Abstract

INTRODUCTION

The ageing population has caused changes in the demand for health care services. Disease of the older population consumes more resources, leads to more hospitalizations and their duration is longer, compared with those of other age groups. ¹⁰10 . Lima-Costa MF, Barreto S, Giatti L. Condições de saúde, capacidade funcional, uso de serviços de saúde e gastos com medicamentos da população idosa brasileira: PNAD. Cad Saude Publica. 2003;19(3):735-43. DOI:10.1590/S0102-311X2003000300006
https://doi.org/10.1590/S0102-311X200300... ^{, 11}11 . Louvison MCP, Lebrão ML, Duarte YAO, Santos JLF, Malik AM, Almeida ES. Desigualdades no uso e acesso aos serviços de saúde entre idosos do município de São Paulo. Rev Saude Publica. 2008;42(4):733-40. DOI:10.1590/S0034-89102008000400021
https://doi.org/10.1590/S0034-8910200800... ^{, 18}18 . Sawyer DO, Leite IC, Alexandrino R. Perfis de utilização de serviços de saúde no Brasil. Cienc Saude Coletiva. 2002;7(4):757-76. DOI:10.1590/S1413-81232002000400012
https://doi.org/10.1590/S1413-8123200200... ^{, 23}23 . Veras R, Parahyba MI. Anacronismo dos modelos assistenciais para os idosos na área de saúde: desafios para o setor privado. Cad Saude Publica. 2007;23(10):2479-89. DOI:10.1590/S0102-311X2007001000022
https://doi.org/10.1590/S0102-311X200700...

There are many reasons behind the use of health care services by older individuals. These include factors concerning the individual and the structure of the services provided, as well as factors concerning the social environment in which the older individual lives. Identifying the factors which influence this demand may help in proposing suitable public policies.

Little is known about the extent to which chronic pain in older individuals influences the use of the services, as it is rarely recorded in official health care statistics. Pain can be associated with chronic pathological processes, which last for months or years, or to the variety of diseases that affect older adults and may be the source of chronic pain. Chronic pain is defined as that which persists beyond the time reasonably expected for the healing of the injury, or pain that lasts for more than six months, according to the criteria established by the International Association for the Study of Pain (IASP). ^aaMerskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2 ed. Washington (DC): Internacional Association for the Study of Pain; 1994. , ^bbInternational Association for the Study of Pain. IASP-Taxonomy. Proposed Taxonomy Changes. Washington (DC); 2008:1-4 [cited 2012 Jan 24]. Available from: http://www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=6633

Pain is often the cause for use of health care services by individuals of all ages and in all parts of the world, ³3 . Blyth FM, March LM, Cousins MJ. Chronic pain-related disability and use of analgesia and health services in a Sydney community. Med J Aust. 2003;179(2):84-7. ^{, 5}5 . D’Avolio DA, Feldman J, Mitchell P, Strumpf N. Access to care and health-related quality of life among older adults with non urgent emergency department visits. Geriatr Nurs. 2008;29(4):240-6. DOI:10.1016/j.gerinurse.2008.06.005
https://doi.org/10.1016/j.gerinurse.2008... ^{, 12}12 . Mossey JM, Gallagher RM. The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents. Pain Med. 2004;5(4):335-48. DOI:10.1111/j.1526-4637.2004.04041.x
https://doi.org/10.1111/j.1526-4637.2004... ^{, 15}15 . Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(6):793-97. DOI:10.1093/gerona/60.6.793
https://doi.org/10.1093/gerona/60.6.793...

