Helping the Elderly Maintain Function and Mobility
Research in Action, Issue 4
Research shows how elderly patients with osteoarthritis can become more active and responsible for their own care, make more informed decisions, help to control the costs of health care, and improve their quality of life.
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Contents
Introduction
Background
AHRQ Research Has Improved Osteoarthritis Management
Physician-patient Partnership Improves Physical Functioning
Use of NSAIDs Contributes to High Costs
Educating Health Care Providers Reduces NSAID Use
Knee Surgery Has Benefits and Risks
High-volume Hospitals and Surgeons Have Lower Complication Rates
With New Funding, Researchers Can Make a Difference
Conclusion
For More Information
References
Introduction
Osteoarthritis is the most prevalent form of arthritis in the United States,
1 affecting over 20 million adults.2,3 More than half of all people age 65, and over have evidence of
osteoarthritis.3 It is the leading cause of disability in this age group.4
Research funded by the Agency for Healthcare Research and Quality (AHRQ) indicates that
treatment involving patient self-management, occupational therapy, pharmaceutical therapy, and surgery can reduce pain, maintain or improve joint mobility, and limit
functional disability. AHRQ's research shows how elderly patients with osteoarthritis can:
- Become more active and responsible for their own care.
- Make more informed decisions.
- Help to control the costs of health care.
- Improve their quality of life.
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Background
Research funded by AHRQ shows that the effects of osteoarthritis accumulate as people age. The presence of osteoarthritis significantly predicts whether or not elderly
people will become functionally limited in their ability to care for themselves.5
According to AHRQ's Healthcare Cost and Utilization Project (HCUP), 250,000 people ages 65-79 were hospitalized in 1997 because of osteoarthritis.6 There is no known cure for osteoarthritis, and therapy becomes more and more complicated as people age.1,7,9
Osteoarthritis of the knee and hip joints causes the most difficulty for the elderly because it significantly impacts their ability to conduct their normal activities of daily living, such as walking, cooking, bathing, dressing, using the toilet, and performing household chores.1,3,7,9 Joints can become painful, stiff, and swollen.3
The resulting pain causes limited motion, reduced physical capability,
restriction of social activities, and compromised work capacity.1,4 The interaction of these factors—pain, loss of social contact, and diminished income—can create
emotional distress, which further reduces physical activity.4 Increased disability results when the affected joints are exercised less, and the elderly begin to lose muscle tone, leading to reduced strength.4 Because there is no cure, the therapeutic goal of treatment for osteoarthritis is to minimize the effects of the disease and its consequences over time.4
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AHRQ Research Has Improved Osteoarthritis Management
AHRQ has funded studies devoted to helping patients become partners in their own care. These studies have contributed to improved functional ability among older adults. For example:
- The Chronic Disease Self-Management Program (CDSMP) has helped patients manage their symptoms and reduce health care use. The CDSMP is discussed in Research in Action Issue 3.10
- The Well Elderly Study showed that providing
preventive occupational therapy to the elderly helps
improve their personal and social relationships as well
as their health status.
Researchers funded by AHRQ were instrumental in
identifying the high costs of treatment for osteoarthritis
with nonsteroidal anti-inflammatory drugs (NSAIDs) and
suggesting alternatives to that treatment. Specifically,
AHRQ studies revealed that:
- NSAIDS provided very little relief of pain or
improvement in function, and they were associated with
ulcers, bleeding, and gastrointestinal perforation.
- Patients who used NSAIDs utilized more hospital and
emergency services than nonusers, resulting in increased
medical care costs.
- An educational program for physicians and nursing
home staff resulted in a significant reduction of NSAID
use and increased the use of acetaminophen without any
increase in pain.
AHRQ research revealed that the elderly face higher risks
of complications and mortality than younger people when
they have surgery, including surgical knee repair. However,
AHRQ studies also showed:
- The elderly reported better quality of life, less pain, and
better physical function after knee replacement surgery.
- Surgical complications and mortality rates were lower
for surgeons and hospitals that performed more knee
replacement surgeries.
