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14 - Pain and Sensory Disorders |
437
48. Boi R, Racca L, Cavallero A, et al. Hearing loss and
depressive symptoms in elderly patients. Geriatr
Gerontol Int. 2012;12(3):440–445.
49.
Karp JF, Shega JW, Morone NE, et al. Advances
in understanding the mechanisms and manage-
ment of persistent pain in older adults. Br J Anaesth.
2008;101:111–120.
50.
Argo CE, Cole BE, Fishbain DA, et al. Diabetic
peripheral neuropathic pain: clinical and quality-of-life
issues. Mayo Clin Proc. 2006;81:S3–S11.
51.
Niv D, Maltsman-Tseikhin A. Postherpetic neuralgia:
the never-ending challenge. Pain Practice. 2005;5:327–
340.
52.
AGS Panel on Persistent Pain in Older Persons. e
management of persistent pain in older persons. J Am
Geriatr Soc. 2002;50:S205–S224.
53.
Fox PL, Raina P, Jadad AR. Prevalence and treatment
of pain in older adults in nursing homes and other
long-term care institutions: a systematic review. CMAJ.
1999;160:329–333.
54.
Torrance N, Smith BH, Bennett MI, et al. e epide-
miology of chronic pain of predominantly neuropathic
origin. J Pain. 2006;7:281–289.
55. Davies M, Brophy S, Williams R, et al. e prevalence,
severity, and impact of painful diabetic periph-
eral neuropathy in type 2 diabetes. Diabetes Care.
2006;29:1518–1522.
56. Lundstrom E, Smits A, Terent A, et al. Risk factors for
stroke-related pain 1 year after rst-ever stroke. Eur J
Neurol. 2009;16:188–193.
57. Weiner DK, Rudy TE, Morrow L, et al. e relation-
ship between pain, neuropsychological performance,
and physical function in community-dwelling
older adults with chronic low back pain. Pain Med.
2006;7:60–70.
58.
Chou R, Fanciullo GJ, Fine PG, et al. Clinical guide-
lines for the use of chronic opioid therapy in chronic
noncancer pain. J Pain. 2009;10:113–130.
59. WHO’s Pain Ladder. World Health Organization
Web site. http://www.who.int/cancer/palliative/pain-
ladder/en/. Accessed October 1, 2008.
60. McAlindon TE, Bannuru RR, Sullivan MC, et al.
OARSI guidelines for the non-surgical management
of knee osteoarthritis. Osteoarthritis Cartilage. 2014
Mar;22(3):363–388. doi:10.1016/j.joca.2014.01.003.
61.
Christo PJ, Hobelmann G, Maine DN. Post-herpetic
neuralgia in older adults. Drugs Aging. 2007;24:1–19.
62. Argo CE, Backonja MM, Belgrade MJ, et al.
Consensus guidelines: treatment planning and options.
Mayo Clin Proc. 2006;81:S12–S25.
63. Pharmacological management of persistent pain
in older persons. AGS Panel on pharmacological
management of persistent pain in older persons. http://
www.americangeriatrics.org/education/nal_recom-
mendations.pdf. Accessed February 12, 2014.
64.
Pergolizzi J, Boger RH, Budd K, et al. Opioids and
the management of chronic severe pain in the elderly:
consensus statement of an international panel with
focus on the six clinically most often used World
Health Organization step III opioids. Pain Practice.
2008;8:287–313.
65.
Temple AR, Benson GD, Zinsenheim JR, et al. Multi-
center, randomized, double-blind, active-controlled,
parallel-group trial of the long-term (6–12 months)
safety of acetaminophen in adult patients with osteo-
arthritis. Clin er. 2006;28:222–235.
66.
Altman RD, Zinsenheim JR, Temple AR, et al.
ree-month ecacy and safety of acetaminophen
extended-release for osteoarthritis pain of the hip or
knee: a randomized, double-blind, placebo-controlled
study. Osteoarthr Cartil. 2007;15:454–461.
67.
Roth SH, Fleischmann RM, Burch FX, et al. Around-
the-clock, controlled-release oxycodone therapy
for osteoarthritis-related pain. Arch Intern Med.
2000;160:853–860.
68.
e American Geriatrics Society 2012 Beers Criteria
Update Expert Panel. American Geriatrics Society
updated Beers Criteria for potentially inappropriate
medication use in older adults. J Am Geriatr Soc.
