Aging Table 11: Aging and Secondary Health Complications after SCI

Author Year; Country
Score
Research Design
Total Sample Size

Methods

Outcome

Finnerup et al. 2016;

Denmark & Sweden

Level 2 Evidence

Longitudinal
N=81

Population: N=81 (88% M, 12% F); mean age at follow up (y) = 51.8±15.9 (range 21-80); mean TSI (y) = 3.5±0.6

SCI impairment: Complete (30%), incomplete (68%), paraplegia (42%), tetraplegia (56%),

Methodology:  Adults with traumatic SCI admitted over a 3-year period to two neurosurgical departments underwent clinical examination and questionnaires within 3 months after injury (baseline) and at 6, 12 and 42 months following SCI. Ninety individuals with SCI were originally recruited but only 81 completed the 3.5-year follow-up to examine presence of pain and psychological function.

Outcome Measures: Pain intensity and interference within the last 7 days, a global quality of life (QoL) item, the 5-item Mental Health Index (MHI-5) and the 6-item Catastrophizing scale (CSQ-CAT) were used

  1. Following SCI, 91, 82, 83 and 75% reported at last some pain in the previous week at baseline and at 6, 12 months and 3.5 years, respectively.
  2. At 3.5 years, musculoskeletal pain was present in 66% (no other type of nociceptive pain was reported), neuropathic SCI pain in 49%, at-level pain reported in 30% and below-level pain in 25% (29% if excluding participants with cauda equina lesions) of the sample
  3. Neuropathic pain had an onset within the first 12 months and tended to become persistent, whereas musculoskeletal pain more often had a late onset or resolved in cases of early onset.
  4. Younger age but not sex, baseline CSQ-CAT, MHI-5 or QoL scores predicted the presence of pain at 3.5 years
  5. Both psychological functioning and QoL improved over time. At 3.5 years, the measures of psychological functioning correlated with pain interference but not pain intensity. However, QoL scores increased less in participants who reported an increase in pain intensity from baseline to the 3.5-year follow-up, relative to those reporting either a decrease or no change in pain intensity.

Jorgensen et al. 2016;

Sweden

Level 5 evidence

Cross-sectional

N=123

Population: N=123 (71% M, 29% F), mean age (y)=63±9 (range 50-89), mean YPI=24±12 (range 10-56);

Tetraplegia AIS A-C (n=22), paraplegia AIS A-C (n=41), all AIS D (n=60)

Methodology: All participants are community dwelling individuals ≥50 years old and are ≥10 years post-injury. Data was collected from their medical records and through structured interviews and assessments in their homes to describe secondary health conditions, activity limitations, and life satisfaction in older adults with long-term SCI and to investigate how sociodemographics, injury characteristics, and secondary health conditions are associated with their activity limitations and life satisfaction.

Outcome Measures: Bowel and bladder function, nociceptive and neuropathic pain, spasticity, the Spinal Cord Independence Measure, third version, and the Satisfaction With Life Scale.

  1. Bowel-related and bladder-related problems were reported by 32% and 44%, respectively
  2. 66% reported moderate or severe nociceptive and/or neuropathic pain, and 44% reported spasticity.
  3. Participants who reported moderate or severe neuropathic pain were older at injury, had a shorter time since injury, and were less likely to be vocationally active compared with those reporting no or mild neuropathic pain.
  4. Activity limitations were moderate where injury characteristics and spasticity explained 68% of the variance.
  5. Participants who had a partner and/or were working full-time or part-time rated their life satisfaction significantly greater, as did those reporting voluntary bowel function, and/or voluntary voiding.

Murray et al. 2016;

USA

Level 5 evidence

Cross-sectional

N=187

Population: N=187 (62% M); mean age (y)=34.3±7.4 (range 19-52); mean age at injury (y)=14.1±4.5 (range 0-19); mean TSI (y)= 20.2±8.5 (range 1-45); tetraplegia (56.1%), paraplegia (43.9%)

Methodology: Participants who sustained an SCI before 19 years of age and received care at the Shriner’s Hospital for Children, but who were ≥19 years old during the study period completed interviews to determine medical and psychological correlates of pain in adults with pediatric-onset SCI.

