Fibromyalgia severity according to age categories: results of a cross-sectional study from a large national database - Clinical ...
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Fibromyalgia severity according to age categories: results
of a cross-sectional study from a large national database
M. Di Carlo1, S. Farah1, L. Bazzichi2, F. Atzeni3, M. Govoni4, G. Biasi5, M. Di Franco6, F. Mozzani7,
E. Gremese8, L. Dagna9, A. Batticciotto10, F. Fischetti11, R. Giacomelli12, S. Guiducci13, G. Guggino14,
M. Bentivegna15, R. Gerli16, C. Salvarani17, G. Bajocchi18, M. Ghini19, F. Iannone20, V. Giorgi21,
M. Cirillo3, S. Bonazza4, S. Barbagli5, C. Gioia6, N.G. Marino7, A. Capacci8, G. Cavalli9, A. Cappelli10,
F. Carubbi22, F. Nacci13, I. Riccucci16, M. Cutolo23, L. Sinigaglia24, P. Sarzi-Puttini21, F. Salaffi1
1
Rheumatology Clinic, Dept. of Clinical and Molecular Sciences, Università Politecnica delle Marche, Jesi,
Ancona; 2Rheumatology Unit, AOU Pisana, Pisa; 3Rheumatology Unit, Dept. of Internal Medicine, University
of Messina; 4Rheumatology, Dept. of Medical Sciences, University of Ferrara and Azienda Ospedaliera-
Universitaria S. Anna di Ferrara; 5Rheumatology Unit, Dept. of Medical Sciences, Surgery and Neurosciences,
University of Siena; 6Dept. of Internal Medicine, Anesthesiological and Cardiovascular Sciences,
Rheumatology Unit, Policlinico Umberto I, Sapienza University of Rome; 7Internal Medicine and
Rheumatology Unit, Azienda Ospedaliero-Universitaria di Parma; 8Rheumatology Unit, Fondazione
Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; 9Unit of Immunology, Rheumatology, Allergy and
Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan;
10
Rheumatology Unit, Internal Medicine Department, ASST Settelaghi, Ospedale Di Circolo, Fondazione
Macchi, Varese; 11Unit of Rheumatology, ASUGI an\d Clinical University Dept. of Medical, Surgery and
Health Sciences, University of Trieste; 12University of Rome “Campus Biomedico”, School of Medicine,
Division of Rheumatology and Clinical Immunology, Roma; 13Dept. of Experimental and Clinical Medicine,
Divisions of Rheumatology AOUC, University of Florence; 14Dept. of Health Promotion Sciences, Maternal
and Infant Care, Internal Medicine and Medical Specialties, University of Palermo; 15Integrated Reference
Centre of Rheumatology, ASP 7, Scicli Hospital, Ragusa; 16Rheumatology Unit, Dept. of Medicine and
Surgery, University of Perugia; 17University of Modena and Reggio Emilia, Azienda USL-IRCCS di Reggio
Emilia; 18Rheumatology Unit, S. Maria Hospital, USL, IRCCS Institute, Reggio Emilia; 19Rheumatology Unit,
Azienda USL di Modena; 20Rheumatology Unit, Dept. of Emergency and Organ Transplantations, University
of Bari; 21Rheumatology Unit, Internal Medicine Department, ASST Fatebenefratelli-Sacco, Milan University
School of Medicine, Milan; 22Clinical Unit of Rheumatology, School of Medicine, University of L’Aquila;
23
Research Laboratory and Division of Clinical Rheumatology, Dept. of Internal Medicine, University of
Genova, IRCCS San Martino, Genova; 24Division of Rheumatology, ASST Gaetano Pini-CTO, Milano, Italy.
Abstract
Objective
The role of age in influencing the severity of fibromyalgia (FM) is still controversial. The aim of this study is to define the
contribution of age in the severity of FM from data from a large national database.
Methods
This cross-sectional study included adult patients with FM diagnosed according to the 2010/2011 American College of Rheumatology
criteria. Disease severity was assessed with the revised Fibromyalgia Impact Questionnaire (FIQR) and the modified Fibromyalgia
Assessment Status (FAS 2019mod). Patients were grouped into five age categories (between 18-40 years, between 41-50 years,
between 51-60 years, between 61-70 years, and ≥71 years). Differences in disease severity between groups were assessed by
one-way analysis of variance (ANOVA).
