90+ year olds w/severe OA - what to do?

[DrMDAware]

What advice does the community have for the patients who are way too old to have any joint surgery and have failed steroid injections and radiofrequency ablations?

I recently had a handful of 90+ year old patients with severe hip, knee, shoulder OA. Of course no surgeon would touch them. I walked them through nerve blocks and RFAs without much relief unfortunately.

Their family is somewhat understanding they’re not surgical candidates and usually understand their loved ones aren’t going to be doing backflips. However, they seem to want a touch more than what I feel is reasonable - ie not use the walker, get up from the bed comfortably etc.

What am I missing? Aquatic therapy? Treatment for depression? Palliative care consult? Low dose opioids? “An old car doesn’t have new parts” talk?

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[DubVille]

What advice does the community have for the patients who are way too old to have any joint surgery and have failed steroid injections and radiofrequency ablations?

I recently had a handful of 90+ year old patients with severe hip, knee, shoulder OA. Of course no surgeon would touch them. I walked them through nerve blocks and RFAs without much relief unfortunately.

Their family is somewhat understanding they’re not surgical candidates and usually understand their loved ones aren’t going to be doing backflips. However, they seem to want a touch more than what I feel is reasonable - ie not use the walker, get up from the bed comfortably etc.

What am I missing? Aquatic therapy? Treatment for depression? Palliative care consult? Low dose opioids? “An old car doesn’t have new parts” talk?

Do they have several comorbidities? (I know that is a stupid question about a 90 y/o) but my n of 2 has been 3 relatively healthy 90ish patients with awful OA. Had them see a good surgeon in town who takes train wrecks and revision work.
They all did awesome and were told no by a few ortho in town. All 3 had a new lease on life

They got a few weeks from the shots but were miserable otherwise. Tramadol not much help and 2 of the 3 it made them a bit more forgetful. All 3 had great family support.

 

[Agast]

I don’t know about shoulders and knees, but a 90 yo with good protoplasm could probably find someone to do their hip replacement. I do low dose opioids if they have someone who can help them with their meds and family understands the limitations of use and side effects. When I get the phone call later that they’ve passed away from old age, I can feel good that I didn’t let them suffer. Sometimes gabapentin and Tylenol is sufficient.

 

[BobBarker]

Norco 5mg bid

 

[lobelsteve]

Butrans 5. Triple cream. Live with it, die with it.

 

[Analgesia108]

tylenol #3 (1/2 to full tab ) bid prn with Senna - this combo has helped over the years

 

[pmrmd]

Butrans. Don’t procedurize these folks.

 

[willabeast]

Consider pulverized Glucosamine with MSM (for dosing read the bottle) and Turmeric (read the container for dosing). Make sure PCP agrees. Take every day. Worked well on 40% of my patients. I know you can find literature to dispute the efficacy - may I suggest there is a bias in the literature against generic non profitable by Pharma treatments. Try it for 3 weeks. If it fails, go off it.

 

[kstarm]

Butrans 5. Triple cream. Live with it, die with it.

Usually this.

I do recommend turmeric and glucosamine as low risk options but discuss the data isn't great. Though frankly that is true for most of our field

 

[clubdeac]

PNS of axillary nerve works well for intractable non operable shoulder pain. Could probably do it for the knee as well but I'm not experience in that.

If you want to think outside the box try IA phenol, sarapin, PRP, stem cells, capsaicin etc.

Randomized, Double-Blind, Placebo-Controlled Trial of Intraarticular Trans-Capsaicin for Pain Associated With Osteoarthritis of the Knee - PubMed

In this study, CNTX-4975 provided dose-dependent improvement in knee OA-associated pain. CNTX-4975 1.0 mg produced a significant decrease in OA knee pain through 24 weeks; CNTX-4975 0.5 mg significantly improved pain at 12 weeks, but the effect was not evident at 24 weeks.

pubmed.ncbi.nlm.nih.gov

 

[deleted875186]

Voltaren, compound cream, they can try CBD cream. Then I will try tramadol, if nothing then tylenol #3, if nothing then vicodin. Rarely I will use oxycodone. Maximum TID dosing for anything.

 

[paindoctor2014]

Any studies that show butrans patches don’t work under a certain bmi? Not enough sun q fat?

 

[Orin]

Any studies that show butrans patches don’t work under a certain bmi? Not enough sun q fat?

In general the stuff I saw on google said no.

BMI little effect on opioid patch’s - Medical Update Online

The pain-relieving efficacy of the buprenorphine transdermal medication system didn’t seem to be altered by a patient’s body mass, researchers said. In the pooled analysis of previous research,... read more.

medicalupdateonline.com

In cancer patients with fentanyl patches, seems to work fine.