Outcome Measures: Beck Anxiety Inventory, Patient Health Questionnaire-9, pain intensity scale (11-point NRS)

  1. Longer duration of injury and older age at injury predicted greater pain intensity, frequency and interference in sleep owing to pain. Longer duration of injury was also significantly associated with longer pain duration.
  2. Individuals with pediatric-onset tetraplegia experience greater sleep interference due to pain compared with individuals with paraplegia.
  3. A significantly higher percentage of participants with tetraplegia endorsed pain in their head or neck compared with individuals with paraplegia. In addition, a higher percentage of individuals with paraplegia endorsed pain in their hand/wrist (32.9% paraplegia, 9.5% tetraplegia) and back compared with those with tetraplegia (67.1% paraplegia, 41.9% tetraplegia). There were no group differences in the following pain locations: chest/abdomen, shoulder, arm/elbow  and lower extremities.
  4. The participants endorsed low levels of depression and anxiety on average.

Smith et al. 2016;

USA

Level 2 evidence

Longitudinal

N total=1594
N SCI=414

Population: 1594 participants (64% F) that included people with SCI (n=414), MD (n=282), MS (n=509), and PPS (n=389);

Mean age (y)=56.0±12.9 (range 20-94); mean disability duration (y)=15.3±10.5

Methodology: Survey questions were sent out to assess demographics and self-reported diagnosis of chronic comorbid medical conditions (CCMC) twice, 3.5 years (t1 and t2) apart, to study the incidence, prevalence, age of onset and predictors of five chronic conditions in a sample of adults with long-term physical disabilities (MS, MD, PSS, or SCI).

Outcome Measures: self-reported diagnosis of 5 CCMC’s: coronary heart disease, hypertension, arthritis, diabetes and cancer, and health behaviors (alcohol use, smoking, physical activity).

  1. Arthritis was the most commonly reported new condition, making up 40% of all newly reported conditions. 170/1034 who did not report arthritis at TI reported having it at T2, suggesting an incidence rate of 16% in the sample during the 3.5-year study period. The average age of those reporting new onset of arthritis during the study period was 61 years at T2.
  2. Hypertension was the second most commonly reported new onset condition (22% of all newly reported conditions). 92/984 who did not report hypertension at TI reported it at T2 (new incidence rate of 9%). The average age at T2 for individuals reporting a new onset of hypertension was 59.
  3. Cancer was the third most common new diagnosis, and made up 21% of all newly reported diagnoses. 89/1371 who did not report a history of cancer at T1 reported it at T2 (7% new incidence rate, with an average age of 65 at T2).
  4. Among those who entered the study without a condition, when new chronic comorbid conditions did appear, they did so most often between the ages of 53 and 62 years. Specifically, participants who were between the ages of 56 and 65 at T2 were significantly more likely than those who were younger or older to report a new incidence of coronary heart disease or cancer within the last 3.5 years of the study.

Yeh et al. 2016;

Taiwan

Level 2 evidence

Longitudinal

N SCI=10 125

N control=10 125

Population: SCI group (50% F): mean age (y)=56.3±17.8 (range 20-90)Methodology: A total of 10 125 people with at least 2 ambulatory visits with a diagnosis of SCI in 2001 were enrolled in the SCI group. The non-SCI group comprised 10 125 propensity score-matched (age, gender etc) people without SCI. The median follow-up time was 30.4 months to investigate whether patients with SCI are at an increased risk of developing Parkinson’s disease (PD)

Outcome Measures: Incidence of Parkinson’s disease (PD)

  1. For the SCI group, a total of 99 (0.98%) PD cases occurred during 24113.8 person-years of follow-up, resulting in an incidence rate of 4.10 per 1000 person-years. For the non-SCI group, 59 (0.58%) PD cases occurred during 23 984.7 person-years of follow-up, giving an incidence rate of 2.4 per 1000 person-years. The PD-free survival rate of the SCI group was significantly lower than that of the non-SCI group
  2. The HR of PD for the SCI group was 1.39 within the first year of follow-up and was 2.05 after the first year of follow-up. The results show that the association between SCI and PD was more prominent after the first year of follow-up.

