2010 Pilot Study 1

Age Differences in the Joint Influence of Emotional Context and Temporal Discounting on Pain Management Decisions.

Principal Investigator: C. Loeckenhoff (Developmental Psychology)

Specific Aims: Compared to younger adults, chronic pain in older adults is systematically undertreated (1) and leads to lower quality of life, higher functional disabilities, and, ultimately, higher healthcare costs (2). In addition to underdiagnosis and environmental barriers, age differences in pain management preferences may be a contributing factor (3). Decisions about pain management are characterized by the need to weigh immediate and delayed effects as well as costs and benefits against each other. This makes them susceptible to age-related emotional biases that have been previously found to affect health-related decision making (4,5). However, this line of research has not been translated to the context of pain management. It is also unclear how emotional biases interact with age differences in the tendency to discount temporally delayed consequences.

This pilot project addresses these questions by: 1) using a participatory focus group approach to examine temporal perspectives in pain management among patients and providers; 2) experimentally testing the joint influence of temporal discounting and emotional context on pain management preferences in younger and older adults; and 3) determining the extent to which individual differences in personality, mood, health beliefs, and cognitive abilities contribute to such effects.

Background and Significance:  Age differences in perceptions and beliefs about pain management may contribute to the problem of undertreating pain in older persons. Older adults report high concern about medication side effects (6), doubt treatment efficacy (7), and show poor treatment adherence (3,8). In part, such effects may be due to age differences in responses to the inherent trade-offs of various treatment choices. Conventional pain medications provide immediate relief but pose the risk of delayed health consequences. In contrast, alternative treatments, such as exercise regimes, may involve some immediate discomfort but lead to beneficial outcomes in the long run. Because of such trade-offs, pain management choices are likely to be influenced by patients’ relative emphasis on positive versus negative outcomes and their tendency to discount temporally delayed events. Previous research suggests that compared to younger adults, older adults show a disproportionate focus on positive relative to negative information during healthcare choices (4,5,9). In contrast, only a few studies have examined age differences in temporal discounting (10,11), and results are limited to paradigms examining positive financial outcomes. Thus, we know little about age differences in the temporal discounting of positive versus negative health outcomes, although a better understanding of such effects would be highly relevant for understanding age disparities in pain management. For example, older adults’ low adherence to pain medication could be due to a tendency to discount the immediate benefits in pain reduction more steeply than future side effects.

In this pilot project, Study 1 will use a participatory focus group approach to examine perceptions of short-term and long-term goals in the context of chronic pain management. To obtain a comprehensive understanding of associated trade-offs among different groups of stakeholders, focus groups will recruit younger and older adults with chronic pain as well as physicians and physical therapists. Based on focus group data, we will develop an experimental paradigm (Study 2) examining the joint influence of temporal discounting and emotional context on pain management decisions among a life-span sample of individuals living with chronic pain. This study will also examine possible correlates of such effects as a first step in developing appropriate interventions.

Design and Methods: Focus groups (Study 1) will include patients with chronic pain (n = 40-60, aged 25-99 years) as well as physicians and physical therapists (n = 20-40, aged 25-75 years). The experimental study (Study 2) will include a life-span sample of individuals with chronic pain (n = 60, aged 25-99 years). Pilot studies (n ~ 20) might enroll healthy volunteers. Eligibility criteria include fluency in English, and, for patient samples, the presence of chronic pain and the absence of dementia.

Focus group discussion guides (Study 1) will draw on the clinical literature as well as informant interviews to capture key aspects of temporal trade-offs in pain management. The experimental design for Study 2 will be modeled after existing temporal discounting paradigms (11) and require participants to weigh immediate against delayed changes in pain levels. Insights gained from focus groups will help to adapt the paradigm to real-life clinical choices in pain management. To examine the relative influence of positive versus negative outcomes on the discounting function, trade-offs will involve immediate versus future increases in pain levels, immediate versus future decreases in pain levels, as well as immediate decreases versus future increases and immediate increases versus future decreases in pain level. Control variables in will include self-rated health (SF-12), pain levels, personality traits (NEO-FFI), current mood, control beliefs (MHLOC), self-efficacy about pain management, and a cognitive battery. Next Steps: We plan to secure additional funding to develop a more naturalistic version of the decision task that corresponds directly to existing treatment choices and considers additional variables (e.g., cost, relative probability of different outcomes). Ultimately, we plan to develop and test guidelines that help clinicians to present pain management choices in a context that optimizes patients’ decision making across the life span. Based on the outcomes of the study, TRIPLL will consider funding for a second year to promote these next translational steps.

References:

  1. Pitkala, K.H., Strandberg, T.E., Tilvis, R.S. (2002). Management of nonmalignant pain in home-dwelling older people: a population-based survey. J Am Geriatr Soc, 50:1861-1865.
  2. Brennan, F., Carr, D.B., Cousins, M. (2007). Pain management: a fundamental human right. Anesthesia & Analgesia, 105:205-21.
  3. Sale, J., Gignac, M., Hawker, G. (2006). How “bad” does the pain have to be? A qualitative study examining adherence to pain medication in older adults with osteoarthritis. Arthritis Rheum, 55:272-278.
  4. Löckenhoff, C.E., and Carstensen, L.L. (2007). Aging, emotion, and health-related decision strategies: Motivational manipulations can reduce age differences. Psychology and Aging, 22:134-146.
  5. Löckenhoff, C.E., and Carstensen, L.L. (2008). Decision strategies in health care choices for self and others: Older adults make adjustments for the age of the decision target, younger adults do not. Journals of Gerontology: Psychological Sciences, 63:P106-P109.
  6. Fraenkel, L., Wittink, D.R., Concato, J., et al. (2004). Informed choice and the widespread use of antiinflammatory drugs. Arthritis Rheum, 51:210-214.
  7. Blomqvist, K., Edberg, A. (2002). Living with persistent pain: experiences of older people receiving home care. J Adv Nurs, 40:297-306.
  8. Marks, R., and Allegrante, J.P. (2005). Chronic osteoarthritis and adherence to exercise: A review of the literature. Journal of Aging and Physical Activity, 13:434-460.
  9. Löckenhoff, C.E., and Carstensen, L.L. (2004). Socioemotional selectivity theory, aging, and health: The increasingly delicate balance between regulating emotions and making tough choices. Journal of Personality,72:1393-1424.
  10. Green, L., Myerson, J., and Ostaszewski, P. (1999b). Discounting of delayed rewards across the life span: Age differences in individual discounting functions. Behavioural Processes, 46:89–96.
  11. Ostaszewski, P. (2007). Temporal discounting in “gain now-lose later” and “lose now-gain later” conditions. Psychol Rep, 100:653-60.