AHRQ-Funded/Sponsored Research on Osteoarthritis and Elderly Health Care
- Improving Chronic Disease by Self-Management Education, Stanford University. This study developed, operated, and
evaluated the Chronic Disease Self-Management Program and assessed its effectiveness in improving health while lowering
costs for patients with chronic disease.
- Effectiveness of Two Occupational Therapy Treatments for the Elderly, University of Southern California. AHRQ co-sponsored
this study with the National Institute on Aging and the National Center for Medical Rehabilitation Research. It provided an
occupational therapy service to low-income elderly and evaluated the program's cost effectiveness and its impact on quality
of life.
- Assessing and Improving Outcomes. Total Knee Replacements, Indiana University: Also referred to as the Total Knee
Replacement Patient Outcomes Research Team (TKR PORT), this study investigated the variation in total knee replacement
rates and outcomes and constructed a decision model to help physicians and patients make decisions regarding surgery.
- Effectiveness and Outcomes of Noncardiac Surgery, Brigham and Women's Hospital. This study investigated adverse
outcomes among patients undergoing major noncardiac surgery, identified the factors that predict adverse outcomes,
evaluated the impact of adverse outcomes on length of postoperative stay, and assessed the long-term effectiveness of high-volume
procedures.
- Improving Outcomes in Elderly NSAID Users, Vanderbilt University. This study developed and tested an educational program
that encouraged physicians to reassess elderly NSAID users with osteoarthritis who were at high risk of peptic ulcer disease.
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Physician-patient Partnership Improves
Physical Functioning
AHRQ research shows that patients have better outcomes
when they receive education and training about their
condition because they become more involved in their care.
Two ways to achieve improved outcomes are through self-management
and occupational therapy.
AHRQ researchers indicate that the key to good
management of osteoarthritis is an effective physician-patient
partnership. This partnership should:
- Promote proper use of medications.
- Encourage patients to change their behavior to improve
symptoms or slow disease progression.
- Instruct patients on how to interpret and report
symptoms accurately.
- Help patients adjust to new social and economic
circumstances and cope with emotional consequences.
- Support patients' efforts to participate in treatment
decisions and maintain normal activities.4
Creating patient education programs helps patients achieve
this role by giving them the knowledge and skills they need
for self-management. AHRQ funded the development of
the Chronic Disease Self-Management Program, which is
based on changes in diet, exercise, and compliance with
treatment regimens. The CDSMP has been shown to
improve health status and reduce costs. Specifically, the
CDSMP helps patients interpret and report symptoms
accurately and has led to substantial reductions in pain,
depression, and the use of health services in patients with
chronic disease.4
Changing the patient's health behaviors and perception of
symptoms can improve the symptoms or slow the
progression of osteoarthritis.4
Regular exercise helps
patients retain mobility and counteracts loss of muscle
strength.1,4
Exercise such as walking or aquatics improves
aerobic capacity and stamina while decreasing depression
and anxiety.1,7
If patients attribute pain to the progression
of osteoarthritis, then they may avoid activities that increase
pain. However, if patients attribute pain to loss of muscle
tone and strength, then they may increase physical activity.4
Patients can be referred to organizations in their
community that offer exercise programs, swimming
facilities, information meetings, social activities, self-help
education, support groups, and mobile services for
transportation and meals.4
Finally, research sponsored by
AHRQ indicates that patients can be supported from the
physician's office by telephone with no significant increase
in costs to either the patients or physicians.1
These telephone conversations can be used to discuss joint pain,
medications, treatment compliance, drug toxicities, date of
next scheduled visit, and barriers to receiving care.1
Occupational therapists can evaluate a person's ability to
perform daily living activities and recommend devices such
as elevated toilet seats or wall bars for bathtubs. They also
teach joint protection and energy conservation. For
example, living on one floor of the home helps to avoid
painful step climbing and avoiding kneeling or squatting
helps to protect the joints.1,7
AHRQ cofunded the Well Elderly Study with the National
Institute on Aging and the National Center for Medical
Rehabilitation Research. This study evaluated the
effectiveness of preventive occupational therapy as a way to
avoid functional disability in people age 60 and over.