Lin et al. 2015;

Taiwan

Level 2 evidence

Longitudinal

N SCI=11 913
N control=59 565

Population: SCI group (n=11913, 48.8% F): mean age (y)=56.0±17.9 (range 20-90)

Methodology: The SCI group consisted of individuals who had received a diagnosis of SCI in ambulatory medical care between January 1, 2001 and December 31, 2001. For every SCI subject, there were 5 propensity score-matched non-SCI controls to determine whether patients with SCI are at a higher risk for developing multiple sclerosis (MS) after a median follow-up time of 30.6 months.

Outcome Measures: Development of MS or other comorbidities.

  1. Of the 11,913 patients with SCI, 5 developed MS during 28,424.2 person-years of follow-up, giving an incidence rate of 17.60 per 100,000 person-years.
  2. Of the 59,565 subjects in the non-SCI group, 4 developed MS during 141,828.7 person-years of follow-up, giving an incidence rate of 2.82 per 100,000 person-years.
  3. SCI patients had an 8.33-fold higher risk of MS, compared with non-SCI subjects.
  4. SCI group had a higher prevalence of the pre-existing medical comorbidities diabetes, hypertension, and hyperlipidemia than the non-SCI group

Saunders et al. 2015;

USA

Level 5 evidence

Cross-sectional
N=1678

Population: N=1678 (74% M); mean age (y)=48.4±13.3, mean YPI=15.9±9.9; high tetraplegia (<10%), low tetraplegia (25.4%), paraplegia (33.6%), 31.2% ambulatory regardless of injury level

Methodology: Mail-in surveys were distributed to perspective participants recruited from a large specialty rehab hospital to assess the lifetime prevalence of 7 chronic health conditions (CHCs) among a cohort of adults with traumatic SCI.

Outcome Measures: CHCs measured using questions from Behavioral Risk Factor Surveillance System (BRFSS) for diabetes, heart attack, angina/coronary artery disease, stroke, hypertension, high blood cholesterol, or cancer

  1. Although the prevalence of CHCs significantly increased with increasing age, only hypertension and cancer were significantly associated with years post-injury.
  2. High cholesterol appeared to be inversely related to years post-injury, but generally increased with each increasing age group

Chung et al. 2014;

Taiwan

Level 2 evidence

Nationwide Longitudinal

N­­ SCI­=47 916
N control= 191 664

Population: In both SCI and control groups, there were 62.7% males and 37.3% females. The mean age was around 50.0± 19.9 years. 51% were younger than 50 years old, 21.6% were between 50-65, and 27.4% were older than 65.

Methodology: We studied the entire hospitalized population in Taiwan for the 1998–2008 period, with a follow-up period extending to the end of 2010. We identified SCI patients using the Taiwan National Health Insurance Research Database (NHIRD) to assess the risks of deep vein thrombosis (DVT), pulmonary thromboembolism (PE), and other comorbidities.

Outcome Measures: Risk of DVT and PE, comorbidities: atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accident, congestive heart failure, lower leg fracture/surgery, cancer.

  1. The SCI cohort was more likely to have atrial fibrillation, hypertension, diabetes, hyperlipidemia, CVA, congestive heart failure, lower leg fracture or surgery, or cancer compared with the non-SCI cohort.
  2. SCI patients have a 2.46-fold and 1.57-fold increased risk of developing DVT and PE, respectively, compared with that of the general population
  3. The highest risk of DVT and PE developed within 3 months after an SCI occurred (HR: 16.9 and 3.64, respectively). The adjusted HR of DVT and PE rose markedly with increasing age. The adjusted HR of DVT was highest among C-spine SCI patients, and the adjusted HR of PE was highest among T-spine SCI patients.

