Low back pain in older adults

A 102 yr old female in a care home facility complains of back pain every morning but she is un-medicated, still walks, dances, sits often during the day and loves to eat. She has good teeth, does not worry like others of her peers and loves to dance. She has early Alzheimer’s disease.

Connie


Low back pain in older adults: risk factors, management options and future directions

Abstract

Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.

Keywords: Risk factors, Spine, Disc degeneration, Management, Low back pain, Elderly, Genetics, Falls, Brain, Pain assessment

Background

The average lifespan of humans has dramatically increased in the last decade due to the advance in medicine [1]. According to the United Nations, the world population of individuals aged 60 years or above will triple by 2050 [2]. In the UK alone, approximately 22% of the population will be 65 years or older by 2031, exceeding the number of those aged less than 25 years [3]. However, the fast-growing aging population also increases the likelihood of non-communicable diseases (e.g., musculoskeletal complaints). Studies have suggested that the prevalence of musculoskeletal pain in older adults ranges from 65 to 85% [4, 5], with 36 to 70% of them suffering from back pain [5, 6].

Low back pain (LBP) is the most common health problem among older adults that results in pain and disability [4, 710]. Older adults, aged 65 years or above, are the second most common age group to visit physicians for LBP [11]. Earlier research suggests that LBP prevalence progressively increases from teenage [12] to 60 years of age and then declines [1316], which may be ascribed to occupational exposure among working-age adults [17, 18], or age-related changes in pain perception or stoicism [19]. However, recent studies have revealed that LBP remains ubiquitous among older adults at their retirement ages [20, 21]. In population-based studies, the 1-year prevalence of LBP in community-dwelling seniors ranged from 13 to 50% across the world [4, 13, 2224]. Similarly, while up to 80% of older residents in long-term care facility experience substantial musculoskeletal pain [2527] and one-third of these cases are LBP [28], often older residents’ pain is underreported and inadequately treated [2527].

It is noteworthy that both the incidence and prevalence of severe and chronic LBP increase with older age [13, 29, 30]. Docking et al. [17] reported that the 1-month prevalence of disabling back pain (pain that affected daily activities within the past month) increased from 3.8% among people aged between 77 and 79 years to 9.7% among those aged between 90 and 100 years. Williams and coworkers [31] also found that individuals aged 80 years or above were three times more likely to experience severe LBP than those aged between 50 and 59 years. Because severe LBP usually results in poor treatment outcomes and functional disability [17, 32], timely LBP management of older adults is crucial. Importantly, compared to working-age adults, older adults aged 65 years or above are more likely to develop chronic LBP that lasts for more than 3 months [13, 33]. A Spanish study found that the prevalence rates of chronic LBP among females and males aged 65 years or older were 24.2 and 12.3%, respectively [34], while an Israeli study documented that the prevalence of chronic LBP in people aged 77 years was as high as 58% [35].

Notwithstanding the high prevalence of LBP among older adults, their pain is usually undertreated. A recent study showed approximately 25% of senior nursing home residents with chronic pain did not receive analgesics, and only 50% of all analgesics were prescribed as standing orders at suboptimal doses, which did not follow geriatric clinical guidelines [36, 37]. According to those guidelines, older patients with chronic pain should receive analgesics as a standing dose rather than on an as-needed basis in order to ensure adequate concentration of analgesic in serum for continuous pain relief [36, 38]. Standing-dose analgesics are particularly important for people with cognitive impairment because they cannot appropriately request medication.

While undertreatment of LBP in older adults may be ascribed to the avoidance of high-dose analgesics (e.g., opioid) prescription, it may also be attributed to the difficulty in identifying the presence or causes of LBP. Research has shown that less than 50% of primary care physicians have strong confidence in diagnosing the causes of chronic LBP in older adults [32]. Consequently, this may result in over-reliance on medical imaging or improper LBP management (e.g., undertreatment). Imperatively, untreating or undertreating older adults with LBP may result in sleep disturbances, withdrawal from social and recreational activities, psychological distress, impeded cognition, malnutrition, rapid deterioration of functional ability, and falls [39]. These LBP-related consequences may compromise their quality of life and increase their long-term health care expenses [40].

Although various medical associations have published clinical guidelines on conservative management of chronic pain in older adults [37, 41, 42], there is paucity of literature summarizing various causes or risk factors of developing severe/chronic LBP among older adults. Since a better understanding of these factors can improve LBP management, the objectives of the current narrative review were to summarize potential causes of LBP, risk factors for chronic LBP, special consideration for LBP management (e.g., pain evaluations among patients with dementia) in older people aged 60 years or older, and future research directions.

Search strategies and selection criteria

Potential articles were identified for review through PubMed from January 1, 1990, to November 30, 2016. Search terms included keywords and medical subject headings related to “low back pain,” “LBP,” “older adult*,” “senior*,” “elderly,” “cognitive impairment,” “dementia,” “nonverbal,” “community-dwelling,” “nursing home,” “long-term care facilities,” “risk factor*,” “brain,” “genetics,” “assessment*,” and “intervention*.” Various Boolean terms were used in conjunction with various search terms. Articles were selected based on the relevance of topic and restricted to the English language. The reference lists of relevant articles were also included for review. A total of 2182 citations were identified from the search. Of them, information from 320 articles was used in the current review.

Potential causes of low back pain

Non-specific or mechanical low back pain

Like among young adults, the majority of LBP among older adults has no definite pathology (e.g., fracture or inflammation) and is diagnosed as non-specific LBP. These patients experience LBP that is altered by posture, activity, or time of the day. Non-specific LBP may originate from different pain sources [43]. Disc degeneration on magnetic resonance imaging (MRI) is more prevalent with age progression and as such in older adults; however, it is less likely to be the pain source as compared to young adults [44]. Conversely, facet joint pain in seniors may present as localized LBP with or without posterior thigh pain during walking. The pain may be aggravated during trunk extension, ipsilateral lateral flexion, and/or rotation [45]. Lumbar degenerative spondylolisthesis (defined as forward or backward slippage of a cephalic vertebra over a caudal one secondary to a degenerated disc and altered facet joint alignment) is common among women aged 60 years or older and is usually associated with facet hypertrophy [46]. The presence of degenerative spondylolisthesis alongside facet hypertrophy and thickening of ligamentum flavum may results in pain, spinal stenosis, and neurological deficits in older adults [46, 47]. Although spinal degenerative changes may induce LBP, not all anomalies on lumbar medical imaging are related to LBP because abnormal imaging phenotypes are ubiquitous among asymptomatic older adults [44, 4850].

Additionally, non-specific LBP may originate from structures other than the lumbar spine. Many older patients with chronic LBP display physical findings comparable to sacroiliac joint pain (83.6%) and myofascial pain (95.5%) [51]. Symptoms of sacroiliac joint disorders are similar to facet joint pain, which includes localized LBP with or without posterior thigh pain that can be alleviated by lying [52]. Myofascial pain is a localized palpable tenderness and tightness within a muscle that resists passive stretching and reproduces predictable referred pain pattern on palpation [53]. Myofascial pain in lumbar muscles or piriformis are common among seniors. Collectively, it is difficult to identify the sources of non-specific LBP because its causes are usually multifactorial. Various factors (e.g., anxiety, depression, coping strategies, and pain genes) can modify the severity and chronicity of LBP [31, 35, 50].

Radiculopathy

While non-specific LBP is usually localized at the lumbar region and/or thigh, the compression of nerve roots or spinal meninges by degenerated spinal structures (e.g., herniated discs, facet joints, and/or epidural fat) [54] may lead to radiculopathy that radiates distal to the knee. The clinical presentation of radiculopathy depends on the location of neural tissue compression. Lumbar spinal stenosis (LSS) secondary to degenerative changes (e.g., osteophytes and hypertrophic ligamentum flavum) at a single or multiple level(s) may lead to unilateral or bilateral radiculopathy and neurogenic claudication with or without LBP [5557]. Neurogenic claudication is characterized by numbness and heaviness of legs after prolonged walking, which can be eased by a flexed position (e.g., forward leaning or sitting) [5860]. On the contrary, the presence of osteophyte/narrowing in the lateral recess or in the vertebral foramen may result in radicular leg pain without LBP [61]. Research on asymptomatic or some clinical populations have suggested that the prevalence of degenerative LSS ranged from 6 to 13.1% [62, 63] and the rate increases with age [64]. A population-based imaging study found that the prevalence of degenerative LSS (i.e., ≤10-mm anteroposterior diameter of spinal canal) in young (<40 years) and older adults (>60 years) were 4.0 and 14.3%, respectively [64].

Osteoporotic vertebral fractures

Given the hormonal changes following menopause, women are more susceptible to osteoporotic fracture and related LBP [65, 66]. Approximately 25% of all postmenopausal women suffer from vertebral compression fracture and the prevalence of this condition increases with age [65]. It is estimated that the prevalence of vertebral compression fracture in women aged 80 years or above can be as high as 40% [65]. As compared to patients with non-specific LBP, patients with vertebral fractures experience more disability [67]. Unfortunately, only one third of the cases are correctly diagnosed because many seniors assume bone and joint pain as part of the aging process [68]. As such, physicians should pay more attention to examine seniors with acute onset of localized LBP that may or may not present with paraspinal muscle spasm. A recent systematic review suggests that older age, corticosteroid use, and significant trauma are the risk factors for vertebral fractures [69]. The common site of compression fractures occur at the thoracolumbar region [7072]. Depending on the mechanism of fractures, some vertebral compression fracture may result in radiculopathy. The most common fracture mechanism is due to a flexion movement or trauma that causes an anterior wedge fracture [73]. Since the posterior vertebral body remains intact and the collapsed anterior vertebra heals without regaining height, it will result in a kyphotic deformity without compromising the spinal cord [73]. Another type of vertebral compression fracture involves the center part of the vertebral body without affecting the anterior or posterior wall. This type of fracture does not affect the spinal cord. A less common osteoporotic vertebral fracture involves the axial compression of the entire vertebral body or the posterior portions of the vertebra that may compress the spinal canal and results in neurological deficit [7173].

