Depressive Symptoms, Pain Experiences, and Pain Management Strategies Among Residents of Taiwanese Public Elder Care Homes

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1 Vol. 30 No. 1 July 2005 Journal of Pain and Symptom Management 63 Original Article Depressive Symptoms, Pain Experiences, and Pain Management Strategies Among Residents of Taiwanese Public Elder Care Homes Yun-Fang Tsai, RN, PhD, Shu-Ling Wei, RN, MS, Yea-Pyng Lin, RN, MS, and Chih-Cheng Chien, MD, PhD School of Nursing, Chang Gung University (Y.-F.T.), Department of Nursing, Mennonite Christian Hospital (S.-L.W., Y.-P.L.), and Department of Anesthesiology, Cathay General Hospital (C.-C.C.), Taiwan, Republic of China Abstract The purpose of this study was to explore depressive symptoms, pain experiences, and pain self-care management strategies among residents of public elder care homes in Taiwan. Random sampling was used to recruit participants (n 200). In this sample, the prevalence of depressive symptoms was 49.0%. Pain prevalence was significantly higher in the depressed group (59.2%) than in the non-depressed group (43.1%). Depressed participants tended to report more severe pain intensity, worst pain, average pain, and more interference with walking than the non-depressed group. Most participants (60.0%) took prescribed medications for dealing with pain. Self was the main information source for pain management strategies. Participants reported severe bouts of pain but used limited self-care pain management strategies. Due to the limited number of health care providers in elder care homes, the authors recommend increasing knowledge about depression, pain, and pain management strategies of both institutional health care staff and residents. J Pain Symptom Manage 2005;30: U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Depression, pain elderly, care home, self-care Introduction Advances in medical technology are contributing to longer life expectancies, making care of the elderly an important global health issue. Address reprint requests to: Yun-Fang Tsai, RN, PhD, School of Nursing, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan, 333, ROC. Accepted for publication: January 11, U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. Many studies indicate that the prevalence of elderly depression is high. For example, the prevalence of depression was 12 15% in elders living in the community 1 and was about doubled in institutionalized elderly in the UK. 2 Depression prevalence ranged from 1 20% in the U.S. 3 5 and from % in Taiwan. 6 8 These data indicate that depression in the elderly has become a critical issue for health care systems worldwide. Pain among the elderly has also been highlighted as a significant problem because of its /05/$ see front matter doi: /j.jpainsymman

2 64 Tsai et al. Vol. 30 No. 1 July 2005 negative impact on quality of life and functional independence. 9,10 Studies have indicated a high prevalence of pain among elders living in communities and in long-term care institutions The negative consequences of pain among the elderly are multiple, 20 and depression is commonly reported in elders with pain. 11,21 24 In Taiwan, the life expectancy for women in 2003 was 79.1 years and 73.4 years for men. 25 By the end of 2003, the elderly ( 65 years) accounted for 9.2% of all Taiwanese (22.6 million people). 25 Adults in Chinese society are expected to assume the responsibility of caring for their aging parents. Living arrangements for Taiwanese elders who are poor and single (or whose children cannot provide care) has become a pressing issue for the government of Taiwan, which established public elder care homes to take care of this population. 26 To be eligible to live in these institutions, elders must be 60 years old and able to care for themselves without need for skilled nursing care. 26 Throughout Taiwan, there are 18 public elder care homes, with about 6000 vacancies available in Because these institutions are free of charge, the number of vacancies varies from year to year, depending on the government budget. However, as the family structure changes in Taiwan and the economy remains depressed, the number of elders seeking admission to these institutions is expected to increase. Social support has been reported as a strong predictor of elderly depression. 