Hwang et al. 2014;

USA

Level 2 Evidence

Longitudinal
N=351

Population: N=351 (226 M, 125 F); at initial interview: mean age (y) = 26.7; mean duration of injury (y) = 12.9; mean age at injury (y) = 13.8 (range 0-18)

Impairment group: C1-4 ABC (14.8%), C5-8 ABC (35.9%), T1-S5 ABC (38.7%), AIS D (9.7%)

Methodology: To determine longitudinal changes in the occurrence of medical complications in adults with pediatric-onset SCI, participants who sustained an SCI before 19 and who were ≥23 years during the study period were followed annually between 1996 and 2011 through interviews.

Outcome Measures: Generalized estimating equation (GEE) models were formulated to obtain the odds ratio (OR) of having a medical complication over time.

 

  1. Severe UTIs and spasticity had significantly increased risk of occurrence over time in the C1-4 ABC group.
  2. AD and pneumonia/respiratory failure had increased risk of occurrence over time in the C1-4 ABC and C5-8 ABC groups.
  3. Hypertension/cardiac disease had significantly increased OR in the C1-4 ABC and T1-S5 ABC groups.
  4. Activity limiting-shoulder pain was found to have increased odds of occurrence over time in all impairment groups, while activity-limiting elbow and wrist pain had increased risk of occurrence in the C5-8 ABC, T1-S5 ABC, and AIS D groups.
  5. The odds of AD and spasticity decreased with time in the T1-S5 ABC group, and the risk of occurrence of UTI, pressure ulcers, urolithiasis, spasticity, and bowel accidents were found to decrease over time in those with AIS D injury.

Molton et al. 2014;

USA

Level 5 evidence

Cross-sectional

N total=1862

N SCI=492

N MS=584

N MD=340

N PPS=446

Population:  Ntotal=1862

N MD=340 (42.1% M), mean age (y)=53.2 (range 20-89); mean years since diagnosis=14.7±11.5

N MS=584 (17.5% M), mean age (y)=54.5 (range 21-84); mean years since diagnosis=15.3±10.1

N PPS=446 (24.7% M), mean age (y)=67.2 (range 41-94), mean years since diagnosis=16.1±10

N SCI=492 (66.7% M), mean age (y)=50.0 (range 21-88), mean years since diagnosis=16.0±10.9; cervical (49.2%), thoracic (47.8%), lumbar (16.1%), sacral (1.4%)

Methodology: Participants living with MS, SCI, MD, or PPS were recruited and completed an ongoing longitudinal survey to test a conceptual model of SHCs, age, and function in persons aging with long-term physical disabilities.

Outcome Measures: Patient Health Questionnaire (PHQ-9), pain severity (, medical symptoms, speech and swallowing, Sleep Disturbance item bank from the Patient Reported Outcomes Measurement Information System (PROMIS), skin problems and UTI using the Washington State Behavioral Risk Factor Surveillance System (BRFSS) Disability Supplement, fatigue (PROMIS), chronic medical conditions (CMCs), instrumental activities of daily living (IADLs), physical functioning

  1. Increasing age was associated with greater Physical SHCs, greater functional impairments, and greater frequency of CMCs
  2. The functional impairments factor was significantly related to CMCs, Physical SHCs, Psychosocial SHCs, and Pain, and individuals over age 65 years reported the greatest levels of functional impairments compared to other age groups
  3. Individuals in the middle-aged group (i.e., those between 45 and 65 years) reported more Psychosocial SHCs than did either younger or older adults. Being over age 65 years was associated with lower levels of Psychosocial SHCs, and being younger than 45 years did not show a statistically significant difference from the other groups
  4. Middle-aged individuals reported the highest pain levels relative to younger or older adults.
Molton et al. 2014;