Results
The study included 2889 patients (199 males and 2690 females), mean age of 52.58 (±11.82) years, with a mean FIQR score of 59.22
(±22.98) and a mean FAS 2019mod of 25.50 (±8.66). Comparing the mean values of the various indices between age categories,
there were no statistically significant differences between the groups for FIQR total score and FAS 2019mod. However, the 60–70
years category showed the lowest scores for both scales. The main difference emerged for the FIQR physical function subscale,
where the ≥71 years category showed significantly higher scores (pFM severity and age / M. Di Carlo et al.
Marco Di Carlo, MD* Introduction social functioning (r= -0.42) and physi-
Sonia Farah, Eng* Fibromyalgia (FM) is a syndrome char- cal role (r= -0.38) (11). Another study,
Laura Bazzichi, MD acterised by a wide range of symp- conducted on 214 FM patients (mean
Fabiola Atzeni, MD, PhD
toms, the most prominent of which are age 46.9±9.5) and using a dedicated
Marcello Govoni, MD
Giovanni Biasi, MD chronic widespread pain, fatigue, and disease severity index, i.e. the Fibro-
Manuela Di Franco, MD unrefreshing sleep (1). The prevalence myalgia Impact Questionnaire (FIQ),
Flavio Mozzani, MD of FM is variable depending on the set showed that age is a variable linked to
Elisa Gremese, MD of diagnostic/classification criteria used greater disease severity (p=0.02) (12).
Lorenzo Dagna, MD (2). In Italy, it is estimated that FM af- In contrast to what has already been
Alberto Batticciotto, MD, PhD fects 2.22% of the general population described, a work carried out on a
Fabio Fischetti, MD
(3). more robust sample size (978 patients),
Roberto Giacomelli, MD, PhD
Serena Guiducci, MD, PhD, PH The pathophysiological mechanisms of categorising the patients into young
Giuliana Guggino, MD FM are still not fully understood and, to (age ≤39 years), middle-aged (age 40-
Mario Bentivegna, MD date, there are no imaging or laboratory 59 years) and older (age ≥60 years),
Roberto Gerli, MD markers that can be used for diagnostic showed a significantly higher severity
Carlo Salvarani, MD purposes in daily clinical practice. The of symptoms (pFM severity and age / M. Di Carlo et al. as patients with chronic inflammatory Table I. Data regarding age, FIQR, its subscales and individual items, and distribution of joint diseases or connective tissue dis- case series. eases, psychosis or severe depression, Mean SD Median IQR normal uncontrolled endocrinopathies, and distribution* current malignancies. All patients gave written informed consent for participa- Age 52.68 11.82 53.00 46.00 - 60.00
FM severity and age / M. Di Carlo et al.
Table II. Mean values of FIQR, its subscales, and FAS 2019mod distributed across age categories.
FIQR total FIQR physical function FIQR symptoms FIQR overall impact FAS 2019mod
Age categories Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
18–40 years 57.90 (21.76) 15.51 (7.56) 31.32 (10.49) 11.19 (5.86) 25.48 (8.34)
41–50 years 59.26 (23.31) 16.44 (7.78) 31.57 (11.32) 11.25 (5.99) 25.28 (8.65)
51–60 years 60.32 (22.89) 16.77 (7.51) 32.10 (11.02) 11.50 (5.94) 25.80 (8.62)
61–70 years 57.13 (23.59) 15.97 (7.83) 30.68 (11.48) 10.58 (6.11) 24.89 (9.03)
≥71 years 62.14 (22.45) 17.69 (7.27) 32.24 (11.34) 12.21 (5.97) 26.59 (8.44)
FIQR: revised Fibromyalgia Impact Questionnaire; FAS 2019mod: revised Fibromyalgia Assessment Status; SD: standard deviation.
Table III. One-way analysis of variance (ANOVA) data for FIQR, its subscales, and FAS tween-categories differences for both
2019mod. FIQR total score (p=0.030), FIQR
Source of variation Sum of Mean df F-ratio p overall impact (p=0.012), and, most
squares square importantly, for FIQR physical func-
tion (p=0.006) (Table III). However,
FIQR total Between groups 5671.23 1417.80 4 2.691 0.030 when comparing one category versus
Within groups 1519304.35 526.80 2884
Total 1524975.58 2888 the other through the Scheffé test, the
only statistically significant difference
FIQR physical function Between groups 838.19 209.54 4 3.597 0.006* (pFM severity and age / M. Di Carlo et al.
ciations emerged between the subscales that this age category coincides with
of the SF-36 and age (11). Similarly, a retirement from employment in Italy
2008 study investigating variables as- and generally in Western countries. Be-
sociated with QoL in patients with FM ing retired seems to have a positive in-
documented that older age was associ- fluence on several health domains. An
ated with greater disease severity (12). Australian study conducted on women
There are studies showing an opposite showed that retirement is beneficial on
attitude of FM severity with respect to several key health aspects in patients
age. Jiao and colleagues revealed how, with FM, namely physical function-
when distinguishing patients into three ing, role physical and bodily pain (23).