2012;60(4):616–631.
69. Morello CM, Leckband SG, Stoner CP, et al.
Randomized double-blind study comparing the
ecacy of gabapentin with amitriptyline on diabetic
peripheral neuropathy pain. Arch Intern Med.
1999;159:1931–1937.
70. Dallocchi C, Bua C, Mazzarello P, et al. Gabapentin
vs. amitriptyline in painful diabetic neuropathy:
an open-label pilot study. J Pain Symptom Manage.
2000;20:280–285.
71. Watson CP, Vernich L, Chipman M, et al. Nortripty-
line versus amitriptyline in postherpetic neuralgia: a
randomized trial. Neurology. 1998;51:1166–1171.
72.
Raskin J, Pritchett YL, Wang F, et al. A double-blind,
randomized multicenter trial comparing duloxetine
with placebo in the management of diabetic peripheral
neuropathic pain. Pain Med. 2005;6:346–356.
73. Wernicke JF, Pritchett YL, D’Souza DN, et al. A
randomized controlled trial of duloxetine in diabetic
peripheral neuropathic pain. Neurology. 2006;67:1411–
1420.
74.
Rowbotham M, Harden N, Stacey B, et al. Gabapentin
for the treatment of postherpetic neuralgia: a random-
ized controlled trial. JAMA. 1998;280:1837–1842.
75. Stacey BR, Dworkin RH, Murphy K, et al. Prega-
balin in the treatment of refractory neuropathic pain:
results of a 15-month open-label trial. Pain Med.
2008;9(8):1202–1208.
https://t.me/medicina_free
438
| Fundamentals of Geriatric Pharmacotherapy
76. Baron R, Brunnmuller U, Brasser M, et al. Ecacy
and safety of pregabalin in patients with diabetic
peripheral neuropathy or postherpetic neuralgia: open-
label, non-comparative, exible-dose study. Eur J Pain.
2008;12:850–858.
77.
Raja SN, Haythornthwaite JA, Pappagallo M, et
al. Opioids versus antidepressants in postherpetic
neuralgia. Neurology. 2002;59:1015–1021.
78.
Gilron I, Bailey JM, Tu D, et al. Morphine, gaba-
pentin, or their combination for neuropathic pain. N
Engl J Med. 2005;352:1324–1334.
79.
Watson CPN, Moulin D, Watt-Watson J, et al.
Controlled-release oxycodone relieves neuropathic
pain: a randomized controlled trial in painful diabetic
neuropathy. Pain. 2003;105:71–78.
80.
Lin PL, Fan, SZ, Huang CH, et al. Analgesic eect
of lidocaine patch 5% in the treatment of acute herpes
zoster: a double-blind and vehicle-controlled study.
Reg Anesth Pain Med. 2008;33:320–325.
81. White WT, Patel N, Drass M, et al. Lidocaine patch
5% with systemic analgesics such as gabapentin: a
rational polypharmacy approach for the treatment of
chronic pain. Pain Med. 2003;4:321–330.
82.
Morrison RS, Siu AL. A comparison of pain and its
treatment in advanced dementia and cognitively intact
patients with hip fracture. J Pain Symptom Manage.
2000;19:240–248.
83. Nygaard HA, Jarland M. Are nursing home patients
with dementia diagnosis at increased risk for
inadequate pain treatment? Int J Geriatr Psychiatry.
2005;20:730–737.
84.
Reynolds KS, Hanson LC, DeVellis RF, et al. Dispari-
ties in pain management between cognitively intact
and cognitively impaired nursing home residents. J
Pain Symptom Manage. 2008;35:388–396.
85.
Herr K, Bjoro K, Decker S. Tools for assessment
of pain in nonverbal older adults with dementia: a
state-of-the-science review. J Pain Symptom Manage.
2006;31:170–192.
86.
O’Neil CK, Hanlon JT, Marcum ZA. Adverse eects
of analgesics commonly used by older adults with
osteoarthritis: focus on non-opioid and opioid analge-
sics. Am J Geriatr Pharmacother. 2012;10:331–342.
87.
Food and Drug Administration. Acetaminophen
information. http://www.fda.gov/drugs/drugsafety/
informationbydrugclass/ucm165107.htm. Accessed
February 13, 2014.
