Osteoarthritis and Osteoporosis

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Osteoarthritis and Osteoporosis

• Rochelle M. Nolte, MD
• CDR USPHS

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Objectives

• Participants will be able to
• Discuss the epidemiology of osteoarthritis and
  osteoporosis in the geriatric population
• List 3 risk factors for osteoarthritis and
  osteoporosis in the geriatric population
• Describe the management of osteoarthritis and
  osteoporosis in the geriatric population

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What is Osteoarthritis?

• According to the American College of
  Rheumatology
• a heterogeneous group of conditions that leads
  to joint symptoms which are associated with
  defective integrity of the articular cartilage in
  addition to related changes in the underlying
  bone at the joint margins.

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Etiology of OA
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Etiology of Osteoarthritis

• Growth of cartilage and bone at the joint margins
  leads to osteophytes which can restrict movement
• Chronic synovitis and thickening of the joint
  capsule further restrict movement
• Periarticular muscle wasting is common and plays
  a major role in sx and disability

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Etiology of Osteoarthritis
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Symptoms of osteoarthritis

• PAIN (Articular cartilage is aneural)
• OA pain is not from the cartilage
• Stretching of nerve ending in periosteum covering
  osteophytes
• Microfractures in subchondral bone
• Stretching of joint capsule
• Synovitis
• Ligament stretching or muscle pain
• STIFFNESS (esp. after inactivity)

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Radiology Findings in OA
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Radiology Findings in OA
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Radiology Findings in OA
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Epidemiology of OA

• OA of the knee is the leading cause of chronic
  disability in the elderly in developed countries
• Estimated 60 billion economic impact in US
• Decreased quality of life for gt 20 million
  Americans
• In patients over the age of 55
• Hip OA is more common in men
• IP and 1st MCP OA is more common in women
• Knee OA (with sx) is more common in women

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Epidemiology of OA

• In patients under the age of 55
• Joint distribution of OA is equal between men and
  women
• Due to genetics or joint usage?????
• Mother and sister of a woman with DIP OA are 2
  3 X more likely to have the same
• Racial differences in prevalence and pattern of
  joint involvement also point to genetic basis

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Epidemiology of OA

• Age is the most powerful risk factor for OA
• Women lt 45 years of age 2 with OA
• Women 45-64 30 with OA
• Women gt65 68 with OA

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Epidemiology of OA

• Does exercise cause osteoarthritis?

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Epidemiology of OA

• There is no convincing data to support an
  association between nonspecific nonprofessional
  athletic activities and osteoarthritis
• (excluding major trauma)
• Neither long-distance running nor jogging has
  been shown to cause osteoarthritis

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Epidemiology of OA

• Exercise does not cause osteoarthritis

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Epidemiology of OA

• OBESITY causes osteoarthritis

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Epidemiology of OA

• Obesity is a risk factor for knee (and hand)
  osteoarthritis
• In the highest quintile of BMI
• Relative risk of developing OA in the next 36
  years was 1.5 for men and 2.1 for women
• For SEVERE OA, the RR rose to 1.9 for men and 3.2
  for women
• Weight loss of 5kg was associated with a 50
  reduction in the odds of developing OA

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Epidemiology of OA

• Disability in subjects with knee OA
• More strongly associated with QUADRICEPS WEAKNESS
• than with joint pain or radiographic severity
• Demographics associated with increased likelihood
  of being symptomatic women, unemployed,
  divorced, poor social support

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Risk factors for OA

• Age
• Sex
• Race
• Genetic factors
• Congenital defects
• Malalignment
• Prior inflammatory disease
• Metabolic disorders

• Major joint trauma
• Repetitive stress
• Vocational
• Recreational
• Obesity
• Muscle weakness
• Joint laxity
• Proprioception loss

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Risk factors for OA

• Systemic
• Age
• Gender
• Ethnicity
• Genetics
• Hormonal status
• Bone density
• Metabolic/nutritional status

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Risk factors for OA

• Local
• Obesity
• Major trauma
• Joint deformity/laxity
• Physical disability
• Muscle weakness
• Loss of proprioception
• Occupational/sports stress

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Prevention of OA

• Physical activity is the best way to ensure the
  maintenance of functional capacity
• Physical activity also aids in the prevention of
  obesity

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Prevention of Osteoarthritis

• Weight reduction (IA)
• Recreational exercise/sports (IA)
• Maintain physical fitness (B)
• Avoid obesity (B)
• Participate in adequate physical exercise (B)

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Prevention of OA

• Current studies
• Isokinetic exercise for improving knee flexor and
  extensor muscles in healthy adults to assess
  safety and effectiveness
• Will also assess in adults with neurological,
  orthopedic, and rheumatological conditions
• Currently lt 1 of money spent on Osteoarthritis
  is spent on research

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Management/Treatment of OA

• Goals
• Educate patient about disease and management
• Improve function
• Control pain
• Alter disease process and its consequences
• (we just dont know that much about biomarkers
  and disease-modifying drugs just yet)

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Management/Treatment of OA

• No known cure for OA
• HOWEVER
• Impaired muscle function
• Reduced fitness
• Affect pain and dysfunction
• Are amenable to therapeutic exercise

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Management/Treatment of OA

• Pharmacologic
• Acetaminophen
• NSAIDS
• Cox-2 specific inhibitors
• With PPI or misoprostol
• Nonacetylated salicylate
• Tramadol
• Opioids