De novo degenerative lumbar scoliosis

De novo degenerative lumbar scoliosis (DNDLS) is a spinal deformity in older adults that results in disabling LBP/leg pain and suboptimal quality of life. [7476]. DNDLS is defined as a lumbar scoliotic curve with a Cobb angle ≥10° in the coronal plane that develops after 50 years of age in people without a history of adolescent idiopathic scoliosis. [77]. The reported prevalence of DNDLS in the adult population has ranged from 8.3 to 13.3% [7880], while that in adults older than 60 years was as high as 68% [81]. Multifactorial causes have been suggested for DNDLS, including intervertebral disc degeneration and genetic predisposition [8284]. It is believed that the asymmetrical biomechanical load on the vertebral endplate on the concave side of the curve may cause inflammatory responses in the endplate and adjacent bone marrow of the vertebral body, which may result in LBP. [8587]. This premise has been substantiated by a recent study that found (1) bone marrow edema in DNDLS was more prevalent in older adults with LBP than those without LBP, (2) bone marrow edema was more frequent on the concave side of the DNDLS curve, and (3) the location of bone marrow edema on MRI was closely associated with local lumbar tenderness [87]. However, no significant relation between Cobb angle and LBP symptoms in older adults has been reported [81]. Interestingly, the curve progression rate of DNDLS is higher than that of adolescent idiopathic scoliosis [77]. Three radiological variables (i.e., increased intervertebral disc degeneration, an intercrest line passing through the L5 level (not L4 or higher), and apical lateral vertebral translation for at least 6 mm)) have been identified as predictors of DNDLS curve progression [77].

Tumors/cancers

The incidence rates for all neoplasms exponentially increase with age [88] although only less than 1% of the causes of LBP presented to primary care physicians are attributed to spinal tumors [89]. A majority of these tumors are related to metastasis and only a handful of them are primary tumors [9095]. The common metastatic sources of LBP are prostate and kidney although primary malignant tumors (e.g., chordoma, plasmacytoma, or lymphoma) are also be found in older adults [90]. Unlike young adults, seniors are unlikely to have primary benign tumors (e.g., osteoblastoma, osteochondroma, osteoma, eosinophilic granuloma, and aneurysmal bone cysts). Clinically, typical symptom of spinal tumors is progressive, unremitting, localized, or radiating pain that are aggravated by movement, worse at night, and cannot be eased by rest. In addition, patients may experience weakness and feel the presence of a lump [96].

Spinal infection

Vertebral osteomyelitis (VO) is a life-threatening infectious musculoskeletal disease in older people caused by an infection of vertebral bones [97]. Given the growing aging population, the incidence of VO is increasing [98100]. Although the reported incidence rate of VO in the general population only ranges from 2.5 cases to 7 cases per 100,000 people-years [99, 101], the mortality of these patients can be as high as 12% [99, 102]. Four causes of VO have been suggested. First, pathogenic bacteria may be disseminated hematogenously from a distant infected source and multiply at the metaphyseal arterioles of vertebral bone that causes microabscess formation, bone necrosis, and fistula within bone [103]. Staphylococcus aureus is the most common pathogen. Second, tubercular VO may occur in seniors who have contracted tuberculous infection at young age. Mycobacterium tuberculosis may be transmitted to and remains in the vertebral bone. Age-related deterioration of the host’s immunity or certain incidences (e.g., osteoporosis, trauma, or non-myobacterial infections) may reactivate M. tuberculosis in the bone that causes osteomyelitis. Third, aerobic gram-negative bacilli in older men with urinary tract infection may rarely reach the lumbar spine through Batson’s plexus and cause VO [97]. Fourth, iatrogenic infection following spinal surgeries or injections may cause vertebral osteomyelitis. Clinically, patients with VO may present with fever, elevated C-reactive protein, paraspinal muscle spasm, LBP, neurological deficits, and epidural abscess. Additionally, patients with tuberculous osteomyelitis may have a groin mass because of the presence of abscess in psoas muscle [97]. Taken together, greater age and certain comorbidities (e.g., diabetes, hemodialysis usage, liver cirrhosis, malignancy, and infectious endocarditis) are known to increase inpatient mortality of VO [99]. Clinicians should be suspicious of VO if older patients with the abovementioned comorbidities demonstrate unidentified fever and/or LBP [99]. Clinical findings, laboratory results, bone scintigraphy, and/or spinal biopsy are usually used to make differential diagnosis of VO.

Similarly, older people are more prone to develop pyogenic spondylodiscitis, which involves the infection of disc and adjacent vertebral bones. It has been estimated that the incidence rate of non-tuberculous or non-postoperative spondylodiscitis in the general population is approximately 0.2 to 2.4 cases per 100,000 people-years [101, 104106], while that for people over 65 years old is as high as 9.8 cases per 100,000 person-years [107]. A recent population-based study reported that males aged 70 years or older displayed six times higher incidence rate of pyogenic non-tuberculosis spondylodiscitis than males under 70 years old. Likewise, females aged 70 years or above were three times more likely to exhibit pyogenic non-tuberculosis spondylodiscitis than younger counterparts [98]. Clinical presentations of spondylodiscitis are comparable VO. S. aureus is the major cause of pyogenic spondylodiscitis [108], while other bacteria (e.g., Streptococcus and Pneumococcus) may also cause the disease [98]. Magnetic resonance imaging is the gold standard for imaging pyogenic spondylodiscitis, which is visualized as reduced signal intensity of the affected disc and adjacent vertebral bodies with unclear endplates definition on T1-weighted images and enhanced signal intensity on T2-weighted images [109].

Visceral diseases

Since it is not uncommon for seniors to have co-morbidities, it is important to consider other non-spinal pathologies that usually present as chronic LBP. Several visceral diseases (e.g., dissecting abdominal aortic aneurysm, cholecystolithiasis, nephrolithiasis, prostatitis, urinary tract infection, and pelvic inflammatory disease) have known to generate symptoms comparable to chronic LBP [110].

Cauda equina syndrome

This syndrome is ascribed to the compression of multiple lumbar and sacral nerve roots in the spinal canal that lead to bowel, bladder, and/or sexual dysfunction, as well as perianal region numbness [111]. Depending on the location of nerve roots compression, patients with cauda equina syndrome may or may not experience sciatica. Potential causes of this syndrome include central disc herniation or spondylolisthesis at the lower lumber levels, spinal tumors, dislocated fracture, and abscess within the spinal canals [111]. Additionally, this syndrome may be secondary to some rare iatrogenic causes (e.g., spinal anesthesia or postoperative hematoma).

Risk factors of developing severe/chronic low back pain in older adults

Although most LBP is self-limiting and begins to improve after a few days and resolves within a month [110], some patients are susceptible to chronic LBP that lead to significant disability. While age is a well-known risk factor for chronic LBP [112], other factors may perpetuate LBP in older adults (Fig. 1). The understanding of these factors can help identify high-risk patients and improve their LBP management. Since older adults usually face both age-related physical and psychosocial issues, comprehensive assessments and treatments are needed to effectively manage LBP in seniors.

Fig. 1

Factors affecting the development of severe or chronic low back pain among older adults

Non-modifiable risk factors

Altered supraspinal pain processing

Recent evidence suggests that normal aging may be associated with alterations in pain perception [113, 114] central pain processing [114] and/or neuroplastic changes to pain responses [115]. Both experimental pain and functional neuroimaging studies have found that older people display age-related increase in the heat pain threshold [116] and reduced responses in middle insular and primary somatosensory cortices toward a 44 °C heat stimulus [117]. These age-related neuropsychological changes in pain processing may reduce older peoples’ awareness and reporting of pain that may lead to undiagnosed health problems/injuries.

Conversely, some psychophysical studies reported that older adults displayed lower tolerance to various types of pain stimuli (e.g., ischaemic, mechanical, electrical, heat, or cold) [113, 114, 118] decreased pain thresholds for mechanical pressure [114, 116] or ischemic pain stimuli [119] and higher pain rating for noxious stimuli as compared to young adults [120]. Although speculative, the increased pain sensitivity in older adults may be attributed to diminished descending pain inhibition in older adults. Neuroimaging studies have shown that the volumes of brain regions responsible for pain processing (i.e., the cingulate, insula, striatum, hippocampus, cerebellum, and prefrontal cortex) significantly reduce as people age [121126]. These findings may indicate age-related reduction in perceptual motor processing, diminished coordination of inhibitory motor response to noxious stimuli, and/or impaired descending endogenous pain inhibitory modulation [127130]. Since patients with fibromyalgia are known to have significantly less striatal release of dopamine in response to experimental muscle pain [131] and people with chronic LBP are characterized by regional decreases in gray matter density in bilateral striatum (especially nucleus accumbens, putamen, and caudate) [132], the reduced pain-related striatal activity in seniors may indicate age-related impairment in endogenous pain modulation [127129].

Additionally, age-related changes in neuroplasticity may decrease the pain tolerance in older adults. Compared to younger individuals, older people tend to show more rapid temporal summation of noxious heat stimuli in their central nervous system [116, 133135]. Similarly, older adults display a prolonged period of capsaicin-induced hyperalgesia that may lead to relentless pain sensitization and sluggish resolution of neuroplastic change [115]. Importantly, the central pain processing can be further complicated by dementia-related neurodegeneration [113, 136]. Depending on the severity, locations or types of neurodegenerative changes, seniors with dementia or Alzheimer’s disease have demonstrated increased pain threshold and tolerance [137] or decreased pain threshold [138, 139]/pain tolerance [140]. Taken together, age-related changes in central pain processing of older adults may contribute to severe or chronic LBP in seniors.

