Abstract

Background: Osteoarthritis results in enlargement and swelling of the bone, which may sometimes be visible in both smaller joints such as the interphalangeal joints and larger joints such as the knee. Aim: This study aimed to assess knee osteoarthritis among elderly women at Beni-Suef city. Design: A descriptive cross-sectional research design was utilized in the current study. Setting: the study was carried out at Beni-Suef university hospital in orthopedics outpatient clinic and the physiotherapy unit. Subjects: A non-probability consecutive sampling technique of a total 300 studied women was recruited in the current study. Tools: Interviewing questionnaire. Results: more than half (60.7%) of studied elderly women had ages ranged from 65 <70 year. More than one third (40%) of the studied elderly women had knee joint problem from ≥ 5 years. About two-thirds (65.3%) of the studied elderly women had no treatment of knee joint osteoarthritis, 21.7% had surgical intervention, Conclusion: Based on the result of the current study it can be concluded that: more than half of the studied women had knee joint problem in two knees, the majority of them their pain in increasing, most elderly women had no treatment of knee joint osteoarthritis, most of them took medications 2-3 & 5-6 times daily. Recommendations: Help elderly women with osteoarthritis to enhance coping strategies in Beni-Suef university hospital.

1. Introduction

Aging is a gradual, continuous process of natural change that begins in early adulthood. During early middle age, many bodily functions begin to gradually decline. Common conditions in older age include hearing loss, cataracts and refractive errors, back and neck pain and osteoarthritis, chronic obstructive pulmonary disease, diabetes, depression and dementia. As people age, they are more likely to experience several conditions at the same time ^{1, 2, 3, 4}.

Women outlive men and make up the majority portion of older people with their percentage of the population group increasing with age. Between the ages of 65-74, one finds 82 men for every 100 women. In the age group between 65 and 74, 65 men are found for every 100 women, while in the age group between 75 and 84, the ratio is 41 men for every 100 women. Currently women outlive men by 4.8 years. Globally women aged 65 are expected to live another 18 years, while men at the same age add on the average of 16 years. Projections indicate that in 2050 women will comprise 54% of the global population aged 65 or over ^{5, 6, 7, 8}.

The changes in the bone are of the most important effects of age on the body. Both quality and quantity of the bone matrix are influenced by age, therefore bone matrix becomes less strength and less flexible than bone matrix of the young adult. Furthermore matrix break down by osteoclast occurs at a rate faster than matrix formation by osteoblasts. The most significant change in bone is loss of calcium, which is due to the disturbance in the Ca2+ level regulation by hormones. Cancellous bone is missed because trabeculae become weak and thin. Compact bone begins to lose about age 40 years ^{9, 10, 11}.

The rate of loss increases with age. Other factor that may contribute to bone loss is slow protein synthesis, which affects the collagens fibers what give the bone its strength and flexibility. In general the bone of man is stronger than that of women, due to the effect of testosterone hormone which makes the bone denser. Moreover bone loss in women is more severe than in men. In women loss of calcium from bone begins around age 30 and increase with age reaching to 30% of calcium lost form bone ^{12, 13, 14}.

On the other hand, in men, calcium loss begins where they reach age 60. Loss of bone increases the risk of fracture in old people. These change cause pain, stiffness and deformity. The height may decreases and the spine becomes more curvature. Bone loss makes old people prone to teeth loss. It has been thought at that all these changes occur because of the changes in the hormonal balance and the level of activities ^{15, 16}.

As person ages the cartilage becomes thinner and wear out. This affects the movements and makes them painful and less flexible. Costal cartilage becomes calcified that resulting in restricted breathing. Fibro cartilage the cartilages that provide cushioning for vertebrae experience loss of water and cells after the age 40, which lead to decline in the level of cushioning ^{17, 18}.

The influenced cartilages cause many changes in the joints and synovial joints in a way that may create difficulties and problems to the old people. In addition to the decline in the synovial fluid, elastic and collagen fibers which are responsible for elasticity and flexibility of the tissue. The range of the motility decreases due to shortening and reduced flexibility of the ligaments and tendons. Moreover, the decreased activities of old people lead to further reduction in flexible joints and limit of motions ¹⁹.

Skeletal muscles mass declines with age. It has been reported that decline in muscles mass throughout the life is 0.37% per year in female and o. 47% per year in male. This percentage in the muscles loss increased when people reach 75years of age in both sex. It has also been found that atrophy in skeletal muscles is accelerated when the physical activities are absent, and the muscle loss is used to be accompanied by a decrease in strength, in a way which may increase the risk of physical impairment and disorders later on ²⁰.