16 . Reyes-Gibby CC, Aday L, Cleeland C. Impact of pain on self-rated health in the community-dwelling older adults. Pain. 2002;95(1/2):75-82. DOI:10.1016/S0304-3959(01)00375-X
https://doi.org/10.1016/S0304-3959(01)00... ^{- 17}17 . Rosa MRQP, Patrício ZM, Silvério MR, Rumel D. Motivos que levaram idosos a buscar atenção em uma unidade básica de saúde. Rev Lat Am Enferm. 2009;17(5):670-76. DOI:10.1590/S0104-11692009000500012
https://doi.org/10.1590/S0104-1169200900... ^{, 19}19 . Sha MC, Callahan CM, Counsell SR, Westmoreland GR, Stump TE, Kroenke K. Physical symptoms as a predictor of health care use and mortality among older adults. Am J Med. 2005;118(3):301-6. DOI:10.1016/j.amjmed.2004.12.015
https://doi.org/10.1016/j.amjmed.2004.12... ^{, 21}21 . Thorstensson CA, Gooberman-Hill R, Adamson J, Williams S, Dieppe P. Help-seeking behaviour among people living with chronic hip or knee pain in the community. BMC Msuculoskelet Disord. 2009;(10):153. ^{, 22}22 . Venturi I, Rosado LEFP, Cotta RMM, Rosado GP, Doimo LA, Tinoco ALA, et al. Identificação da área de influência do serviço de atenção básica do sistema público de saúde à população idosa, município de Viçosa-MG. Cienc Saude Coletiva. 2008;13(4):1293-304. DOI:10.1590/S1413-81232008000400026
https://doi.org/10.1590/S1413-8123200800... and individuals suffering from chronic pain make more use of these services compared with other patients. ¹1 . Blay SL. Andreoli SB, Gastal FL. Chronic painful physical conditions, disturbed sleep and psychiatric morbidity: results from an elderly survey. Ann Clin Psychiatry. 2007;19(3):169-74. DOI:10.1080/10401230701468099
https://doi.org/10.1080/1040123070146809... ^{, 2}2 . Blyth FM, March LM, Brnabic AJ, Cousins MJ. Chronic pain and frequent use of health care. Pain. 2004;111(1-2):51-8. DOI:10.1016/j.pain.2004.05.020
https://doi.org/10.1016/j.pain.2004.05.0... ^{, 6}6 . Eriksen J, Sjogren P, Ekholm O, Rasmussen NK. Health care utilisation among individuals reporting long – term pain: an epidemilogical study based on Danish National Health Surveys. Eur J Pain. 2004;8(6):517-23. DOI:10.1016/j.ejpain.2003.12.001
https://doi.org/10.1016/j.ejpain.2003.12... ^{, 12}12 . Mossey JM, Gallagher RM. The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents. Pain Med. 2004;5(4):335-48. DOI:10.1111/j.1526-4637.2004.04041.x
https://doi.org/10.1111/j.1526-4637.2004...

Pain is the motive for using emergency health care services, ⁵5 . D’Avolio DA, Feldman J, Mitchell P, Strumpf N. Access to care and health-related quality of life among older adults with non urgent emergency department visits. Geriatr Nurs. 2008;29(4):240-6. DOI:10.1016/j.gerinurse.2008.06.005
https://doi.org/10.1016/j.gerinurse.2008... primary health care services ⁷7 . Jordan K, Jinks C, Croft P. A prospective study of the consulting behavior of older people with Knee pain. Br J Gen Pract. 2006;56(525):269-76. ^{, 12}12 . Mossey JM, Gallagher RM. The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents. Pain Med. 2004;5(4):335-48. DOI:10.1111/j.1526-4637.2004.04041.x
https://doi.org/10.1111/j.1526-4637.2004... ^{, 17}17 . Rosa MRQP, Patrício ZM, Silvério MR, Rumel D. Motivos que levaram idosos a buscar atenção em uma unidade básica de saúde. Rev Lat Am Enferm. 2009;17(5):670-76. DOI:10.1590/S0104-11692009000500012
https://doi.org/10.1590/S0104-1169200900... and consultations. ¹1 . Blay SL. Andreoli SB, Gastal FL. Chronic painful physical conditions, disturbed sleep and psychiatric morbidity: results from an elderly survey. Ann Clin Psychiatry. 2007;19(3):169-74. DOI:10.1080/10401230701468099
https://doi.org/10.1080/1040123070146809... ^{, 7}7 . Jordan K, Jinks C, Croft P. A prospective study of the consulting behavior of older people with Knee pain. Br J Gen Pract. 2006;56(525):269-76. ^{, 15}15 . Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(6):793-97. DOI:10.1093/gerona/60.6.793
https://doi.org/10.1093/gerona/60.6.793... ^{, 16}16 . Reyes-Gibby CC, Aday L, Cleeland C. Impact of pain on self-rated health in the community-dwelling older adults. Pain. 2002;95(1/2):75-82. DOI:10.1016/S0304-3959(01)00375-X
https://doi.org/10.1016/S0304-3959(01)00... However, decreases in the use of these services is associated with serious depression. ⁷7 . Jordan K, Jinks C, Croft P. A prospective study of the consulting behavior of older people with Knee pain. Br J Gen Pract. 2006;56(525):269-76.

