Osteoarthritis — Management

Osteoarthritis is the commonest joint disease of older adults and a leading cause of pain, immobility and disability. Management is symptom-directed and function-directed, since no agent has been shown to reverse structural damage.

Optimal management involves multiple treatment modalities, and the best combination varies from patient to patient (Kane's) — a core, quotable line.

Treating arthritis optimally requires a differential diagnosis, because several arthritides coexist in older adults. Distinguish OA from inflammatory arthritis: stiffness lasting minutes not hours, pain with activity rather than at rest and at night, fatigue unusual, swelling present but with little synovial reaction, and erythema and warmth unusual.

Education and self-management, with realistic goal-setting and an explanation that OA is manageable rather than inevitable disability.

Exercise is first-line: quadriceps and hip abductor strengthening, range-of-movement work, and low-impact aerobic activity. Patients referred for joint replacement should be encouraged to lose weight and strengthen the relevant muscles before surgery.

Weight reduction — the single most effective disease-modifying intervention for knee and hip OA.

Physiotherapy and occupational therapy: joint protection, energy conservation, activity pacing, and assessment for assistive devices — walking stick held in the contralateral hand, walking frame, raised toilet seat, tap turners, jar openers.

Orthoses and footwear: shock-absorbing insoles, appropriate footwear, knee braces for varus/valgus instability, thumb-base splint for first carpometacarpal OA.

Local physical measures: heat, cold, and transcutaneous electrical nerve stimulation as adjuncts.

Paracetamol is the traditional first-line oral analgesic in older people because of its favourable safety profile, though its efficacy in OA is modest; maximum 3 g/day in the frail elderly.

Topical NSAIDs are preferred over oral NSAIDs for knee and hand OA in older adults, giving useful analgesia with minimal systemic exposure. Topical capsaicin is an alternative.

Oral NSAIDs — lowest dose, shortest duration, always with a proton-pump inhibitor. Hazardous in the elderly: gastrointestinal bleeding, acute kidney injury, fluid retention and heart failure decompensation, hypertension, and interaction with ACE inhibitors and diuretics ("triple whammy"). They appear on the AGS Beers Criteria as potentially inappropriate for chronic use.

Intra-articular corticosteroid injection for a painful effusive flare gives short-term relief; limit to three or four injections per joint per year. Local steroid injection also gives dramatic relief in bicipital tendinitis, olecranon and trochanteric bursitis, which are common in geriatric patients and must be sought on examination.

Nutraceuticals: glucosamine and chondroitin — although there may be a placebo effect resulting in benefit, there is no evidence of significant improvement in pain; likewise vitamin D does not decrease pain or facilitate repair of structural damage in OA.

Duloxetine and, cautiously, low-dose weak opioids (tramadol) are reserved for refractory pain; opioids carry falls, delirium, constipation and dependence risk in older adults.

Arthroscopic interventions (debridement and lavage, osteotomy, cartilage transplant) have been recommended where inflammation is present and non-invasive measures have failed, but there is little evidence to support their efficacy (Moseley et al.).

Joint replacement should be reserved for individuals with severe symptomatic disease who do not respond to more conservative interventions; patients referred should have stable medical conditions and be prepared with weight loss and muscle strengthening pre-operatively.

Post-operative care needs structured rehabilitation, delirium prevention, VTE prophylaxis and falls prevention.

Address the consequences as much as the joint: OA causes immobility, deconditioning, sarcopenia, falls, depression, social isolation and caregiver burden — a comprehensive geriatric assessment is appropriate.

Look actively for treatable non-articular mimics — tendinitis, bursitis, and carpal tunnel syndrome, which is common in older adults and can be confused with gout, rheumatoid arthritis or pseudogout.