Osteoarthritis Management in the Geriatric Population

Osteoarthritis, or degenerative joint disease, is predominantly prevalent among older adults and is a significant cause of disability in elderly populations. Breakdown of cartilage, the roughened tissue padding osseous ends of joints, comprises the pathophysiology; the consequence of such breakdown is pain, stiffness, and loss of mobility. Using conservative estimates, nearly 32.5 million adults in the United States have osteoarthritis (OA), while prevalence substantially increases for individuals aged 65 years and above (Hawker & King, 2022). Osteoarthritis imposes a significant burden on the geriatric population not only because of the physical limitations imposed by the disease itself but also because of its impacts on quality of life, health care costs, and ability to stay independent. Consequently, OA is multifactorial in origin, influenced by such variables as aging, obesity, joint injuries, genetic predispositions, and mechanical stress. With the aging of the population, the prevalence of OA will continue to rise, and evidence-based management will become even more important, especially among healthcare providers whose role is often the management of chronic conditions in older adults.

Etiology and Pathophysiology

Osteoarthritis is a degenerative bone disease characterized by the breakdown of the upper smooth articulating cartilage lining of joints-usually an interaction of genetic, mechanical, and biological factors. Cartilage acts like an important protector, minimizing friction and absorbing shock in most joints, especially weight-bearing ones (Di et al., 2023). Over time, this protective cartilage deteriorates, becoming frayed and rough, with potential risk factors of age, among others. The bones eventually rub against each other, leading to pain, swelling, and loss of joint motion. It affects primarily the weight-bearing joints, although other joints such as the knees, hips, spine, and hands can be involved.

The pathophysiology consists of degeneration of the cartilage, changes in the bone, and inflammation of the synovium, or membrane lining the joint. Although classically considered a non-inflammatory disease, osteoarthritis was recently proven to imply low-grade inflammation in all its pathogenetic steps. This is often associated with the development of osteophytes or bone spurs, which contribute to joint stiffness and pain. Other degenerative changes include thickening of the subchondral bone, synovial inflammation, and alteration in the ligaments and muscles surrounding the joint (Coaccioli et al., 2022). While age is still the strongest risk factor, obesity, previous joint injury, and genetic predisposition are other contributing factors to the development of OA. Other mechanical factors that also play a role in furthering the disease include misalignment of the joints and overuse.

Clinical Presentation and Assessment

In general, symptoms of osteoarthritis include joint pain and stiffness, functional limitation, exacerbation with activity, and improvement with rest. Clinical features may include morning stiffness that does not usually last longer than 30 minutes and crepitus, which is a grating feeling inside the joint. Complications of the joint may develop as the disease progresses, including decreased joint mobility, joint pain and swelling, and joint instability that interferes with various aspects of life, such as walking, climbing stairs, and holding objects (Sen & Hurley, 2023). Thus, the manifestation of the disease may be mild discomfort and, on the other hand, significant impairments that limit one’s independence.

In evaluating a patient with suspected osteoarthritis, a thorough history and physical examination are mandatory. In the history evaluation, one should pay attention to the presence, frequency, nature, and duration of joint, obesity, previous injuries, and family history of OA. Physical examinations are also needed to assess tenderness, swelling, crepitus, and range of motion for the affected joints. Palpation of the joint may reveal bony enlargement, especially in the hands, with typical findings including Heberden’s nodes at the distal interphalangeal joints and Bouchard’s nodes at the proximal interphalangeal joints (Hunter et al., 2008). Plain radiographic imaging is an important diagnostic modality to confirm the presence of OA.

Typical radiographic findings for involved joints include joint space narrowing, subchondral sclerosis, and osteophyte formation. Advanced cases may have a complete loss of joint space with visible bone-on-bone contact. MRI may be indicated in cases where soft tissue involvement or other joint abnormalities are suspected; however, it is not routinely required for the diagnosis of OA (Braun & Gold, 2012). Laboratory analysis is usually unnecessary since there are no specific biomarkers for osteoarthritis. However, testing may be done to rule out other types of arthritis, such as rheumatoid arthritis, in patients presenting with symptoms atypical for OA.

Differential Diagnoses

A number of conditions may present similarly to osteoarthritis and thus need to be considered in the differential diagnosis. Most often, RA is a differential diagnosis, given that it also presents with joint pain and stiffness. However, RA is distinguished by its systemic inflammatory nature, symmetrical joint involvement, and the presence of autoantibodies such as RF and anti-CCP antibodies (Chauhan et al., 2023). Unlike OA, which primarily affects weight-bearing joints, RA often involves the small joints of the hands and feet. A differential diagnosis related to RA is gout, wherein the deposition of monosodium urate crystals in joints leads to inflammatory arthritis. Gout usually presents with instantaneous severe pain, swelling, and redness in one joint, often the big toe. Pseudogout—due to the deposition of calcium pyrophosphate crystals—manifests similarly to gout but tends to affect larger joints, such as the knees. Cautioning on septic arthritis, especially in patients presenting with acute joint pain, fever, and signs of infection, is destined for urgent treatment.