Importantly, people with chronic back pain suffer from global and regional changes in functional connectivity and/or gray matter density in the brain that may perpetuate persistent pain [132, 141]. Human resting-state functional MRI research has revealed that, as compared to asymptomatic individuals, patients with chronic pain (i.e., back pain, osteoarthritis, and complex pain regional syndrome) demonstrate significantly decreased functional connectivity of the whole-brain and diminished regional connectivity in specific brain regions (e.g., supplementary motor cortex, mid-anterior cingulate cortex, superior parietal lobe, and part of the somatosensory network) but enhanced connectivity in thalamus and hippocampus [141]. These patients also display changes in allegiance of insula nodes or some lateral parietal nodes to certain brain modules (e.g., the sensorimotor brain module, default–mode network module, and attention module) [141]. These findings indicate that chronic pain is associated with decreased motor planning (supplementary motor cortex) and attention (superior parietal lobe) but increased somatosensory inputs to the cortex (thalamus) and chronification (hippocampus) [142, 143]. Similarly, a 1-year longitudinal study showed that people who experienced persistent back pain during the study period demonstrated significant decreases in global gray matter density as compared to healthy controls and patients who recovered during the period [132]. The same study found that patients with persistent back pain had significant regional decreases in gray matter density at bilateral nucleus accumbens (a key mesolimbic region), insula (pain perception cortex) [144146], and left primary sensorimotor cortex, yet reduced negative functional connectivity between insula and precuneus/dorsolateral prefrontal cortex, and diminished functional connectivity of primary sensorimotor cortex [132]. The consistent findings of various studies suggest that chronic pain may lead to global and/or regional disruption of functional connectivity and structures of the brain that may hinder the treatment effectiveness for people with a history of recurrent or chronic pain [141].

Gender

Females are more susceptible to chronic LBP than males regardless of age [20, 31, 34, 112]. Jimenez-Sanchez and coworkers [34] estimated that women were two times more likely to develop chronic LBP than men. The higher prevalence of chronic pain in females may be attributed to complex biopsychosocial mechanisms (e.g., less efficient pain, habituation or diffuse noxious inhibitory control [147], genetic sensitivity, pain coping [148], and a higher vulnerability to develop temporal summation of chemically [149] or mechanically evoked pain) [150]. Further, women commonly have a higher number of concomitant chronic diseases (e.g., osteoporosis, osteopenia, and osteoarthritis), which are known to be risk factors for developing chronic LBP and psychological distress in older adults [34, 112].

Genetic influences

Recent research has highlighted that genetic factors play an imperative role in modulating pain sensitivity, responses to analgesics, and vulnerability to chronic pain development [50]. Some genetic factors not only predispose people to spinal disorders (e.g., scoliosis [151] and intervertebral disc degeneration [152, 153]) but also alter brain structures [154, 155] that may modify central pain processing and perception [156]. For instance, polymorphisms of the catechol-O-methyltransferase gene are known to affect the cognitive and emotion processing of pain in the brain [156]. While variations in some gene expression (e.g., val158met single-nucleotide polymorphism (SNP)) may modulate temporal summation of pain [157], other SNPs (e.g., catechol-O-methyltransferase gene, interleukin-6 GGGA haplotype or SCN9A gene, or hereditary sensory neuropathy type II gene) may alter pain sensitivity through different mechanisms (e.g., affecting voltage-gated sodium channels, altering myelination of nerve fibers, or modulating anabolism/catabolism of catecholamine neurotransmitters) [158163]. Collectively, some people (including seniors) may be more susceptible to develop chronic LBP because of their genetic makeup. Future studies are warranted to examine if age may modify the expression of pain genes in older adults.

Additionally, genetic variations may influence the analgesic requirement or treatment responses to opioid analgesics [164]. A recent meta-analysis underscores that SNP A118G (a genetic variant of μ-opioid receptors, OPRM1) can modify postoperative opioid requirement and analgesic responses [165]. Notably, while Asians with minor G allele require more postoperative opioid analgesics, Caucasian counterparts do not display increased opioid analgesic requirements. This discrepancy highlights the genetic differences between the two ethnic groups and/or distinct interactions between A118G SNP and environmental influences [165]. Interestingly, the OPRM1 A118G SNP has significant influence only on the treatment responses of patients receiving morphine but not fentanyl [165]. The divergent pharmacogenetic responses indicate that different opioids may have different ligand-receptor dynamics [166]. Importantly, the expression of other pain genes (e.g., COMT or beta-2 adrenergic receptor alleles) [158, 167, 168] and other polymorphisms in the OPRM1 gene locus [169] can interact with A118G SNP and environment to cause differential pain sensitivity and opioid treatment responses in different races and gender [164, 170]. As such, it highlights that individual treatment responses of patients with LBP may be related to different pharmacogenetic variations.

Prior work exposures

While occupational exposures to whole-body vibrations, lifting, bending, twisting, stooping, have been identified as potential risk factors for LBP in the working-age group [171], increasing evidence suggests that previous occupational exposure to physically strenuous work increases the risks of LBP in retired seniors [172, 173]. A prospective study involving more than 1500 individuals showed that previous occupational biomechanical exposure to bending/twisting or driving for at least 10 years increased the odds of having persistent LBP in retired adults aged 58 to 67 years after adjusting for body mass index and psychological disorders [172]. Likewise, retired post office workers aged 70 to 75 years with LBP were characterized by more than 20 years of work-related regular lifting of heavy weights [173].

Demographic factors

Lower education levels, lower income, and smoking are related to higher propensity of LBP in older people [20, 21, 31, 112]. It is suggested that more educated individuals experience less LBP symptoms because they have a better understanding of pain, a better compliance to treatment, and a strong willingness to adopt a healthy lifestyle [174]. Conversely, people with poor economic status may have difficulty in accessing healthcare in certain places [175]. Patients with limited resources may delay seeking healthcare until their symptoms are intolerable, which in turn increases the chronicity/severity of LBP across the life course [176]. A multinational study has shown that people in the poorest socioeconomic quintile were 1.4 times more likely to have LBP with reference to the highest quintile [31]. Interestingly, compared to those older adults who have never married, those divorced, married, separated, and widowed have at least 1.5 times odds to experience LBP [31].

Modifiable risk factors

Yellow flags

Psychological distress (e.g., anxiety or depression) is a risk factor for persistent or debilitating LBP in older adults [34]. A longitudinal study showed that older persons with a high depressive symptom score at baseline were two times more likely to have LBP at the 4-year follow-up [17]. Similarly, Reid et al. [177] found that depression was significantly correlated to disabling LBP in seniors aged 70 years or above. Importantly, since persistent LBP can also be a predictor of depression and anxiety [178], psychological assessments should be incorporated in the examination of older patients with chronic LBP.

Multiple studies have found that fear-avoidance beliefs (FAB) are closely related to chronic LBP in older people [179181]. A cross-sectional study consisting of 103 older patients with chronic LBP (65 years or older) and 59-age-matched asymptomatic controls showed that higher FAB as measured by a questionnaire, older age, and higher LBP intensity predicted poorer self-reported functional capacity [179]. Another study on 200 older adults with chronic LBP revealed that higher physical activity subscale scores of the FAB questionnaire were related to higher Roland Morris Disability Questionnaire scores and slower gait speed [180]. Similarly, a population-based survey study found that increased FAB were related to higher self-reported LBP-related disability, poorer physical health, and higher risk of falls in older people (62 years or older) with LBP [181]. Vincent et al. also found that kinesiophobia was related to chronic LBP-related disability in obese older adults [182]. These consistent findings suggest that FAB are important therapeutic target to address among older people with chronic LBP.

Conversely, some studies reported inconsistent findings regarding the relation between other yellow flags (e.g., kinesiophobia and pain catastrophizing) and functional capacity or LBP-related disability [182184]. A recent randomized controlled trial among 49 obese, older adults with chronic LBP demonstrated that reduction in pain catastrophizing following 4-month resistance exercise was related to decreased self-reported LBP-related disability [184]. However, Ledoux and coworkers found that kinesiophobia, pain catastrophizing, and depression were unrelated to the functional capacity among older adults with chronic LBP [185]. Kovac and colleagues also found that FAB and pain catastrophizing had only a minimal clinically significant effect on self-reported LBP-related disability of community-dwelling older (above 60 years) adults with LBP [183]. This discrepancy may be attributed to differences in study designs, cultures, living environment, or age-related changes in the relative influence of FAB on LBP-related disability level [183]. Given that multiple psychological factors (e.g., anxiety, depression, FAB, and coping strategy) may have different interactions among themselves and other age-related physical and social factors in influencing the genesis and persistence of chronic LBP, future studies should clarify the effect of individual yellow flags on LBP progression among older adults. The findings may help develop optimal multimodal treatment approaches for older adults with LBP [186].

Physical activity

Different types and amounts of physical activity are related to persistent LBP in older adults [112]. Generally, moderate or vigorous physical activity heightens the risk of LBP regardless of age [112, 171]. A population-based study found that moderate (at least 30 min of moderate intensity activity on five or more days per week) and vigorous (at least 20 min of vigorous activity on three or more days per week) physical activity were significantly associated with increased risk of persistent LBP among women aged greater than or equal to 65 years, while walking for 30 min on five or more days a week and strength exercises on two or more days per week lowered the risk of persistent LBP after adjusting for age and body mass index (BMI) [112]. Similarly, the study identified that strength exercises lowered the risk of LBP among men aged greater than or equal to 65 years after accounting for age and BMI [112]. As such, clinicians should evaluate the activity level of patients and provide recommendations accordingly.

Smoking

Like in other age groups, smokers are more likely to experience LBP. It is thought that smokers may have different pain perception as compared to non-smoker although the effect of smoking on pain perception remains unclear [187]. However, animal and human studies have shown that smoking may induce degenerative changes in spinal structures, such as intervertebral discs [188191]. As such, these degenerative changes may compress the neural structures and cause neuropathic LBP.