88. Zeppetella G. Opioids for cancer breakthrough pain:
a pilot study reporting patient assessment of time
to meaningful pain relief. J Pain Symptom Manage.
2008;35:563–567.
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M
C T
D
MARY BETH O’CONNELL and MICHELLE A. FRITSCH
L O
1. Identify differences in the presentation and risk factors of common musculoskeletal disorders and pressure
ulcers in older adults.
2.
Apply evidence to support age-adjusted therapies for common musculoskeletal disorders and pressure ulcers.
3.
Recommend appropriate nonpharmacologic and medication therapy to achieve treatment goals for common
musculoskeletal disorders and pressure ulcers.
4.
Resolve pharmacotherapy-related problems unique to older adults with musculoskeletal disorders and pressure
ulcers.
15
K T D
BIOLOGIC RESPONSE MODIFIERS (BRMs): Products that modulate the activity of immunologic substances
such as monoclonal antibodies, cytokines, or colony stimulating factors.
DEBRIDEMENT: Removal of nonliving tissue from pressure ulcers, burns, and other wounds. Sharp debride-
ment is a form of selective debridement where surgical instruments are used to remove specific areas of
necrotic tissue. Enzymatic debridement is a nonselective technique that employs the use of enzyme gels
placed into the wound.
FRICTION: Force resisting the relative parallel motion of solid surfaces. As a risk factor for pressure ulcers, this
term refers to stress on the skin surface caused by sliding a patient across bed sheets.
NUTRACEUTICAL: Nutritional product that claims to have, in addition to nutritional benefits, medicinal effects.
PRESSURE: The force per unit area applied in a direction perpendicular to the surface of an object. As a risk
factor for pressure ulcers, this refers to the downward pressure of the body against the surface of a bed or
chair.
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SHEAR: The stress applied in a direction parallel to the surface of an object. Somewhat different from friction,
this refers to the stress on the internal layers of skin and soft tissue caused by shifts of internal structures. For
example, when raising the head of a bed without providing assistance in repositioning, the skin of the back is
pulled slightly upward while gravity pulls the ribcage and internal structures downward.
I
M
obility is very important to older adults
and can represent the difference
between independent and assisted living. Aging
is associated with changes in muscle, joint, and
bone physiology and function that ultimately lead
to musculoskeletal diseases such as osteoar-
thritis, osteoporosis, and polymyalgia rheumatica,
all of which have higher incidences in older
adults. Prevention can help eliminate or delay the
onset of these conditions. For many older adults,
these conditions require treatment, which usually
provides only symptom relief, slowing of disease
progression, or both, but not disease cure. Health-
care providers have an important role in promoting
and encouraging healthy lifestyle behaviors for
older adults, preventing disease development,
assessing and identifying disease at early stages,
and prescribing and monitoring age-adjusted
therapies. Lifestyle adjustments are key prior
to diagnosis and as a component of functional
disease adaptation. Prevention and intervention
can improve older adult quality of life and reduce
older adult and societal healthcare costs.
F
Etiology, Epidemiology, and
Clinical Presentation Specic to
Older Adults
Falls and their consequences are serious
health issues for older adults because they can
decrease quality of life, lead to loss of indepen-
dence, and sometimes result in death. They also
create a challenge for healthcare providers and
caregivers because of their multifactorial nature
and complexity. Falls are either provoked (e.g.,
push, syncope, seizure related, icy walkway) or
unintentional/unexpected (e.g., loss of balance,
weakness) with the latter type being the focus
of this section. Risk factors are related to patient
characteristics, disorders, medications, and the
environment (Table 15-1).
1-3
Most of the medica-
tions associated with falls have a central nervous
system effect.
1,4
Medications can also induce
falls through effects on blood pressure, glucose
concentration, electrolytes, vision, gait, balance,
and muscle weakness.
About a third of older adults residing in the
community
2
and 50% to 75% of nursing home
residents
5
experience at least one fall every year.
In 2011, falls resulted in 2.4 million emergency
department visits and 689,000 hospitalizations.
5
Health expenditures for falls are significant (2005
data: $349 million for fatal falls and $8.45 billion
for nonfatal fall hospitalizations).
