Osteoarthritis is a progressive disease of the joints characterized by the loss and remodeling of the joint cartilage. It affects not only the cartilage but the entire joint — bone, ligaments, joint lining, surrounding muscles. In the context of geriatrics and the medicine of aging, it is the most frequently treated joint disease of all.
The term „wear and tear“ is misleading. Osteoarthritis is not a mechanical wearing down like that of a tire, but an active biological process with inflammatory, hormonal and metabolic components. This is clinically important, because therapeutic approaches that go beyond mere pain management can be derived from it.
- Knee osteoarthritis (gonarthrosis): The most common form. Often medial (inner) in emphasis. Symptoms: start-up pain in the morning, load-related pain when climbing stairs, later pain at rest.
- Hip osteoarthritis (coxarthrosis): The second most common form. Pain in the groin, when standing up and walking longer distances. Often recognized only late, because the pain tends to radiate into the thigh or the knee.
- Finger joint osteoarthritis: Especially in women after the menopause. Heberden's nodes on the end joints, Bouchard's nodes on the middle joints. Painful, but functionally often surprisingly manageable.
- Thumb saddle joint osteoarthritis (rhizarthrosis): Very widespread. Pain when gripping, especially when opening jars.
- Spinal osteoarthritis: Often experienced as back pain. A complex interplay with intervertebral disc degeneration and changes in posture.
- Shoulder and ankle osteoarthritis: Less common, but increasingly frequent in advanced age.
→ On surgical treatment when conservative therapy is not sufficient: Joint replacement in old age.
→ Specifically on the hip prosthesis: Hip THR from 80.
→ Specifically on the knee prosthesis: Knee prosthesis in old age.
- Radiological signs of osteoarthritis: detectable in over 70 percent of those over 65
- Symptomatic osteoarthritis: about 40 percent of those over 65
- The most common cause of chronic joint pain in old age
- One of the most common causes of reduced mobility and an increased risk of falling in old age
An important point: not every radiological osteoarthritis causes symptoms. And not every complaint has a correlate on the X-ray image. The discrepancy between image and symptom is the rule, not the exception.
- Age: The strongest single factor.
- Female sex: Especially after the menopause.
- Overweight: Effective both mechanically and metabolically. Every excess kilogram acts on the knee with fourfold load when walking.
- Previous joint injuries: Ligament injuries, meniscus damage, fractures increase the risk of osteoarthritis — as does a femoral neck fracture in old age that has been overcome.
- Malpositions: Knock-knees or bow legs, hip dysplasia.
- Muscle weakness: Weak thigh musculature accelerates knee osteoarthritis and is frequently a sign of beginning sarcopenia.
- Metabolic diseases: Diabetes in old age, gout.
- Genetic disposition: In finger joint osteoarthritis, partly also in knee and hip osteoarthritis.
The diagnosis is made clinically and radiologically:
- Detailed medical history and a targeted physical examination
- Functional tests: range of motion, load-bearing capacity, gait pattern — a structured gait analysis can provide valuable clues here
- X-ray — standard in symptomatic osteoarthritis
- MRI rarely necessary — if so, then for unclear findings, suspicion of a meniscus problem or bone edema
- Joint puncture in case of suspicion of an inflammatory accompanying component
- For unclear findings: rheumatological clarification to distinguish from inflammatory joint diseases such as rheumatism. A frailty screening, too, is recommended in older patients in order to assess the overall condition. A comprehensive geriatric assessment thereby enables the systematic recording of all relevant functional areas.
Exercise — the most important single measure
The most common mistake in osteoarthritis treatment is the advice „Take it easy“. The opposite is true. Exercise — in the right dosage — is the best-documented single measure:
- Strength training strengthens the joint-supporting musculature and reduces the load on the joint
- Aerobic training improves circulation, metabolism and general well-being
- Mobility exercises maintain the range of motion
- Physiotherapy with guidance is particularly worthwhile for patients with fear of movement — especially when there is concurrent immobility in old age
Recommendation: a combination of 2 to 3 sessions of strength training per week plus regular aerobic activity (swimming, cycling, walking) — gentle on the joints, but effective. With severe complaints, begin with low-load activity, then increase.
→ On the importance of musculature in old age: Sarcopenia.
Weight reduction
In overweight, one of the most effective interventions. Studies show: a 5 to 10 percent weight loss can reduce knee joint pain by 30 percent or more. This is worthwhile even with moderate overweight — also because malnutrition in old age is equally problematic on the other side, and a balanced nutritional consultation should therefore always keep both in view.