28,29 Due to lack of family support and poverty, elderly residents of public elder care homes may be vulnerable to depression, which could increase the likelihood of physical problems, such as pain. However, the major concern of these institutions is to provide living arrangements for elderly residents, so their health issues may be underestimated. To the best of the authors knowledge, no studies to date have focused on understanding depression and pain among residents of public elder care homes in Taiwan. Therefore, this study was undertaken to explore depressive symptoms, pain experiences, and pain self-care strategies among elders living in public elder care homes in Taiwan. Methods Sample and Setting Two of 18 public elder care homes were selected using a random sampling method. To have enough participants, the recruitment of 100 elderly from each elder care home was planned in advance. The inclusion criteria were: 1) resident of one of these two elder care homes and age 65 years or above, and 2) without severe cognitive deficit (Mini-Mental State Examination [MMSE] score 16 for participants with no formal education; MMSE score 20 for primary school graduates or above). 30,31 Computerized randomization was used to choose potential participants from a list of all residents names. Of 215 residents approached, 10 did not meet the inclusion criteria and 5 refused to participate. Therefore, the final sample size was 200. Instruments The Chinese version of the short-form of the Geriatric Depression Scale (GDS-S) 32 was used to measure depressive symptoms. It consists of 15 items with yes and no answers. After translation and adaptation into Chinese and using a cut-off score of 8, the GDS-S had a sensitivity of 96.3% and a specificity of 87.5% for identifying depression in a Chinese population. The Brief Pain Inventory-Chinese version (BPI-C) 33 was used to assess the multidimensional nature of pain, including pain sites, intensity, and subsequent interference with life activities in the previous seven days. The first part of the BPI-C consists of figures representing back and front body outlines. Participants were asked to mark their pain on the figures, sequentially numbering the different pain sites. The second part of the BPI-C consists of four single-item measures of pain intensity: worst pain, least pain, average pain, and current pain. Each item is rated from 0 ( no pain ) to 10 ( the worst pain I can imagine ). These four items were averaged to represent overall pain intensity. The third part of the BPI-C consists of seven items that assess the extent to which pain interferes with general activity, mood, walking, working, relations with others, sleeping, and enjoyment of life. Each item is rated on a 0 10 scale. Because elderly residents of care homes don t work, the item about interference with working was deleted. Scores on the remaining six items were averaged to give an overall pain interference score. Self-report and semi-structured questionnaires were used to measure pain management

3 Vol. 30 No. 1 July 2005 Depression and Pain in Elder Home Residents 65 strategies. Participants were asked to freely describe three common self-management strategies they used to relieve pain, the level of effectiveness (1 not effective, 10 extremely effective), and the source of each strategy. No suggestions or list of alternatives was presented to them. A demographic sheet covering basic questions regarding age, sex, education, marital status, and number of diseases was developed for this study. In addition, the Barthel Index 34 was used to measure participants activities of daily life (ADL). Procedures The two elder care homes chosen by random sampling were approached individually. After obtaining permission from each care home, a research assistant (RA) approached elderly residents who were chosen by computerized randomization, described the study, and obtained their oral consent to participate. If they agreed to participate and met the inclusion criteria, the RA then read the questionnaire items to each participant and recorded their answers. Analysis Descriptive statistics were used to describe the sample characteristics in terms of demographic and pain-related variables. Chi-square or t-tests were used to compare the characteristics and pain experiences of participants with and without depressive symptoms. Content analysis was used to categorize all management strategies for pain symptoms. Frequencies of use were also computed for each strategy. Results The prevalence of depressive symptoms in the total study sample was 49.0%. Table 1 presents demographic data of the study participants. Two significant differences were found