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.