One of every three adults in the United States, nearly 70 million Americans, has arthritis or chronic joint symptoms (Centers for Disease Control and Prevention [CDC], 2002). As individuals age, their risk of developing arthritis increases substantially. Osteoarthritis (OA), previously known as degenerative joint disease, is the most common type of arthritis, especially in individuals older than 60. It is the leading cause of disability in the United States (CDC, 2002). Symptoms of OA include joint pain, morning stiffness that lasts less than 30 minutes, and loss of function (Brandt, Doherty, & Lohmander, 1998). Although coping with these symptoms is a challenge for older adults and the nurses who work with them, both pharmacological and non-pharmacological treatments are available. In addition, research has demonstrated that individuals with OA can maintain function and quality of life when they are able to implement selfmanagement strategies (Lorig & Holman, 1993; Lorig, Mazonson, &Holman, 1993).
PHARMACOLOGICAL TREATMENTS FOR OSTEOARTHRITIS (OA) PAIN
Osteoarthritis can affect both weight-bearing joints, such as hips and knees, as well as joints that are non-weight-bearing, such as those in the hand. Older women are disproportionately affected by this disease, but OA also affects many older men (Verbrugge & Patrick, 1995). Although the exact causes of primary or idiopathic OA are unknown, there is a strong association with age. Despite this relationship, the changes that accompany OA are not simply the result of wear and tear. Some important risk factors that influence the incidence of OA include obesity, joint injury, and heredity. Overweight or obese women are at a greater risk of developing knee and possibly hip OA, although this is a modifiable risk factor. Substantial weight loss (from obese to overweight to normal weight range) will prevent 21% of knee OA in men and 33% of knee OA in women (Felson, 1998). Even after a diagnosis of OA, weight loss can significantly reduce symptoms. Physiological factors involved in the disease process include biomechanical stresses that damage the articular cartilage and the subchondral bone, as well as biochemical changes in the joint surface, the synovium, and synovial fluid (Brandt et al., 1998).
Symptoms that result from irregularities in the normally smooth articular surface of the joint pose a continuous challenge to individuals with OA. Efforts to manage these symptoms often require the help of health care professionals and the support of friends and family. Although nurses play a vital role in assessing patient needs and planning treatment, the self-directed actions of individuals in the management of arthritis symptoms can measurably improve outcomes. With so many treatment options currently available, the choice of an appropriate plan for each individual is often difficult and complex.
Nurses who work with older adults in a variety of settings have a unique opportunity to assist in this effort by being knowledgeable about the different treatment options and by encouraging their clients to participate in the management of their OA symptoms. Nurses who work with older adults can use the trusting relationship they have with patients and their families to help them access resources and make informed decisions.
GOALS OF TREATMENT
Although there is no known cure for OA, many strategies are available for dealing with the symptoms, and research is continuing in an effort to test potential disease-remitting agents (Brandt, 2001). The primary goals for management of OA in older adults are controlling pain, improving function, and maintaining health-related quality of life (Altman & Howell, 1998). To address these goals, a multifaceted treatment approach must be used. Pain caused by OA is usually a dull aching sensation experienced after activity. However, in the later stages it can also occur at rest. In older adults, disability will often begin with an inability to complete even simple tasks, such as bathing and dressing, because of pain and stiffness, and progress to overall immobility. Both pharmacological and non-pharmacological treatments can be used to relieve these symptoms and to maintain function. When the joint has become severely damaged by OA, surgical procedures such as total joint replacement are available as well. As with other chronic illnesses, the patients' role in managing their symptoms and maintaining their functional health is very important.
A common misconception is that OA is simply a natural part of the aging process and nothing can help treat it. Contrary to this belief, research has shown that many types of treatments are effective in alleviating the symptoms of OA in older adults and in reducing the secondary problems associated with this disease (Brandt et al., 1998). As a patient advocate, the nurse can be a primary source of accurate information related to effective treatment options. This is often difficult because no single treatment is equally effective for all.