Among the older population, pain is one of the causes of seeking health care at all levels of the service. But there is little that can be concluded about which characteristics of pain are most burdensome for the health care services, especially for the older population in Brazil.

Venturi et al ²²22 . Venturi I, Rosado LEFP, Cotta RMM, Rosado GP, Doimo LA, Tinoco ALA, et al. Identificação da área de influência do serviço de atenção básica do sistema público de saúde à população idosa, município de Viçosa-MG. Cienc Saude Coletiva. 2008;13(4):1293-304. DOI:10.1590/S1413-81232008000400026
https://doi.org/10.1590/S1413-8123200800... and Rosa et al ⁷7 . Jordan K, Jinks C, Croft P. A prospective study of the consulting behavior of older people with Knee pain. Br J Gen Pract. 2006;56(525):269-76. identified pain as the most frequent complaint in the older individuals who used the Brazilian Unified Health System. Another study analyzed the presence of chronic pain and health care service use by 7,000 older individuals who were interviewed about sleep disturbances and pain complaints, and showed that it was those individuals who suffered from pain and insomnia who had the most consultations and hospitalizations. ¹1 . Blay SL. Andreoli SB, Gastal FL. Chronic painful physical conditions, disturbed sleep and psychiatric morbidity: results from an elderly survey. Ann Clin Psychiatry. 2007;19(3):169-74. DOI:10.1080/10401230701468099
https://doi.org/10.1080/1040123070146809...

There are issues which need to be clarified, such as which characteristics of chronic pain affect health care service use by the older population living in the community, or what personal, socioeconomic and health characteristics are possessed by the older individuals with chronic pain who make the most use of health care services.

The aim of this study was to analyze the association between health care service use among older adults suffering from chronic pain and sociodemographic and health variables.

METHODS

This was a cross-sectional population based study. The data came from the Saúde, Bem-estar e Envelhecimento (SABE – Health, Well-Being and Ageing) project, which aimed to identify the health and living conditions in older individuals resident in seven cities in Latin America and the Caribbean. The SABE is a longitudinal study, with data collected in 2000, 2006 and 2010. The data analyzed were from 2006, when questions about chronic pain were included.

The sample of the 2006 survey was made up of the surviving older individuals who had participated in the 2000 survey, who were re-interviewed (n = 1,115) and individuals aged 60 to 64, who composed a new cohort representing the 60-64 year old population in the municipality of Sao Paulo, SP. New weighting was carried out, allowing these two samples to be combined, resulting in 1,413 individuals in 2006. Details on the sampling technique can be found in Silva et al ²⁰20 . Silva NS, Nazário CL, Lima FD. Aspectos metodológicos. In: Lebrão ML, Oliveira, YA. SABE – Saúde, Bem-estar e Envelhecimento – O Projeto SABE no município de São Paulo: uma abordagem inicial. Brasília (DF): Organização Pan-Americana; 2003. p. 45-72. (2003) and Lebrão & Laurenti ⁹9 . Lebrão ML, Laurenti R. Saúde, bem estar e envelhecimento: o estudo SABE no município de São Paulo. Rev Bras Epidemiol. 2005;8(2):127-41. DOI:10.1590/S1415-790X2005000200005
https://doi.org/10.1590/S1415-790X200500... (2005). The diagram summarizes the composition of the sample of individuals interviewed in 2006 and included in the analyses in this article ( Figure 1 ). Considering the subjectivity of pain, it was decided not to include individuals with cognitive deficiencies in the analyses.

The older individuals, totaling 1,271, had a mean age of 69.5 (SE = 0.6), the majority (59.5%) were women, did not work (68.3%), had between one and four years of schooling (59.4%) and did not live alone (86.6%). The most common household income was between one and three minimum wages (42.8%).

The dependent variable “use of health care services” was measured by the presence of one hospitalization lasting at least one day, and by having requested more than four consultations in the preceding 12 months.

