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Writing about arthritis: What you need to know

Liz Seegert
Liz Seegert

By Liz Seegert

Arthritis is the most common cause of disability in the United States, affecting about 52.5 million people, or one in five adults, according to the Centers for Disease Control and Prevention. It is projected that 67 million adults will develop some form of arthritis by 2030, yet the condition often is overlooked when it comes to public awareness of chronic diseases.

Arthritis causes pain, fatigue and sleep deprivation. It affects a person’s ability to conduct activities of daily living, such as walking or bending. It also complicates other chronic diseases, such as heart disease and diabetes. Roughly $128 billion in total arthritis-related health costs in 2003 (the most recent year available) included $80.8 billion in medical care spending and $47 billion in lost earnings, the CDC said.

The term arthritis is an umbrella for more than 100 conditions affecting the joints, surrounding tissues and other connective tissue. Symptoms vary but generally include aches, pains and stiffness in and around joints. Certain rheumatic conditions can affect the immune system and internal organs. Symptoms can either develop gradually or appear suddenly. Among the most common types of arthritis are osteoarthritis, rheumatoid arthritis, gout, lupus, and fibromyalgia.

Demographics

  • Two-thirds of people with arthritis are younger than age 65, but prevalence increases with age and is more common among women than men at all ages.

  • Arthritis affects all race and ethnic groups. More than 36 million people with the condition are Caucasian, more than 4.6 million are African-American and 2.9 million are Hispanic, according to the Arthritis Foundation. But the CDC notes that, compared with whites, blacks and Hispanics tend to report a higher prevalence of severe pain and activity limitations due to the disease.

Health Care Utilization

Arthritis is a more frequent cause of activity limitations than heart disease, cancer or diabetes. About 22.7 million adults, or one in 10 people, report having arthritis-attributable activity limitations (AAAL), a circumstance that is growing much faster than originally projected. The number of adults with AAAL was not expected to reach 22 million until 2020.

  • AAAL is much more common among adults with arthritis who also have diabetes, heart disease or are obese.

  • About one-quarter of adults with any of these other conditions have AAAL.

CDC data shows:

  • About one quarter of adults diagnosed with arthritis report severe pain in the last 30 days. People with heart disease or diabetes in conjunction with arthritis are more likely to be inactive than people with none or just one of those conditions.

  • Nearly one third of obese Americans have arthritis; the combination of obesity and arthritis makes these adults 44 percent more likely to be inactive than adults only with obesity.

  • One-third of adults age 45 and older who have arthritis also have anxiety or depression.

Types of Arthritis

Osteoarthritis (OA): One of the most common forms of arthritis. It occurs when the cartilage that cushions the joints breaks down, causing the bones to rub against each other. This results in stiffness, pain and loss of joint movement. The cause is not fully understood. Nearly one in two people may develop symptomatic knee OA by age 85. Nearly half of U.S. adults who were 65 years or older reported an arthritis diagnosis in the period 2010-2012.

About 27 million people in America have osteoarthritis. Common risk factors include increasing age, obesity, genetics, previous joint injury, overuse of the joint and weak thigh muscles. The pain and stiffness of more severe osteoarthritis can make it difficult to walk, climb stairs, sleep, or perform other daily tasks.

OA accounts for nearly 70 percent of all arthritis-related hospitalizations. There were 814,900 hospitalizations with OA as primary diagnosis in 2006, according to the Arthritis Foundation.

Common OA medications include nonsteroidal anti-inflammatory drugs (NSAIDs) that target inflammation, a cause of pain and swelling. Other treatments include analgesics (which treat pain only), topical treatments to temporarily ease pain or swelling, and injectable treatments, such as hyaluronic acid therapy. Injectables are administered in a doctor’s office and aim to replace joint fluid depleted by OA.

Osteoarthritis treatment plans often include teaching pain management techniques such as exercise, rest, joint care, pain relief, weight control, medicines and surgery.