In many cases, it is the nurse who assists and supports patients and their families in accurately assessing pain and other problems with OA, in managing medications, and in selecting appropriate treatment modalities. This article offers nurses an overview of the latest pharmacological treatments and non-pharmacological measures for the management of OA symptoms in older adults (Tables 1 and 2). Surgical procedures are briefly discussed as well.
Joint pain, the most common symptom of OA, is characteristically a chronic pain that is exacerbated by activity and somewhat relieved by rest. Because the joint itself has very few nerve endings, the most likely sources of pain in OA lie in the structures that surround the joint, such as muscles, tendons, and tissues that are stretched over extra bone growth in the form of osteophytes or bone spurs (Creamer, 2000). In addition, instability in the joint can also be a source of pain. This usually occurs later in the disease process.
Unlike rheumatoid arthritis, there is no systemic inflammation with OA. However, there can be a local inflammatory response at times. Medications that are commonly prescribed for OA pain are analgesics and non-steroidal anti-inflammatories (NSAIDs). Guidelines for OA pain management established by the American College of Rheumatology (Hochberg et al., 1995a, 1995b) and the American Pain Society (2002) suggest the use of acetaminophen as the first line of treatment. The analgesic properties of acetaminophen are well-established, and it is considered to be a safe, cost-effective treatment for OA pain. The recommended dosage is 325 mg to 650 mg every 4 hours with a maximum dosage of 4 grams per day (American Pain Society, 2002). Older adults with compromised renal or hepatic function are encouraged not to take the maximum dosage of this medication, but most individuals can safely take acetaminophen. To provide adequate to effective relief of pain, patients should be encouraged to take acetaminophen on a regular basis rather than waiting until the pain is severe.
When acetaminophen fails to provide adequate relief for mild and moderate pain, NSAIDs are often prescribed. This category of drugs includes medications such as aspirin, Ibuprofen, and naproxen. There are numerous NSAIDs available worldwide (American Pain Society, 2002). Most NSAIDs are classified as nonspecific because they act on the cyclooxygenase (COX) enzyme system inhibiting the production of both the COX-I and COX-2 prostaglandins as opposed to the more specific COX-2 inhibitors (Brooks, 1998). Non-specific NSAIDS are available by prescription or over-the-counter. Side effects for this type of medication include a substantial risk of dyspepsia, gastrointestinal (GI) ulcers, and bleeding (Brandt et al., 1998). The risk of serious side effects is increased in elderly individuals who often have other chronic conditions and take numerous other medications. To reduce this risk, a gastro-protective agent such as misoprostal can be prescribed prophylactically to be taken with non-specific NSAIDs, or aspirin can be taken in the enteric- coated form (American Pain Society, 2002). While these gastro-protective measures reduce the risk of GI side effects, they also increase the overall cost of using NSAIDs. It is important to note that serious GI side effects in elderly individuals are dose-dependent, so they can be avoided with careful monitoring of NSAID dosage. Use of multiple NSAIDs is not recommended and can result in serious problems.
NON-PHARMACOLOGICAL MEASURES FOR OSTEOARTHRITIS
A history of drug use should include over-the-counter medications and herbal preparations, as well as prescription drugs. The interaction of medications and herbal preparations can pose a serious risk for patients with OA. One resource that provides a comprehensive list of these interactions is the Natural Medicines Comprehensive Database available in book format (Jellin, 2004) or electronic format from www.NaturalDatabase.com. The Handbook of Herbs & Natural Supplements (Skidmore-Roth, 2004) is another useful reference book for herbal interactions.
The newest NSAIDS - rofecoxib, celecoxib, and valdecoxib - are classified as COX-2 inhibitors because they specifically inhibit production of the COX-2 enzyme produced with joint inflammation and do not inhibit the COX-I enzyme. The COX-I enzyme acts as a protective agent in the stomach; therefore, COX-2 inhibitors have a reduced risk of GI side effects while providing pain relief (American Pain Society, 2002). These medications provide pain relief comparable to other NSAIDs (McKenna, Borenstein et al., 2001; McKenna, Weaver, Fiechtner, Bello, & Fort, 2001). Although they are available only by prescription and often cost more than non-prescription NSAIDs, one distinct advantage is the daily dosing for these medications.