in demographic characteristics of participants with and without depressive symptoms. Depressed participants had lower MMSE scores and more diseases than non-depressed participants. Diseases in this sample of elders are shown in Table 2. Three significant differences in the prevalence of diseases were found between these two groups. The prevalence rates of osteoarthritis, digestive system diseases, and urinary system diseases were higher in the depressed group than the non-depressed group. Among the depressed elderly, 58 participants (59.2%) reported pain. The average number of pain sites was 1.88 (SD 1.0, range 1 5). Twenty-eight depressed participants (48.3%) experienced pain at only one site, 18 participants (31.0%) had pain at two separate sites, 4 participants (6.9%) experienced pain at three sites, 7 participants (12.1%) had pain at four sites, and 1 participant (1.7%) had pain at five sites. Knees (36.2%) and lumbar spine (32.8%) were the most commonly described pain sites. Among the non-depressed elderly, 44 participants (43.1%) reported pain. The average Table 1 Demographic Characteristics of Elder Care Home Residents With and Without Depressive Symptoms Elders with Depressive Elders without Depressive Characteristic Symptoms (n 98) Symptoms (n 102) t or χ 2 Age, years (%) 79.7 (7.1) 81.4 (7.6) t(198) 1.67, ns Sex, n (%) Male 66 (60.8) 65 (70.4) χ 2 (1) 0.29, ns Female 32 (39.2) 37 (29.6) Education, n (%) No formal education 60 (58.8) 49 (50.0) χ 2 (3) 4.66, ns Primary school 22 (26.5) 29 (24.5) Junior high school 8 (5.9) 8 (10.2) Senior high or above 8 (8.8) 16 (15.3) Marital status, n (%) Never married 43 (42.2) 48 (49.0) χ 2 (3) 1.80, ns Married 8 (7.8) 13 (13.3) Widow/widower 38 (42.2) 33 (28.6) Other 9 (7.8) 8 (9.2) MMSE 22.5 (3.7) 24.3 (3.3) t(198) 3.61, P 0.00 ADL 93.9 (6.2) 95.4 (5.7) t(198) 1.87, ns Number of diseases 1.9 (1.2) 1.4 (1.1) t(198) 2.65, P 0.01

4 66 Tsai et al. Vol. 30 No. 1 July 2005 Table 2 Diseases in Elder Care Home Residents With and Without Depressive Symptoms Elders with Depressive Elders without Depressive Symptoms (n 98) Symptoms (n 102) Disease n (%) n (%) χ 2 Hypertension 43 (43.9) 46 (45.1) χ 2 (1) 0.03, ns Heart disease 28 (28.6) 25 (24.5) χ 2 (1) 0.42, ns Osteoarthritis 19 (19.4) 9 (8.8) χ 2 (1) 4.63, P 0.03 Urinary system disease 17 (17.3) 7 (6.9) χ 2 (1) 5.20, P 0.02 Diabetes 16 (16.3) 13 (12.7) χ 2 (1) 0.52, ns Digestive system disease 13 (13.3) 2 (2.0) χ 2 (1) 9.21, P 0.00 Respiratory disease 11 (11.2) 7 (6.9) χ 2 (1) 1.16, ns Cataract 10 (10.2) 12 (11.8) χ 2 (1) 0.12, ns Stroke 10 (10.2) 14 (13.7) χ 2 (1) 0.59, ns Renal disease 6 (6.1) 4 (3.9) χ 2 (1) 0.51, ns Fracture 5 (5.1) 5 (4.9) χ 2 (1) 0.004, ns Cancer 5 (5.1) 2 (2.0) χ 2 (1) 1.46, ns number of pain sites was 1.57 (SD 0.7, range 1 5). Twenty-three non-depressed participants (52.3%) experienced pain at only one site, 19 participants (43.2%) had pain in two separate sites, and 2 participants (4.5%) had pain at four sites. Knees (31.8%) and lumbar spine (25.0%) were also the most commonly described pain sites. Pain prevalence was significantly higher in the depressed group than in the non-depressed group (χ , df 1, P 0.02). However, no significant differences were found in the average number of pain sites between the two groups. The overall pain intensity in elders with depressive symptoms was 4.41 (SD 1.43), indicating moderate pain. Speaking to the worst pain intensity, 12.1% (n 7) of these participants suffered mild pain (score 1 3), 46.6% (n 27) had moderate pain (score 4 6), and 41.4% (n 24) had severe pain (score 7 10), indicating that most participants with depressive symptoms (88.0%) suffered from moderate to severe pain. The overall pain interference was 3.81 (SD 2.44), indicating moderate interference. Depressed participants reported that their pain most interfered with their walking and general activity. The overall pain intensity in elders with nondepressive symptoms was 3.80 (SD 1.25), indicating moderate pain. Speaking to the worst pain intensity, 22.7% (n 10) of these participants suffered mild pain, 50% (n 22) had moderate pain, and 27.3% (n 12) had severe pain, indicating that most participants with nondepressive symptoms (77.3%) suffered from moderate to severe pain. The overall pain interference was 3.17 (SD 2.25), indicating slight interference. Non-depressed participants also reported that their pain most interfered with their walking and general activity. Some significant differences were found between these groups. The