Social factors

Social factors may affect the genesis and persistence of LBP [192]. It is well known that social factors (e.g., the social environment or groups that individuals live, grow up, or belong) can influence the onset and progression of diseases or disability (including widespread pain) [193, 194], especially among older adults [195, 196]. Because social conditions can induce social stressors (e.g., poor housing, crime, and poor living environment), affect risk exposure (e.g., poor eating habit leading to obesity), influence psychology and emotion (e.g., social pressure and sense of inequalities), and compromise access to health services (e.g., health-care education or use of healthcare) [192]. Health-care stakeholders should recognize and address various social factors that can impact older adults with LBP. For example, since older adults with less social ties are more likely to experience disabling pain because of depression [192], proper public health programs and resource allocation (e.g., social work counseling services and health education) may target these vulnerable seniors (e.g., oldest old or seniors with depression). Importantly, residents with LBP living in long-term care facilities may rely on nursing home staff (e.g., nursing assistants) to provide medications or personal care. The attentiveness and responsiveness of nursing home staff will affect the recovery and persistency of LBP in these residents.

Self-perceived health

Seniors with poor self-perceived health status are more likely to experience severe LBP. A cross-sectional study on adults aged between 70 to 102 years found that poor self-rated health was strongly associated with LBP [197]. Similarly, a longitudinal study revealed that people with poor self-reported health were four times more likely to report LBP at the 4-year follow-up than those reporting very good health [17]. The same study also found that those who required health or social services (e.g., meals on wheels or home help) at baseline had a significantly higher risk of reporting LBP at follow-up [17].

Comorbidity

Research has shown that comorbidities are related to chronic LBP in seniors. Jacobs et al. [35] found that females, hypertension, joint pain, pre-existing LBP, and loneliness, were predictors for developing persistent LBP in individuals aged 70 years. Another study revealed that comorbid chronic conditions were positively related to at least one LBP episode in the last month in low- and middle-income countries [31]. Specifically, the odds of LBP were 2.7 times higher among seniors with one chronic comorbid condition, compared to seniors without comorbidities, while the odds ratio was 4.8 for people with two or more comorbidities [31]. As mentioned above, patients with Parkinson’s disease may experience hypersensitivity of pain due to the decrease in striatal dopaminergic function [198, 199]. However, such pain can be alleviated by the administration of L-dopa [200].

Special considerations for low back pain management of seniors

While comprehensive history taking, self-reports of pain characteristics and pain-related disability, as well as proper physical examination all are necessary for differential diagnosis among older adults with LBP [201], attention should be also given to assessment and treatment of seniors with LBP so as to optimize pain management (Fig. 1).

Self-reported pain assessments

While patients with mild-to-moderate dementia can reliably report pain intensity using traditional visual analog scale or Numeric Rating Scale (NRS) [202, 203], other self-reported pain assessment tools have been developed and validated in the older population to improve pain evaluation (Table 1). The 11-point NRS is commonly used in clinical settings, where 0 means no pain and 10 means the worst pain imaginable [204]. Faces Pain Scale and Revised Faces Pain Scale (FPS) comprise different facial expressions indicating different severity of pain experienced by patients [205]. They have been validated among different older populations [168, 204, 206208] and were rated as preferred tools over the NRS by Chinese [209] and African-Americans [210]. The Iowa Pain Thermometer (IPT) is a descriptor scale presented alongside a thermometer to help patients conceptualize pain intensity as temperature levels [204]. Compared to the FPS, Verbal Descriptor Scale, and visual analog scale, the IPT is deemed to be the most preferred scale among older adults [204].

Table 1

Self-reported pain assessment tools for older adults with cognitive impairment

Observational pain assessments

Although self-reported pain assessment is the gold standard, clinicians need to validate the self-reported pain with observed pain behavior during physical examination. While some seniors with cognitive impairment may report exaggerated pain without coherent pain behavior due to perseveration [211214], others (e.g., with severe dementia or poststroke aphasia) may have difficulty in communicating pain intensity or pain-related disability [215] that may lead to insufficient/inappropriate treatment [216]. Currently, there is no consented guideline regarding the relation between the trustworthiness of self-reported pain and cognitive functioning [217]. Therefore, health-care providers (e.g., physicians or nursing home nurses) should identify people with potential cognitive impairment and modify their pain assessment and treatment in order to effectively manage cognitively impaired patients with LBP. It has been suggested that clinicians should consider assessing the cognitive function of older adults with LBP if patients have a known history of dementia, self or family report of memory loss, difficulty in providing details of LBP history that requires supplementary input from caregivers, age above 85 years, or inconsistency between observed pain behaviors and self-reported pain [212, 213, 218]. Some dementia screening tools (e.g., Montreal Cognitive Assessment [219], Mini-Cog [220, 221], and Saint Louis University mental status examination [222]) have been recommended based on their psychometric properties, ease of use, and accuracy in identifying people with dementia [223]. Patients with positive screening results should be referred to subspecialty dementia experts (e.g., neurologists, geriatricians, or geriatric psychiatrists) for formal dementia evaluation in addition to LBP treatment. Collectively, early identification of cognitive impairment and psychiatric comorbidity (e.g., depression) in older adults with LBP can optimize the pain management plan (e.g., assistance from caregivers and prescription of psychiatric medications).

Since people with moderate to severe dementia may display agitation, anxiety, or nonverbal pain behaviors (e.g., grimacing, yelling, hitting, or bracing), failure to detect pain as a potential cause of agitation may result in unnecessary prescription of anxiolytics or antipsychotics [224]. As such, proper procedures for evaluating nonverbal dementia patients should include: using a validated observational assessment tool to evaluate pain behaviors during rest and painful conditions/procedures, seeking surrogate report of pain behaviors, and monitoring responses following an analgesic trial [223]. Since the prevalence of dementia in people aged 85 or older can be as high as 50% [218], family members or informants are recommended to accompany these patients to meet health-care providers so as to provide detailed pain information [223]. Several recent reviews have identified at least 24 observational pain assessment instruments for estimating pain in nonverbal patients [225227]. Table 2 describes six commonly used assessment instruments. Unfortunately, since many of them only detect the presence/absence of pain, rather than quantify the pain severity [217, 228], these tools may be better used to monitor longitudinal changes in pain (e.g., increases/decreases in pain behavior) or treatment responses. Regardless, if the observational pain behavior assessment indicates the presence of significant pain in patients, the sources of pain should be identified through physical examination and proper treatment should be given. If inconsistency occurs between the observational assessment and self-report of pain, other causes (e.g., fear of pain and depression) should be identified and managed. If comprehensive evaluations and an analgesic trial cannot identify any sources of pain experienced by patients with dementia, the persistent pain complaint may be attributed to pain perseveration, which is the repetitive reporting of pain without actual distress. Collectively, future studies should refine existing observational tools by identifying the most important behaviors for evaluating the presence and severity of pain (including LBP) in cognitively impaired patients.

Table 2

Six commonly used nonverbal pain tools for older adults with cognitive impairment

It is noteworthy that although certain physiological parameters (e.g., increased heart rate, blood pressure, and perspiration) may indicate the presence of pain, these physiological indicators may be inaccurate among older adults with chronic pain [217]. Additionally, older adults with dementia may have diminished autonomic reactions to pain [229, 230]. Therefore, effective evaluation of pain behavior may be more relevant for older adults with severe dementia and pain.

Fall assessment and prevention

Given that older people usually display reduced physical capacity [231], cardiac output [232], muscle mass and strength [233], and older adults with LBP are more likely to suffer from decreased mobility and functional deterioration than younger sufferers. In addition, older adults with musculoskeletal pain are more likely to experience fear of falling [234] and fall incidents [23]. Specifically, LBP is known to be an independent risk factor for repeated falls in older women [235]. A prospective study revealed that community-dwelling seniors with chronic LBP (more than 3 months) had a significantly higher risk of falls (adjusted OR for injurious falls ranged from 2.11 to 2.46) as compared to asymptomatic counterparts [236]. Likewise, seniors with LBP in the past 12 months are more likely to be recurrent fallers [23]. Since falls is the leading cause of persistent pain, disability, and mortality among seniors [36, 237], physicians and nursing home workers should assess fall risks of older adults with LBP [238] and refer them for fall prevention intervention, if necessary.

Pain medications

The American Geriatrics Society has published recommendations on pain management of geriatric patients with nonmalignant pain. In particular, a standing order of analgesic (e.g., acetaminophen) is recommended for older adults with chronic pain so that they can have a steady concentration of analgesic in the blood stream [239]. Tramadol is recommended to be prescribed with caution for patients with a known risk of seizure (e.g., stroke, epilepsy, and head injury) or for those taking medications that may lower seizure threshold (e.g., neuroleptics and tricyclics) [239]. In addition, the guideline also suggests that if acetaminophen cannot control pain, non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., COX-2 therapy or non-acetylated salicylates) may be used as adjunct therapy [239]. However, since some traditional NSAIDs may cause gastrointestinal upset, clinicians are recommended to prescribe non-acetylated salicylates for older patients with peptic ulcer and gastrointestinal bleeding. Although there is no ideal dose for opioid prescription among older adults with LBP, the effective dose should be carefully titrated to fit individual needs. To attain better pain relief with minimal side effects secondary to a high dose of a single medication, it is recommended to concurrently use two or more pain medications with different mechanisms of action or different drug classes (e.g., opioid and non-opioid analgesics). It is noteworthy that opioid (e.g., codeine) may increase the risk of falls and other drug-related adverse effects (e.g., depression, nausea, tachycardia, seizure, or falls [240, 241]) in opioid-naïve older patients during the opioid initiation period (i.e., within the first 3 months) or during the use of long-acting opioids [242, 243]. Therefore, specific education and caution should be given to these patient groups.

