1. Examining the Relationship Between Chronic Pain and Health-Related Quality of Life Among Older Canadian Adults with Disability Kristina Zawaly, B.A., B.Sc. & M.Sc. University of Manitoba

2. Outline Acknowledgment Background Study Objectives Conceptual Framework Research Methods Descriptive Results Results from Multivariate Analyses Summary of Findings Strengths and Limitations Conclusions and Implications of Research Findings

3. Acknowledgments Advisor: Shahin Shooshtari, Ph.D. University of Manitoba Committee Members: Nancy Hansen, Ph. D., Verena Menec, Ph.D. and Ian Clara Ph.D. University of Manitoba Funding: The University of Manitoba Centre on Aging (2011, Graduate Fellowship) & The University of Manitoba Research Data Centre (2011, Graduate Fellowship) & Research Data Centre (2012, Travel Grant)

4. Background With the aging of the Canadian population, there will be a significant increase in the number of individuals, who will be aging with/into disability. Pain related disability is common affecting approximately 27% of the older Canadian population (Ramage-Morin, 2008). Prevalence of chronic pain increases with age: 55-64 [Males: 15.2%; Females: 19.2% ] 65-74 [Males: 20.6%; Females: 24.8%] 75+ [Males: 28.8%; Females: 38.5%] (Statistics Canada, 2011b) Previous research clearly shows that chronic pain is associated with reduced health-related quality of life (HRQoL) (Picavet & Hoeymans, 2004; Kim et al., 2005; Lamé, Peters, Vlaeyen, Kleef & Patijn, 2005 ).

5. Gaps in the Literature Prevalence of chronic pain among older Canadian adults with disability; The impact of chronic pain on HRQoL in older Canadian adults with disability

6. Study Objectives 1) To estimate the prevalence of chronic pain among older Canadian adults with disability. 2) To examine the relationship between chronic pain and HRQoL among older Canadian adults with disability. 3) To assess if there is a dose-response relationship between chronic pain and HRQoL among older Canadian adults with disability.

7. ICF Framework

8. Conceptual Framework

9. Research Methods Study Design: Analysis of cross-sectional data Data Source: 2006 Participation and Activity Limitations Survey (PALS) - Adult survey Post-censual survey Conducted by Statistics Canada Target population: Canadian adults (15+) and children (<15) with disability living in 10 Canadian provinces and 3 territories. Purpose: To collect information on the prevalence of various disabilities, support for persons with disabilities, their employment profile, income and participation in society. (Statistics Canada, 2009)

10. Research Methods Study Sample : Individuals who were at least 55 years of age at the time of the survey who reported “Yes” to having a disability. Study Population: The number of participants in the study sample are representing 2,582,500 of all Canadians 55+ who experience disability.

11. Study Measures  Dependent Variables (DV):  To address objective #1: Chronic pain  To address objectives #2 & #3: HRQoL  Independent Variables:  Chronic pain  Sociodemographic characteristics (Age, sex, education, marital status, total household income and social network);  Disability measures (Type of disability, severity of disability, and onset of disability).

12. Data Analysis Population weights were applied and weighted frequencies were used to describe the target population and their characteristics. Bivariate analyses (t-test and chi-square test) were used to examine the cross-sectional relationship between study variables and chronic pain as well as HRQoL. Multiple logistic regression modeling was used to examine the independent effect of chronic pain in relation to HRQoL controlling for the effects of all the other study factors. Bootstrap weights were applied using SUDAAN software to estimate variance and 95% confidence intervals.

13. Results

14. Descriptive Results Study Population: Canadian Population with Disability Aged 55+, PALS 2006

15. Variablesn% Total2,582,500100 Age 55 to 64824,92031.90 65 to 74739,50028.60 75+1,018,09039.40 Sex Female1,451,86059.60 Male1,130,64040.40 Income in Canadian Dollars 0 – 22,445550,55021.30 22,446 - 42,415738,15028.60 42,416 – 72,040673,44026.10 ≥72,041618,01024.10 Marital Status Living Alone1,167,88045.20 Living With a Partner1,414,16054.80 Variablesn% Education No High School Diploma533,29034.80 High School Diploma245,83016.00 Higher than High School Diploma754,68049.20 Chronic Pain No 804,50431.37 Less Severe 1,162,79045.34 More Severe 579,17023.29 HRQoL Positive1,346,52056.40 Negative1,040,02043.60

