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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M400-M404 (2001)
© 2001 The Gerontological Society of America

Impact of Pain on Disability Among Older Mexican Americans

Soham Al Sniha,b,c, Kyriakos S. Markidesb,c, Laura Rayb,c and James S. Goodwina,b,c

a Department of Internal Medicine, University of Texas Medical Branch, Galveston
b Sealy Center on Aging, University of Texas Medical Branch, Galveston
c Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston

James S. Goodwin, Sealy Center on Aging, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0460 E-mail: jsgoodwi{at}utmb.edu.

Decision Editor: John E. Morley, MB, BCh


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Joint pain is a very common complaint among elderly persons and may lead to functional disability. The purpose of this study is to estimate the prevalence of self-reported pain on weight bearing and its impact on the 2-year incidence of limitation in lower-body activities of daily living (ADL) in initially nondisabled Mexican American elderly subjects.

Methods. We studied a probability sample of 2167 noninstitutionalized Mexican American men and women aged 65 or older residing in five Southwestern states. Subjects were asked about pain on weight bearing, ADL, depressive symptomatology, and the presence of chronic diseases. The body mass index was computed using measured height and weight. Finally, a three-task (tandem balance, 8-foot walk, and repeated chair stands), performance-based, lower-body function test was performed.

Results. The overall prevalence of pain on weight bearing in the sample was 31.9%, with 37.7% for women versus 24.0% for men (p < .001). The most prevalent sites of pain were knees (14.7%), followed by ankle/feet (12.1%). In a logistic regression analysis, pain was a significant independent predictor of subsequent disability and of the inability to perform tandem balance, 8-foot walk, and repeated chair stands.

Conclusions. Pain on weight bearing is prevalent among older Mexican Americans and is a major independent risk factor for subsequent disability.

PAIN is one of the most common and among the most personally compelling reasons for seeking medical attention (1). Pain interferes with daily activities, causes worry and emotional distress, and undermines confidence in one's health. When pain persists for weeks or months, it affects psychological health and performance of social responsibilities in work and family life (1). Joint pain is a very common complaint among elderly persons and may lead to functional disability (2)(3)(4)(5)(6)(7).

Several epidemiological studies have shown the prevalence of pain from middle age to old age (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25). The overall prevalence of any type of pain or discomfort in the population of older people has been estimated to range from 25% to 75% (10)(14)(15)(24). Musculoskeletal pain has been estimated to range from 10% to 75% in the older population (8)(9)(12)(13)(14)(17)(18)(19)(20)(22)(23)(24)(25).

Little is known, however, about the impact of pain on physical disability, particularly among older minority populations. In this study we used data from a sample of older Mexican Americans to estimate the prevalence of self-reported pain on weight bearing and its impact on the 2-year incidence of limitation in lower-body activities of daily living (ADL) and lower-body function.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Data are from the first wave (1993–1994) and the second wave (1995–1996) of the Hispanic Established Population for the Epidemiological Study of the Elderly, a population-based study of 3050 noninstitutionalized Mexican Americans aged 65 and over residing in five Southwestern states (Texas, New Mexico, Colorado, Arizona, and California) (26). The sampling methods and field work are described in previous publications (27). In the first wave, 2873 subjects were interviewed in person and 177 (5.8%) by proxy. In the second wave, 2167 subjects were reinterviewed in person, and another 272 (8.9%) subjects were interviewed by proxy. The interviews were conducted in Spanish or English, depending on the respondent's preference.

To estimate the prevalence of self-reported pain on weight bearing and predictors of pain at baseline, we used the data from the first wave. To evaluate the impact of pain on 2-year incidence of limitation in lower-body activities, we examined respondents who were not disabled in lower-body activities at baseline. There were 2611 subjects who reported no ADL disability at baseline, of whom 2108 completed the follow-up 2 years later. We also examined the impact of pain on three simple performance-based measures of lower physical function: tandem balance, 8-foot walk, and repeated chair stands. Those interviewed via proxy were not included in the analyses. Those who refused to answer the interview questions and those who did not know the answers were excluded from the analyses.

Measures
Demographic characteristics were evaluated from responses to questions about birth date, gender, marital status, and years of education.