Fig. 1. Box-and-whisker plot for the revised categories, the burden of FM is more The positive health effects of retirement
Fibromyalgia Impact Questionnaire total score
severe in the two age categories be- are thought to be related to increased
according to age categories differences (one-way
analysis of variance). low 39 years and between 40–59 years. physical activity, among other factors.
Boxes represent the interquartile range. The Young and middle-aged patients would The fundamental role of exercise in
middle line within the plot represents the mean. have a worse QoL than older patients the management of FM patients is well
X-axis age categories expressed in years.
(above 60 years), and also higher FIQ known (24), and is one of the main ther-
scores. In the subscale analysis of the apeutic indications suggested by the
SF-36, this study also found that physi- recommendations for the management
cal component summary (PCS) scores of FM (14). However, this explanation
were lower (indicative of worse physi- remains a matter of hypothesis and will
cal health-related QoL) in young FM need to be evaluated in further popula-
patients than in middle-aged or older tion studies.
patients. This same study also revealed The most significative finding of the
that mental component summary scores present study is the difference in FIQR
are indicative of reduced QoL in mid- physical function between the older and
dle-aged patients (13). The findings re- younger categories, with a greater bur-
garding the PCS are in contrast to those den in the older subjects. Although, as
of the general population, however, already discussed, the evidence in the
Fig. 2. Box-and-whisker plot for the revised they are not the only ones. Campos and literature is contradictory, this result
Fibromyalgia Impact Questionnaire subscale
physical function according to age categories dif- Vazquez, while showing stability in was somewhat expected. Conditions
ferences (one-way analysis of variance). the absence of significant differences characterised by chronic pain tend to
Boxes represent the interquartile range. The between age categories, documented become more prevalent with aging.
middle line within the plot represents the mean. that scores on health domains related to A meta-analysis on the prevalence of
X-axis age categories expressed in years. Signifi-
cative difference between the first (18–40 years) physical function were better in older chronic pain conducted in the United
and the last (≥71 years) category. patients (21). Cronan et al., in turn, Kingdom showed that the prevalence
have documented that as age and dis- of chronic pain increases with age,
social burden since it affects up to 24% ease duration increase, symptoms re- ranging from a prevalence of 14.3%
of the general population in some stud- lated to FM severity are reduced (22). between the ages of 18–25 years to a
ies, and age seems to be a risk factor These last three studies cited were all prevalence of 62% over the age of 75
(18). The relationship between pain and based on the distinction of three age years (25). FM generally is a condition
age is complex. Ageing does not seem groups (≤39 years, between 40 and 59 that is associated with other comorbidi-
to have a relevant effect on pain toler- years, and ≥60 years). Arguably, the ties that negatively impact functional
ance, but only to reduce the sensitivity distinction into five categories instead capacity, primarily osteoarthritis (OA)
to low intensity painful stimuli (19). of three allowed for a more detailed (26). The association between OA and
Chronic pain tends to show a higher analysis of trends in FM severity in advanced age is well known, and it is
prevalence in older patients than in relation to age. This categorisation re- also known that OA is a predisposing
younger patients (20). There is a strand vealed that the population with the low- condition for frailty (27). A portion of
of literature that indicates for FM, as for est overall FM severity (considering the FIQR physical function is likely in-
other chronic pain conditions, this kind total FIQR and FAS 2019mod scores) is fluenced by comorbidities. An elegant
of age-related trend. that between 60–70 years of age. This study by Dutta and colleagues dem-
Tander et al., in a comparative study of finding, although not statistically sig- onstrated that genetic predisposition
quality of life (QoL) and depression in nificant, may be of some interest, as it predominantly affects individuals with
patients with FM and rheumatoid ar- has not been documented by any other FM diagnosed at a younger age, i.e.
thritis (RA), documented a correlation study before. those with a primary FM condition. In
mainly between age and worsening of The explanation for the deflection in older subjects, the genetic predisposi-
physical functioning and bodily pain. FM severity in the decade 60–70 years tion to FM would wane, so they would
Conversely, in RA patients, no asso- could be provided mainly by the fact be more prone to develop FM concom-
1088 Clinical and Experimental Rheumatology 2022FM severity and age / M. Di Carlo et al.
itant with other nociceptive pain condi- Acknowledgements severity and quality of life in patients with
tions (28). The authors would like to thank the fibromyalgia. Mayo Clin Proc 2014; 89: 199-
206.
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