6
Injuries from falls range from minor to severe
and sometimes precipitate nursing home resi-
dency. Moderate to severe injury occurs in about
20% to 30% of falls, most notably lacerations,
head trauma, and fractures.
5
In older adults, 3%
to 12% of falls result in a fracture, and less than
1% result in a hip fracture.
2
Ten to twenty percent
of falls occurring in the nursing home result in
serious injury, resulting in a fracture 2% to 6% of
the time.
5
After hospitalization for a fall, 51% of
the patients were discharged to a skilled nursing
facility, 6% to home with assistance, and 5% to
an inpatient rehabilitation facility.
7
Men, whites,
and non-Hispanics have a higher mortality rate
after a fall.
5
Unintentional injury was the ninth
leading cause of mortality for older adults in
2010.
8
After a fall, patients can become fearful of
subsequent falls, resulting in restricted mobility,
social isolation, depression, and further balance
and strength deficits.
5
Assessment of patients with falls begins
with a history, gait and balance evaluation, and
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15 - Musculoskeletal and Connective Tissue Disorders |
441
routine physical examination, progressing to
multifactorial assessments and more complex
mobility tests.
9
Simple tests such as the Timed
Up and Go
5
(described in Chapter 4) and obser-
vation of gait and balance can easily be done in
the clinic, whereas other more complex assess-
ments require an occupational therapist, phys-
ical therapist, or both.
A complete medication
assessment, including over-the-counter (OTC)
medications, herbals, and supplements should
be conducted. Patients with osteoporosis are
more likely to fracture after a fall; therefore, a dual
energy x-ray absorptiometry (DXA) test should
be performed . A 25-hydroxy vitamin D (25[OH]
vitamin D) level could be ordered to evaluate for
vitamin D deficiency–related muscle weakness,
gait abnormalities, and decreased strength.
Other tests ordered will be based on the specific
comorbidities and medications.
Summary of Standard Treatment
A comprehensive falls guideline with resources
is accessible on the American Geriatrics Society
website.
9
It describes patient assessment, inter-
ventions, and education and evaluates quality
of available data. As part of the National Patient
Safety Program, The Joint Commission created
fall reduction goals (number 9, 2014) for home
care and long-term care facilities related to
patient assessment, patient harm reduction, and
program evaluation.
10
Review of Evidence Base
Supporting Treatment
Recommendations for Older Adults
A multifactorial and multidisciplinary approach to
evaluate and resolve falls risk using nonpharma-
cologic and pharmacologic interventions should
be employed to prevent falls (Figure 15-1).
2,9,11
An interprofessional team of physicians, other
healthcare professionals, and community
members (patients, family members, older adult
centers) can decrease the number of serious
falls, pain, immobility, emergency department
visits, and healthcare costs.
Each medication,
especially psychoactive medications, should
be evaluated for need, lower dose, and/or safer
alternatives including nonpharmacologic inter-
ventions because these changes can decrease
falls risk.
2,9
The guideline recommends 800 units
vitamin D for those at risk for falls or with proven
or suspected vitamin D deficiency.
9
The majority
of studies and meta-analyses documented
a 14% to 17% decrease in falls with vitamin D
therapy of 700–1,000 units daily.
2,12
Lack of effect
might be related to study design (differences in
Table 15-1. Fall Risk Factors
Patient Characteristics Disorders Medications Environment
Advanced age Cognitive impairment Antidepressants Throw rugs
Female sex Depression Benzodiazepines Poor lightning
Walking assistance devices
(e.g., walker)
Stroke Sedative hypnotics Loose electrical
cords
Decreased ADLs Parkinson disease Antipsychotics Steps
Alcohol use Muscle weakness Anticonvulsants
History of falls Gait and balance difficulties Pain medications
Poorly fitting footwear Vision difficulties
Nocturnal voids
Peripheral neuropathy
Mobility problems
(e.g., arthritis)
Cardiovascular diseases
(e.g., syncope, orthostatic
hypotension, arrhythmias)
ADLs, activities of daily living.
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| Fundamentals of Geriatric Pharmacotherapy
patient sample, dose, vitamin D status at base-
line, or both).
KEY POINT:
Because of the multifactorial
causes of falls, interprofessional team care is
often benecial in resolving fall problems.
Lifestyle and environmental changes
are also effective.