At the myocellular level, the studies showed a significant reduction in the size of muscle fibers. This reduction depends on the type of the muscle fibers .Type II become smaller in size in about 10-40% compared to that in young ,while type I are not affected by age. As well as the total number of muscle fibers reduces. This observation suggested that muscle atrophy with age could be contributed to muscle fibers loss. The main reason for loss of skeletal muscle is attributed to imbalance between protein synthesis and protein breakdown of the muscle ¹².

The contractile function and the excitation-contraction coupling undergo changes. These changes are represented by reduction in the force per unit of area in the skeletal muscle level. The change in the force generating capacity is attributed to the change in the excitation – contraction coupling process (E-CC) of the muscle. E-CC participates in the physiological events that turn the neural signal into muscle contraction and then into force initiation. The change in elastic fiber is another factor that contributes to the change in E-CC properties ²¹.

In fact the degeneration of the anatomical and physiological processes governing these systems results in impairment in muscle performance. These systems are all influenced by life style, biological and psychological factors the physical activities and nutritional habits are essential life style agents. While the biological factors include: genetic, hormones, inflammatory processes and the psychological factors including: stress, fear, loneliness and self-efficacy are of direct or indirect effect on skeletal muscle functions ⁹.

Osteoarthritis (OA) is a major cause of severe joint pain, physical disability and quality of life impairment in the aging population across the developed and developing world. Bone, cartilage, and muscle are in close relationship and their functionality is concomitantly affected with aging. The co-existence in older adults of osteoarthritis and sarcopenia, especially in the context of fracture, their multifactorial origin, and deleterious effect on quality of life has been largely reported ²².

Increased catabolism in the extracellular matrix (ECM) of the articular cartilage is a key factor in the development and progression of OA. The molecular mechanisms leading to an impaired matrix turnover have not been fully clarified, however cellular senescence, increased expression of inflammatory mediators as well as oxidative stress in association with an inherently limited regenerative potential of the tissue, are all important contributors to OA development. All these factors are linked to and tend to be maximized by aging ²³.

Age-related factors that contribute to osteoarthritis development include reduced muscle mass and increased fat mass alter joint loading and are associated with an increase in adipokine and cytokine production, resulting in low-grade systemic inflammation, Changes in the extracellular matrix, including accumulation of advanced glycation end-products, reduced aggrecan size, reduced hydration, and increased collagen cleavage alter the mechanical properties of cartilage and make it more susceptible to degeneration ²⁴.

Moreover, extracellular matrix disruption and reduced cell density in the meniscus and ligaments promote degeneration and can potentially alter joint mechanics, impairment in the function of subchondral bone due to reduced numbers of osteocytes and altered mineral composition and Mitochondrial dysfunction, oxidative stress and reduced autophagy in chondrocytes alters their function, promoting catabolic processes and cell death over anabolic processes ²⁵.

Differences between normal joint ageing and osteoarthritis as with normal joint ageing, articular cartilage remains intact but loses thickness and has reduced glycosaminoglycan (GAG) content. With osteoarthritis (OA), fibrillation of the cartilage surface occurs in focal areas and can be associated with a complete loss of staining for GAGs, Non-enzymatic crosslinking of collagen by advanced glycation end-products (AGEs) increases in cartilage with age. A mouse model of injury-induced OA demonstrated that collagen crosslinking occurs through a distinct mechanism involving lysyl oxidase ²⁷.

The density of chondrocytes in cartilage decreases with age, but chondrocyte ‘clusters’ emerge during the development of OA near sites of tissue damage and may indicate attempted repair or altered cellular signals, Aged chondrocytes have reduced levels of extracellular matrix gene expression and synthesis, whereas during OA chondrocytes become highly active with increases in both anabolic processes for example, matrix synthesis and catabolic pathways for example, those induced by inflammatory cytokines ²⁸.

Synovial inflammation and hypertrophy occur in OA but have not been described in normal joint ageing, bone mass and density decrease with ageing, whereas subchondral bone thickening is seen in patients with OA and nine cellular and molecular hallmarks of ageing were proposed to highlight the underlying causes of age-related dysfunction ²⁹.

2. Aim of the Study

The current study is conducted to assess knee osteoarthritis among elderly women at Beni-Suef city.

3. Subjects and Methods

3.1. Research Design: A descriptive cross-sectional research design was utilized in the current study.

3.2. Subjects & Setting:

3.2.1. Setting: The current study was conducted at Beni-Suef university hospital in orthopedics outpatient clinic and the physiotherapy unit.

3.2.2.1. Sample Size: The estimated sample size is 278 subjects.

3.2.2.2. Sampling Type: A non-probability consecutive sampling technique was used to recruit elderly women according to the eligibility criteria.

3.2.2.3. Sample criteria: Any elderly women suffering from knee osteoarthritis (OA) pain and attended the study settings was selected in the study sample after fulfilled the following criteria.