Outpatient care and primary care consultations were included. Given the high prevalence of high blood pressure and diabetes among the older population, and that programs ^ccGoverno do Estado de São Paulo. Secretaria de Estado da Saúde. Assessoria Técnica do Gabinete do Secretário. Documento Linha do Cuidado - Diabetes – Quadro Sínteses – Atenção na Unidade Básica de Saúde. São Paulo; 2010 p. 29. [cited 2011 Dec 25]. Available from: http://www.saude.sp.gov.br/ses/perfil/cidadao/areas-tecnicas-da-sessp/hipertensao-arterial-e-diabetes-mellitus/linhas-de-cuidado-sessp/hipertensao-arterial-sistemica/documento-da-linha-de-cuidado/quadros-sinteses , ^ddGoverno do Estado de São Paulo. Secretaria de Estado da Saúde. Assessoria Técnica do Gabinete do Secretário. Documento Linha do Cuidado - Diabetes – Quadro Sínteses – Atenção na Unidade Básica de Saúde. São Paulo; 2010 p. 2. [cited 2011 Dec 25]. Available from: http://www.saude.sp.gov.br/ses/perfil/cidadao/areas-tecnicas-da-sessp/hipertensao-arterial-e-diabetes-mellitus/linhas-de-cuidado-sessp/diabetes-mellitus/documento-tecnico-da-linha-de-cuidado/quadros-sinteses , ^eeMion Jr D, Kohlmann Jr O, Machado CA, Amodeo C, Gomes MAM, Praxedes JN, et al. Diagnóstico e Classificação. In. Sociedade Brasileira de Hipertensão. V Diretrizes Brasileira de Hipertensão. São Paulo; 2006. p. 7-13. recommend three to four consultations per year for these diseases, more than four consultations/year was considered the cutoff point for analyzing use of health care services potentially related to pain.

Two subgroups were created for the analyses: older individuals with up to four consultations/year and with no hospitalization during the period, and those with more than four consultations/year or with at least one hospitalization during the period.

Older individuals suffering from pain for more than 12 months were selected for analyses of the outcomes of use of health care services, as issues concerning health care service use investigated episodes in the preceding 12 months.

The independent variables used were: sociodemographic characteristics; presence of pain and chronic pain; chronic pain was characterized as that which most discomfited the older individual, and was characterized according to location, duration, intensity and frequency; depression; self-reported disease; functional capacity, evaluated based on activities of daily living (basic and instrumental); assessment of mobility; interference caused by pain, assessed using the SF12 quality of life scale, by the question: “During the last four weeks (the last month), to what extent has the presence of pain interfered with your normal work?” (including work within and outside of the home). The categories of analysis were: not at all; a little/moderately and quite a lot/extremely.

In the univariate analysis the relationship between the outcome “use of health care services” and the independent variables was analyzed using the Rao & Scott ¹³13 . Rao JNK, Scott AJ. On chi-squared for multiway contingency tables with cell proportions estimated from survey data. Ann Stat. 1984;12(1):46-60. DOI:10.1214/aos/1176346391
https://doi.org/10.1214/aos/1176346391... test of association for complex samples. Variables with p < 0.25 were included in the multiple analysis. Prevalence ratios obtained using Cox’s regression (with robust variance) were analyzed.

The data were analyzed using the Stata 11.0 program (StataCorp LP, College Station, Texas, USA). The Rao & Scott ¹³13 . Rao JNK, Scott AJ. On chi-squared for multiway contingency tables with cell proportions estimated from survey data. Ann Stat. 1984;12(1):46-60. DOI:10.1214/aos/1176346391
https://doi.org/10.1214/aos/1176346391... test of association, which considers the sample design, was used to analyze the relationship between the outcome variables (use of health care services) and the possible independent variables.

The project was approved by the Research Ethics Committee of the Faculdade de Saúde Pública, Universidade de São Paulo (Process COEP/83/06 March 14, 2006).

RESULTS

Pain was most frequently reported in women (p < 0.007). The intensity of the pain was associated with household income (p = 0.005): 37.0% of the older adults with household income ≥ 3 minimum wages reported mild/moderate pain and 17.0% intense pain, whereas in individuals with income ≤ 1 minimum wage, 20.9% reported mild/moderate pain and 42.7% intense or very intense pain. The other sociodemographic variables did not prove to be significantly associated with the presence of pain.

The presence of individuals suffering from pain for more than one year was 26.9% (95%CI 22.8;31.1); the percentage of those with more than four consultations in the last year and/or at least one hospitalization was 48.6% (95%CI 43.8;53.4). Use of health care services by the older adults suffering from pain for at least one year was 44.0% (95%CI 35.1;52.8) and there was no difference when compared with service use by individuals not suffering from pain (prevalence: 50.5%; 95%CI 45.1;55.9; p = 0.190).

No association was found between the sociodemographic variables and suffering from pain for one year or more and the use of health care services ( Table 1 ).