USA

Level 5 evidence

Cross-sectional w/ AB

Ntotal=910

NSCI=239

NMS=282

NPPS=218

NMD=171

Population: Ntotal=910 mean age (y)=53.3; mean time living with disability (y)=15.2

Methodology:  Participants living with either SCI, MS, PPS, or MD were mailed a survey with the outcome measures to describe rates of pain and pain interference in a large sample of adults aging with long-standing physical disabilities relative to a normative US population sample (PROMIS).

Outcome Measures: Patient Reported Outcomes Measurement Information System (PROMIS), pain severity, pain interference, other secondary symptoms (eg. Fatigue, physical function, mobility, depression, sleep) and health conditions (eg. Recent relapse, skin problems, UTI)

  1. In SCI, self-reported levels of pain interference were higher than the national mean from young adulthood through middle age.
  2. Younger individuals with SCI reported similar levels of pain interference during younger and middle adulthood (35 to 44, 45 to 54, and 55 to 64). Individuals from older cohorts reported levels of pain that were slightly lower than their middle-aged counterparts, at around 0.6 SD greater than the PROMIS norm.
  3. Differences from national PROMIS data were not significant over the age of 65, but the small sample size of individuals with SCI in these age bands makes results more difficult to interpret.
  4. All disability groups reported a higher mean pain and pain-related interference than did the normative sample.

Molton at al. 2014;

USA

Level 5 evidence

Cross-sectional

Ntotal=521

NSCI=239

NMS=282

Population: Younger aged (61 M, 87 F): SCI (n=87), MS (n=61); years since onset=10.6±6.6;

Middle aged (120 M, 189 F): SCI (n=127), MS (n=182); years since onset=17.4±9.9;

Older aged (31 M, 33 F): SCI (n=25), MS (n=39); years since onset=22.7±13.0

Methodology:  Individuals with either MS or SCI experiencing chronic pain who have participated in previous University of Washington studies through disability specific registries were recruited and given surveys to complete.  Participants were split into 3 age groups: younger (18-45 years), middle (45-65 years), and older (65+ years) to evaluate relationships among chronic pain, age, pain-related interference with activities, and depressed affect in a group of individuals with disability due to either SCI or MS.

Outcome Measures: Pain severity (11-point NRS), Patient Reported Outcomes Measurement Information System (PROMIS), Pain Interference Short Form (PRO-PI-SF), Patient Health Questionnaire-9 (PHQ-9), Primary Care Evaluation of Mental Disorders (PRIME-MD)

  1. (1) Pain severity significantly predicted depression, (2) pain- related interference with activities significantly predicted depression, and (3) pain severity significantly predicted pain-related interference with activities.
  2. For all age groups, the relationship between pain severity and depressed mood was fully mediated by pain-related interference with activities. That is, pain severity was no longer a significant predictor of depression after controlling for the interference in activities caused by pain.
  3. Pain-related interference significantly mediated the relationship between pain severity and depression for younger aged, middle-aged, and older aged individuals with MS and SCI.

Ullrich et al. 2013;

USA

Retrospective longitudinal

N=286

Population: 286 veterans with SCI (97% male): Age (yrs): mean 53; Duration of injury (yrs): mean 17; Type of SCI: 49% paraplegia, 38% low tetraplegia, 13% high tetraplegia; 46% complete.

Methodology: 3 standardized annual psychological evaluations given to participants were reviewed. Administrative databases were used to collect SCI specialty care utilization data. Participants were categorized as having elevated pain, elevated depression, both elevated pain and depression, or neither elevated, using cut-off scores on the pain and depression scales.

Outcome Measures:  Center for Epidemiological Studies Depression Scale (CES-D), Numerical Rating Scale (NRS) for pain, medical comorbidities, SCI specialty care utilization.