Inclusion criteria:

√ Elderly ( age ≥65 years old)

√ Diagnosed as having knee osteoarthritis (OA) for at least one year; this will be confirmed by chart review or medical report and history.

Exclusion criteria:

√ Cognitive impairment

√ Life-threatening or functionally severely limiting health problems other than OA (e.g., cancer, Chronic Obstructive Pulmonary Disease COPD, etc.).

3.2.3. Tools of Data Collection: Interviewing questionnaire: it was developed by the researcher; it is consisted of 2 parts: -

a. Part I: Demographic data: It was developed by the researcher in an Arabic language. This part was concerned with elderly women's demographic characteristics, such as; age, educational level, occupational status, marital status and residence.

b. Part II: Knee arthritis medical history: It aimed to assess patients’ present medical history regarding the knee osteoarthritis.

• Content Validity: tools was examined by a panel of five experts in the field of community health nursing to determine whether the included items are comprehensive, understandable, applicable, clear and suitable to achieve the aim of the study.

• Reliability: In the present study, reliability was tested using Cronbach’s Alpha coefficients

3.2.5. Pilot study: A pilot study was carried out on 30 patients (10%) of the study subjects.

3.2.6. Field Work: The actual work of this study started and completed within eight months from beginning of August (2021) to the end of March (2022).

The research approval was obtained from the faculty scientific ethical committee before starting the study. The researcher clarified the objectives and aim of the study to the patients included in the study before starting.

An official written letter was issued from the faculty of Nursing in Beni-Suef University to the director of Beni-Suef University Hospital in which the study was conducted by which permission obtained for data collection and help in conducting the study in their facilities.

The data were collected, coded and entered into a suitable excel sheet and analyzed using an appropriate statistical method. Data were analyzed using statistical program for social science (SPSS) version 26.0, quantitative data were expressed as a mean ± standard deviation (SD), and qualitative data were expressed as frequency and percentage.

4. Results

Figure 1 shows socio-demographic data for the studied women. It presents that, more than half (60.7%) of studied elderly women had ages ranged from 65 <70 year, 50.7% of them had intermediate education, 36.7% of them had retired from governmental job. While, 70.3% of studied elderly women were married, 60.3% of them lived at rural areas, 39% of them had people in their house ranged from 5-6 people, 50.7% of them had 3 rooms in their house, 52% of them had inadequate monthly income and 90.3% of them were living with their families.

Figure 2 portrays frequency and percentage distribution of medical history for the studied elderly women. It reveals that, more than one third (40%) of the studied elderly women had knee joint problem from ≥ 5 years. It indicates that (60%) of the studied women had knee joint problem in two knees, (80.3%) of them their pain in increasing, 40% pain altered their sleep, and (90%) of them had problems in other joints.

Figure 3 Illustrates that 65.3% of the studied elderly women had no treatment of knee joint osteoarthritis, 21.7% had surgical intervention, while 13% of them treated knee joint osteoarthritis by injection.

Figure 4 presents types of treatment of knee osteoarthritis for the studied sample. It reveals that, 50% of them were treated by physiotherapy (29,7% by themselves & 20.3% by Physiotherapist). For women studied elderly women who treated their knee osteoarthritis medically; 39.75% of them used by analgesic injection, 20% used tablets, 10% used ointments, and 30% used mixture of all of them. Most of them (40.3% & 39.7%) took medications 2-3 & 5-6 times daily. Moreover, none of them practices exercise regularly.

5. Discussion

Osteoarthritis results in enlargement and swelling of the bone, which may sometimes be visible in both smaller joints such as the interphalangeal joints and larger joints such as the knee. Bone swelling occurs due to numerous pathological changes that take place during OA. Among the changes are soft tissue oedema, blockage of blood circulation, damaged chondrocytes, increased bone density, and the formation of cystic changes ^{30, 31, 32, 34}.

Recent research studied pointed out that there is increasing evidence for the role of nurses in the management of patients with chronic inflammatory arthritis. Community health nurses help patients with OA achieve the ultimate goal of remission or low disease activity. Based on the patient’s individual needs, encourage and assist patient to establish health behaviors and activities that promote rest and exercise, reduce stress, and encourage independence ^{35, 36}. So the current study is conducted to assess knee osteoarthritis among elderly women at Beni-Suef city. As regarding the personnel characteristics of the studied women the present study indicated that more than half of studied elderly women had ages ranged from 65 <70 year old & lived at rural areas, nearly one third of them had governmental jobs, more than two third of them were married. These findings are in the same line with Abdelaleem et al., (2018) who revealed that the majority of patient was in age from 50 to 70 years old and were married ³⁷. On the other hand, the present study findings are disagreed with Östlind et al., (2022) who added that the majority of the studied sample lived at urban settings and were working ³⁸.

