Osteoarthritis Helping the Elderly Maintain Function and Mobility Cathryn Caton, MD, MS
Osteoarthritis
Helping the Elderly Maintain Function and Mobility
Cathryn Caton, MD, MS
Objectives
Define OsteoarthritisDefine scope of problemReview potential causesDescribe associated symptomsReview diagnostic criteriaReview treatment optionsReview interventions/skills
DefinitionDegenerative arthritis or
degenerative joint disease
Mechanical abnormalities◦Degradation of the joints
Articular cartilage Subchondral bone
Why do we care?Most prevalent form of arthritis in
USAffects 50 – 80% of people >65Responsible for ½ of all
disabilitiesAssociated with
◦Pain◦Functional disability◦Being homebound
Potential CausesAgingWear and tear
◦ Bony spurs or formation of extra bone◦ Weakening and stiffening of ligaments and muscles
around the jointBeing overweightFractures or other joint injuriesJobsPlaying sportsBleeding disorders that cause bleeding into
jointsDisorders that block blood supply to the jointGout, pseudogout, or RA
SymptomsMost common are
◦Pain Worse with exercise and weight bearing
◦Stiffness
Over time rubbing grating crackling
Morning stiffness (~30mins)
Making the DiagnosisPhysical Exam
◦Crepitation◦Joint swelling – bones around joints
may feel larger than normal◦Limited Range of Motion◦Tenderness to palpation◦Normal movement often results in
pain
Making the DiagnosisRadiographs
◦ Insensitive to early pathologic features◦ Absence of findings does not r/o symptomatic
disease◦ Presence of findings does not guarantee that OA is
the cause of patient’s current pain – peri-articular sources including pes anserine bursitis or
trochanteric bursitis
◦ Loss of joint space◦ Wearing down of the ends of bone and bone spur
formation in advanced cases
No available blood tests to aid diagnosis
TreatmentGoals of treatment are
◦Pain relief
◦Improvement or maintenance of functional status
Treatment – Lifestyle Changes
Weight loss –
◦through exercise and a calorie-restricted diet
◦24% improvement in physical function
◦30% decrease in knee pain
Treatment – Lifestyle Changes
Exercise◦Encourage patients to do something
they enjoy◦Low-impact aerobic exercise
program Walking, biking or swimming
◦Quadriceps strengthening exercises◦Avoid high-velocity impact
Running and step aerobics
Treatment – Physical Therapy
Refer if patients do not seem to be obtaining maximum benefit from their own exercise program
Improve muscle strength and motion of stiff joints and balance
If no benefit after 6-8 weeks then likely to not work
Range of motion, joint protection instruction and splinting
Treatment - DevicesCane useful in patients with
persistent ambulatory pain from hip or knee OA◦Self-reported higher functional ability◦Increased ablility to perform more
functional tasks
Splints or braces support weakened joints◦If used incorrectly, may result in
worsening of symptoms
Treatment - MedicationsAcetaminophen
◦< 3 g/day
◦AGS, ACR and others recommend as first line analgesic
◦Less effective overall on pain than NSAIDs
◦Similar efficacy to NSAIDs on improvements in functional status
Treatment - Medications NSAIDs
◦ More effective than acetaminophen◦ More GI and Renal Toxicities◦ 2.2 to 5.4 greater risk of various adverse GI events◦ Risk estimates for Renal events 1.6 to 4.1 and 2.1 to 8.8 in
CKD patients
If at high risk for bleeding then use PPI◦ Age >75◦ Peptic Ulcer Disease◦ h/o GI bleeding◦ Warfarin use◦ Chronic steroid use
Tramadol is an option for patients with a contraindication for NSAIDs
Treatment - MedicationsTopicals may help with symptomatic
reliefCapsaicin
◦0.1% cream, applied QID◦May cause burning, erythema
Diclofenac topical ◦2 grams – Hand◦4 grams – Knees ◦Applied QID; 6% systemic absorption;
should not be used with oral NSAID therapy
Treatment - MedicationsSteroid Injections
◦Reduces swelling and pain◦Useful for short-term relief
1 -2 weeks
◦Improves pain and function◦Do not use more frequently than Q 4
months◦Repeated use can cause cartilage
and joint damage Results in disease progression
Treatment – MedicationsGlucosamine and Chondroitin
◦Meta-analyses show that symptom modifying effect similar to placebo
◦Structure modifying benefits are not clear
◦AAOS clinical practice guideline recommend against prescribing
Drug Dose Frequency ADE/Monitoring
acetaminophen 325-500 mg Q4-6 hours(Most effective when dosed around the clock)
Max of 3g/dayLiver toxicity
NSAIDS Varying Varying GI and renal toxicitiesGI prophylaxis in patients:>75, hx of bleed, PUD, warfarin use, long-term steroid use
Tramadol 50-100 mg Q 4-6 hours SedationDose reduction required for CrCl <30 mL/min
Capsaicin 0.1% cream Apply QID Burning, erythemaShould not be applied to broken skin.Wash hands thoroughly after use.
Diclofenac topical 2 grams-Hand4 grams-Knee
Apply QID 6% systemic absorptionShould not be used with oral NSAID therapy.
Treatment – Surgical Intervention
After conservative therapyDurable pain reliefFunctional improvementImprove quality of lifeRisk of complications
◦Increases with age
Treatment – Surgical Intervention
Total Knee Replacement◦Average age 65 years◦After 4 years, nearly 90% had good
to excellent outcome◦After 5 years
75% had no pain 20% had mild pain 3.7% had moderate pain 1.3% had severe pain
ACOVE Interventions
As part of this ACOVE you will learn how to quickly do a functional assessment
ACOVE Interventions
ACOVE Interventions
ACOVE Interventions
References 1. A.D.A.M. Medical Encyclopedia. Osteoarthritis.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001460/. Accessed May 30, 2012.
2. Diseases NIoAaMaS. What is Osteoarthritis? [Web Site]. 2010; http://www.niams.nih.gov/Health_Info/Osteoarthritis/osteoarthritis_ff.pdf. Accessed May 30, 2012.
3. Hunter DJ. In the clinic Osteoarthritis. Ann Intern Med. Aug 2007;147(3):ITC8-1-ITC8-16.
4. MacLean CH, Pencharz JN, Saag KG. Quality indicators for the care of osteoarthritis in vulnerable elders. J Am Geriatr Soc. Oct 2007;55 Suppl 2:S383-391.
5. Quality AfHRa. Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility. In: Research CfOaE, ed. Rockville, MD: AHRQ; 2002.
6. Richmond J, Hunter D, Irrgang J, et al. Treatment of Osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. Sep 2009;17(9):591-600.