Chronic Illness and Aging Section 5: Osteoarthritis— A Chronic Incapacitating Disease Victoria Rizzo, PhD Columbia University School of Social Work Resource Review for Teaching Resource Review for Teaching

Osteoarthritis (OA) Prevalence  26.9 million people aged 25 years and older have doctor diagnosed OA.  By 2030, 72 million people aged 65 and older (20% of the population) will be at increased risk for OA (CEDC, 2007b).  OA is the leading chronic illness cause of disability (19 million people in 2005) (CDC, 2008A).

Changing Trajectory of Osteoarthritis  Increases in obesity from 15% in 1980 to 33% in 2004 have the potential to significantly increase number of older adults diagnosed with OA.  Freedman & colleagues (2007) predict national increase of 16% in doctor diagnosed OA between 2005 and  14 states will see increases of 30% to 87% in doctor diagnosed OA cases by 2030.

Osteoarthritis in Older Adults  In 2006, women 85 years and older represented 60% of all doctor-diagnosed arthritis reported (CDC, 2008a).  Women report greater physical limitations, psychological stress, and knee/ hip pain that requires surgery than men.  Black patients have fewer surgeries but many more complications and higher mortality rates than their white counterparts (Theis, Helmick, & Hootman, 2007).

Source: Centers for Disease Control. (2008a). Chronic Disease-Arthritis-at-a-glance. Retrieved from Sex-specific prevalence of doctor-diagnosed arthritis by age group, National health Interview Survey,

Factors affecting the Impact of OA in Older Age  OA is a significant public health issue for older adults.  Older adults underutilize programs proved to be effective in managing OA.  The Arthritis Foundation Self-help Program (Lorig & Fries, 2000), a course designed for people diagnosed with all types of arthritis, is among the most popular disease management courses offered.  Despite the effectiveness of these disease management courses, only 11% of persons with arthritis participate in them.

Critical Challenges of OA in Older Adults  Managing OA and co-morbidities: More than half of adults diagnosed w/OA also have heart disease and/or diabetes.  Increasing participation in disease management programs for OA: For example, only 1% of eligible people participate in New York State.  Development & implementation of interventions (e.g., care coordination) to address biopsychosocial issues that impact OA and are not addressed with current interventions.

Biopsychosocial Health Needs  Vary by intensity of osteoarthritis symptoms & disease duration.  Physical stresses include pain, stiffness, decreased mobility, and decreased ability to participate in work and leisure activities.  Psychological distress can include depression and/or anxiety, & social isolation.  OA patients request a need for information about diagnosis, its implications, & available treatments.  OA patients request strategies for coping with the consequences of OA: fear, depression, uncertainty, pain, fatigue.

Relational Concerns of the Older OA patient  Patients are concerned about relationships with family & friends as their abilities to fully participate in the home and work environment decrease. They may feel socially isolated and lonely.  As patients become more physically disabled, their social networks may become smaller and more fragmented.

Biopsychosocial Needs & Formal Services to Address Needs 1)Information about illness, treatments, health, and services for patients and caregivers:  Provision of information, e.g., on illness, treatments, effects on health, biopsychosocial services, and helping patients/families understand and use information.  Varies by intensity of osteoarthritis symptoms and disease duration.

2) Help in coping with emotions accompanying illness and treatment:  Peer Support Programs.  Counseling/psychotherapy to individuals or groups.  Pharmacological management of psychological symptoms.  Pharmacological treatment for depression/anxiety coupled with psychotherapy and pain coping skills training. Biopsychosocial Needs & Formal Services to Address Needs

3)Help in managing illness:  Comprehensive disease management/self-care programs.  Coordinated care programs that organize patient care to facilitate more appropriate delivery.  Development & implementation of outreach strategies to engage vulnerable populations in disease management programs. Biopsychosocial Needs & Formal Services to Address Needs

4) Assistance changing behaviors to minimize impact of disease and delay/prevent disease progression:  Behavioral/health promotion interventions such as:  Provider assessment/monitoring of health behaviors such as diet, smoking, exercise.  Brief physician counseling.  Patient education on risk reduction. Biopsychosocial Needs & Formal Services to Address Needs

5) Material and logistical resources such as transportation, home care, assistive equipment, home modification:  Provision of resources, improvement of home environment.  Help to provide and manage resources needed to allow patient to remain in the community with maximum independent and quality of life. Biopsychosocial Needs & Formal Services to Address Needs

6) Help in managing disruptions in work, activities, family life, and social network & Preparing for care transitions due to disease progression:  Family/caregiver education, counseling.  Assistance with activities of daily living (ADLs), and instrumental activities/chores (IADLS).  Legal protections and services.  Social network development.  Social network maintenance over time (friends & family). Biopsychosocial Needs & Formal Services to Address Needs

7) Financial advice and/or assistance & identifying sources of funding for many non-covered equipment items and non-prescription NSAIDS:  Financial planning/counseling including management of activities such as bill paying.  Insurance counseling/advocacy.  Eligibility assessment for other benefits (SSI and SSDI).  Supplemental financial grants.  Ongoing assistance with out of pocket expenses, such as assistive devices and home modifications. Biopsychosocial Needs & Formal Services to Address Needs

Social Work Role: Care Coordination Currently, health system’s focus on OA patients’ biopsychosocial needs is:  Medical treatment of the disease, (e.g., joint replacements, & pharmacological interventions), and  Management of the disease through evidenced-based programs (e.g., the Arthritis Foundation Self-help Program) to delay or prevent progression of the disease.

Limitations of disease management programs include a lack of:  Access to information concerning diagnosis and its implications and available treatments,  Continuity of care,  Coordination of care,  Strategies for coping with symptoms, such as pain, fatigue, and loss of independence,  Ways to adjust to consequences of the disease, such as fear, depression, and uncertainty (der Ananian et al., 2006), and  Ability to successfully recruit the populations that could benefit the most from them (Rizzo et al., 2006, 2007). Social Work Role: Care Coordination

Barriers to participation in programs are:  Physical (pain, mobility, co-morbidity, arthritis-related illness, and fatigue),  Psychological (attitudes/beliefs, perceived negative outcomes, and depression), and  Social/environmental (insufficient advice from physicians regarding the benefits of exercise, competing roles/responsibilities, lack of available exercise programs, lack of transportation, and weather. (Der Ananian et al., 2006; Schoster et al., 2005). Social Work Role: Care Coordination

Social workers need to develop and implement care coordination programs that:  Incorporate better screening and assessment of functional impairment, pain, depression, and anxiety of patients with osteoarthritis when they implement the treatments described in the program’s manual (e.g., the Arthritis Foundation Self-help Program).  Educate patients about their diagnosis and it implications as well as available treatments. Include the disease as a part of the routine assessment of all older adults practitioners work with, given its increasing prevalence with age. Social Work Role: Care Coordination

 Advocate for the delivery of disease management programs in tandem with social work intervention strategies for coordination of care in health facilities and in nontraditional settings that may attract underserved populations (e.g., churches, community centers, and libraries).  Develop and implement better outreach and screening and assessment strategies for use with the most vulnerable and underserved populations (e.g., people of color, people of low income, frail older adults with few social supports). Social Work Role: Care Coordination