2,9
Exercises to strengthen
muscles and improve balance, such as tai chi,
should be suggested.
9,13
Older adults should
be encouraged to wear their glasses and use
their hearing aids. As patients lose weight
and height, appropriateness of footwear and
assistive devices should be re-evaluated and
adjusted or replaced as needed. The patient,
family members, or a healthcare provider can
do a home safety assessment and make adjust-
ments to correct problems.
Although hip protec-
tors do decrease fractures from falls in nursing
home residents, adherence with usage is poor.
Bedrails can be appropriate in select cases, but
other restraints should be avoided because they
do not decrease falls and can cause death.
5
The impact of various fall intervention
programs has been evaluated by many meta-
analyses with mixed evidence for effectiveness of
both single strategies and multifactorial interven-
tions.
2
Fall prevention can decrease injury. Abso-
lute elimination of falls is often not an achievable
goal, and not all intervention programs are prac-
tical or cost effective. Thus, interventions should
be individualized to the specific patient’s needs
and causes of falls and implemented following
an approach similar to Figure 15-1.
11
Older
adults at high risk for falling might benefit from a
referral to a falls clinic or program.
Figure 15-1. Multifactorial approach to minimizing or eliminating falls.
Source: Reprinted from Moylan KC, Binder EF. Falls in older adults: risk assessment, management, and preven-
tion. Am J Med. 2007 Jun;120(6):493.e1–e6. ©2007, with permission from Elsevier.
Ask patient about falls in
the past year
Patient reports two or more
falls in the past 6 months, any
fall resulting in an injury, or
fear of falling
Patient denies two or more falls
in the past 6 months, any fall
resulting in an injury, or fear
of falling
Evaluate and treat contribu-
tors to fall risk (usually
multifactorial etiology and
intervention)
Reassess in
1 year
Syncope
Gait or
mobility
problem
Vision
impairment
Cognitive
impairment
Postural
hypotension
Polypharmacy
or high-risk
medications
Environmental
hazards
Vitamin D
deficiency
Physical
therapy: assis-
tive devices;
tr
eat musculo-
skeletal pain;
regular physical
activity
Medical
evalua-
tion for
syncope
Refer to
ophthalmology
for corrective
lenses, cata-
ract removal;
home low
vision modifi-
cations
Exclude
reversible
etiologies;
eliminate or
reduce dose
of high-risk
medications
Establish
etiology;
remove
offending
medica
-
tions; treat
symptomatic
patients
Review indica
-
tions for all
drugs; eliminate
non-essential
agents; use
lowest effective
doses; avoid
high-risk
medications
Home
safety
evaluation;
provide fall
literature for
patients
Treat
patients with
25-OH-vitamin
D levels
<30 ng/mL
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Common Problems Encountered
When Treating Older Adults with
is Condition
Determining if the fall risk is from a medication or
treated condition can be difficult. One risk factor
modification at a time should be made to deter-
mine cause. Slow discontinuation of medications
with a high fall risk should be tried, especially if
the reason for use is unclear or no longer valid.
To determine benefits and risks of a medication
discontinuation, patient and caregiver follow-up
is required, sometimes lasting weeks to months.
Adverse medication withdrawal reactions can be
precipitated by well-meaning medication reduc-
tion attempts if not done correctly.
KEY POINT:
A thorough patient history
is required to assess the contribution of
medications to fall risk. Medication changes
should be made slowly, one drug at a time,
followed by careful observation of the results.
Limited functional status and harm from a fall
create barriers to independent living and timely
medical attention. Many older adults live alone,
making it more complicated to seek help after a
fall. An older adult can wear a device that trig-
gers medical assistance, such as a Lifeline, that
can be pressed after a serious fall for medical
help to come to the home. Periodic checks from
relatives and friends can also be an informal yet
important mechanism for ensuring continued
home safety. If a person lies on the floor too
long, a pressure ulcer can occur. More serious
complications related to delays in medical atten-
tion include dehydration, rhabdomyolysis, and
renal failure.
Useful patient and provider information
on falls and fall prevention are available from
the Centers for Disease Control and Preven-
tion, the American Geriatrics Society, and the
Health Foundation for Western and Central New
York.
5,9,14
Their websites include toolkits with
a variety of healthcare provider information,
such as assessment tools and information on
risks and medications and consumer or patient
education materials, such as a home safety self-
assessment tool that healthcare providers can
give to patients and caregivers.