16. Variablesn% Friends None 191,020 9.90 One to Two 418,030 21.80 Three to Five 617,650 32.20 Six to Ten 388,060 20.20 11 to 20 165,260 8.60 More than 20 140,700 7.30 On Set of Disability Birth to 18 years 148,8806.12 19 to 54 years 804,68033.10 55 to 64 years 551,64022.69 65 to 74 years 497,59020.47 75+ years 428,04017.61 Severity of Disability Mild to moderate 1,539,220 59.0 Severe to very severe 1,043,290 40.40 Variablesn% Type of Disability Agility 1,871,740 72.50 Communication 224,100 8.70 Developmental 26,470 1.00 Emotional 204,770 8.00 Hearing 966,420 37.50 Learning 212,210 8.20 Memory 261,760 10.20 Mobility 1,947,000 75.40 Seeing 515,270 20.00 Unknown Disability 68,170 2.60

17. Bivariate Results Description of Study Population by Chronic Pain Study Population: Canadian Population with Disability Aged 55+, PALS 2006

18. Variables Severe Chronic Pain Less Severe Chronic Pain No Chronic PainX2X2 p Value %% Sex21.080.0000*** Female24.748.726.6 Male21.541.137.5 Age13.51 0.0000*** 55 to 6428.048.223.8 65 to 7421.248.430.5 75 +21.040.838.2 Income in Canadian Dollars 0.610.6716 0 - 224525.144.730.2 22446 - 4241523.343.832.9 42416 - 7204023.145.631.4 ≥ 7204121.947.530.7 HRQoL207.270.0000*** Positive10.847.142.1 Negative 38.842.318.9 *** p<0.001, **p<0.01, *p<0.05 Table (1): Chronic Pain by Sociodemographic and Disability Characteristics

19. Variables Severe Chronic Pain Less Severe Chronic Pain No Chronic PainX2X2 p Value %% Education4.000.0032** Less than high school23.347.229.5 High school15.152.232.7 Moe than high school25.245.129.7 Friends4.250.0051** None27.037.435.6 One to Two27.544.628.0 Three to Five21.748.330.0 Six to Ten17.650.232.2 11 to 2018.143.638.3 More than 2016.445.438.2 Onset of Disability12.960.0000** Birth to 18 years24.332.243.4 19 to 54 years30.149.020.9 55 to 64 years21.150.828.1 65 to 74 years19.545.435.1 75+ years20.038.939.2 Severity of Disability607.620.0007** Mild to moderate3.351.345.5 Severe to very severe52.736.610.6 *** p<0.001, **p<0.01, *p<0.05

21. Bivariate Results Description of Study Population by HRQoL Study Population: Canadian Population with Disability Aged 55+, PALS 2006

22. Table (2): HRQoL by Sociodemographic and Disability Characteristics VariablesNegative HRQoLPositive HRQoLX2X2 p Value % Sex0.480.4872 Female44.1055.90 Male42.9057.10 Age1.370.2536 55 to 6445.4054.60 65 to 7442.1057.90 75 +43.2056.80 Income in Canadian Dollars 12.000.0000*** 0 – 22,44550.5049.50 22,446 – 42,41546.0053.00 42,416 – 72,04041.7058.30 ≥ 72,04135.4064.60 Marital Status7.180.0075** Living Alone46.1053.90 Living With a Partner41.5058.50 ***p<0.001, **p<0.01, *p<0.05

23. VariablesNegative HRQoLPositive HRQoLX2X2 p Value % Education4.320.0135 Less than high school41.558.5 High school33.266.8 More than high school41.858.2 Friends10.290.0000*** None 51.448.6 One to Two 49.950.1 Three to Five 39.260.8 Six to Ten 37.462.6 11 to 20 30.070.0 More than 20 37.262.8 ***p<0.001, **p<0.01, *p<0.05

24. VariablesNegative HRQoLPositive HRQoLX2X2 p Value % Onset of Disability1.320.0718 0 to 1 years 29.370.7 1.1 to 5 years 41.258.8 5.1 to 10 years 35.664.4 10.1 to 15 years 48.951.1 15.1 to 20 years 49.750.3 20 plus years 44.555.5 Severity of Disability Mild to moderate28.971.1467.710.0000*** Severe to very severe65.934.1 ***p<0.001, **p<0.01, *p<0.05

26. Multiple Logistic Regression Model Predictors of HRQoL Study Population: Canadian Population with Disability Aged 55+, PALS 2006

27. VariablesAOR95% CIp Value Sex Female0.69**(0.55-0.88)0.0024 Male1.00(1.00-1.00)- Age 55 to 641.00(1.00-1.00)- 65 to 740.98(0.67-1.17)0.28.39 75 +0.96(0.64-1.46)0.4970 Income in Canadian Dollars 0-22,4451.68*(1.13-2.25)0.0108 22,446-42,4151.64**(1.20-2.25)0.0019 42,416-72,0401.30(0.97-1.73)0.0748 ≥ 72,0411.00(1.00-1.00)- Marital Status Living Alone1.00(1.00-1.00)- Living With a Partner1.12(0.87-1.43)0.3851 ***p<0.001, **p<0.01, *p<0.05 Table (3): Socio-demographic Predictors of Negative HRQoL