  1. 20% of the sample showed both elevated pain and depression at Year 1. 59% of participants had either elevated pain or depression or both at Year 1.
  2. Pain scores were stable over time.
  3. Depression scores improved over 3 years, but persons with elevated pain and depression showed less improvement on depression scores than did persons with depression alone.
  4. Persons with pain and depression tended to utilize more SCI specialty care (number of SCI outpatient visits, number of psychologist visits, inpatient admissions).

Pershouse et al. 2012; Australia

Longitudinal

N=270

Population: 270 persons with traumatic SCI (81% male); mean (SD) age in yrs: 43.3(11.4), range 20-76; mean (SD) age at injury in yrs: 27.3(9.7).

Methodology: Data were collected via telephone interviews and written questionnaires annually over 5 years, between 2004 and 2008, across 6 strata comprising participants grouped according to time since injury (<5y, 5–9y, 10–14y, 15–19y, 20–24y, ³25y).

Outcome Measures:  Secondary Conditions Surveillance Instrument (SCSI)

  1. There was a significant increase in secondary conditions with increasing time since injury.

Saunders et al. 2012;

USA

Prospective longitudinal

N=801

Population: 801 adults with traumatic SCI; mean (SD) age in yrs at Time 1 of survey: 44.8(13.8); mean (SD) YPI in yrs at Time 2: 23(10.6).

Methodology: There were 2 data collection time points: the first between 2002 and 2004 (Time 1) and second between 2007 and 2009 (Time 2). There were 1543 participants at Time 1 and of those, 993 participated at Time 2; Using information from participants who had valid depression scores at both time points (n=801), change in probable major depression (PMD) status was assessed between the two time points.

Outcome Measures:  Older Adult Health and Mood Questionnaire (OAHMQ).

  1. 22.1% of participants had probable major depression (PMD) at Time 1 and 20.2% at Time 2.
  2. Of those who had PMD at Time 1, 55.7% had PMD at Time 2. Between the two time points, the most change occurred in the group with clinically significant symptomatology.
  3. Demographic factors (race-gender, age, time since injury) and health behaviours (pain medication use, hours out of bed, days out of the house, exercise) were significantly associated with PMD over time.
  4. Socio-economic factors (income, education) were significantly related to depression but were not significant after controlling for behavioural factors.

Hitzig et al. 2010;

Canada

Longitudinal

N=344

Population: 344 subjects with SCI (293M 51F); 62 incomplete tetraplegia, 81 complete tetraplegia, 92 incomplete paraplegia, 109 complete paraplegia; age range 24-86 yrs; YPI 7-58.

Treatment: AT Jousse Long-Term Follow-Up Questionnaire administered over the telephone during 1995-1997 (time 1) and 2003-2004 (time 2). Data collected on socio-demographics, mortality, impairment, health status, secondary health concerns and mobility.

Outcome Measures:  Chi square analyses, dependent samples t-test.

  1. Secondary health conditions (spasticity, pressure ulcers, bladder infections, kidney problems, cardiac problems, high blood pressure, respiratory complications, arthritis/joint pain, chronic pain, and psychological stress) increased significantly over time except for bowel problems, which decreased.
  2. Mean health status at Time 1 decreased significantly by Time 2.

Charlifue et al. 1999;

USA

Longitudinal

N enrolled=439

N final=315

Population: 315 individuals with SCI, mean(SD) age 37.1(0.6) yrs, mean(SD) YPI 9.3(0.2).

Methodology: Subjects studied initially at their 5th, 10th, and 15th anniversaries post-injury and subsequently 5 yrs later at their 10th, 15th, and 20th anniversaries post-injury.

Outcome Measures:  Physical and psychosocial status.

  1. Para AIS ABC group reported significantly more fatigue between Time 1 and 2. Tetra AIS ABC group reported an increase in the need for physical assistance but had fewer reports of constipation, bladder stones and bleeding.
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