1. Osteoarthritis Helping the Elderly Maintain Function and Mobility Cathryn Caton, MD, MS

2. Objectives Define Osteoarthritis Define scope of problem Review potential causes Describe associated symptoms Review diagnostic criteria Review treatment options Review interventions/skills

3. Definition Degenerative arthritis or degenerative joint disease Mechanical abnormalities ◦ Degradation of the joints  Articular cartilage  Subchondral bone

4. Why do we care? Most prevalent form of arthritis in US Affects 50 – 80% of people >65 Responsible for ½ of all disabilities Associated with ◦ Pain ◦ Functional disability ◦ Being homebound

5. Potential Causes Aging Wear and tear ◦ Bony spurs or formation of extra bone ◦ Weakening and stiffening of ligaments and muscles around the joint Being overweight Fractures or other joint injuries Jobs Playing sports Bleeding disorders that cause bleeding into joints Disorders that block blood supply to the joint Gout, pseudogout, or RA

6. Symptoms Most common are ◦ Pain  Worse with exercise and weight bearing ◦ Stiffness Over time rubbing grating crackling Morning stiffness (~30mins)

7. Making the Diagnosis Physical 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

8. Making the Diagnosis Radiographs ◦ 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

9. Treatment Goals of treatment are ◦ Pain relief ◦ Improvement or maintenance of functional status

10. Treatment – Lifestyle Changes Weight loss – ◦ through exercise and a calorie-restricted diet ◦ 24% improvement in physical function ◦ 30% decrease in knee pain

11. 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

12. 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

13. Treatment - Devices Cane 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

14. Treatment - Medications Acetaminophen ◦ < 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

15. 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

16. Treatment - Medications Topicals may help with symptomatic relief Capsaicin ◦ 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

17. Treatment - Medications Steroid 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

18. Treatment – Medications Glucosamine 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

19. DrugDoseFrequencyADE/Monitoring acetaminophen325-500 mgQ4-6 hours (Most effective when dosed around the clock) Max of 3g/day Liver toxicity NSAIDSVarying GI and renal toxicities GI prophylaxis in patients: >75, hx of bleed, PUD, warfarin use, long-term steroid use Tramadol50-100 mgQ 4-6 hoursSedation Dose reduction required for CrCl <30 mL/min Capsaicin0.1% creamApply QIDBurning, erythema Should not be applied to broken skin. Wash hands thoroughly after use. Diclofenac topical2 grams-Hand 4 grams-Knee Apply QID6% systemic absorption Should not be used with oral NSAID therapy.

20. Treatment – Surgical Intervention After conservative therapy Durable pain relief Functional improvement Improve quality of life Risk of complications ◦ Increases with age

21. 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

22. ACOVE Interventions As part of this ACOVE you will learn how to quickly do a functional assessment

23. ACOVE Interventions

26. 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.