Pain was evaluated from the response to the question, "In the past month, did you notice any pain or discomfort when you stood or walked?"

Limitation in lower-body activities was assessed by five items from a modified version of the Katz ADL scale (28): walking across a small room, bathing, dressing, transferring from a bed to a chair, and using the toilet. Respondents were asked to indicate if they could do the activities without help, if they needed help, or if they were unable to do them.

Performance-based lower-body function was assessed with three independent measures (29): standing balance, a timed 8-foot walk, and five timed repeated chair stands. The standing balance test included tandem, semi-tandem, and side-by-side stands. The 8-foot walk was timed twice to the nearest second, with the faster of the two walks used in the analysis. Timed repeated chair stands were calculated to the nearest tenth of a second among those who demonstrated that they were capable of standing once from a sitting position with arms folded across their chest. Those subjects unable to complete each task were assigned a value of one, and those subjects able to complete each task were assigned a value of zero.

Depressive symptomatology was measured with the Center for Epidemiologic Studies Depression Scale (CES-D) (30). Persons scoring 16 or over were categorized as having high depressive symptomatology (31). The presence of various chronic diseases was assessed by asking the respondents if they had ever been told by a doctor that they had adult-onset arthritis, diabetes mellitus, heart attack, stroke, or cancer. Actual measures of body weight and height were used to calculate the body mass index (BMI). Persons with a BMI of 30 or over were considered obese.

Analysis
The Cochran-Mantel-Haenszel chi-square statistic was used to test differences in demographic variables and pain on weight bearing. Sampling weights and design effects were adjusted using the SUDAAN program (32) to estimate the prevalence of pain. A weighted logistic regression model with categorical predictors was used to predict the odds of having pain on weight bearing associated with selected chronic conditions and sociodemographic variables. Unweighted logistic regression models with categorical predictors were used to predict the impact of pain on lower-body limitations at follow-up, controlling for age, gender, marital status, education, and chronic conditions at baseline. These analyses were restricted to those who were independent in lower-body activities at baseline. In Model 1, arthritis was included along with age, gender, marital status, and education. In Model 2, only pain was included in addition to the control variables. In Model 3, both pain and arthritis were included, and in Model 4, the other chronic conditions were added. We also performed analyses of interaction effects of pain with each medical condition.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Table 1 presents the prevalence of self-reported pain on weight bearing (i.e., the answer to the question, "In the past month, did you notice any pain or discomfort when you stood or walked?") by selected sociodemographic characteristics. The overall prevalence in the sample was 31.9%, with 37.7% among women and 24.0% among men (p < .001). There were also significant differences in prevalence for arthritis, depressive symptomatology, obesity, and marital status. There were no significant differences by age and years of education.


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  		Table 1. Prevalence of Self-Reported Pain\|[dagger]\| on Weight Bearing in Older Mexican Americans, by Selected Sociodemographic Characteristics and Chronic Conditions

 
Table 2 presents the results of a logistic regression analysis predicting the odds of having pain on weight bearing at baseline by demographic characteristics and selected chronic conditions. Arthritis, high depressive symptomatology, and obesity were significantly associated with pain. None of the sociodemographic variables were significant.


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  		Table 2. Odds of Self-Reported Pain on Weight Bearing* by Selected Population Characteristics (n = 2687\|[dagger]\|)

 
Table 3 presents the number and percentage of subjects reporting weight-bearing pain by location of pain. The most prevalent sites were knees (14.7%), followed by ankle/feet (12.1%), hips (11.6%), and back (8.4%).


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  		Table 3. Number and Percentage of Subjects Reporting Pain on Weight Bearing* by Location of Pain (n = 2721)

 
Table 4 presents the results of different logistic regression models predicting odds of any lower-body ADL limitation at follow-up among nondisabled subjects at baseline. These models investigate the relative contributions of arthritis, weight-bearing pain, and other factors to the development of subsequent disability. In Model 1 the presence of arthritis at baseline was predictive of lower-body ADL disability at follow-up (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.14–2.17). In Model 2, pain on weight bearing predicted disability (OR 2.51, 95% CI 1.78–3.54). In Model 3, both arthritis and pain on weight bearing are entered. Pain remains a strong predictor (OR 2.46, 95% CI 1.64–3.68), whereas arthritis loses significance (OR 1.03). In Model 4, other possible predictors of subsequent disability are entered. Pain remains a significant predictor (OR 2.14, 95% CI 1.35–3.39).