Rofecoxib and valdecoxib, two of the most common COX-2 inhibitors, have been voluntarily removed from the market by their manufacturers during the past 6 months based on the discovery of an increased risk of cardiovascular events with the use of these drugs. In addition, the U.S. Food and Drug Administration (FDA) is asking manufacturers of all marketed prescription NSAIDs, including celecoxib, to add labels to their products highlighting the increased risk for GI bleeding and increased cardiovascular risk. These risks are especially important to consider in older adults who may have co-morbid conditions.
For moderate to severe pain, tramadol, an analgesic medication with weak opioid activity, has been found to be effective (Reig, 2002). Often prescribed prior to the use of opioids because of its analgesic potency, tramadol is a non-controlled substance with a low addiction risk. Tramadol is a stronger pain reliever than other weak opioids such as codeine or dextropropoxyphene, yet has fewer adverse side effects. It can also be used in combination with NSAIDs if necessary (American Pain Society, 2002).
While low-dose opioids have been found to be an excellent treatment for chronic severe pain unrelieved by other medications, their use remains controversial. Common concerns include the high incidence of adverse effects and the fear of addiction by both patients and providers.
The most common side effects of opioid medications are constipation, drowsiness, and nausea. Constipation can be prevented or reduced by starting the patient on a prophylactic bowel protocol with daily milk of magnesia, stool softeners, and laxatives, along with the opioid medications (McCarberg & Herr, 2001). Titrating the dose of the opioid can also reduce the occurrence of side effects. Older adults are generally started on an initial dose that is 25% to 50% of the standard adult dose with gradual increases until pain relief is achieved (McCarberg & Herr, 2001). Short-acting opioids can be given around the clock to maintain pain relief. However, long-acting, controlled-release codeine has also been shown to effectively relieve pain. The single daily dose improves compliance in taking the medication (Peloso et al., 2000).
Although opioids as a class of medication can be addicting, studies have shown addiction rarely occurs in older adults being treated for chronic OA-related pain (McCarberg & Herr, 2001). Research has shown that opioid therapy for chronic musculoskeletal pain is highly effective when used with individuals who have no previous history of addiction, receive a titrated dosage of the medication, and who are closely monitored throughout their therapy (Simpson, 2002).
Other medications useful in the treatment of OA symptoms are topical analgesics and intraarticular injections. Creams containing capsaicin and methylsalicylate are the most commonly used topical analgesics for OA joint pain. They are applied directly to the skin over the joint and can decrease pain over time. With capsaicin, a chemical reaction blocks the transmission of pain sensation (Brandt et al., 1998). These creams are available as over-the-counter medications and can be used in conjunction with other systemic therapies or nonpharmacological treatments.
Intraarticular joint injections must be provided by a health care provider using sterile technique. One type of medication injected into the joint when there is evidence of a local inflammatory response is corticosteroid (Raynauld et al., 2003). These injections begin relieving pain very quickly and relief usually lasts several weeks. Advantages of steroid injections are that they can be used for most joint sites and can be administered by most primary providers. A recent longitudinal study found there were no deleterious effects of long-term (2-year) administration of intraarticular steroid injections for knee OA and they provided clinically effective relief of symptoms (Raynauld et al., 2003).
Viscosupplementation agents are the newest type of intraarticular joint injection. The goal of viscosupplementation is to restore lubrication in the joint by adding supplemental hyaluronic acid, a key component of normal joint fluid (Goorman, Watanabe, Miller, & Perry, 2000). Patients generally receive three injections during a 3- to 4-week period in the knee or hip. Synovial fluid in joints affected by OA has been found to be lower in elasticity and viscosity than normal joint fluid (Goorman et al., 2000). Viscosupplementation has been shown to relieve pain and improve function in some individuals for a period of several months and has been found to provide relief comparable to corticosteroids (Goorman et al., 2000; Leopold et al., 2003). Unfortunately, these injections do not provide permanent relief and may need to be repeated.
