What is the recommended treatment approach for osteoarthritis in the elderly?

Treatment of Osteoarthritis in the Elderly

The recommended treatment approach for osteoarthritis in the elderly should begin with non-pharmacological interventions including exercise therapy, weight loss for overweight patients, and education, followed by acetaminophen as first-line pharmacological therapy, with topical NSAIDs preferred over oral NSAIDs when additional pain relief is needed. 1

Non-Pharmacological Interventions (First-Line)

Exercise Therapy

• Strongly recommended with high-quality evidence 1
• Types of beneficial exercise:
  • Land-based exercises (aerobic and resistance training)
  • Aquatic exercises (especially for bilateral hip arthrosis)
  • Tai Chi
  • Balance exercises

Education and Self-Management

• Provide information about:
  • Disease process
  • Joint protection techniques
  • Activity modification strategies
• Self-management programs are strongly recommended 1

Weight Loss

• Target minimum weight loss of 5-10% of body weight for overweight/obese patients
• Strongly recommended with high-quality evidence 1
• Reduces mechanical stress on weight-bearing joints (knees and hips)

Assistive Devices

• Walking aids (canes, walkers) to reduce pain with weight-bearing
• Hand orthoses for hand OA
• Knee orthoses (sleeves, elastic bandages) for knee OA
• Orthopaedic shoes for knee OA 1

Pharmacological Interventions

First-Line Medication

• Acetaminophen/paracetamol (up to 3g/day)
  • Recommended as initial oral analgesic 1
  • Safer profile in elderly compared to NSAIDs 2
  • Regular full-dose treatment should be tried before moving to other options

Second-Line Medications

• Topical NSAIDs (e.g., diclofenac sodium topical solution)

  • Safer alternative for elderly with comorbidities 1
  • Lower systemic absorption reduces risk of adverse effects
  • Should be preferred over oral NSAIDs in the elderly

• Oral NSAIDs (with caution)

  • Use lowest effective dose for shortest duration 1
  • CAUTION: Enhanced susceptibility to gastrointestinal and renal side effects in patients over 65 3
  • All NSAIDs, including COX-2 inhibitors, increase cardiovascular risk 3
  • Consider naproxen when needed, but monitor closely for adverse effects 4
  • Monitor for GI side effects and consider gastroprotective agents

Third-Line Medications

• Intra-articular corticosteroid injections

  • For persistent pain not responding to other therapies 1
  • Provides short-term relief

• Duloxetine

  • May be effective for OA pain 1
  • Consider especially when pain has a neuropathic component

• Tramadol

  • Alternative when NSAIDs are contraindicated 1
  • Use with caution in elderly due to side effects

• Avoid long-term opioid use

  • Higher risk of side effects and dependency 1
  • Limited evidence of superior efficacy

Surgical Interventions

• Consider total joint replacement for end-stage disease not responding to conservative measures 1
• Joint-preserving procedures may be considered for younger elderly with specific deformities

Special Considerations for Elderly Patients

Medication Safety

• "Start low, go slow" approach for analgesics 3
• Be vigilant about drug interactions due to polypharmacy 3
• Regular monitoring of renal function with NSAID use 1
• Transient abnormalities in hepatic and renal function may occur with naproxen, though age doesn't appear to increase this risk 4

Comorbidity Management

• Monitor diabetes control, as poor glycemic control worsens OA symptoms 1
• Consider cardiovascular risk when prescribing NSAIDs 3
• Assess fall risk when prescribing medications that may cause dizziness

Treatment Algorithm

1. Start with non-pharmacological approaches (exercise, education, weight loss if applicable)
2. If pain persists, add acetaminophen (up to 3g/day)
3. If inadequate relief, add topical NSAIDs
4. For persistent pain, consider:
   • Intra-articular corticosteroid injections
   • Duloxetine
   • Oral NSAIDs (with caution and monitoring)
5. For severe pain unresponsive to above measures, consider tramadol
6. Refer for surgical evaluation if conservative measures fail and pain significantly impacts quality of life

Monitoring and Follow-up

• Regularly assess pain control and functional status
• Monitor for medication side effects, particularly with NSAIDs
• Adjust treatment based on efficacy and tolerability
• Continue to emphasize non-pharmacological approaches throughout treatment