• Topical
• Capsaicin
• Methylsalicylate
• NSAIDS
• Intra-articular
• Corticosteroids
• Hyaluronan

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Management/Treatment of OA

• Non-pharmacologic
• Patient education
• Self-management programs
• Weight loss
• PT/OT
• ROM exercises
• Muscle strengthening

• Non-pharmacologic
• Assistive devices
• Patellar taping
• Appropriate footwear
• Lateral-wedged insoles
• Bracing
• Joint protection and energy conservation

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Osteoarthritis Summary

• Non-pharmacologic therapy is important for the
  prevention and treatment of OA
• The best-studied and most effective
  non-pharmacologic therapy is EXERCISE
• Exercise helps control weight, increase strength,
  improve and maintain function and decrease pain

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Osteoporosis

• Skeletal disorder characterized by diminished
  bone strength predisposing a person to an
  increased risk of fracture

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Osteoporosis

• Bone is dependent on nutritional, hormonal, and
  mechanical influences
• Normal remodeling has equal rates of formation
  and resorption

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Demographics of Osteoporosis

• In 2004
• 10 million American women with osteoporosis (OP)
• 34 million American women with osteopenia
• Women gt50
• 20 with OP
• 52 low BMD

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Demographics of Osteoporosis

• 1.5 million OP related fx per year in US
• 500,000 hospitalizations
• 800,000 Emergency Room visits
• 2.6 million physician visits
• 180,000 nursing home (NH) placements
• 18 billion in direct health care costs

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Hip Fractures

• 300,000 hip fractures per year in US
• Over ½ occur in gt80 year old patients
• ½ of hip fracture patients go to NH
• ½ d/cd to NH become long-term resident
• One year mortality is 20-24
• 60 never return to baseline function
• gt ½ women gt75 prefer death to hip fx

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Osteoporosis/Hip fx Risk Factors

• Low BMD
• Age
• Previous fx
• Fall in past year
• Low body weight
• Maternal history of hip fracture

• H/O amenorrhea
• Asian or white
• Cigarette smoking
• Excessive EtOH use
• Low Ca2 intake
• Vitamin D deficiency
• Long-term immobilization

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Secondary Osteoporosis

• Hypogonadal states
• Glucocorticoid use
• Excess thyroid
• Hyperparathyroidism
• Hypercalciuria
• Malabsorption states
• Renal failure
• Rheumatoid arthritis

• COPD
• Alcoholism
• Chronic Liver Disease
• Organ transplant
• Malnutrition
• Eating disorders
• Type I DM
• Medications

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Osteoporosis Prevention
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Osteoporosis Prevention

• Adequate caloric intake
• Exercise
• Weight-bearing
• Swimming
• Intermittent dynamic loading
• Avoid tobacco
• Avoid/decrease alcohol intake

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Osteoporosis Prevention

• 92 of total bone mass by age 18
• 99 by age 26
• Bone mass not obtained during this time cannot be
  made up later

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Osteoporosis prevention

• Different sites mature at different ages
• Peak bone mass complete by age 16 in the femoral
  neck
• Later in lumbar spine and distal radius

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Osteoporosis Prevention

• Adequate caloric intake
• Calcium 500mg mg TID
• Vitamin D 800 IU qd
• May consider OCPs if above are met
• Goal is to restore reproductive and metabolic
  hormones by increasing energy availability

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Osteoporosis Management

• Goals of osteoporosis management
• Prevention of fracture
• Stabilization or increase of bone mass
• Relief of sx of fx and skeletal deformity
• Maximization of physical function

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Osteoporosis Management

• Non-pharmacologic management
• Same as for osteoporosis prevention
• Nutritional
• Calcium 500mg TID
• Vitamin D 80 IU qd

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Pharmacologic Management

• Estrogen Therapy
• Not approved for treatment (only prevention)
• Bisphosphonates
• Approved for prevention and treatment
• Therapy of first choice
• Selective Estrogen Receptor Modulators
• Approved for prevention and treatment
• Raloxifene

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Pharmacologic Management

• Calcitonin
• Approved for treatment of osteoporosis in women
  who have been postmenopausal for gt5 years
• Bisphosphonates seem to be more efficacious
• Anabolic Therapy (teriparatide)
• Daily SubQ injection
• Approved for treatment in high risk patients

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Physicians challenges

• Identify potential osteoporosis risk factors
• Educate patients
• Initiate interventions proactively
• PREVENTION AND DIAGNOSIS OF OSTEOPOROSIS IS FAR
  FROM WIDESPREAD
• Despite Surgeon Generals report in 2004

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Missed opportunities

• Vertebral fractures noted incidentally
• Should be reported and prompt further eval
• Patients with history of fragility fractures
• Should be evaluated and treated for OP
• Women over age 65 or with risk factors
• Should be screened with DEXA
• Women should be educated on OP

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Osteoporosis Summary

• Much of what can be done to prevent osteoporosis
  and osteoporosis-related fractures is not being
  done
• Prevention of osteoporosis begins in childhood
• Treatment to prevent osteoporosis-related
  fractures should be targeted to high risk patients

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Summary

• Osteoarthritis and osteoporosis are important
  public health issues in a rapidly enlarging
  geriatric population
• Prevention of both can be promoted through a
  physically active lifestyle and a healthy diet
  beginning at a young age

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Thanks for listening

• Questions?