Currently available pharmacological treatments provide relief of immediate symptoms, but do not affect or alter the disease process. The search for a dis ease- modifying drug for osteoarthritis (DMOAD) continues. Some substances being tested for their disease-remitting properties include nutritional supplements, such as glucosamine sulfate and chondroitin sulfate; commonly prescribed NSAIDS, such as piroxicam; and enzyme inhibitors, such as the tetracyclines (Altman & Howell, 1998; Brandt, 2001; Pavelka et al., 2002). In addition, genetic research is being conducted using animal models in an effort to discover genetic markers for OA (Brandt et al., 1998). These studies may reveal the key to primary prevention of OA in the future.
When pharmacological treatments are used for OA in older adults, there is always a concern about co-morbidity and interaction with other medications. For most individuals, OA pain is considered mild to moderate, and inflammation in the joint is relatively low level. Anti-inflammatory medications are used cautiously because of the risk of serious side effects. Acetaminophen is the drug of choice for pain relief. When taken on a regular basis and in the recommended doses, it has been found to be a very effective analgesic. Elderly individuals with OA should be encouraged to use analgesics in combination with nonpharmacological treatments (American Geriatrics Society [AGS] Panel on Chronic Pain in Older Persons, 1998; American Pain Society, 2002). Polypharmacy is a major concern in older adults with chronic illness, and drug interactions are possible, especially with NSAID use. Nurses and pharmacists can help by closely monitoring the medication use in older adults and by being alert to possible side effects and drug interactions.
In older adults, pharmacological treatments for OA are often only moderately effective in relieving pain and stiffness and have very little effect on function. The American College of Rheumatology (Hochberg et al., 1995a, 1995b) guidelines for treatment of OA as well as the American Pain Society guidelines (2002) stress the use of non-pharmacological treatment options in combination with pharmacological therapy. A key recommendation is patient participation in a program of s elf- management education. Patients who are knowledgeable about their illness and who are aware of the many actions they can take to decrease pain and increase function report better overall health status and quality of life than those who rely on medication alone (Lorig, 2001). Nurses who work with elderly individuals need to familiarize themselves with the various available options so they are well-prepared to provide evidence-based recommendations for a multifaceted treatment approach. As a vital part of any selfmanagement program, patients need to be encouraged to access the many resources available to them through organizations such as the Arthritis Foundation. Information about programs offered in local communities can be accessed through their website at www.arthritis.com.
Self-management patient education for individuals with arthritis is different from traditional patient education programs. These programs are not only educational, but also interactive. They assist participants in learning more about arthritis, and also help them gain a sense of control over their arthritis symptoms (Lorig & Holman, 1993; Lorig et al., 1993; Lorig, 2001). By far the most wellestablished program is the Arthritis Self -Management Program (ASMP), first developed at Stanford University (Lorig & Holman, 1993). This program includes six sessions held once a week for 2 hours taught by lay leaders who often have arthritis themselves. Participants take an active role in their care, set goals, and plan their activities to maximize their function with a minimum amount of discomfort. The ASMP is offered through the Arthritis Foundation in most states and several countries. Follow-up studies of ASMP participants have demonstrated a 20% improvement in self-reported pain, a 14% improvement in depression, and a significant reduction in the number of visits made to their physicians (p < .01) (Lorig, 2001), and these effects continue as long as 4 years after completion of the course (Lorig & Holman, 1993). Similarly, participants in mail-delivered self-management programs have reported significantly less pain and improved health status that remained stable over time (Burks, 2001; Fries, Carey, & McShane, 1997). The reference book used in the ASMP program is The Arthritis H elpbook by Lorig, Fries, and Gecht (2000) and is often available at local libraries.
