Joint diseases of the elderlyY Hayashi Blackwell Science, LtdOxford, UKGGIGeriatrics and Gerontology International1444-15862003 Blackwell Publishing Asia

Pty LtdMarch 2003316063Original Article

Geriatrics and Gerontology International 2003; 3: 6063

ORIGINAL ARTICLE

Joint diseases of the elderly

Yasufumi Hayashi

Introduction
As the average life span of Japanese people increases year by year, reaching 78.07 years for males and 84.93 years for females in 2002, so senior citizens prefer to live well with a high quality of daily life rather than extending their span of life during the aged period. In order to increase the quality of daily life, both the relief of pain and improvement of function in affected joints of the elderly are as essential as the treatment of internal diseases because an investigation by the Japanese Government1 revealed that joint pain was the complaint of 15% of the elderly, which makes it the second most important of the various abnormal symptoms of this age group. In addition, approximately 7% of the bed-ridden elderly, who accounted for 1 million persons in Japan at 1998 and whose number increases gradually every year, are affected by joint disease (Table 1). On the basis of new knowledge, the correct diagnosis and treatment of the three main joint diseases of the elderly are expected to increase the quality of their life by preventing their functional deterioration and relieving the pain.

Joint diseases of the elderly

Rheumatoid arthritis
In the 20th century, the treatment of rheumatoid arthritis (RA) aimed to reduce the daily pain and swelling in the inamed joints, but in the 21st century, the extended life span of patients has changed the purpose of the treatment of RA to maintaining a good long-term outcome in relation to physical function. In addition, if their physical function deteriorates, disabled Japanese patients with RA are supported by the welfare policy for handicapped persons or, if not yet fully disabled, by the new welfare policy that began in 1997 and consists of a home-care service and delivery of care devices, such as beds, bath chairs etc. (Table 2). Disabled patients with RA who are aged 65 years and over are cared for by the

public insurance system that started in 2000. So Japanese patients with RA are supported by a triple system of welfare policy that supports their care whether or not their physical function has deteriorated.2 It is the joint deformity caused by destruction and narrowing of joint space that results in the disability of patients with RA. The advancement of the erosive or narrowing changes of the joint space are measured at 34 or 36 joints, respectively, in bilateral ngers and wrists on 106 X-ray lms3 (Fig. 1). The number of joints showing erosive change and narrowing signicantly increases according to the duration of the disease in both the patients treated by corticosteroid hormone and mildly increases in patients treated by disease modifying anti-rheumatic drugs (DMARD)4 (Table 3). From the viewpoint of long-term outcome related to joint deformity, patients with RA should be treated with DMARD at an early stage of the disease5 (Table 4). Of the patients with RA that is diagnosed as the early stage (Table 4), approximately 77% have the typical course of classical RA and approximately 22% are revealed to have other diseases such as Sjogrens syndrome, systemic lupus erythrematosus etc. after a few years. However, only one-third of the patients treated from the early stage of RA become disabled in the long term, although approximately two-thirds of the patients with RA diagnosed by the ordinary criteria of the American College Rheumatology become disabled.6 If DMARD are actively prescribed from the initial stage of RA according to the step-down bridge method proposed by Wilske and Healey7 (Fig. 2), the long-term outcome of the physical function of the patient can be expected to be excellent.

Osteoarthritis
Thick articular cartilage in the joint serves to maintain the normal function of the weight-bearing joint, even in old age, because it is designed to bear the repeated load of heavy weight and to move smoothly with low friction. Although repeated load on the articular cartilage of young adult guinea pigs through running effectively thickened the weight-bearing cartilage, repeated load in the aged animal does not8 (Fig. 3). Extrapolating from the animal experiment, daily activity or exercise during the young adulthood produces a healthy joint, as much as the exercise builds strong bones for later in life. How-

Accepted for publication 12 December 2002. Correspondence: Dr Yasufumi Hayashi, Tokyo Metropolitan Geriatric Hospital, 173-0015 35-2, Sakae-cho, Itabashi-ku, Tokyo, Japan. Email: hayashi@tmgh.metro.tokyo.jp

