Osteoarthritis in Middle-Aged Women: Nursing & Care

Introduction and Overview

Osteoarthritis presents many challenges to nurses and healthcare professionals at all levels. The condition disproportionately affects women and tends to occur particularly in women over the age of forty. The literature on this topic also emphasizes the complexity of treating osteoarthritis, owing to the wide range of external factors necessary for a full understanding of the condition.

This paper provides a brief overview of osteoarthritis with a focus on factors that affect the treatment of middle-aged female patients. Topics addressed include demographics and prevalence, as well as extraneous factors that affect patients in terms of quality of life and treatment protocols — including social, political, and economic dimensions. Following this analysis, the implications for professionals, the community, and nursing practice are explored. The paper concludes with a discussion of political action plans and strategies that are, or should be, implemented to improve treatment and understanding of this condition.

History and Description of Osteoarthritis

Osteoarthritis is defined by Walker (2009) as "a degenerative disorder of the synovial joints that results in localised loss of hyaline cartilage, remodeling of underlying bone and osteophyte formation at the joint margins" (p. 35). The disease is also characterized by a range of common symptoms, including joint pain, stiffness, and limited range of movement (Walker, 2009, p. 35). While the disease can negatively affect any synovial joint, it most commonly impacts the hands, hips, lumbar or cervical spine, shoulders, and feet (Walker, 2009, p. 35).

A central facet of osteoarthritis, in terms of nursing care and the larger social and political implications discussed in this paper, is that nurses may often encounter patients with osteoarthritis even when this is not the primary reason for seeking healthcare (Walker, 2009, p. 35). In other words, the condition can be a contributing factor in other healthcare issues that the patient presents. It is also important to note that osteoarthritis is a complex disorder that is becoming increasingly prevalent among middle-aged to older age groups. Furthermore, "biomechanical factors such as intra-articular fractures and sports injuries, such as cruciate ligament tears in the knee or lateral ligament damage in the foot, may predispose individuals to developing osteoarthritis as a result of joint instability" (Walker, 2009, p. 35).

Experts consistently note that "the incidence of osteoarthritis increases with age and affects women more than men" (Walker, 2009, p. 35). Another key consideration is that "the co-existence of OA and obesity has been recognized by epidemiologists for decades… Epidemiological data suggest that obesity is of very large importance for the development of knee OA" (Bliddal et al., 2006, p. 323).

It is therefore evident that osteoarthritis is a condition that is complicated in terms of its epidemiology and treatment history. This complexity becomes clear when we consider research studies indicating the range of contributing factors that can cause the disease. For example, genetic inheritance is one factor linked to its pervasiveness: "familial studies have demonstrated that inheritance is a considerable factor, especially in hand and generalized osteoarthritis" (Schroeder, 2010). Social issues are equally important to understanding and treating osteoarthritis, and these are discussed in detail in the following sections.

In terms of signs and symptoms, pain and stiffness usually occur, although pain may be absent in some cases. While pain is typically felt only in association with movement, in more extreme forms of osteoarthritis it can occur even when the individual is at rest. One important implication of this is restriction of movement and reduced ability to care for oneself — which has direct nursing implications. Clinical features can include crepitus, reduced range of movement, joint instability, joint line tenderness, pain on movement or when the joint is stressed, and mild synovitis (Schroeder, 2010).

Pervasiveness and Demographics

According to Schroeder (2010), an alarmingly high proportion of adults suffer from various forms of arthritis — as many as twenty-two percent, or forty-six million individuals, in the United States alone. This figure increases with age, with fifty percent of adults sixty-five years and older reporting an arthritic diagnosis (Schroeder, 2010). Research also indicates that arthritic diagnoses are not limited to adults but affect children as well.

In the United States, Canada, and other countries, there has been a corresponding increase in reported cases of osteoarthritis, linked to rises in contributing factors such as obesity and poor fitness levels. Estimates suggest that ten million individuals already have osteoporosis and eighteen million more have low bone mass, placing them at increased risk. One out of every two women and one in eight men over the age of fifty will experience an osteoporosis-related fracture in their lifetime (Osteoarthritis: The most common form, this disease affects 20.7 million Americans, usually over age 45).

An important point stressed by many healthcare experts is that this disease is not necessarily a natural consequence of aging; other factors must be considered, particularly with regard to middle-aged groups. Women are demographically more prone to most forms of osteoarthritis — the exception being hip osteoarthritis, which has the same prevalence in men. Research has found that osteoarthritis is "a major health problem in postmenopausal women, and the condition is more debilitating in this population" (Wright et al., 2008, p. 1736).