Deterioration of cartilage and fluid may become severe enough to warrant surgery, which can include partial or total replacement of the joint or bone fusion. In Arthritis Today, read Kurt Ullman’s article about knee replacements and Linda Rath’s article on hip replacements.

National Estimates of Musculoskeletal Procedures Among Adults

Procedure

Hospital discharges

Total Knee Replacement

645,062

Total Hip Replacement

306,600

Partial Hip Replacement

105,509

Total Shoulder Replacement

29,414

Partial Shoulder Replacement

15,860

Spinal Fusion

465,070

SOURCE: HCUP Nationwide Inpatient Sample, 2011; Agency for Healthcare Research and Quality.

One interesting note is that in 2000, two-thirds of total knee replacements were performed on adults older the 65 years — 63 percent between 65-84 years and 3 percent 85 years and older. Less than one-third of procedures were performed on those who were age 45-64 years. But by 2011, the age mix had changed dramatically. About 43 percent of patients were age 45-64 years and 53 percent were age 65-84. The percentage of patients 85 years and older was unchanged.

Rheumatoid Arthritis (RA): Though rheumatoid arthritis affects the joints, it is more a disease of the immune system. For reasons no one fully understands, RA causes the immune system to go askew and mistakenly attack healthy cells such as the synovium, a thin membrane that lines the joints. As a result, fluid builds up in the joints, causing pain and inflammation. Over time this can wear away the cartilage and erode bone, causing a lack of function and mobility. In most people, the inflammation becomes systemic and affects organs such as the skin, heart and lungs. RA is the most common type of autoimmune arthritis.

The events that trigger this abnormal process remain a mystery. Most doctors agree that genetic and environmental factors are major contributors. Researchers have identified genetic markers that cause a ten-fold greater probability of developing rheumatoid arthritis. These genes are associated with the immune system, chronic inflammation, or the development and progression of RA.

RA affects an estimated 1.5 million Americans, about one percent of which are older than age 65. It increases in incidence up to age 80. Women are affected at a ratio of 2.5:1, and prevalence increases with age. It can affect anyone from any ethnic group or background.

RA most commonly affects the joints of the hands, feet, wrists, elbows, knees and ankles. Joint involvement usually is symmetrical. That means if one joint is affected, the same joint on the other side of the body also is affected.

Many older adults with RA developed it when they were younger. Many begin developing RA symptoms in their mid-30s and become disabled by the time they become older adults. But a variation known as late-onset RA (LORA) hits abruptly, has a more equal gender distribution, and affects more large joints. It also is associated with fever, weight loss and depression. Disease-modifying antirheumatic drugs (DMARDs) and low-dose prednisone have become mainstream therapy for LORA.

The goals of RA treatment are to prevent and control joint damage, prevent loss of function and decrease pain.

  • People with RA have a harder time functioning than those with osteoarthritis, and those without arthritis.

  • Current treatments, including disease-modifying antirheumatic drugs (DMARDs) that can give most patients good or excellent relief of symptoms and enable them to function at or near normal levels. Drugs such as methotextrate can not only relieve symptoms, but also slow progression of the disease.

  • Doctors often prescribe DMARDs with NSAIDs and/or low-dose corticosteroids to lower swelling, pain and fever. Cortisone, hydrocortisone, and prednisone are some commonly used steroids.

  • Patients with a more serious version of disease may need biologic response modifiers, also called “biologic agents.” These target parts of the immune system which send signals causing inflammation, resulting in joint and tissue damage. These medications are part of the DMARDs group.

Fibromyalgia: A condition causing widespread chronic pain, fatigue, memory problems and mood changes. Fibromyalgia affects up to four percent of the U.S. population, or about 3.7 million people. The majority of patients are women between the ages of 40 and 75 but the disorder also affects men, young women and children.

Fibromyalgia is not considered a disease, but a constellation of symptoms that can be managed. It is not considered life threatening and does not lead to muscle or joint damage. Fibromyalgia can occur by itself, or in conjunction with osteoarthritis, rheumatoid arthritis, lupus and other related inflammatory diseases.