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Joint diseases of the elderly

Table 1 Causes of disability in Japanese who need care Age (years) Estimated no. in Japan (1000) 1243 1000 364 Proportion of causes (%) Stroke 29.3 30.3 17.4 Disuse through aging 12.1 14.9 29.7 Dementia 10.1 12.2 13.8 Fall and fracture 10.4 11.7 17 Joint diseases 6.6 6.8 4.2 Others 31.4 36.1 17.9

All > 65 > 85

Based on a government survey of the state of life in Japan, 1998.1

Table 2 New welfare policy since 1997 for residential patients with rheumatoid arthritis5 Home care services Assistance with bathing, urination and meals Assistance with cooking and cleaning Consultation and advice for the improved QOL Delivery of care devices Bedside commode, appropriate mattress and bed Bath chair etc.

Cortico-steroid Hormone Methotrexate Gold (injection) Gold (oral intake) Azathioprine Penicillamine Sulphasalazine Recurrence

(months)

Figure 2 Treatment according to step-own bridge method propsed by Wilske et al.7

Figure 1 Joints counted the erosive or narrowing change of joint space.4

repaired, but progress in regenerative medicine currently changes the concept of limitation of cartilaginous replication. The third approach for the patient with OA is the administration of DMAOD (Table 5), which have been used in European countries9 and are expected to produce healthy cartilage even in elderly patients with osteoarthritis and thus relieve the pain.

ever, in the elderly daily heavily repeated load on the weight-bearing joints induces the degenerative cartilage that is the main cause of osteoarthritis (OA). Treatment of the pain of OA, in addition to the administration of the non-steroidal anti-inammatory drugs, is by replacement with an articial joint, cartilage repair and administration of disease modifying antiosteoarthritis drugs (DMAOD). As shown in Fig. 4, replacement with an articial joint has become popular in Japan and the annual number of replaced knee joints was more than 30 000 by 1999. It is estimated that a similar number of total hip joint replacements are performed every year in Japan. Another approach to the treatment of OA is the transplantation of in vitro repaired cartilage. For 100 years, it has been observed that cartilage once destroyed is not

Crystal-induced arthritis
The crystal-induced arthritides are mainly gout and pseudogout. Of these diseases, the mean age of the patient with gout has become lower recently as the number of young, obese adults in Japan increases year by year because of less activity and excessive food intake. In pseudogout, decreased pyrophosphate degradation in the liver precipitates calcium pyrophosphate crystal onto the articular cartilage of large joints, such as the knee or ankle of the elderly10 (Fig. 5), and it is the accumulated crystal that induces an acute arthritis causing severe localized joint pain and a high fever.11 Physicians often misunderstand an attack of pseudogout as pneumonia, and the patients are treated with antibiotic, which does not reduce the fever, but if the patient with pseudogout is treated with non-steroidal anti61

Y Hayashi

Table 3 Comparison of drug treatments for erosive and narrowing joint changes in patients with rheumatoid arthritis Treatment Yes (+)/No () Percentage (%) of Yes (+)/No () (duration of treatment in total of 106 patients) 127 138* Percentage (%) of Yes (+)/No () (advancement of change) No. erosive joints No. narrowed joints 127* 161*** 127* 145***

DMARD (+)/DMARD () Steroid (+)/steroid ()

*P < 0.05, ***P < 0.001 compared with no treatment. Number of erosive or narrowed joints is calculated from the accumulated severity of the changed joints.2 DMARD, disease modifying anti-rheumatic drugs; steroid, corticosteroid hormone.

