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Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions

Chan Shen, Xiaohui Zhao, Nilanjana Dwibedi, R. Constance Wiener, Patricia A. Findley & Usha Sambamoorthi

Odanayza Casanola Chavez

Article title: Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions

Authors: Chan Shen, Xiaohui Zhao, Nilanjana Dwibedi, R. Constance Wiener, Patricia A. Findley & Usha Sambamoorthi

Introduction

Summary: The study by Shen et al. (2018) represents a retrospective-cross-sectional study which aimed at determining the relationship between ADRD (Alzheimer's disease and related dementias) and opioids prescription among elderly patients as compared to their counterparts without ADRD. Through the use of Medicare beneficiaries from 2006 to 2013, the study was able to determine the fact that opioids prescription among elderly patients with ADRD is comparatively lower than their non-ADRD counterparts hence leading to possibly unmet pain management needs for elderly patients with ADRD. This trend is largely caused by the unfounded notion that opioids use have negative effects among ADRD patients in as far as worsening ADRD symptoms is concerned.

Problem: The fundamental problem that informed this study has been clearly stated. Arguably, the problem is quite practical owing to the fact that pain is a major cause of low quality of life among elderly persons. There have been a lot of fears associated with opioids use among elderly patients with ADRD due to the assumptions that opioids may exacerbate ADRD symptoms. Although opioids have been evidently associated with major pain relief capabilities- their use among ADRD patients experiencing pain is minimal. Therefore, the authors hypothesize that there is great risk of going with unmet pain management needs among elderly persons with ADRD as compared to their counterparts without ADRD.

While the research questions have not been explicitly highlighted, it is apparent that as can be extrapolated from the research aims- the primary research questions that the study pursued to answer relates to whether opioids use in elderly patients is in any way linked to increased risk of ADRD and whether elderly patients with ADRD are more likely to endure sub-optimal pain management due to limited prescription of opioids. The researchers utilized a sample of n= 19,347 participants who were Medicare beneficiaries between 2006 and 2013. Among these participants, 7.7% of them had ADRD and the rest were ADRD-free. By analyzing opioids prescription for this period, the study found out that participants with ADRD received less opioids prescriptions as compare to their non-ADRD counterparts therefore confirming that community-dwelling elderly patients with ADRD are more likely to experience unmet pain management needs. In addition to that, the key terms have been clearly highlighted and defined.

Evaluation of research methods

Does the author provide a literature review?

Although there is no particular section that has been purely focused on literature review, it is apparent that a comprehensive review of literature has been conducted especially in the description of the background of the study. The ultimate purpose of a literature review is to retrieve any related research information that has been published in relation to a research topic (Ellis, 2019). This serves the purpose of validating the research based on an identified gap. This is something that the study has appreciably done and there is sufficient utilization of existing literature not only to show case the existing information about the topic but also to validate the need for research enquiry on the area of opioids prescription among elderly patients with ADRD.

Is the research current and relevant to today existing health issues?

The sources of literature that have been used include systematic reviews, quantitative studies and qualitative studies on this topic. These use of these literature sources means that the literature is based on best sources of evidence (LoBiondo-Wood & Haber, 2017). In addition to that, the sources of the literature fall within the last one decade prior to the publication of the study. This means that the research is current and tuned with the present-day healthcare practice in as far as opioids use is concerned. Arguably, use of recent and up-to-date literature translates to increased credibility and sound understanding of a research issue under enquiry and that the knowledge utilized is tuned with the current research knowledge.

Describe the research type utilized? – Experimental, non-experimental, quasi experimental, etc.

The research is non-experimental in nature since there are no causal relationships being established. In this connection, the study can be termed as largely explorative or descriptive in nature since it uses published data on opioids use to describe trends and patterns of opioids prescription among elderly patients with ADRD as compared to elderly patients without ADRD.

Evaluate the sample (size, composition, or in the way the sample was selected in relation to the purpose of the study? Was the sample appropriate for the research or was it bias?

The sample size of any study goes a long way when it comes to influencing the generalizability of research findings. A good sample should be able to represent the larger sample of population under study in terms of age, gender and other pertinent demographic characteristics (Dale, Hallas & Spratling, 2019). The sample size in this study is large and sufficient to paint a clear picture of the issue being investigated. The use of this sample size enhances the accuracy and generalizability of research findings in multiple care settings or scenario. The sample is well represented in terms of gender and there is an even distribution of people from all socio-economic and literacy levels. In addition to that, the sample was inclusive enough since information had been retrospectively retrieved from factual clinical data between 2006 and 2013. In this regard this prevents any room for bias in as far as sample selection is concerned.

How practical does this work seem to you? How does the author suggest research results could be applied and how do you believe they could be applied?

