACE inhibitors has been associated with nephrotoxity (Adhiyaman et al. 2001).

Globally the most common reason of chronic kidney disease (CKD) is diabetes.

It has been associated with the decline of kidney function in many studies (Hemmelgarn et al. 2006, Yokoyama et al. 2009, Hobeika et al. 2015, Fan et al.

2020). Other causes of CKD are hypertension, obesity and infections (Jha et al.

2013).

The prevalence of CKD worldwide is 8-16%. The prevalence of CKD in older patients with type 2 diabetes in primary care is 22-50% wordwide (Thomas et al.

2006, Rodriguez-Poncelas et al. 2013, Lamine et al. 2016). In Finland 35-70% of older patients with type 2 diabetes had CKD in primary care (Metsärinne at al 2015, Hagnäs et al. 2020).

The European Medicines Agency (EMA) has classified the degrees of renal failure into four categories according to the estimated glomerular filtration rate (eGFR): (1) mild 90-60 ml/min/1.73m2, (2) moderate 60-30ml/min/1.73m2, (3) severe 30-15ml/min/1.73m2 and (4) end-stage <15ml/min/1.73m2. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines define chronic kidney disease (CKD) as an ´estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m² for greater than three months (Stevens and Levin 2013).

1.4.3 Pharmacological pain management in older people with diabetes People with diabetes are prone to the harmfull side effects of NSAIDs because of decreased kidney function, hypertension and heart diseases. Therefore NSAIDS are not recommended for people with diabetes, coronary heart disease, heart failure and chronic kidney disease (Mamdani et al. 2004, AGS 2009, Vandraas et al.

2010).

There is a lack of studies concerning the use of analgesics in older people with diabetes compared with those without diabetes. A few studies have been

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conducted in home-dwelling people and they were cross-sectional surveys (Butchart et al. 2009, Jyrkkä et al. 2009, Yang et al. 2019) (table 4).

In the studies presented in Table 4, the prevalence of the use of analgesics have varied between 15-78%. The prevalence of chronic or daily pain has varied

between 42-63% (Butchart et al. 2009, Jyrkkä et al. 2009, Yang et al. 2019). The lowest use of analgesics was 15%, in a study that did not analyze the use separately for people with and without diabetes (Yang et al. 2019). The highest prevalence of the use of analgesics (78%) was reported in US primary care patients, who also reported having pain most frequently (63%). This was the only study in which people experiencing pain were analyzed according to their diabetic status; 74% of people with and 78% without diabetes having pain used analgesics (Butchart et al. 2009) (table 4).

The use of different opioids was reported in one study, where 58% of all participants used non-opioids and 10% opioids (Jyrkkä et al. 2009) (table 4).

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Table 4. Frequent and chronic pain and pharmacological pain management in older people with and without diabetes. Summary of studies*.

Reference Study design, definition of

pain

Data Prevalence of pain

Use of analgesics

Butchart et al. 2009 US

cross-sectional chronic pain

lasting 6 months, present most of the time, survey

N=624, age

≥65 Primary care users

Diabetes, N= 221

Diabetes:

135 (61%) No diabetes:

255 (63%)

Of those with pain:

Diabetes: 100 (74%) No diabetes: 199 (78%)

Use of different analgesics:

not reported Jyrkkä et

al. 2009 Finland

cross-sectional, physical exam, interview, self-

reported regular disturbing daily

pain

N=523, age≥75, community-

dwelling Diabetes, N= 103

285 (54%) N=362(62%) in the whole data

Non-opioids: 300 (58%) of all participants Opiods: 51 (10%) of all

participants

Yang et al.

2019 Taiwan

cross-sectional, questionnaires

BPI

N= 316 people with

diabetes community-

dwelling age 69,9±6,6

N=133

(42%) N=47 (15%)

Use of different analgesics:

not reported

BPI (Brief pain inventory), RAI-HC (Resident Assessment Instrument-Home Care), NSAID (Non-Steroidal Anti-Inflammatory Drug)

*Databases and search terms: PubMed 2001-23.5.2019 neuropathic pain, pain, analgesics/therapeutic use, diabetes, older person;

Scopus 1981- 23.5.2019 diabetes, older person, analgesic, drug therapy

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2 AIMS OF THE STUDY

The main aim of this study was to investigate chronic pain and its effects and pharmacological pain management in home-dwelling older people with and without diabetes.

