© The Editor(s) 2018
Balakrishnan Kichu R. Nair (ed.)Geriatric Medicinehttps://doi.org/10.1007/978-981-10-3253-0_1818. Osteoarthritis
(1)
Centre for Education and Research on Ageing, University of Sydney, Sydney, NSW, Australia
(2)
Ageing and Alzheimer’s Institute, Concord Hospital, Sydney, NSW, Australia
Key Points
Osteoarthritis is a very common disabling condition in older people.
Obesity and injury are common risk factors.
Non-pharmacological treatment is equally important to pharmacological treatment.
Other pathologies should be excluded before making a diagnosis of OA.
Case Study
Case Study: Mrs. Mavis Reynolds is an 83-year-old lady who lives alone. Her husband passed away 6 months ago. She comes to see you because she is getting more pain in her knee that is limiting her function. She had a vertebral fracture as a result of a fall 12 months previously and is concerned about having another fracture. Her comorbidities include chronic heart failure, type 2 diabetes and peptic ulcer in the past. On examination she has evidence of bilateral osteoarthritis of the knees (bone deformities, crepitus and restriction of knee flexion and extension) as well as quadriceps wasting and weakness. She walks with the aid of a pick-up frame.
18.1 Introduction
Osteoarthritis is one of the most common diseases in older people. A longitudinal study in the United States concluded that nearly half the adults in the population of interest would develop symptomatic knee osteoarthritis by age 85 years [1]. Symptomatic hand osteoarthritis is more common, while symptomatic hip osteoarthritis is less common. A recent systematic review on the risk factors for knee osteoarthritis in adults aged 50 and over found that the main factors associated with onset of knee pain were being overweight (pooled OR 1.98, 95% confidence intervals (CI) 1.57–2.20), obesity (pooled OR 2.66 95% CI 2.15–3.28), female gender (pooled OR 1.68, 95% CI 1.37–2.07) and previous knee injury (pooled OR 2.83, 95% CI 1.91–4.19) [2]. It was determined in patients with new onset of knee pain 5.1% of cases were due to previous knee injury and 24.6% related to being overweight or obese. Osteoarthritis is a one of the main reasons or contributing cause for functional limitation and disability in many older people [3] as well as having a significant detrimental effect on quality of life [4]. The main goals of osteoarthritis management are to minimize pain and maximize function.
18.2 Osteoarthritis
18.2.1 Assessing a Patient with Osteoarthritis
Patients with pain due to OA generally describe pain that is worse with activity, with limited morning stiffness (<30 min) and stiffness with rest. On examination the key things to look for are bone enlargements, crepitus and reduced range of movement in the affected joints. One of the most important aims in assessing someone with possible osteoarthritis is to make sure that the pain and disability are due to osteoarthritis and not some other pathology or co-existing condition. For example, knee osteoarthritis needs to be differentiated from an inflammatory anthropopathy. For knee OA some of the important symptoms and signs to be aware of are that a “locking” sensation at the knee could be due to loose bodies or meniscal lesions. Effusions can be present but usually the joint is not hot or red. Quadriceps weakness is important to identify because it may require specific treatment. Hip pain could be due to hip osteoarthritis, but conditions such as trochanteric bursitis, avascular necrosis or even referred pain from lower back pathology need to be thought of. Facet joint arthritis is a common reason for back pain in older people, but osteophytes and disc degeneration can lead to sciatica nerve compression. It is important to ask about sciatica-like pain and examine for signs of nerve compression.
Pain assessment is very important. Acute onset of pain for short duration is less likely to be due to osteoarthritis but could still be due to a “flare” of chronic osteoarthritis. The disability as a result of OA needs to be established. Apart from the use of validated tools to determine activities of daily living, it is important to ask specifically about what activities are affected by symptoms and diminished function in affected joints. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) is an example of a validated tool used widely in the research setting that can be used as a guide to the type of questions that can be asked to assess pain, stiffness and function [5].
In older patients it is important to undertake a comprehensive geriatric assessment to both fully understand the context and impact of OA because many factors will influence the management of OA. For an example, a comprehensive assessment may reveal that exertional dyspnea due to heart failure is the main limitation on physical function rather than OA of the knee or vice versa, which has implications for treatment priorities. Older people are at higher risk of adverse effects due to non-steroidal anti-inflammatory drugs often due to the co-existence of comorbidity such as chronic renal failure, peptic ulcer disease or chronic heart failure. Cognitive impairment can influence pain perception. It can be difficult to gauge how much OA pain someone with dementia has which can lead to under- or overtreatment. It may be important to get information from family members and caregivers. Simple questions can be helpful in determining the impact of OA in terms of pain and function such as “how much pain do they look like they are in?” and “how much is the knee problem impairing their everyday function?”
