Understanding Arthritis in the Elderly
With the aging of the baby boomers, the population of adults over 65 years old is expected to increase to 22% by the year 2050.1 In addition to other chronic conditions - such as diabetes, hypertension, and heart disease?the elderly are more likely than other segments of the population to suffer from rheumatoid arthritis (RA) and osteoarthritis (OA). Arthritis can result in chronic pain (common in older people) and can lead to depression and sleep disturbances, as well as increased health care costs.2 Managing arthritis, or managing chronic pain in general? including choosing an appropriate therapy regimen in the elderly - can be complicated due to many factors. Among these factors are multiple drugs, multiple diseases, potential drug interactions, a decrease in cognitive function, and altered pharmacokinetics.3 All of these factors lead to challenges in achieving good therapeutic outcomes (Table 1).
RA, a chronic autoimmune disease, is a systemic inflammatory condition that causes joint destruction, pain, swelling, and stiffness. 4 The progressive deterioration of the joints can lead to permanent damage and deformity and is a common cause of disability. 5 Yet, the underlying cause of this autoimmune disorder is unknown.
The cardinal symptoms of RA usually begin between the ages of 25 and 50.1 In addition to swelling and stiffness, they include bilateral pain - for example, in the feet, hands, and wrists initially. Pain also can develop in other areas, such as the hips, knees, shoulders, and neck. Because RA affects the body as a whole, other symptoms - such as fever, weight loss, fatigue, and loss of appetite - may be present.6 The diagnosis of RA comprises a physical examination along with a blood test for the presence of rheumatoid factor (an antibody found in patients with RA); the presence of C-reactive protein (responsible for some inflammatory disorders); and an elevated erythrocyte sedimentation rate.
OA, a common form of joint disease, generally afflicts persons over the age of 60. It often is associated with pain, limitation of motion, and disability.7 OA most commonly affects weight-bearing joints and usually is associated with the deterioration or breakdown of the joint.8 Unlike RA, there is no specific diagnostic test for OA. The usual clinical presentation is pain initially when the joint is used; later, pain may occur at rest. Prolonged activity may aggravate the condition, and rest may ease the pain.9 The goal of therapy is to reduce pain and its impact on the patient and his or her quality of life.7
General Management of Arthritis
The goal of treatment in arthritis is generally achieved through a combination of pharmacologic and nonpharmacologic therapy?aimed essentially at minimizing pain and making an impact on a patient?s daily function and quality of life.7 Nonpharmacologic approaches consist of patient and caregiver education, exercise, weight control, and thermal modalities (heat or cold applications).
Effective pain management is mostly achieved by way of analgesic drugs (nonsteroidal anti-inflammatory drugs [NSAIDs] and acetaminophen); invasive techniques (corticosteroid injections); and even opioids. 3 The use of opioids in the elderly, however, remains a controversial subject due to the fear of addiction or illicit drug use. Nevertheless, the recent guideline from the American Pain Society sanctions the use of opioids in instances of severe arthritis pain.10
Management of Rheumatoid Arthritis
Pharmacologic treatment of RA consists of NSAIDs, with emphasis on the new cyclooxygenase-2 inhibitors,5 which control inflammation with less risk of gastrointestinal (GI) toxicity. Oral and intra-articular corticosteroids have been used with success, but the side-effect profile must be considered, especially in the elderly. Also used in RA are the disease-modifying antirheumatic drugs (DMARDs), which have been widely utilized to control disease progression.4 Some of the early agents include hydroxychloroquine, sulfasalazine, and methotrexate, traditionally the ?gold standard?11 and first-line therapy due to its once-weekly dosing and efficacy. The new-generation DMARDs exert their effect by antagonism of the tumor necrosis factoralpha that is involved in the inflammatory process leading to RA. These newly developed agents include infliximab, etanercept, and adalimumab (Table 2). In addition, anakinra (Kineret), an anti-inflammatory cytokine, is available for once-daily dosing via subcutaneous injection.
Management of Osteoarthritis
Pharmacologic therapy in OA consists of acetaminophen, NSAIDs, and often opioids to treat moderate-to-severe pain.7 The use of NSAIDs in the elderly can result in GI adverse effects. With the use of histamine2 receptor antagonists, proton pump inhibitors, or misoprostol, these negative symptoms can be alleviated.12,13 Nevertheless, acetaminophen in adequate doses can be a safer alternative. Another option for pharmacists to recommend would be topical therapy with capsaicin, which inhibits substance P, a pain mediator. Patients should be counseled that optimal results with capsaicin are achieved when it is used on a regular basis.
The Pharmacist?s Role
There are many ways that pharmacists can ensure that older patients understand and adhere to their drug regimen, thus achieving optimal outcomes. Counseling patients on the names of the drugs, the reason why they are prescribed, how they are to be taken, as well as the side effects can increase awareness. Yet, special considerations should be taken into account, and the therapy should be tailored to a patient?s individual needs (Table 3). Pharmacists, as integral members of the health care team, are most qualified to educate the elderly on how best to manage pain with minimum adverse effects and toxicity.