Participants in arthritis self-management programs are encouraged to develop a partnership with health care providers such as nurses, physicians, and therapists related to their individual needs. An open line of communication between the OA patient and their providers means that appropriate referrals can be made and medications adjusted. Older adults may need to be encouraged to share their fears and frustrations. They may feel this condition is a part of the aging process and fail to mention their difficulties unless they are asked. A thorough assessment interview by the nurse will often aid in the accurate evaluation of symptoms, such as pain, loss of range of motion, and decreases in strength. In partnership with physical therapists, occupational therapists, and orthotists, the nurse can help individuals with OA limit discomfort, increase activity, and maintain active lifestyles.
Physical activity or exercise has been shown to have beneficial health effects for all older adults. However, there are added benefits for individuals with OA (Nied & Franklin, 2002). Exercise can improve joint circulation, strengthen muscles, improve joint stability, and aid in loss of excess weight, effectively reducing joint pain and increasing function. Studies have shown that moderate aerobic and strengthening exercise is helpful and does not escalate the OA disease process (Ettinger et al., 1997; Minor, Hewett, Webel, Anderson, & Kay, 1989).
Moderate aerobic exercise (e.g., walking, biking, swimming) is highly recommended for individuals with OA of the hip and knee (Ettinger et al., 1997). Walking is a particularly easy activity for older adults because it can be performed in a variety of locations and does not require special skills or equipment. Walking significantly improves arthritis pain and depression at short-term as well as long-term follow up (Kovar et al., 1992; Minor et al., 1989). Water aerobics has the added benefit of relieving weight-bearing on hip and knee joints for easier movement, while providing warm, moist heat to the joints for pain relief. Local Arthritis Foundation chapters sponsor many aquatic exercise programs, as well as a landbased exercise called People with Arthritis Can Exercise (PACE).
Resistance or strengthening exercise has also been found to be beneficial for individuals with OA (Ettinger et al., 1997). Muscle weakness, particularly in individuals with knee OA, is a factor in functional limitation (Baker & McAlindon, 2000). To decrease the chance of joint damage, it is suggested that individuals with OA perform some gentle range of motion exercises prior to beginning resistance training.
Joint protection measures are important because excessive stress on joints, particularly the small joints in the hand, can cause pain and swelling. Simple steps can be taken to protect joints, such as carrying a shoulder bag instead of a small hand-held purse or using a grocery cart to take bags to the car rather than carrying them. For larger joints, such as knees and hips, prolonged standing or walking on hard surfaces, such as concrete, may also cause discomfort. In some cases, it may be necessary for an individual with OA to get a handicapped parking tag so they can conserve energy and reduce their walking distance. Occupational therapists can evaluate and suggest adaptations that promote joint protection.
Psychological stress also plays a role in the process of coping with the symptoms of OA. The disease is unpredictable. Joints will sometimes hurt for no reason at all and stiffness may arise when least expected. Having a positive outlook, practicing stress reduction techniques, and feeling confident about managing the symptoms of OA will ultimately improve overall health status (Keefe et al., 1990). Pacing activities can reduce stress on joints and decrease symptoms. Patients should be cautioned to allow time for rest and relaxation during their busy days, which will help in the coping process. Resting a joint for short periods of time before and after activity is recommended.
Besides traditional treatments for OA, a number of alternative therapies are also currently being used and tested. These include nutritional supplements and herbal preparations. Unlike medications, these products are not regulated by the FDA. In some cases scientific testing has been conducted; however, it is not required. Despite this lack of regulation, many older adults are currently taking these preparations.
The most commonly used nutritional supplement for OA is a combination of glucosamine and chondroitin. These supplements were first introduced in Europe and are widely sold over-the-counter in the United States. Glucosamine and chondroitin are extracted from animal products and there is limited evidence that these substances enhance the regeneration of cartilage in the joint (Pavelka et al., 2002). There have been several clinical trials testing glucosamine sulfate and fewer trials that added chondroitin (Pavelka et al., 2002; Towheed, 2002, 2003). Although the mechanism for pain relief from these substances is not completely understood, they have been found to have a moderate to large effect on joint pain (McAlindon, LaValley, Gulin, & Felson, 2000; Reginster, Bruyère, & Henrotin, 2003). To date, these supplements are considered to be a safe, viable option for individuals with OA with very few side effects.