It is not necessary to undertake many investigations in the assessment of OA. The diagnosis is primarily a clinical one and can usually be made on the basis of history and clinical examination. Radiographs are not always required. CT and MRI scans are useful to exclude avascular necrosis, stress fractures or osteomyelitis. Laboratory testing is mainly to look for other treatable conditions that may present in similar ways to OA or exacerbate the symptoms of OA such as gout.
18.2.2 Management of Pain and Functional Impairment Due to Osteoarthritis
The management of OA is focused on pain relief, maximizing function, reducing the impact of disability and quality of life. In older people this is often in the context of a comprehensive Geriatric Assessment and Management Plan. OA-specific treatment can be non-pharmacological, pharmacological or surgical [6, 7]. In older people it is likely that the management will involve a number of strategies.
18.2.2.1 Education and Psychosocial Interventions
Talking to the patient and their family about the nature of OA is important. Patient may find it reassuring to know that OA is not rapidly progressive but need to know that there is no cure. The importance of non-pharmacological interventions such as exercise needs to be emphasized and realistic goals set in collaboration with the patient.
The psychological health of the patient is important to assess. The importance of psychological interventions in treating chronic persistent pain should not be underestimated [8]. There is good evidence for the role of cognitive behaviour therapy in chronic persistent pain in adults of all ages and a few trials specifically in older people showing that it is acceptable, people are adherent to the self-management strategies they are taught and there are clinical benefits [9]. Mood disorders such as depression are important to look for. Successful treatment of underlying clinical depression can sometimes result in dramatic improvements in pain and functional impairment that were initially thought to be due to mainly OA.
18.2.2.2 Weight Loss
Epidemiological studies have shown that obesity is a risk factor for knee OA, and BMI is a risk factor progression of OA of the knee. A systematic review found that weight reduction in obese patients with OA of the knee is effective in reducing pain and disability [10]. A clinical trial specifically in older adults aged 60 and over with a body mass index of >28 kg/m2 and knee OA found that moderate weight loss plus moderate exercise resulted in a greater improvement in self-reported measures of function and pain and measures of mobility than either intervention alone [11]. There is less evidence for weight loss in obese people with OA of the hip.
With regard to older people and weight loss however, things are not so simple. In non-obese older people, epidemiological data would suggest that weight loss could be harmful [12]. Many older people with symptomatic OA are frail and/or have sarcopenia where maintaining weight and even increasing weight for overall health benefit, physical function and quality of life are the priorities rather than weight loss for OA. In addition, there is increasing recognition that some older people have sarcopenic obesity in which obesity due to high fat mass is accompanied by relatively low skeletal muscle mass and muscle strength [13]. Currently there is not enough evidence to give precise advise on the best type of exercise programmes in combination with dietary interventions that should be recommended to people with sarcopenic obesity let alone with OA as well [14].
18.2.2.3 Exercise
Quadriceps weakness is common in people with OA of the knee, and there is evidence for the benefit of quadriceps-strengthening exercise for knee OA [15, 16]. A systematic review that included ten clinical trials found that land-based therapeutic exercise programmes can reduce pain and improve physical function in people with symptomatic hip OA [17]. With older people in mind, there is evidence that home-based exercise intervention and hydrotherapy can help with symptoms of knee and hip OA [18]. The intensity of exercise should depend on what the older person can tolerate and remain adherent to as there is no strong evidence that high-intensity exercise is more effective than low-intensity exercise [19]. The limitations of the evidence are that few trials have been specifically been conducted on older frail people and most trials have been of short duration. Many of the exercise trials in older people have been aimed at preventing falls. There is evidence to suggest that lower-extremity OA increases the risk of falls [20] and there is good evidence that the strength and balance exercises (that may be prescribed to help OA) will also reduce the risk of fall [21].
18.2.2.4 Other Modalities
A single-blind trial showed that a walking stick diminished pain and improved function in patients with knee OA [22]. There is some evidence that therapeutic ultrasound may be beneficial for patients with knee OA although the quality of evidence is low and magnitude of effects on pain and function are uncertain for ultrasound [23]. There is conflicting or less evidence for the benefit of diathermy, electrical stimulation, bracing, heel wedges, orthotics, magnetic stimulation [15] and acupuncture [7, 24], but it has been shown that even placebo treatment can be effective in treating OA for pain, stiffness and function [25] so these treatments should not be discouraged if patients say they are clearly helping and not impacting the patient adversely in terms of time, inconvenience or expense. After all, most of these treatments are safer than the pharmacological treatment described below.
18.3 Pharmacological Agents
Pharmacological agents used in OA are aimed at relieving pain rather than altering the disease itself.
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