depressed group tended to have more severe pain intensity, worst pain and average pain than the non-depressed group. Moreover, the depressed group also reported more interference with walking than the non-depressed group (Table 3). Due to the limited number of self-care pain management strategies provided, data for this variable from depressed and non-depressed elderly were pooled for analyses. Self-care strategies to manage pain and sources of this information are shown in Table 4. In general, participants applied different self-care strategies to manage their pain. Most participants took prescribed medications, yet resting and using ointments were also common strategies for relieving pain. Self was the main information source for pain management strategies. Discussion The prevalence of depressive symptoms in this sample of elder care home residents (49.0%) was higher than in previous studies (1 43.3%). 3 8 Poverty and/or lack of family support were predominant problems in this sample because of the criteria for applying to live in public care homes. Many studies have found that poor socioeconomic status may interfere with receiving health care and social support. 28,29 As a result, these factors may contribute to depressive symptoms. Moreover, lower

5 Vol. 30 No. 1 July 2005 Depression and Pain in Elder Home Residents 67 Table 3 Pain Intensity and Interference in Depressed and Non-Depressed Elderly with Pain (n 102) Depressed (n 58) Non-Depressed (n 44) Characteristic Mean (SD) Mean (SD) t Pain intensity 4.41 (1.43) 3.80 (1.25) t(100) 2.27, P 0.03 Worst pain 6.17 (1.90) 5.05 (1.95) t(100) 2.93, P 0.00 Least pain 2.76 (1.60) 2.45 (1.65) t(100) 0.94, ns Average pain 5.07 (1.47) 4.25 (1.45) t(100) 2.80, P 0.01 Current pain 3.64 (2.27) 3.43 (1.58) t(100) 0.52, ns Pain interference 3.81 (2.44) 3.17 (2.25) t(100) 1.35, ns General activity 4.60 (2.75) 3.68 (2.26) t(100) 1.81, ns Mood 3.57 (2.79) 3.07 (2.45) t(100) 0.95, ns Walking 4.97 (3.04) 3.75 (2.97) t(100) 2.02, P 0.05 Relations with others 2.72 (2.38) 2.82 (2.40) t(100) 0.20, ns Sleeping 3.84 (3.15) 3.07 (2.60) t(100) 1.33, ns Enjoyment of life 3.14 (2.76) 2.64 (2.37) t(100) 0.97, ns average MMSE score and greater average number of diseases were associated with depressive symptoms. A lower MMSE score might be caused by depression, rather than the opposite. In addition, pain prevalence was significantly higher in the depressed group than in the nondepressed group. Several previous studies also found that elders with pain had a higher depressive tendency. 11,21 24 Because depressive elders have been found to have a higher suicide rate than the non-depressive elderly, it is important to pay attention to these residents psychological distress. Although it may be difficult to improve financial status, family support, and MMSE scores for these residents, it is possible to provide better care for them for example, to relieve their pain. Therefore, these results demonstrate the importance of relieving pain among the elderly. In general, participants with pain reported multiple sites of pain, similar to previous findings. 10,11 Knee pains were commonly described by the present study s participants, likely explaining why most of them reported severe interference with walking. Compared to the non-depressed group, the depressed group tended to report more severe pain intensity, worst pain, average pain, and more pain interference with walking. After completing the questionnaires, some participants described walking disabilities that interfered with their self-care abilities and caused them to worry about their eligibility to continue living in the current institution. Analysis of the distribution of responses to items on the BPI-C about worst pain intensity revealed a troubling phenomenon in all participants with pain (n 102). About 17% (n 17) Table 4 Self-Care Strategies to Manage Pain Source (frequency) Self-Care Management Strategy (frequency) Effective Level Doctor Nurse Self Friends Take prescribed medications (52) Rest (37) Use ointments (37) Massage (36) Cover with a hot pack (25) Attend rehabilitation classes (23) Ignore the pain (11) Take over-the-counter medications (11) Take a walk (9) Take Chinese medicines (6) (e.g., tui-na, acupuncture, herbs) Visit a Western medical doctor (5) Use brace (5) Don t move (3) Visit a Chinese medical doctor (2) Don t turn on air conditioner (1) Drink water (1)