Strength of birefringence of cartilaginous collagen (AIR(nm/mm2 SEM)

Table 4 Diagnostic criteria of the early stage of rheumatoid arthritis Fullment of 3 of 6 items Pain in 3 or more joints Swelling in 2 or more joints Presence of morning stiffness Presence of rheumatoid nodule Erythrocyte sedimentation rate 20 mm or positive C-reactive protein test Positive for serum rheumatoid factors
Based on the recommendations of the Japan College of Rheumatology.5

1028 week guinea pig running control

Table 5 Disease modifying anti-osteoarthritis drugs (DMAOD)9 Glycosaminoglycan derivatives Arteparon Rumulon Cartrophen Estrogens Tamoxifen Growth hormones IL-1 and TNF inhibitors Tetracyclines Glyvenol Diacetylrhein Superoxide dismutase Asorbic acid Diphosphonates Calcitonin 5-adenosyl-L-methlonine Hyaluronan Silicone oil

S1

S2

S3

D1

D2

D3

Superficial layer

(depth of cartilage)

deep layer

Strength of birefringence of cartilaginous collagen (AIR(nm/mm2 SEM)

4462 week guinea pig running control P = 0.007 P = 0.001

P = 0.001

S1 Superficial layer

S2

S3

D1

D2

D3

(depth of cartilage)

deep layer

inammatory drugs, they recover within a few days. In the aged society of the 21st century, the number of patients with pseudogout is estimated to increase, so physicians must diagnose it correctly. 62

Figure 3 Thickness of articular cartilage in the weight bearing portion of the knee. Comparison of aging by exercise (by Helminen et al.).8

Joint diseases of the elderly

30
No. knee joints replaced by artificial joints

25 20
( 1000)

fetal in origin and do not include severe disability in the prognosis, but many people gradually lose their ability and become wheelchair- or bed-bound patients by bone and joint diseases later in life. In an aged society such as Japan, the correct diagnosis and treatment of joint diseases are important to maintain the quality of older life.

15 10 5 0

References
1 Ministry of Health and Welfare. State of Japanese Life Style Based on Investigation of the Whole Country in 1998. Tokyo: Ministry of Health and Welfare, 2000 (in Japanese). 2 Hayashi Y. Decision of handicapped condition and welfare policies in the patient with rheumatoid arthritis. RA Ther 1999; 5: 2841 (in Japanese). 3 Fries JF, Bloch DA, Dennis J et al. Assessment of radiological progression in rheumatoid arthritis. Arthritis Rheum 1986; 29: 19. 4 Hayashi Y, Yoshida K, Mukai E. Radiographical evaluation of joint deformity in the wrist and nger. In: Azuma T, ed. New Approach Related to Evaluation of Medicative Therapy. Tokyo: Ikagaku Publications, 1993; 1622 (in Japanese). 5 Yamamoto S, Kashiwabara S, Nobunaga T. Diagnostic criteria of early rheumatoid arthritis dened by Japanese College of Rheumatology. The Ryumachi 1994; 34: 10131020 (in Japanese). 6 Yamamoto S. Diagnosis and management of early rheumatoid arthritis. The Ryumachi 1998; 38: 752761 (in Japanese). 7 Wilske KR & Healey LA. Remodeling the pyramid: a concept whose time has come. J Rheumatol 1989; 16: 565568. 8 Helminen HJ, Hyttinen MM, Lammi MJ et al. Regular joint loading in youth assists in the establishment and strengthening of the collagen network of articular cartilge and contributes to the prevention of osteoarthrosis later in life: a hypothesis. J Bone Mineral Metab 2000; 18: 245257. 9 Creamer P & Dieppe PA. Nobel drug treatment strategies for osteoarthritis. J Rheum 1993; 20: 14611464. 10 Hayashi Y. Microscopic examination of synovial uid. J Joint Surg 1989; 8: 697705 (in Japanese). 11 Kamatani N. Crystal induced arthritis. The Ryumachi 1997; 37: 5866 (in Japanese).

1992 1993 1994 1995 1996 1997 1998 1999 (years)

Figure 4

Number of articial knee joints replaced in Japan.

blue Z' yellow 90 rotate sodium urate (gout)

Negative birefringence (weak)

Z'

yellow 90 rotate blue

calcium pyrophosphate (pseudogout)

Positive birefringence (strong)

Figure 5

Differentiation of crystals in synovial uid.10

Bone and joint decade

The World Health Organization declared the years between 2000 and 2010 as the international bone and joint decade. Bone and joint diseases are not usually

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