During a 9-month period, one group of participants
received weekly group and individual occupational therapy.
This therapy focused on home and community safety,
shopping, mastering the public transportation system, joint
protection, adaptive equipment, energy conservation,
exercise, and nutrition. A second group of patients
attended a program that focused only on social activities,
such as community outings, craft projects, films, games,
and dances.
At the end of the study, those who were in the
occupational therapy study group reported:
- Better quality of interaction with other people.
- Improved health status.
- More satisfaction with life.
- Improved mental health, physical functioning, role
functioning, vitality, and social functioning.
- Less pain.
- Fewer emotional problems.11
Six months after the initial study, the patients who received
preventive occupational therapy were reassessed. These
elderly participants continued to experience:
- Better quality of interaction with other people.
- Improved mental health, physical functioning, role
functioning, vitality, and social functioning.
- Less pain.
- Fewer emotional problems.12
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Use of NSAIDs Contributes to High Costs
Medications do not cure osteoarthritis but are intended to
relieve pain.1,7
AHRQ studies indicate that nonsteroidal
anti-inflammatory drugs were the medications of choice for
osteoarthritis pain until research showed that they affect
joint cartilage metabolism, have greater risk of toxicity than
acetaminophen, can cause upper gastrointestinal bleeding,
and may cause or aggravate peptic ulcer disease.1,7,13,14
One AHRQ-funded study showed that 30-40 percent of all
elderly use NSAIDs each year and 10-13 percent of the
elderly use NSAIDs every day.14
A majority of these elderly have a primary diagnosis of osteoarthritis.14
AHRQ research further showed that NSAIDs provided only a
modest decrease in osteoarthritis pain and little
improvement in function, and their association with ulcers,
bleeding, and perforation caused a four- to five-fold
increase in hospitalizations due to gastrointestinal
complications.14
An AHRQ study of Medicaid recipients who were age 65
and over showed that NSAID users were hospitalized and
used the emergency room more often than nonusers (Figure 1, 30 KB). As the elderly increased their use of NSAIDS, medical
care costs also increased (Figure 2, 96 KB).15
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Educating Health Care Providers Reduces
NSAID Use
An educational intervention supported by AHRQ resulted
in about a 70-percent reduction in the use of NSAIDs
among nursing home patients. Physicians and nursing staff
participated in an educational program focused on the best
treatments for muscle and joint pain, which included
information on osteoarthritis, recognizing pain in patients,
and various methods to control pain. These health care
providers were asked to stop regular NSAID therapy in all
patients age 65 and over and substitute acetaminophen. If
the acetaminophen did not control the patient's pain, the
providers were allowed to add ibuprofen to the patient's
treatment regimen. If this regimen did not control the
patient's pain, the providers were to begin using their
standard NSAID therapy again.16
After three months, nursing home residents reduced their
NSAID use from an average of seven days a week to less than two
days per week and increased their use of acetaminophen
from two days per week to five days per week. These patients
did not report any significant increase in pain or disability.
It is expected that, over the long term, these patients will
also decrease their risk for gastrointestinal problems caused
by NSAIDs and the costs associated with them.16
Researchers sponsored by AHRQ have indicated that
acetaminophen (up to 4,000 milligrams per day) is the
recommended drug of choice for osteoarthritis. NSAIDs
can be prescribed if acetaminophen fails to relieve pain.1,7,13
Adverse effects from acetaminophen were limited but
included liver toxicity in patients who were fasting or
consumed large amounts of alcohol and renal failure from
long-term use.1,13
Opioids have been shown to be effective
for short-term treatment of acute exacerbation of pain, but
the elderly have difficulty tolerating codeine on a long-term
basis.1,13
Topical therapy, such as capsaicin cream, has been shown
to be appropriate for patients with knee osteoarthritis who
did not respond to or did not want to take oral
analgesics.7,9,13
Corticosteroid injections into the joint were
helpful in diminishing symptoms in patients with knee
osteoarthritis who had swelling and inflammation,4,7
but they were not recommended for hip osteoarthritis because
of progressive cartilage damage from repeated injections.1
Patients who do not respond to medical therapy1
or who require more than three or four joint injections each year to
control symptoms of knee osteoarthritis are candidates for
surgical intervention.7
Researchers sponsored by AHRQ have indicated that
acetaminophen (up to 4,000 milligrams per day) is the
recommended drug of choice for osteoarthritis.