15
O
Etiology, Epidemiology, and
Clinical Presentation Specic to
Older Adults
OA is the most common musculoskeletal condi-
tion and is due to an imbalance in cartilage
homeostasis. Biomechanical factors, such as
weight bearing responsibilities, repetitive use,
and injury; genetic predisposition; and meta-
bolic factors such as cartilage degradation
impacted by interleukin-1, tumor necrosis factor-
alpha (TNFα), and other pro-catabolic cytokines,
contribute to the condition.
16,17
Hands and knees
are the most commonly affected joints, followed
by hips and other smaller joints.
18
OA risk factors
include advancing age, increased weight,
heredity, overuse or repetitive use of a joint, joint
injury, lack of physical activity, and nerve injury.
17
When obtaining medical histories, healthcare
providers should ask about past events that can
lead to OA, such as history of contact sports,
motor vehicle accidents, and occupations with
repetitive joint use or heavy lifting.
Increasing OA prevalence is a worldwide
dilemma. Over 22% of adults over the age of 18
have self-reported doctor-diagnosed OA.
19
This
prevalence increases to 50% over the age of 65
years. The prevalence of hand OA is 43%, knee
OA is 24% (which has a higher prevalence in
women [27%] than in men [21%]), and hip OA is
11%.
18
As the older adult population increases in
the United States, the prevalence and impact of
OA on function and healthcare costs will continue
to increase. Female sex, being overweight, older
age, smoking, inactivity, lower education levels,
and black or white non-Hispanic origin are all
associated with higher OA incidence and func-
tional limitations.
19
The prevalence of arthritis-
associated activity limitations is over 40% in the
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| Fundamentals of Geriatric Pharmacotherapy
aging population, and higher in those with the
risk factors discussed.
19
OA has a significant impact on function,
social activities, sleep, and quality of life, espe-
cially for older adults.
20
It typically has an asym-
metric presentation as opposed to rheumatoid
arthritis, which is symmetrical. OA pain typi-
cally worsens with use and improves with rest.
Morning stiffness is common, typically lasting
less than 30 minutes. Stiffness can also occur
with extended inactivity. Pain in the joint at night
and joint crepitus are other common signs. Over
time, joint instability, joint enlargement, and
limited range of motion (ROM) can develop.
These joint changes and instability increase the
risk of falls in older patients, who often already
have several other fall risk factors. No laboratory
markers exist for OA. Radiographic imagining
with x-ray, computed tomography scan, and
magnetic resonance imaging (MRI) can assist
with diagnosis and monitoring of OA treatment.
21
Summary of Standard Treatment
The goal of therapy is to maintain function and
manage pain.
18
Assessment of OA impact on
ADLs is required and helpful with treatment deci-
sions. OA treatment includes nonpharmacologic
and pharmacologic therapies. The American
College of Rheumatology (ACR) provides OA
treatment recommendations based on evidence
and patient preference for the most common
affected joints (hand, knee, and hip).
22
For older
adults, special emphasis is placed on nonphar-
macologic and topical single or combination
therapy to avoid side effects.
18
Nonpharmacologic treatment of hand OA
includes assistive devices to facilitate ADLs,
splints for the trapeziometacarpal joint, thermal
modalities, and patient instruction on joint
protection techniques.
22
Thermal treatments can
include heat (wax or paraffin) or cold therapy.
Conditionally recommended pharmacologic
therapy includes topical or oral nonsteroidal
anti-inflammatory drugs (NSAIDs), topical
capsaicin, or tramadol. For knee OA, nonphar-
macologic treatments with strong recommenda-
tions include weight loss and cardiovascular
and strengthening exercises either on land or
in the water. Other nonpharmacologic therapies
(tai chi, transcutaneous electrical nerve stimu-
lation) exist with conditional recommendations.
In the older adult population, social isolation
can deter joint movement and exercise, so the
psychosocial interventions also can be of great
importance. Pharmacologic knee OA treat-
ments include acetaminophen, oral or topical
NSAIDs, tramadol, and intra-articular gluco-
corticoid injections alone or in combination.
Current evidence does not support use of intra-
articular hyaluronates, duloxetine, or opioids.