Several herbal preparations are also advertised as remedies for OA pain. These claims are largely untested in randomized controlled trials. Because they are considered to be "natural" substances, many individuals, including older adults, do not consider them to be harmful and do not realize the side effects and potential interactions with other medications. For example, many herbal products are known to potentiate the effect of blood-thinners (Horstman, 1999).
Treatments such as acupuncture, massage, tai chi, and yoga have been used in other countries for centuries in the treatment of both acute and chronic illnesses of all types. In response to the trend for using these alternative therapies in the United States, the National Institutes of Health has established the National Center for Complementary and Alternative Medicine to study the efficacy of these treatments.
Many senior centers offer both tai chi and yoga classes. Although these practices are not specifically designed to alleviate the symptoms of OA, their approach to physical activity provides slow movement that puts very little stress on joints. Tai chi is an ancient Chinese exercise that combines slow movement with meditation (Li et al., 2001). One nursing study compared pain relief in participants who attended 10 weeks of tai chi classes with those who did not and found that the intervention group had significantly less pain (Adler, 1985). Individuals who participate in these activities should be aware of the need to have adequately trained leaders.
Through a combination of pharmacological and non-pharmacological treatments, individuals with OA can cope with the pain and loss of function that result from degenerative changes in the joint. However, in some cases there is so much destruction of cartilage and misalignment of the joint that surgery is indicated. Joint degeneration is generally a gradual process that occurs over a number of years. During the early stages of joint destruction, surgical procedures such as joint debridement, penetration of subchondral bone, or osteotomies can be performed to stimulate articular surface regeneration and to correct malalignment, but these are only temporary measures and are usually performed in younger individuals with localized bone loss (Brandt et al., 1998).
For older adults, the most common surgical procedure is a total joint replacement. When OA pain is severe and joint function is limited, the hip or knee joint can be replaced with a prosthetic joint. Although joint replacements have been performed for many years, they are major surgical procedures and have associated risks. Management of OA through the use of non-operative treatments is preferable to the risk of surgery (Buckwalter et al., 2001). It is hoped that early diagnosis and treatment of OA will prevent severe articular damage, thus reducing the need for major joint surgeries in the future.
As the population ages, the number of people affected by OA is rising at a rapid rate. This progressive joint disease affects many aspects of an individual's life. Symptoms of OA include joint pain, morning stiffness, and loss of function. The challenge of managing these symptoms on a daily basis is multifaceted. Traditional treatment for OA has focused on medications and surgery to alleviate the pain and loss of function. However, it has recently been demonstrated that the use of non-pharmacological and non-operative treatments are also effective in alleviating pain, improving function, and maintaining quality of life. Older adults with OA can benefit from participation in self-management education programs where they become involved in their arthritis treatment, and learn how to work with health care providers with a comprehensive treatment approach.
Activities such as exercise, joint protection, activity pacing, and stress reduction have all been shown to positively influence both pain and functional abilities. In addition, there are alternative therapies, such as nutritional supplements, herbal preparations, acupuncture, tai chi, and yoga that are emerging as methods for relief of OA symptoms. Although scientific evidence related to these treatments is limited, ongoing studies are being conducted. The treatment of OA is expanding from the once-traditional medical model to a self-management model designed to provide individuals with the information and assistance needed to meet the challenge of this chronic illness. If nurses are to play a vital role in this new emerging model of care for individuals with OA, it is essential that they be knowledgeable of evidencebased treatments and up-to-date on the newest developments in OA care.
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PHARMACOLOGICAL TREATMENTS FOR OSTEOARTHRITIS (OA) PAIN
NON-PHARMACOLOGICAL MEASURES FOR OSTEOARTHRITIS