Does transdermal fentanyl work in patients with low BMI? Patient‐reported outcomes of pain and percent pain relief in cancer patients on transdermal fentanyl

Low body mass index (BMI) is suspected of being associated with low transdermal fentanyl (TDF) blood levels and worse pain relief. Clinical pain data to support this claim are lacking.Using a Chronic Pain Registry, we identified 901 cancer patients who ...

www.ncbi.nlm.nih.gov

 

[Orin]

Agree that low dose opioids seem to do well here. I prefer long acting, low peaking things.

I've had good luck with RFAs and PNS.

I'm looking forward to the intra-articular RTX results as that should be perfect for this scenario

Grünenthal starts Phase III trials for resiniferatoxin in osteoarthritis-related pain

/PRNewswire/ -- Grünenthal announced today that the company has enrolled the first patient in its global clinical Phase III programme for resiniferatoxin (RTX)....

www.prnewswire.com

Sorrento Therapeutics Completes Enrollment of Phase 2 Clinical Trial of Resiniferatoxin (RTX) for Treatment of Knee Pain in Moderate to Severe Osteoarthritis of the Knee (OAK) Patients

Phase 2 trial of RTX for OAK pain completed enrollment with last patient (n=120) dosedNo limiting toxicities have been encountered during the trial to...

www.globenewswire.com

 

[txpain]

Agree with butrans or belbuca to limit side effects. If not an option I’ll slowly titrate low dose opiates. Oxy or norco 5’s. I have one 92 year old with a completely obliterated hip who I have a 12mcg fentanyl patch. Essentially treating as palliative patient. Once you hit 90 you’re playing with house money anyway.

 

[pmrmd]

PNS of axillary nerve works well for intractable non operable shoulder pain. Could probably do it for the knee as well but I'm not experience in that.

If you want to think outside the box try IA phenol, sarapin, PRP, stem cells, capsaicin etc.

Randomized, Double-Blind, Placebo-Controlled Trial of Intraarticular Trans-Capsaicin for Pain Associated With Osteoarthritis of the Knee - PubMed

In this study, CNTX-4975 provided dose-dependent improvement in knee OA-associated pain. CNTX-4975 1.0 mg produced a significant decrease in OA knee pain through 24 weeks; CNTX-4975 0.5 mg significantly improved pain at 12 weeks, but the effect was not evident at 24 weeks.

pubmed.ncbi.nlm.nih.gov

I’ve tried IA phenol a number of times. Underwhelming results.

 

[clubdeac]

I’ve tried IA phenol a number of times. Underwhelming results.

Good to know. The concept seems legit. Destroy all the intra-articular sensory fibers and pain should go away right?

 

[Baron Samedi]

Would definitely do what others suggest first such as butrans, but if other indications (depression severely underdiagnosed in elderly, poor sleep, anorexia) can consider mirtazapine. It's noradrenergic, well tolerated in the elderly, and there's some case reports/series/animal studies suggesting some modest benefit in chronic pain.

 

[bedrock]

PNS of axillary nerve works well for intractable non operable shoulder pain. Could probably do it for the knee as well but I'm not experience in that.

If you want to think outside the box try IA phenol, sarapin, PRP, stem cells, capsaicin etc.

Randomized, Double-Blind, Placebo-Controlled Trial of Intraarticular Trans-Capsaicin for Pain Associated With Osteoarthritis of the Knee - PubMed

In this study, CNTX-4975 provided dose-dependent improvement in knee OA-associated pain. CNTX-4975 1.0 mg produced a significant decrease in OA knee pain through 24 weeks; CNTX-4975 0.5 mg significantly improved pain at 12 weeks, but the effect was not evident at 24 weeks.

pubmed.ncbi.nlm.nih.gov

How do those results compare with sensory RFA for the shoulder and knee? (Using the modern shoulder RFA technique targeting both axillary and SSN?

 

[DrMDAware]

Even for non neuropathic shoulder, hip and knee pain y’all would consider PNS? I thought it was for a neuropathic component only. Maybe I’m using too strict of an inclusion criteria and missing the “big picture”. Happy to hear thoughts.

 

[Ferrismonk]

Maybe I'm a little off here, but how do you guys get pulsed-RF, phenol, PNS, etc covered? In my neck of the woods, nobody pays for any of that.

 

[lobelsteve]

Maybe I'm a little off here, but how do you guys get pulsed-RF, phenol, PNS, etc covered? In my neck of the woods, nobody pays for any of that.

Nor should they.

 

[lobelsteve]

Even for non neuropathic shoulder, hip and knee pain y’all would consider PNS? I thought it was for a neuropathic component only. Maybe I’m using too strict of an inclusion criteria and missing the “big picture”. Happy to hear thoughts.

You are doing it right. PNS is mostly a money grab.

 

[Ducttape]

when all you have is a hammer......

 

[clubdeac]

It’s interesting as well that when a provider doesn’t offer a procedure he is much more likely to dismiss it as a money grab or ineffective regardless of whether he’s ever done the procedure. We all have our personal biases. I would argue that the data for PNS is decent and am going to try it for awhile before throwing it into the bin along with IDET, ozone, chymopapain, peripheral field stim, pulsed RF etc.