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Knee Surgery Has Benefits and Risks
Surgical repair and replacement of the knee joints provide
durable pain relief and functional improvement in patients
with osteoarthritis.7,17
However, the elderly need to consider
certain factors, such as surgical complications and the pros
and cons of having surgery performed on both knees at the
same time.
Knee replacement surgery improves quality of life
The AHRQ total knee replacement Patient Outcomes
Research Team (TKR PORT) showed that, despite the risk
of complications, quality of life improves for the elderly
after knee replacement surgery.18
Elderly patients reported
less pain and better physical function (Figure 3, 60 KB and Figure 4, 62 KB).
Additional AHRQ-funded research confirmed the value of
total knee replacement surgery in a study of patients whose
average age was 65 years. After 4 years, nearly 90 percent
of patients had a good to excellent outcome. After five years:
- 75 percent had no pain.
- 20 percent had mild pain.
- 3.7 percent had moderate pain.
- Only 1.3 percent had severe pain.19
Complications from surgery increase with age
AHRQ research has indicated that the elderly face more
risks of major or fatal complications when undergoing
noncardiac surgery, including orthopedic surgery, than
younger patients (Figure 5, 41 KB). Specifically, older patients
have a significantly higher risk of pulmonary edema, heart
attack, abnormal heart rhythms, bacterial pneumonia,
respiratory failure, and in-hospital mortality.20
Patients ages 70-79 were twice as likely and patients 80
years and over were three times as likely to suffer
postoperative complications or death when compared to
patients ages 50-59.20
Older patients also had longer
hospital stays (Figure 6, 27 KB) regardless of sex, ethnicity,
preoperative clinical characteristics, functional status, and
type of procedure.20
AHRQ research showed that about 18 percent of patients
undergoing knee replacement surgery, whose average age
was 65, had complications (Table 1). The mortality rate
was 7.1 percent at 30 days but dropped to 1.5 percent after
1 year.19
Table 1. Estimated rates and ranges of complications following total knee replacement surgery
Complication |
Average rate (%) |
Range (%) |
Superficial
infections
|
3.9
|
0-14.8
|
Deep
infections
|
1.7
|
0-11.4
|
Pulmonary
embolism
|
2.0
|
0-9.7
|
Deep
venous thrombosis
|
6.5
|
0-56.6
|
Peripheral
nerve damage
|
2.1
|
0-18.8
|
Source: Callahan CM, Drake BG, Heck DA, et al. Patient outcomes following
tricompartmental total knee replacement. JAMA 1994;271(17):1349-57.
Table 2. Comparisons between simultaneous and staged bilateral knee arthroplasties among medicare beneficiaries
Surgery groups |
Surgical complication (%) |
Mortality
rate (%) |
Average intensive care days |
Median |
30-day |
2-year |
Length of stay (days) |
Total charges |
Simultaneous
|
2.4
|
0.99
|
3.75
|
2.11
|
12
|
$20,562
|
Staged:
|
|
|
|
|
|
|
6
weeks
|
3.5
|
0.48
|
4.05
|
1.35
|
20
|
$24,343
|
3
months
|
3.5
|
0.29
|
3.27
|
1.03
|
20
|
$23,753
|
6
months
|
3.4
|
0.31
|
3.42
|
1.09
|
21
|
$24,589
|
1
year
|
3.9
|
0.36
|
2.98
|
1.28
|
21
|
$25,009
|
Source: Ritter M, Mamlin LA, Melfi CA, et al. Outcome implications for the timing of bilateral total knee arthroplasties. Clin Orthop 1997;345:99-105.