Pain lasting for a longer time was a protection factor for health care service use. Individuals with mild or moderate pain used health care services less than those with more intense pain.

Older adults both with and without chronic pain showed a high prevalence of disease ( Table 2 ).

Asthma was the complaint that showed the greatest trend for risk of using health care services by older individuals suffering from pain (PR = 1.53; 95%CI 1.14;2.04) (p = 0.005).

Degree of dependence did not affect the frequency of health care service use among older individuals suffering from pain ( Table 3 ). However, individuals with moderate interference by pain in their work had a 52.0% higher risk of using health care services compared with those whose daily work activities were not affected by pain.

The variables inserted into the multiple analysis were: duration of the pain, asthma, intensity of the pain, interference with work, household income, hypertension, cerebral embolism, cataracts, age, urinary incontinence, sex, fecal incontinence and osteoporosis ( Table 4 ).

The likelihood of using outpatient and/or hospital services was 33.0% lower for an older individual who had been suffering from pain for more than two years, compared with an individual suffering from pain for between one and two years (p = 0.002). Those with strong, intense and very strong, very intense pain had a 55.0% greater likelihood of using health care services compared with those with mild, medium or moderate pain (p = 0.003). Those who experienced moderate interference from pain in their normal work had a 52.0% greater likelihood of using health care services compared with those who experienced no such interference (p = 0.015).

The other variables which were statistically significant in the univariate analysis did not maintain the same significance in the final model.

DISCUSSION

There was no significant use in the use of health care services by older adults with and without chronic pain. The principal hypothesis is that the older individuals in question had a variety of diseases, which constituted a risk of elevated use of health care services. In addition, chronic pain, defined based on the criteria of duration may include different painful conditions, with differing degrees of severity. The size of the sample analyzed in the use of health care services may have influenced the statistical analyses, impeding other associations from being proved.

Studies analyzing the risk factors for the use of health care services by the older population state that complaints of pain is one of the most important factors. ⁵5 . D’Avolio DA, Feldman J, Mitchell P, Strumpf N. Access to care and health-related quality of life among older adults with non urgent emergency department visits. Geriatr Nurs. 2008;29(4):240-6. DOI:10.1016/j.gerinurse.2008.06.005
https://doi.org/10.1016/j.gerinurse.2008... ^{, 15}15 . Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(6):793-97. DOI:10.1093/gerona/60.6.793
https://doi.org/10.1093/gerona/60.6.793... ^{, 16}16 . Reyes-Gibby CC, Aday L, Cleeland C. Impact of pain on self-rated health in the community-dwelling older adults. Pain. 2002;95(1/2):75-82. DOI:10.1016/S0304-3959(01)00375-X
https://doi.org/10.1016/S0304-3959(01)00... ^{, 19}19 . Sha MC, Callahan CM, Counsell SR, Westmoreland GR, Stump TE, Kroenke K. Physical symptoms as a predictor of health care use and mortality among older adults. Am J Med. 2005;118(3):301-6. DOI:10.1016/j.amjmed.2004.12.015
https://doi.org/10.1016/j.amjmed.2004.12...

Two Brazilian studies indicate that pain is the most frequent reason for using health care services. ¹⁷17 . Rosa MRQP, Patrício ZM, Silvério MR, Rumel D. Motivos que levaram idosos a buscar atenção em uma unidade básica de saúde. Rev Lat Am Enferm. 2009;17(5):670-76. DOI:10.1590/S0104-11692009000500012
https://doi.org/10.1590/S0104-1169200900... ^{, 22}22 . Venturi I, Rosado LEFP, Cotta RMM, Rosado GP, Doimo LA, Tinoco ALA, et al. Identificação da área de influência do serviço de atenção básica do sistema público de saúde à população idosa, município de Viçosa-MG. Cienc Saude Coletiva. 2008;13(4):1293-304. DOI:10.1590/S1413-81232008000400026
https://doi.org/10.1590/S1413-8123200800... No Brazilian studies were found which had analyzed whether older individuals suffering from pain made more use of health care services than those not suffering from pain.