This work and the subsequent findings are quite practical. Arguably, pain is a major impediment towards enjoying a high quality of life for elderly patients. The exclusive or somewhat discriminatory use of opioids for certain elderly populations such as those with ADRD is not warranted and leaves them enduring pain due to denied access to opioids for pain management. There is no scientific evidence that links ADRD with opioids and for that reason- healthcare professionals seem to prescribe opioids based on personal persuasions and unfounded evidence. The authors therefore suggest that real life practice should embrace use of opioids for all patient populations including those with ADRD so as to enhance quality of life through effective pain management. However, it is important to acknowledge that the use of opioids should be done in line with existing guidelines and practice protocols in order to prevent the possible scenario of addiction.

Could the study have been improved in your opinion? If so provide how you think it could have improved.

Definitely, the study could have been improved since the issue of opioids use among elderly patients present different facets. The study could thus be improved through incorporating views from elderly patients on opioids for pain management as well as the views of healthcare professionals about their attitudes about opioids use among elderly patients with ADRD. This could have fostered a holistic understanding of the research issue from different perspectives other than clinical data. In this regard, this improvement could have been made through the use of a mixed approach that utilizes both quantifiable clinical data relating to opioids use as well as a qualitative approach that seeks to understand different opinions surrounding opioids use for the study population.

Is the writing in the article clear straightforward?

The article has been written clearly and concisely making it easy for the reader to go through the entire piece without encountering an area of ambiguity. To aid in reading and understanding the research article, the authors have gone an extra mile to define complex terms. In addition to that, there is smooth transition from one section to the other or from one idea to the next hence making it easy to follow through the entire article effectively.

Can further research be conducted on this subject? Explain

It is apparent that opioids use among the elderly patients may be associated with various behavioral problems such as addiction. The use of opioids for management should be done in the most cautious manner to prevent these negative effects. In this regard, future research can be done on characterization of pain in terms of pain intensity and duration and subsequently assist in providing guidelines on which pain characteristics qualify for opioids prescription. Finally, future research can also focus on coming up with factual evidence-based guidelines that can be used to come up with noble prescription opioids practices. It is through such an approach that the larger healthcare system can strike a healthy balance between the pain management needs of elderly persons and the need to shelter elderly persons from various possible behavioral and psychological effects of opioids.

Conclusion

In conclusion it is apparent that opioids use for pain management among elderly patients with chronic pain has been an area of much scholarly and scientific debate. Some quotas hypothesize that opioids increase the risk of dementia or Alzheimer’s among this patient population. Nevertheless, there is no tangible scientific evidence that supports this claim. Such notions have led to decreased use of opioids among elderly patients with chronic pain due to the dementia-related fear. To a large extent, this leaves many elderly patients enduring chronic pain with potential unmet or sub-optimally met pain management needs. In this regard, the findings of this study are of great significance and ought to influence future practice and other similar research undertakings. Old age and frailty attract a myriad of physiological alterations that can hamper the quality of life of elderly persons. For instance, this group of patients experience age-related conditions such as osteoporosis, osteoarthritis, musculoskeletal pains and different forms of cancer.

All these conditions are characterized by severe levels of pain that compromise quality of life and hence lead to impaired uptake of daily living activities and independence (Wang, Hill, Gomes, Pinto, Wijeysundera, Scales & Wunsch, 2020). Opioids have been evidently associated with significant positive effects in as far as pain management is concerned. Therefore, it is not logical to withhold prescription of opioids for elderly persons due to the unfounded fear of the link between opioids and dementia/Alzheimer’s. Nevertheless, there is the need to acknowledge that long-term use of opioids may attract behavioral problems such as addictions and hence the need to use the currently existing standards on opioids prescription so as to shelter elderly patients from the risk of addiction of opioids dependence (Wang, Hill, Gomes, Pinto, Wijeysundera, Scales & Wunsch, 2020). For instance, there is the accentuation to monitor behavioral outcomes for elderly patients under opioids prescription so as to identify signs of addiction beforehand and subsequently pursue interventional measures.

References

Dale, J. C., Hallas, D., & Spratling, R. (2019). Critiquing Research Evidence for Use in Practice: Revisited. Journal of Pediatric Health Care, 33(3), 342-346.

Ellis, P. (2019). Critiquing research: general points. Evidence-based Practice in Nursing, 46.

LoBiondo-Wood, G., & Haber, J. (2017). Nursing research-E-book: methods and critical appraisal for evidence-based practice. Elsevier Health Sciences.

Shen, C., Zhao, X., Dwibedi, N., Wiener, R. C., Findley, P. A., & Sambamoorthi, U. (2018). Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions. Alzheimer's & Dementia: Translational Research & Clinical Interventions, 4, 661-668.

Wang, H. T., Hill, A. D., Gomes, T., Pinto, R., Wijeysundera, D. N., Scales, D. C., ... & Wunsch, H. (2020). Trends in opioid use before critical illness among elderly patients in Ontario. Journal of critical care, 55, 128-133.