28. VariablesAOR95% CIp Value Friends None0.97(0.56-1.67)0.9087 One to Two1.04(0.65-1.65)0.8840 Three to Five0.88(0.56-1.37)0.5695 Six to Ten0.94(0.59-1.50)0.7992 11 to 200.56*(0.33-0.96)0.0340 More than 201.00(1.00-1.00)- Onset of Disability Birth to 18 years1.00(1.00-1.00)- 19 to 54 years1.02(0.61-1.71)0.9351 55 to 64 years1.28(0.77-2.11)0.3416 65 to 74 years1.25(0.72-2.17)0.4358 75+ years1.00(0.51-1.96)0.9966 Severity of Disability Mild to moderate1.00(1.00-1.00)- Severe to very severe 1.51**(1.11-2.06)0.0097 ***p<0.001, **p<0.01, *p<0.05

29. VariablesAOR95% CIp Value Agility Yes1.85***(1.39-2.470.0000 No1.00(1.00-1.00)- Communication Yes1.19(0.73-1.93)0.4861 No1.00(1.00-1.00)- Developmental Yes1.04(0.17-6.43)0.9667 No1.00(1.00-1.00)- Emotional Yes1.33(0.85-2.09)0.2082 No1.00(1.00-1.00)- Hearing Yes1.03(0.81-1.32)0.8042 No1.00(1.00-1.00)- Learning Yes1.56(0.95-2.56)0.0759 No1.00(1.00-1.00)- ***p<0.001, **p<0.01, *p<0.05

30. VariablesAOR95% CIp Value Memory Yes1.35(0.83-2.18)0.2232 No1.00(1.00-1.00)- Mobility Yes 2.26***(1.91-3.61)0.0000 No1.00(1.00-1.00)- Seeing Yes 1.37*(1.05-1.80)0.0209 No1.00(1.00-1.00)- Unknown Disability Yes1.00(0.41-2.42)1.0000 No1.00(1.00-1.00)- Chronic Pan More Severe 3.43***(2.28-5.15)0.000 Less Severe1.39*(1.02-1.88)0.0375 No1.00(1.00-1.00)- ***p<0.001, **p<0.01, *p<0.05

31. Summary of Findings The oldest old Canadian adults reported less chronic pain than did the youngest old adults (X 2 =13.51; p=0.0000). Those affected by chronic pain reported significantly poorer HRQoL compared to those who did not report chronic pain (X 2 =207.27; p=0.0000). The age of onset and the type of disability were significantly associated with reported chronic pain.

32. Summary of Findings (Con’t) Females reported higher levels of chronic pain, but controlling for the effects of all the other factors, they had significantly lower odds of reporting negative HRQoL [AOR=0.69 (95% CI: 0.55-0.88); p=0.0024]. Those with agility and mobility disability reported high levels of chronic pain and high levels of negative HRQoL than those who reported no mobility or agility disability [AOR=1.85 (95% CI: 1.39-2.47); p=0.0000] and [AOR=2.26 (95% CI: 1.91-3.61); p=0.0000 respectively].

33. Strengths and Limitations This research used a national level sample of Canadians, with the ONLY national level data available for individuals with disabilities. HRQoL was measured using a single self-rated health question as it is a better measure of HRQoL for individuals with disabilities. The conceptual framework, used based on the ICF, is the best attempt available in the literature to bring the social and medical model of disability together. PALS 2006 was a cross-sectional survey, where information was obtained from individuals at one single point in time ONLY. No causality conclusions could be made. Proxy responding was allowed. This may have introduced some bias in the results, especially for HRQoL or chronic pain measures, and especially for those with limited communication abilities. All questions in PALS 2006 were self reports and therefore there is a potential risk for recall biase.

34. Implications of Findings Practice: The study findings highlight the importance of “proper pain assessment and management” among older adults with disability (both men and women), especially for those with limited communication skills. Policy: In Canada the collection of information on individuals with disabilities has been discontinued. National level data of longitudinal nature is needed to examine trends over time, and to inform policy and practice. Research: Further research is needed to examine the impact of chronic pain on HRQoL and other outcomes (e.g., social participation), using longitudinal data. study. Given the observed sex differences in the reported rates of chronic pain and HRQoL, it is important to explore sex differences, when examining chronic pain and HRQoL association.

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