IMPORTANCE Chronic noncancer pain (hereafter referred to as chronic pain) is common among older adults and managed frequently with pharmacotherapies that produce suboptimal outcomes. Psychological treatments are recommended, but little information is available regarding their efficacy in older adults. OBJECTIVE To determine the efficacy of psychological interventions in older adults with chronic pain and whether treatment effects vary by participant, intervention, and study characteristics. DATA SOURCES MEDLINE, Embase, PsycINFO, and the Cochrane Library were searched from inception to March 29, 2017. STUDY SELECTION Analysis included studies that (1) used a randomized trial design,(2) evaluated a psychological intervention that used cognitive behavioral modalities alone or in combination with another strategy, (3) enrolled individuals with chronic pain (pain ≥3 months) with a sample mean age of 60 years or older, and (4) reported preintervention and postintervention quantitative data. DATA EXTRACTION AND SYNTHESIS Two of the authors independently extracted data. A mixed-model meta-analysis tested the effects of treatment on outcomes. Analyses were performed to investigate the association between participant (eg, age), intervention (eg, treatment mode delivery), and study (eg, methodologic quality) characteristicswith outcomes. MAIN OUTCOMES AND MEASURES Pain intensity was the primary outcome; secondary outcomes included pain interference, depressive symptoms, anxiety, catastrophizing beliefs, self-efficacy for managing pain, physical function, and physical health. RESULTS Twenty-two studies with 2608 participants (1799 [69.0%] women) were analyzed. Participants’ mean (SD) age was 71.9 (7.1) years. Differences of standardized mean differences (dD) at posttreatment were pain intensity (dD = −0.181, P = .006), pain interference (dD = −0.133, P = .12), depressive symptoms (dD = −0.128, P = .14), anxiety (dD = −0.205, P = .09), catastrophizing beliefs (dD = −0.184, P = .046), self-efficacy (dD = 0.193, P = .02), physical function (dD = 0.006, P = .96), and physical health (dD = 0.160, P = .24). There was evidence of effects persisting beyond the posttreatment assessment only for pain(dD = −0.251, P = .002). In moderator analyses, only mode of therapy (group vs individual) demonstrated a consistent effect in favor of group-based therapy. CONCLUSIONS AND RELEVANCE Psychological interventions for the treatment of chronic pain in older adults have small benefits, including reducing pain and catastrophizing beliefs and improving pain self-efficacy for managing pain. These results were strongest when delivered using group-based approaches. Research is needed to develop and test strategies that enhance the efficacy of psychological approaches and sustainability of treatment effects among older adults with chronic pain.

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The majority of analyzed studies failed to describe how psychological symptoms were identified and treated, which discipline on the team provided the treatment, and whether psychological symptoms improved as a result of the intervention. Future research evaluating the effects of palliative care interventions on psychological symptoms will benefit from using reliable and valid psychological outcome measures and providing specificity regarding the psychological components of the intervention and who provides it.

Cost savings associated with SFR units would justify additional construction and operation costs compared to OPBY units only when evidence on inclusive outcomes such as length of stay or direct costs of care is considered. A specific outcome such as infection rate potentially fails to capture all benefits of SFRs. As more evidence becomes available on full benefits and hazards of SFRs versus OPBYs, future studies should investigate the broader return-on-investment outcomes.

In Reply Our study 1 focused appropriately on cognitive behavioral therapy (CBT) approaches to pain management in older adults because the overwhelming majority of psychologically based intervention studies in the pain field have used this modality. Abbass and colleagues are correct to point out that other psychological therapies, such as short-term dynamic psychotherapy and emotion-focused methods, may have value in the management of later-life pain. However, few studies have examined the efficacy of these modalities in older adults with chronic pain, which contrasts with the growing number of investigations that have evaluated CBT-based approaches. Given that the results of our study showed only modest benefits associated with CBT-based modalities and increasing calls for the use of nonpharmacologic approaches to manage pain, 2 it is important to evaluate other psychological therapies, including short-term dynamic psychotherapy and emotion-focused methods, as treatments for later-life pain.Abbass and colleagues further question the scope of interventions included in our study. We required that all studies use 1 or more CBT modalities to be retained for analysis (ie, interventions had to report the use of behavioral and/or cognitive coping skills training, cognitive restructuring, behavioral activation, or acceptance and commitment therapy [ACT] types of approaches). 1 Although many of the studies evaluated the effects of a given CBT protocol in addition to other modalities (eg, education and exercise), the latter techniques would not be considered CBT therapies. The question of whether ACT is a type of CBT is a matter of debate. 3,4 Given that ACT and CBT use similar behavioral approaches, including problem solving, modeling, role play, and homework exercises, we elected to include ACT intervention studies in our meta-analysis. 4