In addition, because older patients with chronic LBP are commonly associated with depression or anxiety, it is not uncommon for them to take antidepressants (e.g., serotonin reuptake inhibitors) or benzodiazepines. Since some of these psychoactive drugs may compromise their memory, cognition, alertness and motor coordination [244, 245], special care should be given to these patients to minimize their risks of falls, hip fractures, or road traffic accidents [246]. For instance, concurrent prescription of tramadol and the selective serotonin reuptake inhibitor (an antidepressant) may increase the risk of serotonin syndrome (e.g., hyperthermia, agitation, diarrhea, tachycardia, and coma) that may lead to sudden death [247, 248]. If patients have an elevated risk of opioid overdose (e.g., alcoholism [249], a history of opioid overdose/drug abuse [250], concurrent consumption of benzodiazepine or sedative hypnotics [251], or poor compliance to opiate medications [252]), they should undergo an overdose risk assessment, a urine drug abuse screening prior to opioid prescription, an education on drug overdose, and frequent clinical follow-up so as to mitigate their risk [253]. Further, physicians can prescribe naloxone to these high-risk patients and teach them/their caregivers to use it at emergency. Naloxone is an opiate antidote for neutralizing the toxicity of opioid overdoses [253, 254]. For patients who are taking long-acting opioids (e.g., oxycodone or methadone) or having hepatic or renal dysfunction, they should be reassessed regularly in order to ensure timely tapering/discontinuing of opioids if necessary [253]. Collectively, existing medical guidelines generally recommend low-dose initiation and gradual titration of opioid therapy and constipation prophylaxis, increased awareness of potential interactions among concurrent medications, as well as close monitoring of treatment responses in patients. It is necessary to provide updated education to health-care providers so as to optimize pain management for older patients with chronic pain.

Other conservative treatments

Although analgesics are the first line treatment for older people with LBP, older people with LBP (especially those with a prolonged history of LBP) may require other conservative treatments to mitigate pain and to restore function. Growing evidence has indicated that some, but not all, conservative treatments can benefit older people with LBP [255, 256].

While the efficacy of various physiotherapy modalities in treating older people with LBP remains controversial [256], a recent meta-analysis has highlighted that Tai Chi, a mind-body exercise therapy, is an effective intervention for older patients with chronic pain (including LBP, osteoarthritis, fibromyalgia, and osteoporotic pain) as compared to education or stretching [255].

Importantly, in addition to pain relief, various systematic reviews on Tai Chi have revealed promising outcomes in improving balance [257], fear of falling [258], lower limb strength [259], physical function [260], hypertension [261], cognitive performance [262], and depression [263] in seniors as compared to no treatment or usual care. Given the high frequency of physical and psychological comorbidity among older adults (e.g., depression, hypertension, and osteoarthritis), Tai Chi appears to be a viable LBP treatment option for older adults with LBP. Future studies should determine the dose response of Tai Chi in treating older people with LBP in community and institutional settings.

Lumbar surgery

Surgical intervention is indicated for older people only if there is a definite diagnosis of lumbar pathology (e.g., degenerative LSS, cauda equine syndrome, or spinal tumor) that needs to be treated by surgery or that is unresponsive to conservative intervention. While there are many different lumbar surgical interventions, the objective of these approaches is to minimize compression of neural tissues and/or enhance spinal stability. Decompression surgery (i.e., laminectomy, laminotomy, and discectomy) is used to partially or completely remove lumbar structures that are impinging neural tissues [264, 265]. Recent evidence suggests that minimally invasive spine surgery techniques have higher success rate than open lumbar decompression surgery [266].

Unlike decompression surgery, spinal fusion surgery utilizes bone grafts (autograft or allograft) or surgical devices to fuse adjacent vertebrae anteriorly, posteriorly, or circumferentially. Such surgery immobilizes the spinal motion segment, in theory removes key pain generating sources and eliminates intersegmental movement of vertebrae that may compress neural structures in order to alleviate symptoms [267]. In general, both simple and complex spinal fusion surgeries are associated with a higher risk of major complications and postoperative mortality as compared to decompression surgery [264]. While decompressive laminectomy/laminotomy with or without spinal fusion is a common surgical intervention for older patients with degenerative LSS [268], isolated decompression without spinal fusion is a preferred choice for older patients with lumbar degenerative spondylolisthesis without severe LBP/instability [269].

However, two recent randomized controlled trials have reported conflicting results regarding the effectiveness of decompression surgery plus spinal fusion versus decompression surgery alone in treating patients with LSS and degenerative spondylolisthesis [270, 271]. Decompression and spinal fusion are also indicated for patients with symptomatic degenerative lumbar scoliosis [272, 273] although these procedures may increase the risk of complications in older adults (especially those with comorbidities) [268, 272, 274276]. Recently, disc arthroplasty has been adopted to restore the mobility of an intervertebral joint by replacing a degenerative disc with an artificial disc and minimizing the risk of adjacent segment degeneration/disease [277]. Although current evidence notes the safety and efficacy of such intervention for indication for cervical spine pathology in comparison to conventional interbody fusion procedures, outcomes for lumbar disc disorders remain under further evaluation.

Percutaneous transpedicular vertebroplasty and balloon kyphoplasty are two minimally invasive techniques for treating patients with painful osteoporotic vertebral compression fracture [278]. These procedures involve the injection of a small amount of bone cement into the collapsed vertebral body to alleviate excruciating pain and stabilize the fractured vertebral body [279]. However, individual studies have found that these procedures may heighten the risk of new vertebral fractures at the treated or adjacent vertebrae, and other complications (e.g., cement leakage into the lungs, veins, and the vertebral body) [280283]. However, a recent meta-analysis reveals that these vertebral augmentation procedures may attenuate pain and correct deformity of patients with osteoporotic vertebral compression fractures without increasing the risk of complications or new vertebral fractures along the spine [278].

In addition, the past decade alone has seen a significant interest in the concept of sagittal alignment and balance with respect to the preoperative planning and predictive outcome analyses of patients with various lumbar spinal disorders and spinal deformities [284, 285]. Novel imaging software has been developed to quantify such parameters, such as pelvic incidence and tilt, and sacral slope, in a semi-automatic fashion [286, 287]. Numerous studies have noted the clinical utility assessing spinal alignment/balance [288292] a field that continues to gain widespread momentum and motivate future research.

Like conservative LBP treatments, some patients may experience persistent LBP (with or without sciatica) even after spinal surgery. The reasons for the failed back surgery syndrome (FBSS) may be ascribed to technical failure, incorrect selection of surgical patients, surgical complications, or related sequelae [267]. Additionally, since spinal surgery may alter the load distribution at vertebral structures adjacent to the operated segments (e.g., sacroiliac joint), this may result in the adjacent segment disease and pain. Because patients with FBSS are unlikely to benefit from revision surgery, spinal cord stimulation has been suggested to manage pain in these patients. Specifically, spinal cord stimulation involves the placement of electrodes into the epidural space and the generation of electrical current by a pulse generator placed subcutaneously. Studies have noted that there is fair evidence to support moderate effectiveness of spinal cord stimulation in attenuating persistent radicular pain of appropriately selected patients with FBSS although device-related complications are also common [267].

It is noteworthy that while surgical intervention may benefit some patients with LBP, clinicians should weigh the risks and benefits of surgery for each individual patient. A recent Cochrane review summarized the evidence regarding the effectiveness of surgical and conservative treatments for patients with LSS [293]. Two of the five included randomized controlled trials reported that patients undergoing spinal decompression with or without fusion had no significant difference in pain-related disability (measured by Oswestry Disability Index) from those receiving multi-modal conservative care at 6 and 12 months although the decompression group demonstrated improved disability at 24 months [294, 295]. Similarly, a small-scale included study found no significant difference in pain outcomes between decompression and usual non-surgical care (bracing and exercise) at 3 months, and 4- and 10-year follow-ups [296].

Another included study revealed that minimally invasive mild decompression was no better than epidural steroid injections in improving Oswestry Disability Index scores at 6 weeks although decompression had significantly better pain reduction but less improvement in Zurich Claudication Questionnaire scores [297]. Conversely, an included trial found that an interspinous spacer was significantly better than usual non-operative care in reducing symptoms and restoring physical function at 6 weeks, and 6 and 12 months [298]. Regardless of the treatment effects, approximately 10 to 24% of participants experienced peri or postoperative complications (e.g., lesion to the dural sac, hematoma, infection, spinous process fracture, respiratory distress, coronary ischemia, stroke, and even death secondary to pulmonary edema) while no side effect was documented for any conservative treatments [293]. Given above, back surgery should be considered carefully for high-risk patients (e.g., older adults with medical comorbidity). High-quality randomized controlled trials are warranted to compare the effectiveness of surgical versus nonsurgical interventions for older patients with LSS.

Future research

While anecdotal evidence and clinical experience suggest that older people appear to have higher rates of LBP with definite pathology (e.g., vertebral osteomyelitis, degenerative spondylolisthesis, and DNDLS), only a few studies have properly evaluated this issue. Given this knowledge gap, future research should quantify the prevalence of various LBP diagnoses so that health care resources can be better allocated to effectively manage the epidemic of LBP in the older population.

Although self-report of LBP is the gold standard for evaluating subjective pain experience, some patients with cognitive impairment may be unable to effectively verbalize their pain. Clinicians (especially those working in the geriatric field) should improve their competence in assessing nonverbal pain expression in patients with cognitive impairment. While multiple observational pain assessment scales have been developed, there is no consensus on the use of a particular assessment tool. Different clinical guidelines have recommended different scales [223, 225]. Given the rapid development and validation of different observational scales in the last decade, it is necessary to update existing guidelines on this issue.

While the scores of several observational pain behavior assessment tools (e.g., the Abbey Pain Scale and Pain Assessment in Advanced Dementia) have been found to be closely related to self-report of pain [299, 300], there is a paucity of research on the interpretation of scale/subscale scores in relation to pain or other psychological comorbidity (e.g., depression). Future studies should establish this relation. Further, most of the existing behavioral observational pain scales have only been validated in the nursing home setting. Future studies are warranted to compare various existing scales and evaluate their responsiveness and sensitivity to changes in pain following treatments in different settings, which can identify best assessment tools for different settings.

Since recent findings suggest that facial expression can provide many useful indirect information of pain, training health-care providers on the recognition and interpretation of facial expression of pain may improve the accuracy and reliability of pain assessment among patients with dementia. Importantly, future studies should adopt computer vision technology to develop automatic, real-time assessment of pain-related facial expression so as to facilitate the evaluation of pain condition in non-communicable patients with LBP [301].