The spesific aims of this work were as follows:

I To study the frequency, prevalence, intensity and interfering effect of pain in a community-based population setting among women and men aged 65 or older with and without diabetes

II To explore how pain impacts on self-rated health among people with and without type 2 diabetes aged 65 or older

III To compare the analgesic use among people aged 65 and older with and without diabetes

IV To assess the kidney function and the use of nephrotoxic drugs among older people with and without diabetes.

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3 FREQUENT PAIN IN OLDER PEOPLE WITH AND WITHOUT DIABETES – FINNISH COMMUNITY BASED STUDY (I)

3.1 ABSTRACT

Background

The association between pain and diabetes in older people has been largely unexplored. The aim of this survey was to analyze the prevalence and characteristics of pain among Finnish men and women 65 or older with and without diabetes in primary care.

Methods

All home-dwelling persons 65 years or older with diabetes (N = 527) and age and gender matched controls (N = 890) were identified from electronic patient records.

Frequent pain was regarded as any pain experienced more often than once a week, and it was divided into pain experienced several times a week but not daily and pain experienced daily or continuously. The Numeric Rating Scale (0–10) (NRS) was used to assess the intensity and interference of the pain.

Results

The number of subjects who returned the questionnaire was 1084 (76.5%). The prevalence of frequent pain in the preceding week was 50% among women without diabetes and 63% among women with diabetes (adjusted, p = 0.22). In men, the corresponding proportions were 42% without diabetes and 47% with diabetes (adjusted, p = 0.58). In both genders, depressive symptoms and the number of comorbidities were associated with pain experienced more often than once a week and with daily pain. Diabetes was not associated with pain intensity or pain interference in either women or men.

Conclusions

Pain in older adults is associated with depressive symptoms and the number of comorbidities more than with diabetes itself.

Keywords

Diabetes, Older people, Pain

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3.2 BACKGROUND

Diabetes is among the most common chronic diseases in the world and in Finland (WHO 2016). The global prevalence of diabetes has nearly doubled from 1980 to 2014, increasing from 5% to 9% in the adult population (NCD Risk factor

collaboration 2016). In Finland the prevalence of diabetes is estimated to be 11%.

Most patients with diabetes in Finland have type 2 diabetes (89%) (Laakso et al.

2016). The increasing incidence and prevalence of diabetes will inevitably result in accumulation of diabetes in older people (Kirkman et al. 2012). It is assumed that people with diabetes have a bigger load of diseases than people without diabetes (Mäntyselkä et al. 2011).

One important comorbid condition often linked to diabetes is chronic pain. In general, it is very common in the adult population (Verhaak et al. 1998, Mäntyselkä et al. 2003). Chronic pain may be related to general multimorbidity (Kadam et al.

2005) and even to mortality (Macfarlane et al. 2001). Patients with type 2 diabetes have an increased risk of developing specific rheumatic manifestations caused by diabetes, such as stiff hand syndrome, Dupuytren’s disease, tenosynovitis, carpal tunnel syndrome, shoulder capsulitis/periarthritis, and reduced joint mobility. In addition to the conditions probably caused by diabetes, obesity and physical inactivity may predispose to osteoarthritis (Felson et al. 1988), which therefore most likely is associated with rather than caused by the disease.

A clinically important complication of diabetes is neuropathy, which can be painful. The prevalence of neuropathic pain in people with diabetes is difficult to estimate, as definitions have varied enormously between studies. In an

observational study of a large cohort of patients with diabetes in the U.K. the prevalence of painful neuropathy symptoms was estimated to be as high as 34%

(Abbott et al. 2011). Furthermore, non-neuropathic pain is common among patients with diabetes (Davies et al. 2006).