Musculoskeletal pain, ⁵5 . D’Avolio DA, Feldman J, Mitchell P, Strumpf N. Access to care and health-related quality of life among older adults with non urgent emergency department visits. Geriatr Nurs. 2008;29(4):240-6. DOI:10.1016/j.gerinurse.2008.06.005
https://doi.org/10.1016/j.gerinurse.2008... ^{, 7}7 . Jordan K, Jinks C, Croft P. A prospective study of the consulting behavior of older people with Knee pain. Br J Gen Pract. 2006;56(525):269-76. ^{, 15}15 . Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(6):793-97. DOI:10.1093/gerona/60.6.793
https://doi.org/10.1093/gerona/60.6.793... ^{, 19}19 . Sha MC, Callahan CM, Counsell SR, Westmoreland GR, Stump TE, Kroenke K. Physical symptoms as a predictor of health care use and mortality among older adults. Am J Med. 2005;118(3):301-6. DOI:10.1016/j.amjmed.2004.12.015
https://doi.org/10.1016/j.amjmed.2004.12... pain in general, ¹⁶16 . Reyes-Gibby CC, Aday L, Cleeland C. Impact of pain on self-rated health in the community-dwelling older adults. Pain. 2002;95(1/2):75-82. DOI:10.1016/S0304-3959(01)00375-X
https://doi.org/10.1016/S0304-3959(01)00... ^{, 17}17 . Rosa MRQP, Patrício ZM, Silvério MR, Rumel D. Motivos que levaram idosos a buscar atenção em uma unidade básica de saúde. Rev Lat Am Enferm. 2009;17(5):670-76. DOI:10.1590/S0104-11692009000500012
https://doi.org/10.1590/S0104-1169200900... ^{, 19}19 . Sha MC, Callahan CM, Counsell SR, Westmoreland GR, Stump TE, Kroenke K. Physical symptoms as a predictor of health care use and mortality among older adults. Am J Med. 2005;118(3):301-6. DOI:10.1016/j.amjmed.2004.12.015
https://doi.org/10.1016/j.amjmed.2004.12... ^{, 22}22 . Venturi I, Rosado LEFP, Cotta RMM, Rosado GP, Doimo LA, Tinoco ALA, et al. Identificação da área de influência do serviço de atenção básica do sistema público de saúde à população idosa, município de Viçosa-MG. Cienc Saude Coletiva. 2008;13(4):1293-304. DOI:10.1590/S1413-81232008000400026
https://doi.org/10.1590/S1413-8123200800... incapacitating pain ¹²12 . Mossey JM, Gallagher RM. The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents. Pain Med. 2004;5(4):335-48. DOI:10.1111/j.1526-4637.2004.04041.x
https://doi.org/10.1111/j.1526-4637.2004... and insomnia-related pain are among the characteristics of pain related to increased use of health care services. ¹1 . Blay SL. Andreoli SB, Gastal FL. Chronic painful physical conditions, disturbed sleep and psychiatric morbidity: results from an elderly survey. Ann Clin Psychiatry. 2007;19(3):169-74. DOI:10.1080/10401230701468099
https://doi.org/10.1080/1040123070146809...

Suffering intense pain increases the likelihood of using health care services by 55.0%, as does pain which interferes moderately in work (52.0%) ( Table 4 ).

Mild and moderate pain which does not interfere with day-to-day activities may be born and controlled without the need to use the health care services. Intense and very intense pain, and that which impacts negatively on activities at work and in the home are reasons for seeking help, aiming to reduce the suffering. They need to be controlled to decrease the impact on life. Thus, judgments and prejudices, resulting from the conception that pain may be caused by lack of care on the part of the sufferer or used to obtain personal advantages, are avoided.

Use of health care services increases among those suffering from incapacitating chronic ²2 . Blyth FM, March LM, Brnabic AJ, Cousins MJ. Chronic pain and frequent use of health care. Pain. 2004;111(1-2):51-8. DOI:10.1016/j.pain.2004.05.020
https://doi.org/10.1016/j.pain.2004.05.0... ^{, 3}3 . Blyth FM, March LM, Cousins MJ. Chronic pain-related disability and use of analgesia and health services in a Sydney community. Med J Aust. 2003;179(2):84-7. ^{, 15}15 . Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(6):793-97. DOI:10.1093/gerona/60.6.793
https://doi.org/10.1093/gerona/60.6.793... ^{, 21}21 . Thorstensson CA, Gooberman-Hill R, Adamson J, Williams S, Dieppe P. Help-seeking behaviour among people living with chronic hip or knee pain in the community. BMC Msuculoskelet Disord. 2009;(10):153. and intense pain, ³3 . Blyth FM, March LM, Cousins MJ. Chronic pain-related disability and use of analgesia and health services in a Sydney community. Med J Aust. 2003;179(2):84-7. ^{, 12}12 . Mossey JM, Gallagher RM. The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents. Pain Med. 2004;5(4):335-48. DOI:10.1111/j.1526-4637.2004.04041.x
https://doi.org/10.1111/j.1526-4637.2004... ^{, 21}21 . Thorstensson CA, Gooberman-Hill R, Adamson J, Williams S, Dieppe P. Help-seeking behaviour among people living with chronic hip or knee pain in the community. BMC Msuculoskelet Disord. 2009;(10):153. ^{, 24}24 . Weiner DK, Rudy TE, Kim YS, Golla S. Do medical factors predict disability in older adults with persistent low back pain? Pain. 2004;112(1):214-20. DOI:10.1016/j.pain.2004.08.027
https://doi.org/10.1016/j.pain.2004.08.0... as seen in this study.