Clinical Management

Management of osteoarthritis in the geriatric population involves both pharmacologic and non-pharmacologic interventions, which include reduction of pain, improvement in joint function, and retardation in the development of the disease. According to Overton et al. (2022), guidelines regarding evidence-based clinical practice by the American College of Rheumatology and the Osteoarthritis Research Society International provide recommendations for managing OA through individualized care based on the particular symptoms, comorbidities, and overall health status of a patient.

Non-pharmacological treatment is the cornerstone of osteoarthritis management, including patient education, lifestyle modification, and physical therapy. Indeed, patient education concerning disease processes, self-management strategies, and regular exercise empowers them in their participation and care. A focused exercise program for strengthening the muscles around the involved joints coupled with promoting flexibility and balance can help alleviate pain while improving joint function (Wu et al., 2022). Low-impact aerobic exercises, such as swimming and walking, are especially useful for older adults. Weight management is also a critical part of OA treatment, as additional weight further stresses the weight-bearing joints and exacerbates the symptoms, hastening the disease process.

Pharmacologic agents used in the treatment of osteoarthritis include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical analgesics. Given its favorable side effect profile in older adults, acetaminophen is generally considered the first-line medication for mild to moderate pain. In cases where pain cannot be adequately controlled with acetaminophen, NSAIDs may be employed, although caution is needed due to an increased risk of gastrointestinal, cardiovascular, and renal side effects in older adults (Chauhan et al., 2023). Topical NSAIDs—diclofenac gel—exert local analgesic action with minimal systemic side effects and are the drug of choice in patients who poorly tolerate oral drugs. Intra-articular injections of corticosteroids temporarily relieve pain and inflammation, especially in the knee and hip joints. Corticosteroid injections, though, are generally used only a few times a year due to the risk of repetitive use damaging the cartilage. Other injectable treatments involve medications to improve joint lubrication and reduce friction. These include hyaluronic acid. However, their effectiveness is still controversial. Surgical interventional procedures might be considered in patients with advanced osteoarthritis who have also failed to respond to conservative management, such as joint replacement.

Total joint arthroplasty, particularly of the hip or knee, can dramatically alleviate pain and restore joint function in patients with severe OA. Surgery, however, is not without risk, particularly for elderly patients with comorbidities, and must be judiciously considered after weighing all potential benefits and risks. Rehabilitation after surgery is essential for optimal functional outcomes and ensuring a successful recovery.

The management of osteoarthritis often requires an interdisciplinary approach, especially in the geriatric population (Lim & Thahir, 2021). NPs should work collaboratively with physical therapists, dietitians, orthopedic specialists, and other professionals to develop an individualized care plan for each patient. Further, in patients whose depression or anxiety may be related to chronic pain and disability, professional mental health personnel may be involved in the overall care of such patients. Besides, addressing psychological well-being is a part of holistic care.

Expected Patient Outcomes

Outcomes for patients with osteoarthritis vary depending on disease severity and interventions. In the mild stages of OA, non-pharmacologic interventions such as exercise and weight control significantly improve joint function and reduce pain so that the patient is independent with an overall good quality of life. Pharmacologic treatments alleviate pain and improve mobility but do not reverse the degenerative changes in the joint (Sen & Hurley, 2023). The expected outcomes of these patients may include a reduction or moderation of pain, good joint stability, and the ability to perform activities of daily living with more confidence. These, however, are results that must be achieved through treatment adherence and management of the disease process. Surgery, such as joint replacement, may be required in some cases to achieve significant pain and functional improvements. The expected outcome of such joint replacement surgery is a dramatic reduction in pain and restoration of mobility in the joint, but this necessitates rehabilitation for optimal results (Sen & Hurley, 2023). The timeline for such results to be available differs because the interventionist practices differ. The benefits of both non-pharmacologic and pharmacologic treatments are evident within several weeks or a few months and full benefits from surgical interventions take some months due to necessary rehabilitation post-surgery.

Referral and Follow-Up

Osteoarthritis is a chronic condition and requires treatment and regular follow-up to monitor the disease’s progress and the effectiveness of the prescribed treatment. NPs should be scheduled for regular follow-up in order to assess changes in symptoms, functional status, and any side effects from medications or injections. The treatment plan should be altered and individualized based on the response to therapy and any new complaints reported by the patient. More complex cases where there is a need for the greatest intervention in order to relieve symptoms when conservative management does not allow symptom improvement or when surgical intervention is contemplated could be referred to an orthopedic specialist (NICE, 2020). Since orthopedic surgeons are broadly acquainted with joint replacement surgery, they could even determine whether the patient is a candidate for the treatment. It is also important that NPs work to support the surgeon in preparing the patient well for surgery and providing thorough postoperative care. In some patients, especially those with significant psychological trauma secondary to chronic pain, a referral to a mental health specialist may also be warranted.