These agents should be saved for patients who
have failed other treatment combinations or in
whom surgical interventions and NSAIDs are not
options.
As with knee OA, nonpharmacologic treat-
ment recommendations for hip OA include
weight loss and land or aquatic cardiovascular
and strengthening exercises.
22
Other nonphar-
macologic options with conditional recom-
mendations are self-management programs,
physical therapy with supervised exercise,
psychosocial interventions, thermal modalities,
and use of walking aids. Pharmacologic treat-
ment for hip OA includes acetaminophen, oral
NSAIDs, tramadol, and intra-articular glucocor-
ticoids alone or in combination.
Nonpharmacologic therapy is an integral
part of OA management. Exercise is a key
component. The National Institute on Aging’s
Go4Life program provides practical tips to help
older adults maintain fitness and enjoy regular
exercise.
23
Exercise has several positive bene-
fits, from function to mental health, for people
with OA.
24
Muscle strengthening around a joint
with OA decreases the workload on the joint and
improves joint stability. Physical therapists guide
patients in the most appropriate exercises and
training routines and are the best resource for
assistive devices for ambulation. Occupational
therapists help patients find ways to perform
ADLs in spite of OA limitations. For instance,
adaptive tools can assist with the use of eating
utensils, hair brushes, and tooth brushes;
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reaching for items on top shelves; putting on
shoes; and many other ADLs. Such tools can
help to maintain an older adult’s autonomy, func-
tion, independence, and quality of life. In addi-
tion, physical and occupational therapists have
more advanced forms of thermal treatment avail-
able for joint pain relief. Thermal therapy can
effectively increase ROM and decrease pain.
22,25
Acetaminophen is first-line OA therapy
in both younger and older adults followed by
NSAIDs as second line.
22
Refer to Chapter 14 for
a more in-depth discussion of acetaminophen
and NSAID dosing. Cardiovascular, gastrointes-
tinal (GI), and renal function influence treatment
decisions.
Topical therapies are excellent options in
older adults because of fewer systemic side
effects compared to oral therapies.
26
Topical
NSAIDs are specifically recommended for hand
and knee OA, with evidence of efficacy for larger
joints.
22
Prescription diclofenac gel or topical
solution is applied four times a day but has the
same warnings as oral therapy. Other NSAIDs
are compounded by pharmacists for topical use.
Topical salicylates pose greater risk of systemic
adverse effects and are less effective than
topical NSAIDs.
27
Topical trolamine salicylate
and topical capsaicin are conditionally recom-
mended for hand OA.
22
Capsaicin should be
used only on the affected joints, with immediate
and thorough hand washing following applica-
tion to avoid burning and irritation of skin and
eyes.
Tramadol is a weak opioid receptor agonist
that also inhibits serotonin and noradrenaline. It
is recommended as a pharmacologic option for
hand, knee, and hip OA.
22
Evidence supports
tramadol used with a stronger opioid for a syner-
gistic effect that allows for more gradual opioid
dose adjustments, which would be especially
beneficial for older adults.
28
When prescribing
tramadol for OA pain, especially in older adults,
renal function should be considered to deter-
mine appropriate dose, and adverse reactions
(GI, central nervous system, and falls) should be
monitored.
Nutraceuticals for OA prevention and
treatment, such as glucosamine, chondroitin,
methylsulfonylmethane (MSM), and adenosyl-
methionine (SAMe), as either single agents
or combination products have limited efficacy
data, especially in older adults.
29
None of these
agents are recommended in the U.S. guide-
lines
22
for any form of OA. Systematic reviews
of glucosamine and chondroitin have demon-
strated inconsistent efficacy with OA pain and
function improvement.
30,31
Safety and efficacy
data with the European prescription product,
which is a different formulation from the U.S.
OTC product, might not correlate with the
unregulated U.S. products. If they are used,
typically in a person for whom recommended
therapies are contraindicated or ineffective,
the studied dose of glucosamine is 1,500 mg/
day, and chondroitin is 1,200 mg.
32
Insufficient
evidence exists to support MSM or SAMe at
any dose.
Glucocorticoid injections can be effec-
tive for treatment of individually affected joints,
usually the larger joints.
33
Temporary synovitis
can occur but frequently has a short duration.