Epidemiology and Causal Factors

Epidemiology — as the study of factors affecting the health or illness of a population — is essential for understanding the interventions and management of diseases within a particular social environment. In terms of the high incidence of osteoarthritis among older women, one isolated causal factor is a deficiency of the hormone estrogen, which is linked to bone deterioration and loss of calcium. This often occurs at menopause (Osteoarthritis: The most common form, this disease affects 20.7 million Americans, usually over age 45).

Osteoarthritis can be classified as primary or secondary. Primary osteoarthritis is "an idiopathic phenomenon, meaning there is no apparent initiating factor. Primary osteoarthritis is related to the aging process and the individual may be asymptomatic" (Schroeder, 2010). Secondary osteoarthritis, however, is of particular concern. This form is caused by additional factors such as obesity, repeated trauma, congenital abnormalities, diabetes, gout, or surgery to the joint structure (Schroeder, 2010).

This distinction has wide-ranging implications not only for policy and politics but also for nursing practice. As Walker (2009) observes, "a good knowledge of this condition, its effects on functional ability and the consequences of living with it will assist healthcare professionals to support patients and aid their recovery from medical or surgical co-morbidities" (p. 35). This in turn informs the various management strategies that must account for these external and contributing factors.

Social and Other Determinants

In light of the foregoing discussion, social determinants — including political, environmental, and health-related forces — must be taken into account when assessing their effect on female patients. This includes factors pertinent to nursing such as pain and pain reduction, as well as the critical issue of quality of life, including the limiting effects of osteoarthritis on daily living and personal experience. All of these aspects must be considered alongside other social and environmental factors when determining nursing strategies and management.

For example, a middle-aged or older woman who lives alone may be significantly constrained by her condition in various ways, necessitating a particular set of nursing protocols. "Treatment needs to be tailored to suit different circumstances and outcomes need to be monitored. Healthcare professionals should review the effect of symptomatic osteoarthritis on individuals' function, quality of life, occupation and leisure activities periodically" (Walker, 2009, p. 35).

Social, environmental, political, and economic determinants must therefore be understood in relation to these patients. Beyond the feminist argument that women are generally marginalized in modern societies, including Canada, there are other factors to consider when dealing with this demographic. For instance, a link has been established in the literature between eating disorders such as anorexia nervosa and various forms of arthritis in women, including osteoarthritis (Osteoarthritis: The most common form, this disease affects 20.7 million Americans, usually over age 45). Furthermore, if one takes into account that many such disorders have been attributed to the adverse construction of the female body in patriarchal society, this too can be seen as a social determinant that impacts women with osteoarthritis.

Psychological factors also play a role in this condition and can reduce the patient's quality of life. A study by Fujita et al. (2006) found "several problems that have not been mentioned to date, such as an inferiority complex related to abnormal posture prior to THA [total hip arthroplasty] and distress over body image after undergoing THA" (p. 81). Related to this is the real challenge of coping with pain and disability. As the same study notes, "coping with pain and physical disability seem to be predominant features of patients with advanced-stage OA… Baird (2000) characterized the experience of elderly female patients with OA as 'living with pain' and 'living with difficulty'" (Fujita et al., 2006, p. 81).

This is underlined by a significant study from the University of Ontario entitled Personal Experience of Living with Knee Osteoarthritis among Older Adults (2006). The authors found, among other things, that "experiencing mobility limitations devalues self-worth" (Maly and Krupa, 2006, p. 1423). The study also emphasizes that relatively little research has been conducted on this aspect and the related factors that impact patients. The following quotation offers insight into the lived experience of the condition:

"For… females, the pain associated with knee OA was the most intense pain of their lives. One woman spoke at length about the experience of pain. Nobody likes pain, believe me… With this, how long does it go? When is it going to stop? I can't handle this no more… Pain is dominant, it took over everything. Your brain becomes so taken and your mind, you think pain, you see pain, you feel pain, you LIVE pain. You're just lost. It's constantly your focus in life." (Maly and Krupa, 2006, p. 1426)

Conclusion

Osteoarthritis has been conclusively shown to affect many middle-aged and older women. While there are genetic and hormonal causative factors, there are also numerous external factors that impact the patient and her quality of life. The epidemiology of osteoarthritis therefore reflects a degree of complexity that must be acknowledged in both understanding and treating the condition. Among the relevant factors are social marginalization, the debate surrounding alternative medicines, and — critically — the widespread lack of knowledge among patients and sufferers about available remedies and treatments.

These factors necessitate a range of strategies and action plans to address the full complexity of the condition. For example, the community nurse can play an extremely valuable role in ensuring that community members are better informed about osteoarthritis and the latest evidence-based treatments, while also correcting misunderstandings and false perceptions. What this research ultimately demonstrates is that the various factors affecting these patients require an interactive and inclusive approach from the nursing profession, as well as more effective coordination among health authorities, the community, and healthcare professionals.

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