6 68 Tsai et al. Vol. 30 No. 1 July 2005 of these participants suffered mild pain, 48.0% (n 49) had moderate pain, and 35.3% (n 36) had severe pain. These data reveal that most participants suffered from moderate to severe pain. This finding suggests that elder care home residents in Taiwan need help to relieve their pain. Future studies are needed to determine effective strategies for relieving pain in this population. Participants applied different self-care strategies to manage their pain. Some used active strategies to manage their pain for example, cover with a hot pack, attend rehabilitation classes, and take a walk. Participants also rated these strategies as effective. Some participants used passive strategies to manage pain (e.g., don t move and ignore the pain ) but their efficacies were poor. Active strategies appeared more effective than passive strategies in relieving pain. Because these data were selfreported and strategies were not standardized, further studies are needed to explore this issue. In addition, 15.7% of participants could only recall one self-care strategy during interviews, and 38.2% could recall two strategies to manage their pain. These findings indicated limited pain management strategies were used and suggest the need for improving knowledge about pain and pain management skills among the elderly. Six participants reported taking traditional Chinese medicines (TCM) to deal with their pain, including tui-na (a Chinese massage technique at the pain site), acupuncture, or herbal therapy. People in Chinese cultures believe that TCM cause fewer side effects than Western medicines. In the long run, Chinese people believe it is healthier and wiser to take TCM. The ingredients of TCM taken by the present study s participants were unknown. Future studies could be developed to explore in detail the use of TCM among elders in Chinese cultures. Taking medication was the most common strategy used by this sample of elders to relieve pain, in agreement with the literature. 11 Although taking medication can have an impact on the effectiveness of patients self-care strategies for pain management, detailed information about medication use was not emphasized in this study. Further studies need to explore this issue. In conclusion, this study revealed a high prevalence of both depressive symptoms and pain among residents of public elder care homes in Taiwan. Their pain experiences made them suffer and interfered with their daily activities. Their inability to get relief from pain may have been due to their limited use of pain management strategies. Currently, physicians are not required and only one nurse is required for each shift in elder care homes. Paraprofessional health care providers are the main workers in these homes. Due to this limited number of health care providers, in-service training about depression and pain is recommended for all paraprofessionals at these institutions. The content of such training could focus on current knowledge about depression and pain, as well as pain management strategies. Most elder care homes in Taiwan regularly organize group activities for residents at which new knowledge of current medications is presented. Trained elder care home paraprofessionals with a sound understanding and good knowledge of depression and pain could then incorporate such knowledge into this group activity. As a result, these workers could help their elderly residents to obtain current knowledge about depression and pain, and to manage their pain using appropriate self-care strategies. References 1. Beekman ATF, Copeland JRM, Prince MJ. Review of community prevalence of depression in late life. Br J Psychiatry 1999;174: Katona C, Livingston G. Comorbid depression in older people. London: Martin Dunitz Ltd, Katona C. Depression in old age. New York: John Wiley & Sons Inc., Ernst C, Angst J. Depression in old age: is there a real decrease in prevalence? a review. Eur Arch Psychiatry Clin Neurosci 1995;245: Palsson S, Skoog I. The epidemiology of affective disorders in the elderly: a review. Int Clin Psychopharmacol 1997;12(Suppl 2):S3 S Liu CY, Wang SJ, Teng EL, et al. Depressive disorders among older residents in a Chinese rural community. Psychol Med 1997;27: Lu C, Liu C, Yu S. Depressive disorders among the Chinese elderly in a suburban community. Pub Health Nur 1998;15: Tsai YF, Chung JWY, Wong TKS, Huang CM. Comparison of the prevalence and risk factors for depressive symptoms among elderly nursing home residents in Taiwan and Hong Kong. Int J Geriatr Psychiatry 2005;20:

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