Currently, clinical assessments of LBP among older adults rely heavily on self-report or surrogate report of LBP or manual physical assessments. With recent advances in technology, clinicians can use reliable novel objective measurements (e.g., mechanical spinal stiffness assessments [302304], ultrasonic measurements of paraspinal muscles [305], advanced medical imaging [306, 307], or genetic analysis [308]) to examine patients at affordable costs. Given that age-related physical changes (e.g., sarcopenia or fatty infiltration of paraspinal muscles) in older adults may worsen LBP-related physical changes, the adoption of validated objective measurements may enhance the reliability and sensitivity in detecting physical deficits or monitoring posttreatment improvements of LBP in older adults. For example, ultrasonography may be used to quantify atrophy of lumbar multifidus that can guide clinical treatments (e.g., spinal stabilization exercises). Likewise, computerized spinal stiffness tests can be used to identify patients with LBP who are likely to benefit from spinal manipulation [309].

Novel yet more sensitive imaging, such as chemical exchange saturation transfer, T2 mapping, T1-rho, ultra-short time-to-echo and sodium MRI, may identify the pain-generating source allowing for more targeted therapies [50, 310]. Furthermore, a refinement of some of the imaging phenotypes (e.g., disc degeneration, endplate changes, facet joint changes, paraspinal muscle integrity, and sagittal alignment/balance) or the utility of “phenomics” may further aid in proper diagnosis, management options, and the potential development of novel therapeutics. Knowledge gained from such approaches may enhance the exploration of new pathways of pain and potential treatment options in appropriate animal models. Moreover, the role of pain genetics and its actual utility toward the management of LBP in older individuals needs to be further explored. Taken together, while novel technology may gather new information from patients with LBP, clinicians should integrate these objective outcomes with other clinical findings in order to make proper diagnosis and clinical decision.

Given the multifactorial causes of LBP in older adults, it is necessary to consider the entire spectrum of “omic” approaches (e.g., genomics, metabolomics, phenomics, etc), ethnic variations, and all aforementioned risk factors in order to derive appropriate predictive models for future LBP development or severity of pain. These models can then be used to develop cost-effective and personalized LBP intervention for older adults.

Conclusions

Although LBP is ubiquitous among older adults, the dearth of literature on the trajectories of LBP, determinants of chronic LBP, and effective LBP managements in older adults highlights the research gaps in this area. Given that multiple factors (e.g., dementia, psychiatric and physical comorbidities, maladaptive coping, and age-related physical and psychosocial changes) can modify the LBP experience in older adults, clinicians should incorporate comprehensive subjective, observational, and physical examinations, as well as proxy reports to make accurate diagnosis. For patients with persistent LBP, medical imaging may be ordered to rule out malignant causes of pain. To minimize undertreatment of older adults with LBP, it is necessary to recognize the presence of LBP and to titrate pain medications in accordance with individual needs. Through understanding various factors contributing to severe/chronic LBP in older adults, timely and proper treatment strategies can be formulated. In addition, with the expansive understanding of “omic” technologies, study designs, and findings, new pathways of pain may be identified and novel therapeutics may be developed. As such, it is with a hope that with the understanding of pain being broadened and deepened, the management of older patients with LBP may eventually become more personalized or precise and outcomes optimized, leading to a healthier and productive society.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5395891/

Personal or home care aide – caregiver responsibilities

In a bigger community – assisted living facility, a home care or personal aide shall perform the following duties.

  • Provides direct and indirect client care elements to clients under the direction of a case manager.
  • Uses appropriate and safe techniques in personal hygiene.
  • Adheres to plan of care for home health aide or personal aide.
  • Observe, report and document client status
  • Maintain a clean safe environment.
  • Assure adequate nutrition and fluid intake.
  • Recognizes emergencies and knows protocols.
  • Safely transfer and ambulate client.
  • Maintains confidentiality.
  • Help maintain the client’s physical and mental well being.
  • Assist the family to care for their family member and at times relieving the family of such care.
  • Encouraging the family to try new ways to provide care and support by using techniques that help the individual achieve the maximum possible level of physical, mental, emotional and social well being.
  • Attends in-services or training as required.
  • May perform other duties as assigned.

For caregivers serving clients in their homes instead of a larger nursing or assisted living facilities, light housekeeping is included and other tasks such as cooking, shopping, driving, laundry, and ensuring the environment is safe and care is coordinated with pharmacists and other health care professionals for medical appointment and client’s well being maintenance.

Important skill sets: Learn CPR, First Aid, nursing care for bedridden clients, grooming, medication management, and other caregiving tips. Always have a heart when performing your job, as your smile and happy disposition helps ease anxiety from clients.

At Motherhealth, our caregivers are trained to give healing massage to our older adult/senior clients. And always be sensitive to the regular routine of the clients and their needs.

Salary varies depending on level of care and ability to pay, salary range from $15 to $25 per hr. Client fee also varies from $20 to $32 per hr.

Live in fees for clients depends on level of care. It starts from $250 to $350 per 24hr care.

Motherhealth is hiring caregivers, personal aide, home care aide and CNA. Text/call 408-8541883 or email motherhealth@gmail.com of your availability.

Training is offered. Get certified by Motherhealth to be a caregiver. Email or text your contact info.

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Babies Exposed to Stimulation Get a Brain Boost

Summary: Contrary to popular belief, exposing children to stimuli early can help to boost their development, researchers report.

Source: NTNU.

Many new parents still think that babies should develop at their own pace, and that they shouldn’t be challenged to do things that they’re not yet ready for. Infants should learn to roll around under their own power, without any “helpful” nudges, and they shouldn’t support their weight before they can stand or walk on their own. They mustn’t be potty trained before they are ready for it.

According to neuroscientist Audrey van der Meer, a professor at the Norwegian University of Science and Technology (NTNU) this mindset can be traced back to the early 1900s, when professionals were convinced that our genes determine who we are, and that child development occurred independently of the stimulation that a baby is exposed to. They believed it was harmful to hasten development, because development would and should happen naturally.

Early stimulation in the form of baby gym activities and early potty training play a central role in Asia and Africa. The old development theory also contrasts with modern brain research that shows that early stimulation contributes to brain development gains even in the wee ones among us.

Using the body and senses

Van der Meer is a professor of neuropsychology and has used advanced EEG technology for many years to study the brain activity of hundreds of babies.

The results show that the neurons in the brains of young children quickly increase in both number and specialization as the baby learns new skills and becomes more mobile. Neurons in very young children form up to a thousand new connections per second.

Van der Meer’s research also shows that the development of our brain, sensory perception and motor skills happen in sync. She believes that even the smallest babies must be challenged and stimulated at their level from birth onward. They need to engage their entire body and senses by exploring their world and different materials, both indoors and out and in all types of weather. She emphasizes that the experiences must be self-produced; it is not enough for children merely to be carried or pushed in a stroller.

Unused brain synapses disappear

“Many people believe that children up to three years old only need cuddles and nappy changes, but studies show that rats raised in cages have less dendritic branching in the brain than rats raised in an environment with climbing and hiding places and tunnels. Research also shows that children born into cultures where early stimulation is considered important, develop earlier than Western children do,” van der Meer says.

She adds that the brains of young children are very malleable, and can therefore adapt to what is happening around them. If the new synapses that are formed in the brain are not being used, they disappear as the child grows up and the brain loses some of its plasticity.

Van der Meer mentions the fact that Chinese babies hear a difference between the R and L sounds when they are four months old, but not when they get older. Since Chinese children do not need to distinguish between these sounds to learn their mother tongue, the brain synapses that carry this knowledge disappear when they are not used.

Loses the ability to distinguish between sounds

Babies actually manage to distinguish between the sounds of any language in the world when they are four months old, but by the time they are eight months old they have lost this ability, according to van der Meer.

In the 1970s, it was believed that children could only learn one language properly. Foreign parents were advised not to speak their native language to their children, because it could impede the child’s language development. Today we think completely differently, and there are examples of children who speak three, four or five languages fluently without suffering language confusion or delays.

Brain research suggests that in these cases the native language area in the brain is activated when children speak the languages. If we study a foreign language after the age of seven, other areas of the brain are used when we speak the language, explains Van der Meer.

She adds that it is important that children learn languages by interacting with real people.

“Research shows that children don’t learn language by watching someone talk on a screen, it has to be real people who expose them to the language,” says van der Meer.

Early intervention with the very young

Since a lot is happening in the brain during the first years of life, van der Meer says that it is easier to promote learning and prevent problems when children are very young.

The term “early intervention” keeps popping up in discussions of kindergartens and schools, teaching and learning. Early intervention is about helping children as early as possible to ensure that as many children as possible succeed in their education and on into adulthood – precisely because the brain has the greatest ability to change under the influence of the ambient conditions early in life.

“When I talk about early intervention, I’m not thinking of six-year-olds, but even younger children from newborns to age three. Today, 98 per cent of Norwegian children attend kindergarten, so the quality of the time that children spend there is especially important. I believe that kindergarten should be more than just a holding place – it should be a learning arena – and by that I mean that play is learning,” says van der Meer.

Too many untrained staff

She adds that a two-year old can easily learn to read or swim, as long as the child has access to letters or water. However, she does not want kindergarten to be a preschool, but rather a place where children can have varied experiences through play.

“This applies to both healthy children and those with different challenges. When it comes to children with motor challenges or children with impaired vision and hearing, we have to really work to bring the world to them,” says van der Meer.

“One-year-olds can’t be responsible for their own learning, so it’s up to the adults to see to it. Today untrained temporary staff tend to be assigned to the infant and toddler rooms, because it’s ‘less dangerous’ with the youngest ones since they only need cuddles and nappy changes. I believe that all children deserve teachers who understand how the brains of young children work. Today, Norway is the only one of 25 surveyed OECD countries where kindergarten teachers do not constitute 50 per cent of kindergarten staffing,” she said.