 

[Ducttape]

what does research (that is hopefully not industry funded) show?



ASPN does not note robust data to support...

 

[lobelsteve]

It’s interesting as well that when a provider doesn’t offer a procedure he is much more likely to dismiss it as a money grab or ineffective regardless of whether he’s ever done the procedure. We all have our personal biases. I would argue that the data for PNS is decent and am going to try it for awhile before throwing it into the bin along with IDET, ozone, chymopapain, peripheral field stim, pulsed RF etc.

Chymo worked great, it just killed a few people.
Pulsed RF works great, but not lasting relief beyond 6 mo.

Critically important to separate PNS from field stim. PNS has a role over sensory named nerves with reliable anatomical locations.
Suprascpaular, saphenous. I do not see it as reasonable in the multifidi, medial branches, superior cluneal, ilioinguinal locations. Those are just field stim with a different name.

 

[clubdeac]

Chymo worked great, it just killed a few people.
Pulsed RF works great, but not lasting relief beyond 6 mo.

Critically important to separate PNS from field stim. PNS has a role over sensory named nerves with reliable anatomical locations.
Suprascpaular, saphenous. I do not see it as reasonable in the multifidi, medial branches, superior cluneal, ilioinguinal locations. Those are just field stim with a different name.

Fair enough. I may completely agree in 6 months

 

[clubdeac]

what does research (that is hopefully not industry funded) show?



ASPN does not note robust data to support...

View attachment 363334

Hold up duct, are you suggesting that if a product or medical treatment has only industry sponsored studies showing safety and efficacy, these studies may not be accurate or reliable due to a possible conflict of interest? Are you consistent in this belief?

 

[Ducttape]

was going to respond until it dawned on me thay you're joshing with me...


i dont see the magenta font.

 

[Orin]

Chymo worked great, it just killed a few people.
Pulsed RF works great, but not lasting relief beyond 6 mo.

Critically important to separate PNS from field stim. PNS has a role over sensory named nerves with reliable anatomical locations.
Suprascpaular, saphenous. I do not see it as reasonable in the multifidi, medial branches, superior cluneal, ilioinguinal locations. Those are just field stim with a different name.

I think SPR's device is a large volume/field stim to some extent, but multifidus or intramuscular stim is a different beast than that. The PNS placement and subsequent programming for some people is very much field stim, but in general if you can get a paresthesia beyond the lead's positioning, I don't think of that the same I think of the old school box in the pain and pray thing.

I gotta go read about chymo now though as I missed the boat on that...

http://eknygos.lsmuni.lt/springer/525/351-358.pdf

Brah, it could be coming back.

British Association of Spine Surgeons - Research

spinesurgeons.ac.uk

 

[Iamnew2]

What advice does the community have for the patients who are way too old to have any joint surgery and have failed steroid injections and radiofrequency ablations?

I recently had a handful of 90+ year old patients with severe hip, knee, shoulder OA. Of course no surgeon would touch them. I walked them through nerve blocks and RFAs without much relief unfortunately.

Their family is somewhat understanding they’re not surgical candidates and usually understand their loved ones aren’t going to be doing backflips. However, they seem to want a touch more than what I feel is reasonable - ie not use the walker, get up from the bed comfortably etc.

What am I missing? Aquatic therapy? Treatment for depression? Palliative care consult? Low dose opioids? “An old car doesn’t have new parts” talk?

In my neck of the woods, I had a pain doctor who would prescribe 100mcg of Fentanyl for shoulder OA. I wasn't sure if to cry or laugh.

 

[cowboydoc]

In my neck of the woods, I had a pain doctor who would prescribe 100mcg of Fentanyl for shoulder OA. I wasn't sure if to cry or laugh.

What if they had it in both shoulders?

 

[Iamnew2]

What if they had it in both shoulders?

I think that was the dose for both shoulders yet she still had pain. When I discussed it not being an appropriate type of med for that she had a cow.

 

[clubdeac]

I think that was the dose for both shoulders yet she still had pain. When I discussed it not being an appropriate type of med for that she had a cow.

Just switch it out for either a lidoderm or flector patch and don’t tell her. She’ll never know the difference 😂

 

[Iamnew2]

Just switch it out for either a lidoderm or flector patch and don’t tell her. She’ll never know the difference 😂

Oh trust me in my former gig the patients that came to me were sooo over opioided ( I know that’s not a word) that they knew even if a minuscule change was made and had the nurses write down on their room board the exact minute their opioids were given. This person in particular who was on fentanyl for OA was also on norco I believe, Xanax, flexeril, Gabapentin, etc. it was like pulling teeth to try to change patient’s pain management into a reasonable and safe regimen. I had some people who were on like MS Contin 20mg q2-4 hours scheduled from other doctors.