The cause of fibromyalgia is unknown, but is thought to be related to abnormalities in the central nervous system, leading to “amplification” of normal pain signals.

People with rheumatic diseases, such as rheumatoid arthritis or lupus, are at greater risk for fibromyalgia than other groups. For example, about 20 to 30 percent of people with rheumatoid arthritis also develop fibromyalgia, although it is not known why.

Fibromyalgia can result in lower health-related quality-of-life and greater loss of work productively, according to the Arthritis Foundation. Women tend to need hospitalization related to the condition at higher rates than men. People hospitalized with a cardiovascular condition as their primary diagnosis have a high prevalence of reporting fibromyalgia as a secondary condition.

Gout: Caused by a buildup of uric acid in the body, gout is of the most painful forms of arthritis. Normally, uric acid dissolves in the blood, passes through the kidneys and out of the body in a person’s urine. But uric acid can build up in the blood when the body increases the amount of uric acid it makes and the kidneys are unable to process it efficiently. Eating too many foods high in purines, such as dried beans, peas, and anchovies, can aggravate gout in people prone to the disease.

Most people with hyperuricemia (high uric acid levels in the blood) do not develop gout. But it can develop if excess uric acid crystals form in the body.

Risk factors include:

  • Family members with the disease.

  • Being male.

  • Being overweight.

  • Excessive alcohol consumption.

  • Eating an overly purine-rich diet.

  • Having an enzyme defect that makes it difficult for the body to break down purines.

  • Environmental lead exposure.

  • Having had an organ transplant.

  • Using certain medications such as diuretics, aspirin, cyclosporine, or levodopa.

  • Taking too much of the vitamin niacin.

Buildup of uric acid can lead to:

  • Sharp uric acid crystal deposits in joints, often in the big toe.

  • Deposits of uric acid (called tophi) that look like lumps under the skin.

  • Kidney stones from uric acid crystals in the kidneys.

For many people, the first attack of gout occurs in the big toe, which becomes sore, red, warm, swollen and stiff. An attack often can wakes a person from sleep. The symptoms eventually can spread to other joints, including ankles, knees, wrists, fingers and elbows.

Other Considerations

Under the Affordable Care Act, insurance companies no longer can put lifetime caps on out-of-pocket expenses, or exclude people with pre-existing conditions such as arthritis. Some companies now are trying to control costs by moving expensive arthritis drugs such biologics to their Tier 4 lists, which have the highest co-pays for patients. For a biologic, that could mean $6,000 annually out of pocket, according to the Arthritis Foundation.

Production of biosimilars – drugs that act similarly to biologics – is increasing. These drugs should be less expensive than biologics, but not be dramatically cheaper, said Timothy J. Laing, MD, associate chairman of clinical programs at the University of Michigan’s Department of Internal Medicine.

Story Ideas

  • Look at the impact of arthritis on your state. Determine how arthritis affects your area and what actions are being taken by the state health department, Medicaid agency, agencies on aging and other groups.

  • Using the hospital compare databases, look at admissions/discharges for arthritis-related procedures such as TNR and THRs, which are the costs and need for secondary care such as SNFs, outpatient PT and home care.

  • Look at the link between controlling arthritis symptoms and addiction to pain medication.

  • What is the impact of arthritis on your local workforce? Profile businesses in your area. Ask how are they affected by lost work days, disability claims and reduced productivity.

  • Visit a local senior center and talk to some of the attendees. How is arthritis affecting their quality of life and ability to continue living at home? Are they participating in local self-management education programs or specialized activities for people with arthritis and other chronic diseases? Are there local programs or services offered by nearby hospitals or other facilities? How do these older adults manage their ADLs and IADLs?

  • What is happening on the local or state policy front? Is there funding for public education/awareness programs and training for practitioners. Are these programs considered easy to cut because of other priorities?

Resources