More children with special needs

Lars Adde is a specialist in paediatric physical therapy at St. Olavs Hospital and a researcher at NTNU’s Department of Laboratory Medicine, Children’s and Women’s Health. He works with young children who have special needs, in both his clinical practice and research.

Image shows a baby playing.

He believes it is important that all children are stimulated and get to explore the world, but this is especially important for children who have special challenges. He points out that a greater proportion of children that are now coming into the world in Norway have special needs.

“This is due to the rapid development in medical technology, which enables us to save many more children – like extremely premature babies and infants who get cancer. These children would have died 50 years ago, and today they survive – but often with a number of subsequent difficulties,” says Adde.

New knowledge offers better treatment

Adde says that the new understanding of brain development that has been established since the 1970s has given these children far better treatment and care options.

For example, the knowledge that some synapses in the brain are strengthened while others disappear has led to the understanding that we have to work at what we want to be good at – like walking. According to the old mindset, any general movement would provide good general motor function.

Babies who are born very prematurely at St. Olavs Hospital receive follow-up by an interdisciplinary team at the hospital and a municipal physiotherapist in their early years. Kindergarten staff where the child attends receive training in exactly how this child should be stimulated and challenged at the appropriate level. The follow-up enables a child with developmental delays to catch up quickly, so that measures can be implemented early – while the child’s brain is still very plastic.

A child may, for example, have a small brain injury that causes him to use his arms differently. Now we know that the brain connections that govern this arm become weaker when it is used less, which reinforces the reduced function.

“Parents may then be asked to put a sock on the “good” hand when their child uses his hands to play. Then the child is stimulated and the brain is challenged to start using the other arm,” says Adde.

Shouldn’t always rush development

Adde stresses that it is not always advisable to speed up the development of children with special needs who initially struggle with their motor skills.

A one–year old learning to walk first has to learn to find her balance. If the child is helped to standing position, she will eventually learn to stand – but before she has learned how to sit down again. If the child loses her balance, she’ll fall like a stiff cane, which can be both scary and counterproductive.

In that situation, “we might then ask the parents to instead help their child up to kneeling position while it holds onto something. Then the child will learn to stand up on its own. If the child falls, it will bend in the legs and tumble on its bum. Healthy children figure this out on their own, but children with special challenges don’t necessarily do this,” says Adde.

ABOUT THIS NEURODEVELOPMENT RESEARCH ARTICLE

Source: NTNU
Image Source: NeuroscienceNews.com image is in the public domain.
Original Research: Full open access research for “Development of Visual Motion Perception for Prospective Control: Brain and Behavioral Studies in Infants” by Seth B. Agyei, F. R. (Ruud) van der Weel and Audrey L. H. van der Meer in Frontiers in Psychology. Published online February 9 2016 doi:10.3389/fpsyg.2016.00100

Abstract for “Longitudinal study of preterm and full-term infants: High-density EEG analyses of cortical activity in response to visual motion” bySeth B. Agyei, F.R. (Ruud) van der Weel, Audrey L.H. van der Meer in Neuropsychologia. Published online April 2016 doi:10.1016/j.neuropsychologia.2016.02.001

CITE THIS NEUROSCIENCENEWS.COM ARTICLE
NTNU “Babies Exposed to Stimulation Get a Brain Boost.” NeuroscienceNews. NeuroscienceNews, 30 January 2017.
<http://neurosciencenews.com/baby-stimulation-neurodevelopment-5844/&gt;.

Abstract

Development of Visual Motion Perception for Prospective Control: Brain and Behavioral Studies in Infants

During infancy, smart perceptual mechanisms develop allowing infants to judge time-space motion dynamics more efficiently with age and locomotor experience. This emerging capacity may be vital to enable preparedness for upcoming events and to be able to navigate in a changing environment. Little is known about brain changes that support the development of prospective control and about processes, such as preterm birth, that may compromise it. As a function of perception of visual motion, this paper will describe behavioral and brain studies with young infants investigating the development of visual perception for prospective control. By means of the three visual motion paradigms of occlusion, looming, and optic flow, our research shows the importance of including behavioral data when studying the neural correlates of prospective control.

“Development of Visual Motion Perception for Prospective Control: Brain and Behavioral Studies in Infants” by Seth B. Agyei, F. R. (Ruud) van der Weel and Audrey L. H. van der Meer in Frontiers in Psychology. Published online February 9 2016 doi:10.3389/fpsyg.2016.00100


Abstract

Longitudinal study of preterm and full-term infants: High-density EEG analyses of cortical activity in response to visual motion

Electroencephalogram (EEG) was used to investigate brain electrical activity of full-term and preterm infants at 4 and 12 months of age as a functional response mechanism to structured optic flow and random visual motion. EEG data were recorded with an array of 128-channel sensors. Visual evoked potentials (VEPs) and temporal spectral evolution (TSE, time-dependent amplitude changes) were analysed. VEP results showed a significant improvement in full-term infants’ latencies with age for forwards and reversed optic flow but not random visual motion. Full-term infants at 12 months significantly differentiated between the motion conditions, with the shortest latency observed for forwards optic flow and the longest latency for random visual motion, while preterm infants did not improve their latencies with age, nor were they able to differentiate between the motion conditions at 12 months. Differences in induced activities were also observed where comparisons between TSEs of the motion conditions and a static non-flow pattern showed desynchronised theta-band activity in both full-term and preterm infants, with synchronised alpha-beta band activity observed only in the full-term infants at 12 months. Full-term infants at 12 months with a substantial amount of self-produced locomotor experience and neural maturation coupled with faster oscillating cell assemblies, rely on the perception of structured optic flow to move around efficiently in the environment. The poorer responses in the preterm infants could be related to impairment of the dorsal visual stream specialized in the processing of visual motion.

“Longitudinal study of preterm and full-term infants: High-density EEG analyses of cortical activity in response to visual motion” bySeth B. Agyei, F.R. (Ruud) van der Weel, Audrey L.H. van der Meer in Neuropsychologia. Published online April 2016 doi:10.1016/j.neuropsychologia.2016.02.001

Caring for parents by gen X

sandwich gen xnurses and caregivers

Most common issues with ailing parents, age 70 to 100 are: lack of appetite, lack of sleep, chronic conditions such as cough, pain, constipation, UTI, anxiety, depression, pneumonia, kidney and liver health issues from polypharmacy, med addiction, arthritis, inflammation and other degenerative health issues. It is very difficult when a spouse care for her ailing husband. She forgets to care for herself. It is also harder for Generation X, the sandwich generation to care for their parents and children at the same time and care for themselves at 50s who are experiencing more health issues.

Contact Motherhealth at motherhealth@gmail.com or text at 408-854-1883 when you need a live in caregiver in the bay area for your home bound seniors.

In the US, health care costs are higher and meds are more expensive.

health over 65

There are many ways,tools, and support group that we can use to care for ourselves and our parents. Caregivers hourly or live in can provide respite when we need to rest from caring for our parents. Nutrition drinks such as Glucerna, Ensure or Boost can be used to provide nourishment to our seniors who do not have big appetite but needs to eat every 3 hours.

Medications have many side effects so review the timing of meds which can make our seniors pee more often at night which interrupt their sleep and so they nap more during the day when they need to get sunshine and walking exercise and daily routine of 3 meals, stimulation and snacks.

Our dietary supplements should be taken during the day as they are mostly stimulants to get us more sleep during the night. Calcium and magnesium and melatonin which help us sleep more should be taken late afternoon.

The goal of many in home caregivers is to allow our seniors to thrive and be active in the comfort of their homes. We use short-stay nursing homes for respite care, care homes for longer stay in company of 6 other senior clients with two caregivers. A hospice nurse or care attends to senior in care homes or in their own homes. Many times when we stop all meds because the senior is under hospice care, they live for more than 2 years instead 6months which their doctor told them so.  Many seniors in care homes who have taken so many meds every day and for many years, have easily bruised tissues because of the acidity of medications.

We can learn from each other in the way we care for our parents. Please email your stories to motherhealth@gmail.com .

Remember to use your memory or lose it, use your muscles or lose it and experience life each day with less worries but with more learning and activity to nourish the soul and body. Children and grandparents should share their lives more with each other.

Older adults caring for their parents should seek caregiving support. In the bay area, 408-854-1883 motherhealth@gmail.com is for caring caregivers 4hrs or live in.  Also call if you need referrals to care homes in the bay area since your seniors decided to downsize and sell their homes and stay in assisted living senior apartments or care homes instead.

Do visit our seniors in care homes, take them out every Sunday and give them massage for 20min or more.  Hospice means our parents do not or cannot eat anymore with diminishing health issues and the doctor or care home admin suggests for hospice care. Dying at home is the most preferred way for many surrounded by love ones.

hospice death

It is very challenging to live with others in a senior care facility. Private rooms are more expensive but 24 hr care is available with meals and many other caregiving services that would help families with other obligations at work, their own children and just visit their our parents in care homes or nursing homes.

sad stories in nursing homes

No matter where you want to spend your sick days, at home or care home or nursing home, plan your health early with support or network of providers and please do not over medicate.   Signs of cancer include: lose of sleep, lose of appetite and chronic health issues such as coughing and pain. Signs of Alzheimer and Dementia are lose of memory. Signs of stroke are inability to talk, move muscles in the body and face, eyes health issues and more. Do inspect your feet and eyes often as your feet and eyes tell more about your health issues than other parts of your body.

Yelp experience, senior care services in the bay area

In promoting my senior care services, I asked others where to advertise.  Caregivers hotline, newspaper, craigslist and other online social media can help promote a business. I started with word of mouth and giving out seminars on Caregiving tips.  Meeting seniors in senior centers and their homes also helped in finding clients who need caregivers because they have hospice care or living alone with Alzheimer’s or Parkinsons.  Their family would call me from my craigslist ad. I will go to their house and give tips on senior proofing the house to avoid falls and ask them what they are looking for in a caregiver and what the needs of their parents are.