Patients who require surgical repair (arthroplasty) on both
knees often face a choice whether to have the procedure
done on one knee at a time (staged) or both knees at once
(simultaneous). The AHRQ-funded TKR PORT found that
patients who had surgical repair on both knees at the same
time experienced more days in intensive care than those
who chose staged procedures (Table 2). Although the total
length of stay and costs were less for patients receiving
simultaneous surgical repair,21
these patients have been
found to have an increased risk of complications overall.22
Mortality at 30 days was highest for the simultaneous
procedure group but by 2 years, it was nearly the same for
all groups. Researchers concluded that staging the
procedure three to six months appeared to offer the fewest
disadvantages, was only slightly more expensive than
simultaneous arthroplasty, and had the lowest mortality rate.21
Surprisingly, AHRQ studies show that patients who
reported having worse knee function prior to surgery were
the least likely to suffer complications.22
Other factors that
help reduce complications include having surgery during
the middle of the week and having surgery performed by
surgeons or in hospitals that perform more knee
replacement surgeries.22,23,24
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High-volume Hospitals and Surgeons Have
Lower Complication Rates
AHRQ-funded studies conducted as a part of the TKR
PORT indicated that patients generally have fewer
complications when their surgeons perform more than 20
knee replacements per year22
or patients have their surgery in hospitals that perform at least 40 operations per year.23
One study showed that average surgical complication and
mortality rates declined as the hospital performed more
knee replacement surgeries (Figure 7, 66 KB and Figure 8, 67 KB).24
These
reductions were consistent in both medium- and large-size
hospitals.24
Arthritis research continues
AHRQ funded a Center for Education and Research on
Therapeutics (CERTs) focused on musculoskeletal
disorders at the University of Alabama at Birmingham. By
having an arthritis center collaborate with private-sector
entities, the researchers hope to identify variations in
musculoskeletal therapy and explore the causes of these
variations. They will also develop a facility to disseminate
new knowledge about musculoskeletal therapy, including
minimizing adverse effects, cost effectiveness, and effects
on quality of life.
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With New Funding, Researchers Can Make a
Difference
AHRQ's program announcement "Patient-Centered Care:
Customizing Care to Meet Patients' Needs" is intended to
support the redesign and evaluation of new care processes
that lead to greater patient empowerment, improved patient-provider
interaction, easier navigation through health care
systems, and improved access, quality, and outcomes.
Examples of specific strategies include electronic clinical
communication, self-management programs, Web-based
applications for patients and/or health care providers, and
shared decisionmaking programs. AHRQ encourages
projects that emphasize chronic illness, episodes of care
that extend beyond hospitalization, longitudinal care, and
priority populations.
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Conclusion
AHRQ research has shown that the disabling effects of
osteoarthritis can be reduced or prevented through the use
of patient self-management, physical and occupational
therapy, and surgery. As a result of AHRQ-sponsored
research, self-management programs have helped prevent
disability and improve health status. Although the elderly
suffer proportionately more complications and adverse
effects from surgical therapy than younger patients, AHRQ
research has indicated that hospitals that perform more
surgeries have lower complication rates. Finally, surgical
knee repair helps the elderly gain improved functional
ability and quality of life.
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For More Information
This synthesis was written by Barbara L. Kass-Bartelmes,
M.P.H., CHES (Barbara.Kass@ahrq.hhs.gov). For further information
on osteoarthritis or elderly health care, please contact
AHRQ's Center for Outcomes and Effectiveness Research
at (301) 427-1261.
Return to Contents
References
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Guidelines for the medical management of
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Rheum 1995;38(11):1535-40.
2. Arthritis Foundation. Osteoarthritis. Web site:
http://www.arthritis.org/conditions/DiseaseCenter/oa.asp
3. National Institute of Arthritis and Musculoskeletal and
Skin Diseases. Handout on health: osteoarthritis. Web
site: http://www.niams.nih.gov/hi/topics/arthritis/oahandout.htm
*4. Holman H, Lorig K. Overcoming barriers to successful
aging: self management of osteoarthritis. West J Med 1997;167(4):265-8.