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  		Table 4. Logistic Regression Predicting Odds of Lower Body ADL Disability* at Follow-up Among Nondisabled Subjects at Baseline

 
Table 5 uses the same predictor variables as in Model 4 (see Table 4 ), using three different outcomes: inability to perform tandem balance task, inability to perform an 8-foot walk, and inability to perform the repeated chair stands. Pain was a significant independent predictor of subsequent disability in all three analyses.


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  		Table 5. Logistic Regression Predicting Odds of Unable to Perform Three Measures of Lower-Body Function at Follow-up Among Nondisabled Subjects at Baseline

 
No interaction effects were found for pain and arthritis, obesity, depression, heart attack, stroke, cancer, and diabetes in predicting lower-body disability.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
This study demonstrates that the prevalence of self-reported pain on weight bearing in older Mexican Americans is 31.9%. This prevalence compares with results of other surveys where musculoskeletal pain has been estimated to range from 10% to 71% for those aged 65 and older (8)(9)(12)(13)(14)(17)(18)(19)(20)(22)(23)(24)(25). In our study, the prevalence of pain was greater in women and unmarried subjects. The most common location of pain was knees, followed by ankle/feet and hips.

Also, this study examined the impact of pain on subsequent physical function among initially nondisabled older Mexican Americans. Pain predicted future disability in lower-body ADL and also poor performance on performance-based tests of physical functions. These associations remained after controlling for other factors influencing the development of disability. When pain and arthritis were included in the same logistic regression models, pain remained an independent predictor of subsequent lower-body disability. These findings underscore the need for effective and safer agents for controlling pain in older persons.

The degree of functional limitation among individuals with arthritis has been linked to the severity of the disease, but this relationship may be dependent on both the particular joint studied and the measure of function used (33). The assumption that pain, secondary to pathologic changes in normal joint structures, would be the primary factor limiting function appears almost self-evident (34). Pain is strongly linked to the radiographic severity of the disease (35). However, pain alone is not sufficient to explain functional limitations in individuals with osteoarthritis (OA), for example (35). Guccione and coworkers (36) showed that functional deficits are more likely in older subjects with severe radiographic OA but with fewer painful symptoms than in individuals with milder radiographic changes but more symptomatic disease.

As previously published, the presence of depressive symptomatology is also an important predictor of future disability (37)(38). There was no interaction between pain and depressive symptomatology on subsequent disability, but the presence of depressive symptomatology at baseline predicts pain.

A limitation in this study is our reliance on self-reported data for pain on weight bearing and comorbidities. Hughes and colleagues (39) examined the extent and nature of bias associated with self-reported versus standardized physician-examination/assessments-based accounts of musculoskeletal disease in a sample of 406 persons chosen to represent an aging and dependency continuum. They found that self-report tended to underestimate the prevalence in relation to the standardized assessment. Overall, their results indicated that the self-reports of musculoskeletal conditions by elderly subjects capture the vast majority of persons with painful or functionally significant disease and are most valid for persons from ages 65 to 74, but do not reflect the presence of asymptomatic joint pathology (39).

In conclusion, pain on weight bearing is highly prevalent among older Mexican Americans and is associated with subsequent development of lower-body ADL disability and poor performance on functional testing. Primary, secondary, and tertiary prevention of pain on weight bearing by treatment may reduce the onset and progression of lower-body disability among the older population.


   Acknowledgments
 
This study was supported by Grants AG10939, AG00618, and AG17231 from the National Institute on Aging, USA. We thank the following individuals who reviewed the manuscript and provided advice and information: Jean Freeman, Shiva Satish, Sandra Black, and Glenn V. Ostir.

Received December 19, 2000

Accepted February 14, 2001


   References
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 Abstract
 Methods
 Results
 Discussion
 References
 

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