(168) Poor Pain Control and Risk for Anxiety and Sleeping Disorders Among Older Patients with Dementia

Publication Number: 1213

Background: Pain, highly prevalent in older adults with Alzheimer’s Disease and Related Dementias (ADRD), has been implicated as a risk factor for two common neuropsychiatric symptoms: anxiety and sleep disorders, but this association has not been empirically tested in this population.

Objectives: The study objective is to examine the association between uncontrolled pain and risk for anxiety and sleep disorders among patients with ADRD residing in nursing homes (NHs), accounting for time-varying confounders via Marginal Structural Models (MSMs).

Methods: We conducted a retrospective cohort study using a 5% sample of Medicare beneficiaries linked to their Minimum Data Set (MDS) 3.0 data from 2011 to 2015. The study sample included residents aged ≥50 years with a diagnosis of ADRD and chronic non-cancer pain who had ≥1 quarterly MDS pain assessment, with the first assessment designated as the index date. Uncontrolled pain was defined as having a numeric rating of >4, a verbal descriptor scale of moderate or severe pain, or >1 nonverbal pain indicator. Outcomes were newly diagnosed anxiety and sleeping disorders in inpatient or outpatient claims. We analyzed the outcome in a separate cohort with residents being followed from the index date until the corresponding outcome, death, Medicare disenrollment, or study end. Cox proportional hazards models with MSM were used to estimate the hazard ratios (HR) and 95% CI of a new diagnosis of anxiety and sleeping disorders in patients with vs without uncontrolled pain. We compared results from the Cox MSM models with that of Cox models with conventional covariate adjustment and models with inverse probability of treatment weighting (IPTW) analysis.

Results: We identified 32873 residents in the anxiety cohort and 38763 in the sleep disorder cohort (mean follow-up of 1.56 years and 1.88 years, respectively). The unadjusted model showed that uncontrolled pain was associated with a 40% increased risk for anxiety (95% CI 1.60,1.78) and 58% for sleep disorders (95% CI 1.49,1.69). The adjusted HR for both anxiety and sleep disorders was attenuated in the conventional covariate adjustment model (HR=1.13, 95% CI 1.05, 1.21 and HR 1.26; 95% CI 1.17, 1.36) and in the Cox-IPTW model (HR=1.18, 95% CI 1.15, 1.22 and HR=1.19; 95% CI 1.15, 1.24). The Cox MSM model that accounted for time-varying confounders yielded a large estimate, with 44% increased risk for anxiety (95% CI 1.35,1.54) and 68% (95% CI 1.54,1.82) for sleeping disorders.

Conclusions: Uncontrolled pain was associated with an increased risk of anxiety and sleeping disorders, supporting the importance of regular pain assessment and management to reduce the risk of neuropsychiatric symptoms in NH residents with ADRD.