Data on the pain of older people with diabetes are few. Cross-sectional data from a multi-site, prospective cohort study of 11,689 participants with diabetes aged 47–73 years in the United States found that moderate to extreme pain was present in 58% and pain was strongly associated with poorer mental health and physical functioning but not poorer glycemic control (Bair et al. 2010). Another population study based on in-person interviews of adults 65 years old or older in the USA found that bothersome pain in the last month was reported by half of the adult population, while the corresponding prevalence among people with diabetes was 61.5% (Patel et al. 2013). In Taiwan, a large population-based, retrospective

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cohort study found that people aged 18–50 years with type 2 diabetes had a higher 10-year cumulative incidence of and a higher mean number of doctor visits for musculoskeletal pain than a non-diabetic group (Pai et al. 2015). Regardless of the etiology, musculoskeletal complaints are frequent among patients with

diabetes mellitus type 2 and may be of major importance in terms of quality of life (Burner et al. 2009).

Both diabetes and chronic pain are more common among older people than younger people. It can be assumed that older people with diabetes may suffer pain and be affected by pain more than those without diabetes. However, the association between diabetes and pain in old people with a control group of people without diabetes has not been studied much. Therefore, the aim of this study was to analyze the prevalence, frequency, intensity and interfering effect of pain among women and men aged 65 or more with and without diabetes in a community-based population setting.

3.3 METHODS

Study population

This cross-sectional study is based on ISDM (Inner-Savo Diabetes Mellitus) data.

The data is obtained from the Inner-Savo district with a total population of 10,793.

The present study was designed to collect data from a semirural community in order to have information for planning the services for older inhabitants. The study was approved by the Inner Savo Health Care Federation of Municipalities (61 A/2015). The study protocol of the ISDM study was approved by the Research Ethics Committee of the Northern Savo Hospital District, Kuopio, Finland

(256/2015). The questionnaire included information letter about the use of data and returning of questionnaire was voluntary. The autonomy of research subjects was respected and only anonymous data were analyzed. No harm was possible for the subjects and confidentiality of the subjects and research data were protected.

Of the inhabitants, 3093 (29%) were 65 or older representing a semi-rural area of Finland with a larger proportion of older people than in larger cities and average in Finland (20%) (Official Statistics of Finland (OSF) 2017).

Home-dwelling, 65 years or older persons with diabetes (and with Haemoglobin A1c (HbA1c) –levels) were identified from primary care electronic patient records using the International Classification of Diseases (ICD-10) diagnostic codes E10 and E11 (WHO 2017). Because only 12 subjects had type 1 diabetes people with type 1 and type 2 diabetes were combined. For each person with a diagnosis of diabetes,

Pain and pain medication among home-dwelling older people with and without diabetes

MERJA KARJALAINEN

PAIN AND PAIN MEDICATION AMONG HOME-DWELLING OLDER PEOPLE WITH AND WITHOUT DIABETES

Dissertations in Health Sciences

uef.fi

MERJA KARJALAINEN

PAIN AND PAIN MEDICATION AMONG HOME- DWELLING OLDER PEOPLE WITH AND WITHOUT

DIABETES

Merja Karjalainen

PAIN AND PAIN MEDICATION AMONG HOME- DWELLING OLDER PEOPLE WITH AND WITHOUT

DIABETES

ABSTRACT

TIIVISTELMÄ

ACKNOWLEDGEMENTS

LIST OF ORIGINAL PUBLICATIONS

CONTENTS

ABBREVIATIONS

INTRODUCTION

1 REVIEW OF THE LITERATURE

1.1 OLDER PEOPLE AND MANAGEMENT OF DISEASES IN PRIMARY HEALTH CARE

1.2 DIABETES

1.3 CHRONIC OR FREQUENT PAIN

1.4 MANAGEMENT OF CHRONIC AND FREQUENT PAIN

2 AIMS OF THE STUDY

3 FREQUENT PAIN IN OLDER PEOPLE WITH AND WITHOUT DIABETES – FINNISH COMMUNITY BASED STUDY (I)

3.1 ABSTRACT

3.2 BACKGROUND

3.3 METHODS