Alexander K. Smith, MD, MS, MPH; Irena Stijacic Cenzer, MA; Sara J. Knight, PhD; Kathleen A. Puntillo, RN, DNSc; Eric Widera, MD; Brie A. Williams, MD; W. John Boscardin, PhD; Kenneth E. Covinsky, MD, MPH
Abstract versions of this work were presented at the Annual Meeting of the American Geriatrics Society, Chicago, Illinois, 29 April–3 May 2009, and the 32nd Annual Meeting of the Society of General Internal Medicine, Miami, Florida, 13–16 May 2009.
Acknowledgment: The authors thank Jessamyn Conell-Price, BA, for her assistance in preparing this manuscript for publication.
Grant Support: Dr. Smith is supported by a Research Supplement to Promote Diversity in Health Related Research from the National Institute on Aging (R01AG028481), the National Center for Research Resources UCSF-CTSI (UL1 RR024131), and the National Palliative Care Research Center. Dr. Covinsky is supported by a K-24 grant from the National Institute on Aging (K24AG029812) and a grant from the National Institute on Musculoskeletal and Skin Diseases (P60 AR053308).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1398.
Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.
Requests for Single Reprints: Alexander K. Smith, MD, MS, MPH, Division of Geriatrics, University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, 4150 Clement Street (181G), San Francisco, CA 94121; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Smith, Widera, Williams, and Covinsky and Ms. Cenzer: Division of Geriatrics, Department of Medicine, University of California, San Francisco, 4150 Clement Street, San Francisco, CA 94121.
Dr. Knight: Departments of Psychiatry and Urology, University of California, San Francisco, 4150 Clement Street, San Francisco, CA 94121.
Dr. Puntillo: Department of Physiological Nursing, University of California, San Francisco, 2 Koret Way, Box 0610, San Francisco, CA 94143-0610.
Dr. Boscardin: Division of Biostatistics, Department of Epidemiology and Biostatistics, University of California, San Francisco, 4150 Clement Street, San Francisco, CA 94121.
Author Contributions: Conception and design: A.K. Smith, I.S. Cenzer, S.J. Knight, B.A. Williams, K.E. Covinsky.
Analysis and interpretation of the data: A.K. Smith, I.S. Cenzer, S.J. Knight, W.J. Boscardin, K.E. Covinsky.
Drafting of the article: A.K. Smith, I.S. Cenzer, E. Widera.
Critical revision of the article for important intellectual content: A.K. Smith, S.J. Knight, K.A. Puntillo, E. Widera, B.A. Williams, W.J. Boscardin, K.E. Covinsky.
Final approval of the article: A.K. Smith, I.S. Cenzer, S.J. Knight, K.A. Puntillo, E. Widera, B.A. Williams, K.E. Covinsky.
Provision of study materials or patients: A.K. Smith.
Statistical expertise: A.K. Smith, I.S. Cenzer, W.J. Boscardin, K.E. Covinsky.
Obtaining of funding: A.K. Smith, K.E. Covinsky.
Administrative, technical, or logistic support: A.K. Smith, K.E. Covinsky.
Collection and assembly of data: A.K. Smith, I.S. Cenzer.
Smith A., Cenzer I., Knight S., Puntillo K., Widera E., Williams B., Boscardin W., Covinsky K.; The Epidemiology of Pain During the Last 2 Years of Life. Ann Intern Med. 2010;153:563-569. doi: 10.7326/0003-4819-153-9-201011020-00005
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Published: Ann Intern Med. 2010;153(9):563-569.
The epidemiology of pain during the last years of life has not been well described.
To describe the prevalence and correlates of pain during the last 2 years of life.
Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status.
The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006).
Older adult decedents.
Clinically significant pain, as indicated by a report that the participant was “often troubled” by pain of at least moderate severity.
The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195).
Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available.
Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life.
National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.
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Geriatric Medicine, Hematology/Oncology, Pulmonary/Critical Care, Rheumatology, End-of-Life Care.
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