Triamcinolone hexacetonide has the greatest
evidence of efficacy of the intra-articular gluco-
corticoids.
34
Repeated injection of the same joint
could increase risk of systemic side effects and
joint erosion; however, the maximum number of
injections per year is not defined. Good aseptic
technique is critical to avoid infection. For a
patient awaiting knee or hip arthroplasty, gluco-
corticoid joint injections provide temporary pain
relief, and physical therapy improves muscle
strength to aid in surgical recovery and rehabili-
tation.
33
In this instance, the risk of deep infec-
tion following arthroplasty should be carefully
considered prior to injection.
Hyaluronic acid injections received a neutral
recommendation for knee and hip OA because
of a lack of data and a negative recommenda-
tion for hand OA.
22,35
A conditional recommen-
dation is made for older adults in whom arthro-
plasty and other treatments have failed or are
not options. Acid injections are well tolerated,
and the primary adverse effects are a small inci-
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446
| Fundamentals of Geriatric Pharmacotherapy
dence of local injection site pain and swelling.
Hyaluronic acid may have a disease modifying
effect.
36
Data are limited with prolonged use.
35
Opioids are reserved for severe OA pain
significantly impacting daily function and quality
of life for which other treatments have been
ineffective.
22
Opioids have significant adverse
effects, especially pertinent in older patients with
OA, and can increase falls and safety risks.
37
Joint replacement is effective in many
patients but costly and is most often reserved for
failure of nonpharmacologic and pharmacologic
interventions. Data support physical therapy,
exercise, and muscle strengthening prior to joint
arthroplasty and resumption of activity within
a day after the arthroplasty.
38
Delayed time to
ambulation and physical therapy after surgery
significantly increased length of stay and
recovery times.
39
Review of Evidence Base
Supporting Treatment
Recommendations for Older Adults
The most recent evidence for OA treatment
in older adults focuses on prevention of harm
while providing pain relief, maintaining function,
and possibly slowing if not reversing some of
the joint damage.
22
Acetaminophen and topical
NSAIDs are first-line for older adults because
they are effective, relatively safe, and afford-
able compared to alternate treatments. If liver
function is normal and no contraindications
exist, acetaminophen should be started on a
scheduled basis. The Food and Drug Adminis-
tration (FDA) warns about rare but serious skin
reactions (Stevens Johnson syndrome, toxic
epidermal necrolysis, and acute generalized
exanthematous pustulosis).
40
For patients over
age 75 or with contraindications to NSAIDs,
topical NSAIDs are recommended.
22
Exercise has many positive benefits for
people of all ages. Benefits that are particu-
larly important for older adults include improved
cognition, bone density, balance, well-being,
self-care, weight loss, and decreased inflamma-
tion and risks of comorbidities.
24,41
Some evidence supports maintaining thera-
peutic vitamin D concentrations as a means to
prevent OA. Because maintenance of serum
25(OH) vitamin D concentrations at least above
20 ng/mL may have a positive benefit on OA
progression and other benefits in older adults,
42,43
attention to this therapy is warranted.
Some data among older populations
suggest that acceptance of different interven-
tion strategies may vary among different groups.
Older African American people with OA may be
more reluctant to pursue joint arthroplasty and
may respond better than Caucasian counter-
parts to self-management programs with instruc-
tion on techniques to manage symptoms.
44,45
Therefore, patient preference should be under-
stood when designing a treatment plan requiring
long-term adherence.
KEY POINT:
When evaluating older
adults with OA, consider their medical
history, especially GI and cardiovascular
conditions, renal function, medication
history, and risks before choosing to use
an oral NSAID or a COX-2 inhibitor.
Common Problems Encountered
When Treating Older Adults with
is Condition
In older adults, nonspecific symptoms and
unusual symptom presentations are more
common, making evaluation of pain control
and medication adverse effects even more
difficult. Sometimes pain can be expressed as
a decrease in eating, more sadness or depres-
sion, or behavioral problems, especially in indi-
viduals with cognitive impairment. Based on the
OA therapy used, regular evaluation for GI bleed
and ulceration, renal and hepatic function, and
cardiovascular assessment are imperative.
Self-medication is common in OA treatment,
which can lead to under- and overuse of medi-
cation. Thus, when working with older adults,
specific questions related to both prescriptions
obtained through multiple providers and nonpre-
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