Another significant result was the greater duration of the pain being a protection factor against use of health care service use, compared with pain lasting for a shorter time ( Table 4 ).

At first, when suffering from pain, health care service use may be motivated by the expectation of obtaining a diagnosis and treatment which would control the suffering. In cases where this expectation is not met and the pain continues, individuals appear to opt for active analgesic strategies and not depend on health care professionals.

Weiner et al (2004) analyzed the relationship between the duration of pain in the lumbar region and health care service use, and verified results similar to those found in this study, in which pain lasting for shorter periods of time increases use of health care services. ²⁴24 . Weiner DK, Rudy TE, Kim YS, Golla S. Do medical factors predict disability in older adults with persistent low back pain? Pain. 2004;112(1):214-20. DOI:10.1016/j.pain.2004.08.027
https://doi.org/10.1016/j.pain.2004.08.0...

A differing result was found among older individuals with incapacitating pain in the lumbar region, in whom pain lasting for more than four months led them to use health care services more often than those who suffered from pain for up to three months. ¹⁵15 . Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(6):793-97. DOI:10.1093/gerona/60.6.793
https://doi.org/10.1093/gerona/60.6.793... This difference may be due to the fact that Reid et al ¹⁵15 . Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(6):793-97. DOI:10.1093/gerona/60.6.793
https://doi.org/10.1093/gerona/60.6.793... (2005) studied incapacitating lumbar pain. In contrast, Weiner et al ²⁴24 . Weiner DK, Rudy TE, Kim YS, Golla S. Do medical factors predict disability in older adults with persistent low back pain? Pain. 2004;112(1):214-20. DOI:10.1016/j.pain.2004.08.027
https://doi.org/10.1016/j.pain.2004.08.0... (2004) studied lumbar pain in general, which may have included pain that interfered less in the older individual’s life.

Pain is considered, by the elderly and health care professionals alike, to be a normal part of the ageing process. This idea leads to inadequate assessment and control of pain which imposes suffering on the older population. ⁴4 . Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143(6):427-38. DOI:10.7326/0003-4819-143-6-200509200-00007
https://doi.org/10.7326/0003-4819-143-6-... ^{, 8}8 . Karlsson S, Edberg AK, Hallberg IR. Professional’s and older person’s assessments of functional ability, health complaints and received care and service: a descriptive study. Int J Nurs Stud. 2010;47(10):1217-27. DOI:10.1016/j.ijnurstu.2010.03.003
https://doi.org/10.1016/j.ijnurstu.2010.... ^{, 25}25 . Zyczkowska J, Szczerbinska K, Jantzi MR, Hirdes JP. Pain among the oldest old in community and institutional settings. Pain. 2007;129(1-2):167-76. DOI:10.1016/j.pain.2006.12.009
https://doi.org/10.1016/j.pain.2006.12.0... Studies reinforce the hypothesis that decreasing use of consultations by older individuals suffering from pain for more than two years could be related to treatment having little effect. ⁴4 . Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143(6):427-38. DOI:10.7326/0003-4819-143-6-200509200-00007
https://doi.org/10.7326/0003-4819-143-6-... ^{, 25}25 . Zyczkowska J, Szczerbinska K, Jantzi MR, Hirdes JP. Pain among the oldest old in community and institutional settings. Pain. 2007;129(1-2):167-76. DOI:10.1016/j.pain.2006.12.009
https://doi.org/10.1016/j.pain.2006.12.0...