Conclusion

In conclusion, osteoarthritis is a common and debilitating condition among older adults, bringing significant impacts on the quality of life in patients, their functional ability, and utilization of healthcare services. Nurse practitioners play a significant role in the diagnosis, treatment, and long-term management of osteoarthritis by following evidence-based guidelines in individualized care for older adults. Non-pharmacologic interventions, including exercises, weight management, and patient education, form the cornerstone of OA management, with pharmacologic treatments and surgical interventions being necessary in severe cases to attain optimum results. Such a holistic, interdisciplinary approach to care potentially enables NPs to support older adults with osteoarthritis in staying independent, enhancing their quality of life, and coping with the longer-term challenges of living with a chronic degenerative joint disease.

References

Braun, H. J., & Gold, G. E. (2012). Diagnosis of osteoarthritis: Imaging. Bone, 51(2), 278–288. https://doi.org/10.1016/j.bone.2011.11.019

Chauhan, K., Jandu, J., & Al-Dhahir, M. (2023, May 25). Rheumatoid arthritis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441999/

Coaccioli, S., Sarzi-Puttini, P., Zis, P., Rinonapoli, G., & Varrassi, G. (2022). Osteoarthritis: New insight on its pathophysiology. Journal of Clinical Medicine, 11(20), 6013. https://doi.org/10.3390/jcm11206013

Di, J., Chen, Z., Wang, Z., He, T., Wu, D., Weng, C., Deng, J., Mai, L., Wang, K., He, L., & Rong, L. (2023). Cartilage tissue from sites of weight bearing in patients with osteoarthritis exhibits a differential phenotype with distinct chondrocytes subests. RMD Open, 9(4), e003255–e003255. https://doi.org/10.1136/rmdopen-2023-003255

Hawker, G. A., & King, L. K. (2022). The burden of osteoarthritis in older adults. Clinics in Geriatric Medicine, 38(2), 181–192. https://doi.org/10.1016/j.cger.2021.11.005

Hunter, D. J., McDougall, J. J., & Keefe, F. J. (2008). The symptoms of osteoarthritis and the genesis of pain. Rheumatic Disease Clinics of North America, 34(3), 623–643. https://doi.org/10.1016/j.rdc.2008.05.004

Lim, J. A., & Thahir, A. (2021). Perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty. Journal of Perioperative Practice, 31(6), 175045892093694. https://doi.org/10.1177/1750458920936940

NICE. (2020). Osteoarthritis: Care and management. In PubMed. National Institute for Health and Care Excellence (NICE). https://www.ncbi.nlm.nih.gov/books/NBK568417/

Overton, C., Nelson, A. E., & Neogi, T. (2022). Osteoarthritis treatment guidelines from six professional societies. Rheumatic Disease Clinics of North America, 48(3), 637–657. https://doi.org/10.1016/j.rdc.2022.03.009

Sen, R., & Hurley, J. A. (2023). Osteoarthritis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482326/#:~:text=History%20and%20Physical

Wu, Z., Zhou, R., Zhu, Y., Zeng, Z., Ye, Z., Wang, Z., Liu, W., & Xu, X. (2022). Self-management for knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Pain Research and Management, 2022, 1–19. https://doi.org/10.1155/2022/2681240

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Guidelines for the Management of a Selected Health Problem

Paper

The student will select a health problem topic relevant to FNP practice, as it pertains to the care of the adult or geriatric population. The topic must be a different entity than the student’s summer health topic. The student’s topic must be submitted to their assigned grading faculty for approval no later than September 8^th, 2024 @ 11:59 p.m. CT.  Topics must be submitted to faculty by email.

The paper is due October 6^th, by 11:59 p.m. Central Time and will be reviewed through TurnItIn for a plagiarism similarity report and score. The similarity index must be less than 20% as stipulated in the course syllabus and Graduate School policy. The paper is an original individual student assignment, not group work. Plagiarism will result in a grade of “0” for the assignment. The paper should include at least eight (8) references from professional peer-reviewed journals within the last five (5) years. The paper must follow the outline given on the grading rubric on the next page.

The length of the paper must be 5-7 pages (not including title page and reference list). Papers not meeting the page length criteria will receive a 10-point grade penalty.  The paper must be written in current 7^th edition APA format, double-spaced, use headings (use sections of paper as headings), page numbers, and a font appropriate to APA 7^th ed. (such as Times New Roman, 12-point font).  Be sure to proofread your paper carefully before submission.

For the Clinical Management component of the paper, the student must search appropriate professional databases to identify published clinical guidelines/evidence-based practice guidelines for the selected health problem. The guidelines must be incorporated into the clinical management section of the paper. The source (agency organization) of the guidelines must be identified in the paper and included in the reference list. Internet sources are more current than textbook.

A few recommended databases to review include Access Medicine, CINAHL Complete, Evidence-Based Medicine, Evidence-Based Nursing, Health Source, National Guideline Clearinghouse, Nurse Best Practices Guidelines, Ovid, ProQuest, PubMed, SAGE, and U.S. Census Bureau. Follow the instructions to type in topic and any relevant terms to the database search engine and any other parameters. This will allow you to view scholarly articles or texts that may pertain to your topic and assist you in the writing of your paper.

• Paper should be on Osteoarthritis in the geriatric Population.