Some of my business owners friends like and dislike YELP.com

And I am trying yelp this time to have a good start for my business in 2016.

yelp logo.JPG

yelp logo p2.JPG

Motherhealth caregivers for hourly or live in care, 408-854-1883

motherhealth@gmail.com

http://www.clubalthea.com

Caring for clients with anxiety disorders, the brain in the gut

enteric

Most geriatric and family practice doctors prescribe anti-anxiety and anti-depressent meds from Gabapentin to other narcotics with serious side effects as exhibit more Parkinson’s and Alzheimer’s disease.

One client of mine told her doctor that she does not need anti-depressant med and only need to sleep more or a low dose of a sleeping aid pill. She took melatonin from her own research, an anti-aging supplement.

Many seniors in care homes or living alone in bay area homes are set on their ways. They use the same recliner chair, bed, watch the same TV classic show, listen to the same music and so on. They do not want a lot of changes in their daily routines.

At times, when they could not sleep, they may have constipation and disturbed digestive system (see the section below on – The brain in the gut).

So when caring for seniors, ensure that changes are introduced slowly in their daily routines only when necessary and with their full cooperation and approval. Ensure that they are in a warm environment, cared for with proper meals and changed dry clothes, fed warm food, and just observing their daily needs and assist them with care and love.

Most of my caregivers at Motherhealth caregivers do bring love and care to be effective in their caregiving. They take these seniors as if they are part of their family.

The Enteric Nervous System – The Brain in the Gut

The gut has a mind of its own, the “enteric nervous system”. Just like the larger brain in the head, researchers say, this system sends and receives impulses, records experiences and respond to emotions. Its nerve cells are bathed and influenced by the same neurotransmitters. The gut can upset the brain just as the brain can upset the gut.

The gut’s brain or the “enteric nervous system” is located in the sheaths of tissue lining the esophagus, stomach, small intestine and colon. Considered a single entity, it is a network of neurons, neurotransmitters and proteins that zap messages between neurons, support cells like those found in the brain proper and a complex circuitry that enables it to act independently, learn, remember and, as the saying goes, produce gut feelings.

The gut’s brain is reported to play a major role in human happiness and misery. Many gastrointestinal disorders like colitis and irritable bowel syndrome originate from problems within the gut’s brain. Also, it is now known that most ulcers are caused by a bacterium not by hidden anger at one’s mother.

Details of how the enteric nervous system mirrors the central nervous system have been emerging in recent years, according to Dr. Michael Gershon, professor of anatomy and cell biology at Columbia-Presbyterian Medical Center in New York. He is one of the founders of a new field of medicine called “neurogastroenterology.”

The gut contains 100 million neurons – more than the spinal cord. Major neurotransmitters like serotonin, dopamine, glutamate, norephinephrine and nitric oxide are in the gut. Also two dozen small brain proteins, called neuropeptides are there along with the major cells of the immune system. Enkephalins (a member of the endorphins family) are also in the gut. The gut also is a rich source of benzodiazepines – the family of psychoactive chemicals that includes such ever popular drugs as valium and xanax.

In evolutionary terms, it makes sense that the body has two brains, said Dr. David Wingate, a professor of gastrointestinal science at the University of London and a consultant at Royal London Hospital. “The first nervous systems were in tubular animals that stuck to rocks and waited for food to pass by,” according to Dr. Wingate. The limbic system is often referred to as the “reptile brain.” “As life evolved, animals needed a more complex brain for finding food and sex and so developed a central nervous system. But the gut’s nervous system was too important to put inside the newborn head with long connections going down to the body,” says Wingate. Offspring need to eat and digest food at birth. Therefore, nature seems to have preserved the enteric nervous system as an independent circuit inside higher animals. It is only loosely connected to the central nervous system and can mostly function alone, without instructions from topside.

This is indeed the picture seen by developmental biologists. A clump of tissue called the neural crest forms early in embryo genesis. One section turns into the central nervous system. Another piece migrates to become the enteric nervous system. According to Dr. Gershon, it is only later that the two systems are connected via a cable called the vagus nerve.

The brain sends signals to the gut by talking to a small number of “command neurons,” which in turn send signals to gut interneurons that carry messages up and down the pike. Both command neurons and interneurons are spread throughout two layers of gut tissue called the “myenteric plexus and the submuscosal plexus.” Command neurons control the pattern of activity in the gut. The vagus nerve only alters the volume by changing its rates of firing.

The plexuses also contain glial cells that nourish neurons, mast cells involved in immune responses, and a “blood brain barrier” that keeps harmful substances away from important neurons. They have sensors for sugar, protein, acidity and other chemical factors that might monitor the progress of digestions, determining how the gut mixes and propels its contents.

As light is shed on the circuitry between the two brains, researchers are beginning to understand why people act and feel the way they do. When the central brain encounters a frightening situation, it releases stress hormones that prepare the body to fight or flee. The stomach contains many sensory nerves that are stimulated by this chemical surge – hence the “butterflies.” On the battlefield, the higher brain tells the gut brain to shut down. A frightened running animal does not stop to defecate, according to Dr. Gershon.

Fear also causes the vagus nerve to “turn up the volume” on serotonin circuits in the gut. Thus over stimulated, the gut goes into higher gear and diarrhea results. Similarly, people sometimes “choke” with emotion. When nerves in the esophagus are highly stimulated, people have trouble swallowing.

Even the so-called “Maalox moment” of advertising can be explained by the interaction of the two brains, according to Dr. Jackie D. Wood, chairman of the department of physiology at Ohio State University in Columbus, Ohio. Stress signals from the head’s brain can alter nerve function between the stomach and esophagus, resulting in heartburn.

In cases of extreme stress, Dr. Wood say that the higher brain seems to protect the gut by sending signals to immunological mast cells in the plexus. The mast cells secrete histamine, prostaglandin and other agents that help produce inflammation. This is protective. By inflaming the gut, the brain is priming the gut for surveillance. If the barrier breaks then the gut is ready to do repairs. Unfortunately, the chemicals that get released also cause diarrhea and cramping.

There also is an interaction between the gut brain and drugs. According to Dr. Gershon, “when you make a drug to have psychic effects on the brain, it’s very likely to have an effect on the gut that you didn’t think about.” He also believes that some drugs developed for the brain could have uses in the gut. For example, the gut is loaded with the neurotransmitter serotonin. According to Gershon, when pressure receptors in the gut’s lining are stimulated, serotonin is released and starts the reflexive motion of peristalsis. A quarter of the people taking Prozac or similar antidepressants have gastrointestinal problems like nausea, diarrhea and constipation. These drugs act on serotonin, preventing its uptake by target cells so that it remains more abundant in the central nervous system.

Gershon also is conducting a study of the side effects of Prozac on the gut. Prozac in small doses can treat chronic constipation. Prozac in larger doses can cause constipation – where the colon actually freezes up. Moreover, because Prozac stimulates sensory nerves, it also can cause nausea.

Some antibiotics like erythromycin act on gut receptors to produce ascillations. People experience cramps and nausea. Drugs like morphine and heroin attach to the gut’s opiate receptors, producing constipation. Both brains can be addicted to opiates.

Victims of Alzheimer’s and Parkinson’s diseases suffer from constipation. The nerves in their gut are as sick as the nerve cells in their brains. Just as the central brain affects the gut, the gut’s brain can talk back to the head. Most of the gut sensations that enter conscious awareness are negative things like pain and bloatedness.

The question has been raised: Why does the human gut contain receptors for benzodiazepine, a drug that relieves anxiety? This suggests that the body produces its own internal source of the drug. According to Dr. Anthony Basile, a neurochemist in the Neuroscience Laboratory at the National Institutes of Health in Bethesda, MD, an Italian scientist made a startling discovery. Patients with liver failure fall into a deep coma. The coma can be reversed, in minutes, by giving the patient a drug that blocks benzodiazepine. When the liver fails, substances usually broken down by the liver get to the brain. Some are bad, like ammonia and mercaptan, which are “smelly compounds that skunks spray on you,” says Dr. Basile. But a series of compounds are also identical to benzodiazepine. “We don’t know if they come from the gut itself, from bacteria in the gut or from food, but when the liver fails, the gut’s benzodiazepine goes straight to the brain, knocking the patient unconscious, says Dr. Basile.

The payoff for exploring gut and head brain interactions is enormous, according to Dr. Wood. Many people are allergic to certain foods like shellfish. This is because mast cells in the gut mysteriously become sensitized to antigens in the food. The next time the antigen shows up in the gut, the mast cells call up a program, releasing chemical modulators that try to eliminate the threat. The allergic person gets diarrhea and cramps.

Many autoimmune diseases like Krohn’s disease and ulcerative colitis may involve the gut’s brain, according to Dr. Wood. The consequences can be horrible, as in “Chagas disease,” which is caused by a parasite found in South America. Those infected develop an autoimmune response to neurons in their gut. Their immune systems slowly destroy their own gut neurons. When enough neurons die, the intestines literally explode.

A big question remains. Can the gut’s brain learn? Does it “think” for itself? Dr. Gershon tells a story about an old Army sergeant, a male nurse in charge of a group of paraplegics. With their lower spinal cords destroyed, the patients would get impacted. “At 10am every morning, the patients got enemas. Then the sergeant was rotated off the ward. His replacement decided to give enemas only after compactions occurred. But at 10 the next morning everyone on the ward had a bowel movement at the same time, without enemas.” Had the sergeant trained those colons?

The human gut has long been seen as a repository of good and bad feelings. Perhaps emotional states from the head’s brain are mirrored in the gut’s brain, where they are felt by those who pay attention to them.
Reference: Taken from “A contemporary view of selected subjects from the pages of The New York Times, January 23, 1996. Printed in Themes of the Times: General Psychology, Fall 1996. Distributed Exclusively by Prentice-Hall Publishing Company.

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Motherhealth Inc Caregivers for bay area homebound seniors 408-854-1883 motherhealth@gmail.com

http://www.clubalthea.com

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General Comments:

Since older adults are set on their ways, it is also difficult to change their perspectives and political views. For Bernie Sanders to win, all those 18 to 35 yrs old must vote with full research of political issues and truthful news.

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