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that lead to functional limitation in the elderly. J
Gerontol 1994;49(1):M28-36.
*6. Elizhauser A, Yu K, Steiner C, Bierman AS.
Hospitalization in the United States, 1997. Rockville
(MD): Agency for Healthcare Research and Quality;
2000. HCUP Fact Book No. 1. AHRQ Pub. No.
00-0031.
*7. Hochberg MC, Altman RD, Brandt KD, et al.
Guidelines for the medical management of
osteoarthritis. Part II. Osteoarthritis of the knee.
Arthritis Rheum 1995;38(11):1541-6.
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need individualized pharmaceutical care. Philadelphia
(PA): Office of Health Policy and Clinical Outcomes,
Thomas Jefferson University, April 2000.
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and noninvasive therapies for hip and knee
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*10. Agency for Healthcare Research and Quality. Preventing
disability in the elderly with chronic disease. Rockville
(MD); 2002. Research in Action Issue 3. AHRQ Pub.
No. 02-0018.
*11. Clark F, Azen SP, Zemke R, et al. Occupational therapy
for independent-living older adults. JAMA 1997;278(16):1321-6.
*12. Clark F, Azen SP, Carlson M, et al. Embedding health-promoting
changes into the daily lives of independent-living
older adults: long term follow-up of occupational
therapy intervention. J Gerontol 2001;56B(1):P60-3.
*13. Griffin MR, Brandt KE, Liang MH, et al. Practical
management of osteoarthritis. Integration of
pharmacologic and nonpharmacologic measures. Arch
Fam Med 1995;4(12):1049-55.
*14. Griffin MR. NSAID use in the elderly: prevalence and
problems. In: Baker JR and Brandt KD, editors.
Reappraisal of the management of patients with
osteoarthritis. New Jersey: Scientific Therapeutics
Information, Inc. p. 35-7.
*15. Smalley WE, Griffin MR, Fought RL, et al. Excess
costs from gastrointestinal disease associated with
nonsteroidal anti-inflammatory drugs. J Gen Intern
Med 1996;11(8):461-9.
*16. Stein CM, Griffin MR, Taylor JA, et al. Educational
program for nursing home physicians and staff to reduce
use of non-steroidal anti-inflammatory drugs among
nursing home residents. Med Care 2001;39(5):436-45.
*17. Wright JG, Coyte P, Hawker G, et al. Variation in
orthopedic surgeons' perceptions of the indications for
and outcomes of knee replacement. Can Med Assoc J 1995;152(5):687-97.
*18. Hawker G, Wright J, Coyte P, et al. Health-related
quality of life after knee replacement. J Bone Joint Surg
Am 1998;80(2):163-73.
*19. Callahan CM, Drake BG, Heck DA, et al. Patient
outcomes following tricompartmental total knee
replacement. JAMA 1994;271(17):1349-57.
*20. Polanczyk CA, Marcantonio E, Goldman L, et al.
Impact of age on perioperative complications and length
of stay in patients undergoing noncardiac surgery. Ann
Intern Med 2001;134(8):637-43.
*21. Ritter M, Mamlin LA, Melfi CA, et al. Outcome
implications for the timing of bilateral total knee
arthroplasties. Clin Orthop 1997;345:99-105.
*22. Heck DA, Robinson RL, Partridge CM, et al. Patient
outcomes after knee replacement. Clin Orthop 1998;356:93-110.
*23. Norton EC, Garfinkel SA, McQuay LJ, et al. The effect
of hospital volume on the in-hospital complication rate
in knee replacement patients. Health Serv Res 1998;33(5):1191-210.
*24. Gutierrez B, Culler SD, Freund DA. Does hospital
procedure-specific volume affect treatment costs? A
national study of knee replacement surgery. Health Serv
Res 1998;33(3):489-511.
* AHRQ-funded/sponsored research
AHRQ Publication No. 02-0023
Current as of May 2002
Internet Citation:
Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility. Research in Action, Issue 4. AHRQ Publication No. 02-0023, May 2002. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/research/osteoria/osteoria.htm