Naushad Hirani, BSc, MD*

The seronegative arthritides, also commonly referred to as the spondylo-arthropathies because of their predilection for involving the spine, are inflammatory diseases that can be distinguished from the more common rheumatoid arthritis and osteoarthritis based on several general characteristics. In addition to being, by definition (with rare exceptions), rheumatoid factor negative (as opposed to rheumatoid arthritis), they also have distinct patterns of articular and extra-articular involvement, and most exhibit an association with the HLA-B27 gene.

The main conditions encompassed by this classification include Psoriatic arthritis (PSA), Reactive arthritis or Reiter's syndrome, and Inflammatory bowel disease-associated arthritis, although Ankylosing spondylitis⁼ (AS) is the prototypical seronegative disease. The key features of each of the seronegative arthritides are summarized in Table 1. From a geriatric standpoint, most of these conditions are not diagnostic challenges, as they are generally diseases that present in young or middle-aged people. However, an understanding of the group of diseases is helpful for the management of patients in the chronic state, and particularly in the case of distinguishing PSA from rheumatoid arthritis. Many of the features of the seronegative arthritides can be illustrated by first considering AS.

Barry Goldlist, MD, FRCPC, FACP

The most common causes of death in old age are, as expected, cardiovascular disease and cancer. However, for those involved in health care of the elderly, it is no surprise to learn that the elderly consider arthritis the greatest cause of disability. Osteoarthritis, rather than diseases such as rheumatoid arthritis, causes most of the burden of joint disease in old age. The major problems are generally pain and functional limitation. Medical management in the past has generally depended on limitation of activity and intermittent use of analgesics. Often, physicians neglect first principles in dealing with this chronic disease. The patient must be educated about the disease (therapy, exercise, weight reduction, use of assistive devices, etc.), and then the doctor and patient must agree on appropriate goals of therapy. If the patient is expecting total pain relief, and the doctor's goal is only to maintain mobility, neither party will be satisfied. There is much evidence now that excessive rest is harmful in osteoarthritis, and that therapy and exercise can improve function and decrease pain. Currently, regularly administered acetaminophen is the drug of choice for significant pain in osteoarthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are also beneficial, but their use is limited by side effects that are most prevalent in the elderly. The threshold for regular use of NSAIDs might be lowered as the new generation of more specific COX-2 inhibitors become more widely available. The exact role of other modalities, such as oral glucosamine and injections of hyaluronic acid, is not really clear at the present time.

For severe joint disease, the use of surgical joint replacement has been an incredible development. It is clear, however, that the availability of the procedure is greatly restricted in Canada. It is unclear to me how coronary artery surgery (CABG) has prospered in its availability in comparison to joint replacement surgery. Both are primarily done for quality of life issues, not longevity, and CABG is more easily available despite the fact that the elderly say that their joints are a greater source of impaired functional ability than their hearts. Until joint replacement surgery is more widely available, many of our seniors will continue to suffer unnecessarily.

Hannah Hoag, BSc

There are about 100 different forms of arthritis. Gout, lupus, and ankylosing spondylitis are members of the arthritis family, as are the better known osteoarthritic and rheumatic versions. Between birth and death, nearly 3.5 million Canadians are affected by some form of the disease. Osteoarthritis and rheumatoid arthritis (RA) are 2 forms of chronic arthritis that are observed in, but not restricted to, the aging population. Arthritis can be defined, most simply, as an inflammation of the joint, however, the severity of the condition varies significantly. Pain can be mild or severe, and the disease can remain isolated to one joint or have systemic effects. With so many variant forms of the disease, it is not surprising that the causes of arthritis are somewhat unclear. However, the importance of the interplay between cartilage, the immune system, heredity, and the environment has been recognized in the onset of disease. Much of current research has been devoted to understanding normal immune function and how dysfunction causes arthritis.

Osteoarthritis is identified as being of either primary or secondary origin. Primary osteoarthritis is viewed as a consequence of the aging process.¹ Over 85% of people over the age of 70 suffer from osteoarthritis. Secondary osteoarthritis is not associated with the aging process but due to other factors such as injury, obesity, and changes in cartilage chemistry.

Nariman Malik, BSc

Osteoarthritis is the most prevalent rheumatic disease.¹ It affects primarily the elderly and is rarely seen in individuals younger than 40. Osteoarthritis was believed to be an unavoidable consequence of aging, however, it is now believed to be a degenerative process that results from the interaction of metabolic, mechanical, genetic and other factors.

The disease is a heterogeneous disorder that affects different joints.² Each affected joint has different clinical manifestations, prognoses, and patterns of progression. The prevalence of osteoarthritis increases with age. It is more common in women than in men.² Women present more with osteoarthritis of the hand while men present more with problems of weight-bearing joints.³ In general, the management of osteoarthritis is coordinated by the family physician.² If there is any doubt about the diagnosis or any complications, a rheumatologist or geriatrician should be consulted. Physiotherapists and occupational therapists are key members of the multidisciplinary management team critical to the long-term management of this chronic illness.

Pathogenesis

Osteoarthritis is a disorder of the hyaline articular cartilage on the bony surface of joints (see Figure 1).² Hyaline articular cartilage is composed of type II collagen, proteoglycans, as well as chondrocytes and water.

Neil P. Fam, BSc

Arthritis has been called the sleeping giant of Canadian health care. According to Statistics Canada, over 3 million Canadians suffer from osteo-arthritis (OA), with another 300,000 affected by rheumatoid arthritis (RA).¹ Together, these diseases represent one of the leading causes of chronic disability, lost productivity and worker absenteeism in Canada.² As our population ages, more patients are presenting to physicians with musculoskeletal complaints, most of which center around chronic joint pain.

Treatment of the pain of arthritis involves both pharmacologic and non-pharmacologic approaches. Traditionally, treatment of OA and RA has revolved around the use of non-steroidal anti-inflammatory drugs (NSAIDs). Although these medications are often effective in relieving pain, they are associated with significant gastrointestinal and renal complications. Elderly patients are particularly prone to life-threatening complications such as GI bleeding and perforation. For these reasons, other treatment modalities are often utilized. This article presents an overview of pain management strategies, with a focus on OA, the single most common cause of arthritis in seniors.

OA pain

In the management of osteoarthritic pain in the elderly, the best approach is to begin with therapies that are inexpensive and have a low risk of side effects. The following is a stepwise approach, summarized in Table 1.