Severe and chronic pain in multiple areas associated with increased risk of falls in older adults

Older adults who reported chronic musculoskeletal pain in two or more locations, higher levels of severe pain, or pain that interfered with daily activities were more likely to experience a fall than adults who did not reports these types of pain, according to a study in the November 25 issue of JAMA.

"Falls rank among the 10 leading causes of death in older adults in the United States, resulting in more than $19 billion in health care costs annually. Despite a growing body of scientific evidence supporting associations between a number of risk factors and falls, efforts to translate these findings into effective fall prevention strategies have been limited," the authors write. Few reports have examined chronic pain as a risk for falls in older adults. "Pain contributes to functional decline and muscle weakness and is associated with mobility limitations that could predispose to falls."

Suzanne G. Leveille, Ph.D., R.N., of Beth Israel Deaconess Medical Center and the University of Massachusetts-Boston, and colleagues conducted a study to determine whether chronic musculoskeletal pain is associated with an increased occurrence of falls in older adults. The study included 749 adults, age 70 years and older, who were enrolled in the study from September 2005 through January 2008. Pain was assessed via questionnaires. Participants recorded falls on monthly calendar postcards mailed to the study center during an 18-month period.

At the beginning of the study, 40 percent of participants reported chronic pain in more than one joint area and 24 percent reported chronic pain in only one joint area. A total of 1,029 falls were reported by the 749 participants during and up to 18 months of follow-up. Four hundred five participants (55 percent) fell at least once during the follow-up. Analysis indicated that compared with participants who reported no pain or those in the lowest groups of pain scores, participants who reported two or more sites of pain had an increased risk for falls; those reporting the highest levels of pain severity also had an increased rate of falls; and pain interference with activities was also associated with a greater occurrence of falls.

The researchers write that they observed a strong graded relationship in the short term between pain severity ratings each month with risk for falls in the subsequent month. "For example, among persons who reported severe or very severe pain for any given month on their calendar postcard, there was a 77 percent increased likelihood for a fall in the subsequent month compared with those who reported no pain." Persons reporting even very mild pain also had an elevated odds of falling in any given month.

The authors suggest there may be several possible mechanisms for the pain-falls relationship, including neuromuscular effects of pain, which could lead to leg muscle weakness or slowed neuromuscular responses to an impending fall. "Another factor may be gait alterations or adaptations to chronic pain that lead to instability and subsequent balance impairments. Chronic pain may serve as a distractor or, in some way, interfere with cognitive activity needed to prevent a fall. Successful avoidance or interruptions of a fall typically requires a cognitively mediated physical maneuver."

"The findings provide evidence suggesting that the common complaint of the aches and pains of old age is related to a greater hazard than previously thought. Daily discomfort may accompany not only difficulties in performing daily activities but equally as important may be a risk for falls and possibly fall-related injuries in the older population. The significance of this work is in the identification of chronic pain as an overlooked and potentially important risk factor for falls in older adults. A randomized controlled trial is needed to determine whether improved pain control could reduce risk for falls among older patients with chronic pain," the researchers conclude.

(JAMA. 2009;302[20]:2214-2221. Available pre-embargo to the media at www.jamamedia.org)

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