Among 152 older adults seen in public health care in Sweden, the agreement between their self-evaluation and that of the health care professionals was verified. The concordance for pain was poor (Kw = 0.21) (Karlsson et al, ⁸8 . Karlsson S, Edberg AK, Hallberg IR. Professional’s and older person’s assessments of functional ability, health complaints and received care and service: a descriptive study. Int J Nurs Stud. 2010;47(10):1217-27. DOI:10.1016/j.ijnurstu.2010.03.003
https://doi.org/10.1016/j.ijnurstu.2010.... 2010), meaning that very often pain is not properly assessed and is under-identified by health care professionals.

Chodosh et al (2005) analyzed randomized case-control studies in a meta-analysis of the effect of programs of control on chronic disease in older adults. The comparison showed a difference of -0.06 (95%CI -0.10;-0.02), between the intervention and control groups, representing 2 mm in the 100 mm of the analogical visual scale. ⁴4 . Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143(6):427-38. DOI:10.7326/0003-4819-143-6-200509200-00007
https://doi.org/10.7326/0003-4819-143-6-... This meta-analysis concerned the poor effectiveness of programs related to controlling pain from osteoarthritis.

A bibliographical review analyzed 27 studies on the results of programs for older individuals suffering from musculoskeletal pain and found more favorable results: the results were positive in 96.0% of the studies. The proportion by which the pain changed was between 18.0% and 85.0%, with a mean 23.0% improvement. The degree of incapacity provoked by pain ranged from a 2.0% increase to a 70.0% decrease, with a mean 19.0% reduction. The study analyzed programs controlling pain from osteoarthritis, therapies such as yoga, massage and Tai chi , with different designs. ¹⁴14 . Reid MC, Papaleontiou M, Ong A, Breckman R, Wethington E, Pillemer K, et al. Self-Management strategies to reduce pain and improve function among older adults in community settings: a review of the evidence. Pain Med. 2008;9(4):409-24. DOI:10.1111/j.1526-4637.2008.00428.x
https://doi.org/10.1111/j.1526-4637.2008... The methodological differences between the two studies may have influenced the differences in their results.

Another hypothesis which may explain decreasing use of health care services on the part of older individuals suffering from long-term pain, concerns differences in the assessment and perception of pain in this age group. Ageing provokes a decrease in the sensory threshold, which may explain changes in the manifestation of pain, alterations which are well-known in acute injuries. Degeneration of the structure of the peripheral and central nervous system can alter the processing and the perception of painful stimuli. However, it is unclear whether or not this degenerative ageing process affects the perception of chronic pain.

There are many reasons why individuals use health care services and these involve factors related to the individual and to the organization of the services. Factors concerning the client include social and cultural aspects and health conditions’ those related to the health care system include availability of services, conditions of access, quality of health care and the population’s link to the services.

The randomized sampling technique, based on census tracts ensured that the sample was representative of the older population living in the urban area of Sao Paulo. The completeness and the quality of the data collected in the SABE study ²⁰20 . Silva NS, Nazário CL, Lima FD. Aspectos metodológicos. In: Lebrão ML, Oliveira, YA. SABE – Saúde, Bem-estar e Envelhecimento – O Projeto SABE no município de São Paulo: uma abordagem inicial. Brasília (DF): Organização Pan-Americana; 2003. p. 45-72. provided diverse information which enabled the variables to be controlled, strengthening the associations found. The methodological strategy of controlling for the influence of other comorbidities meant that the real influence of pain on health care service use could be shown.

The data used came from a survey on overall health, with no specific focus on pain, which could be considered a limitation of this study. Thus, service use was broadly investigated, without a direct search into the relationship with the presence of pain.

The data were based on self-reporting of the diseases and phenomena analyzed. Memory tends to be effective for outstanding events such as hospitalization, but may be less precise with regards consultations. There is a tendency to underestimate the frequency of health care service use when the data depends solely on the memory. Self-reported diseases are based on the reports of older individuals and were not confirmed with health care service documentation. However, the SABE study carried out a careful assessment of the cognitive state of the older individual and, in cases of cognitive deficiency, a supporting or substitute interviewee was used, to ensure greater reliability in the data collected.

It is possible to show association between the phenomena in question using cross sectional analysis, although no causality should be inferred.

Recognition of pain as a health problem to be assessed, diagnosed and treated and not to interpret it solely as a symptom of another disease means that measures for its control can be proposed, which could improve the living and health conditions of a considerable number of older individuals.

In conclusion, the results show that pain interferes in different aspects of the life of older individuals, as well as burdening the health care service.

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