Regarding the level of education of the studied women, the present study findings revealed that nearly half of the studied women had a secondary education. These study findings are disagreed with Jormand et al., (2022) who indicated that more than half of the studied sample was not educated ³⁹.

Concerning the honest of OA among the studied women, the present study findings revealed that more than one third of the studied elderly women had knee joint problem from ≥ 5 years. These findings are agreed with Jaiswal et al., (2021) who indicated that nearly half of the studied sample had a rheumatoid arthritis disorders from 5 years ago ⁴⁰.

In relation to the past medical history of arthritis among the studied women, the present study results pointed out that more than half of the studied women had knee joint problem in two knees, majority of them had pain, that regularly increasing in its intensity. These findings are in accordance with Saffari et al., (2018) who stated that the main symptoms which characterize OA include persistent pain, swelling, deformation of joints, morning stiffness and general tiredness ⁴¹.

Regarding types of treatment of knee osteoarthritis for the studied sample; the results of the current study revealed that, half of them were treated by physiotherapy; either by themselves or by Physiotherapist. This is in line with literatures emphasized on the importance of physical therapy by specialists and occupational therapy hence play central role in the management of those patients. Physical therapy, starting with quiet motion exercises and some aerobics, aids in muscle strengthening, joint stability, and mobility. The use of heat or low-level laser exposure is recommended. Similarly, occupational therapy methods could be very useful in directing the patient for maximum energy conservation and joint protection, using assistive devices such as crutches or walkers, hence improving joint function via reducing the joint overloading on it. Acupuncture also can be considered as non-pharmacological ways improving the walking patterns of knee OA patients ⁴².

In relation to the treatment of pain, the present study findings revealed that the highest percentage of studied women had an injection for treatment, and one half of them had a physiotherapy also as a treatment of rheumatoid arthritis these findings are in the same line with Viswas et al., (2021) who added that pharmacological interventions for rheumatic diseases have a limited effect on fatigue and further treatment are needed ⁴³.

Although, guidelines recommended an arrangement for obtaining convenient management for OA: at first, non-pharmacological therapy, medications in the middle step, and surgery as a last step when other managements are impossible to help. Non-pharmacological therapy include appropriate education for the patient and their caregivers is considered one of the initial non-pharmacological treatment modalities seeking for the best therapy for each individual throughout lifestyle adjustment and home remedies in the hope of pain amelioration. Patients should be encouraged to participate in self-management programs associated with long-term diseases like OA ⁴⁴. The results of the current study revealed that studied women elderly who treated their knee osteoarthritis medically; either using analgesic injection or tablets or ointments.

Pharmacological therapy include; analgesics/anti-inflammatory agents used in OA treatment, for pain alleviation as paracetamol (or acetaminophen) is usually prescribed as a first-line analgesic and none steroidal anti-inflammatory drugs like diclofenac, ibuprofen, naproxen, and celecoxib have a substantial impact on inflammation together with pain attenuation in OA, Intra-articular injectable compounds are used for obtaining a targeted and a high local bioavailability tool for joint treatment in OA as corticosteroids which effective in reducing OA pain, although their effects are short-lived with no associated benefit seen after 6 months [45-48] ⁴⁵.

Poly-pharmacy has previously been recognized as a key predictor of potentially inappropriate prescription (PIP) in the elderly. The number of medicines used is not always symptomatic of Poly-pharmacy since all of the prescriptions may be clinically required and acceptable for the patient; nevertheless, as the number of prescribed drugs grows, so does the likelihood of Poly-pharmacy. The phenomenon of Poly-pharmacy is rising in the old age population, and the incidence of adverse drug effects and complications is increasing as well. [3-4] ³. Regarding medication usage by studied elderly women for treatment osteoarthritis; the results of the current study revealed that around third of them used mixture of medications (injection, tablets, and ointments). Most of them (took medications 2-3 & 5-6 times daily. This is in line with researches that documented that poly-pharmacy has also been documented as a major risk factor for Adverse drug reactions (ADRs) in the developed countries. In a case-control study carried out among old-age people, Poly-pharmacy was found to be an independent risk factor for hip fractures ^{6, 10}.

6. Conclusion

Based on the result of the current study it can be concluded that: more than half (60%) of the studied women had knee joint problem in two knees, (80.3%) of them their pain in increasing, most elderly women had no treatment of knee joint osteoarthritis, most of them took medications 2-3 & 5-6 times daily.

7. Recommendation

The important recommendations inferred from the study results were:

1. Periodic assessment for elderly women with osteoarthritis in Beni-Suef university hospital.

2. Help elderly women with osteoarthritis to enhance coping strategies in Beni-Suef university hospital.

References