Aids and footwear
- A walking stick on the contralateral side relieves the affected joint
- Well-fitting, cushioned shoes with buffering
- Insoles for malpositions
- In severe knee osteoarthritis, sometimes knee braces or unloading orthoses
- Grab rails, raised toilet seat, bath board in the home environment — also decisive for effective fall prevention
Physical therapy
- Heat for muscular tension
- Cold for inflamed, swollen joints
- Electrotherapy (TENS) for chronic pain
- Manual therapy and massage as adjuvant measures
Drug therapy
Particularly considered application in old age:
- Paracetamol: The first choice for mild pain. Limit the daily dose in older patients to 2 to 3 grams.
- Topical NSAIDs (diclofenac gel, ibuprofen cream): Local application, low systemic side effects, demonstrably effective in knee and finger osteoarthritis.
- Oral NSAIDs (ibuprofen, diclofenac, naproxen): Effective, but problematic in old age. Risk: gastric ulcer, haemorrhages, renal insufficiency, rise in blood pressure, decompensation of heart failure in old age. Possible briefly and at a low dose, not as a permanent therapy.
- COX-2 inhibitors (celecoxib, etoricoxib): Somewhat better gastrointestinal tolerability, but similar cardiovascular problems. Patients with known atrial fibrillation in old age require particular caution with this choice.
- Opioids: Only for uncontrollable pain and after other options have been exhausted. Titrate particularly carefully in old age — risk of falls and delirium. For the targeted prevention of a partly drug-induced delirium: delirium prevention.
- Intra-articular cortisone injection: Effective in the short term in an acute irritated state, but problematic for the cartilage with repeated application.
- Intra-articular hyaluronic acid: Evidence contradictory, sometimes helpful in selected patients.
The most important sentence on drug therapy for osteoarthritis in old age: NSAIDs are not a permanent medication. Anyone who takes ibuprofen or diclofenac daily risks gastric ulcer, kidney failure and heart failure. The alternative strategy: expand exercise, train specifically, use painkillers only for peaks.
→ On medication review in old age: Polypharmacy in old age. Anyone who takes several medications should also be familiar with the topic of deprescribing.
The operation — in particular the joint replacement — is the last stage of the treatment cascade, not the first. Criteria for the decision:
- Pain at night, sleep disturbance due to the joint
- Marked restriction of the walking distance and of everyday activities
- Conservative therapy exhausted over at least 6 months
- Radiologically advanced osteoarthritis (X-ray alone does not justify surgery)
- Quality of life relevantly impaired
- The patient is operable — age alone is not decisive here. In the case of fall-related injuries beforehand, principles similar to those in geriatric traumatology apply.
In older patients, the preoperative geriatric assessment is standard before every elective operation. After the procedure, early geriatric rehabilitation plays a decisive role in the success of recovery.
→ On the joint replacement decision in old age: Joint replacement in old age.
→ On the preoperative risk assessment: Surgical risk in old age.
- Promote exercise instead of rest: Joint walks, small activities, adapted training.
- Support weight reduction: Moderate changes, joint meal planning.
- Adapt the living environment: Check grab rails, stairlift solutions, avoid falls — you will find further tips in our article on falls in old age.
- Observe medication adherence: Especially with painkillers — secret self-medication with over-the-counter NSAIDs is dangerous in old age. If there is uncertainty about interactions, it is worthwhile to take a look at the topic of polypharmacy in old age.
- Accompany to the doctor: In the case of therapy changes or surgical decisions.
- With new joint pain that lasts for weeks
- With a marked increase in existing complaints
- With pain at night or pain at rest
- With increasing restriction of everyday activities — an indication of possible immobility in old age
- With joint swelling, redness or overheating (suspicion of acute inflammation)
- With pain that requires painkillers daily
- Before decisions for or against an operation
The first point of contact is the general practitioner. Orthopaedists bring in the specific joint and surgical expertise. Geriatricians complement in complex situations — multimorbidity, polypharmacy, frailty syndrome, tendency to fall — the overall view. In older patients with additionally impaired kidney function or diabetes in old age, close interdisciplinary coordination is particularly important. If there is concurrent osteoporosis in old age, this too should be included in the therapy planning.
→ On the comprehensive classification in old age: Geriatric assessment.
