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Daily Living Activity among Elderly Women with Knee Osteoarthritis Pain: Impact of Socio-demographic Characteristics

Hanan Elzeblawy Hassan*, Eman Mohamed Alsherbieny, Mariam Riad Fahmy

Maternal and Newborn Health Nursing, Faculty of Nursing, Beni-Suef University, Egypt

Abstract: Background: Knee osteoarthritis is classified as either primary or secondary, depending on its cause. Primary knee osteoarthritis is the result of articular cartilage degeneration without any known reason. Secondary knee osteoarthritis is the result of articular cartilage degeneration due to a known reason. Knee osteoarthritis is a common progressive multifactorial joint disease and is characterized by chronic pain and functional disability. Aim: The current study is conducted to assess effect of socio-demographic characteristics on daily living activity among elderly women with knee osteoarthritis. 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 & Katz scale. Results: Women with severe pain documented sever functional impairment (71.4%) compared to who had moderate and no pain (50% & 0.0%). Statistically significant deference was found (p=0.000). Full function was reported by 32.7% of younger elderly adult women. A statistically significant difference between elderly women’ level of independence in activity of daily living and their age was found (p=0.002). Illiterate women expressed moderate function impairment (18%). A high statistically significant difference between women’ level of independence in activity of daily living and their level of education was found (p=0.000). About 36% of retired women reported full function. A high statistically significant difference between elderly women’ level of independence in activity of daily living and their occupation was found (p=0.000). Married elderly adult women (35%) and rural elderly women (32.7%) reported moderate functional impairment. A statistically significant difference between elderly women’ level of independence in activity of daily living and their age was found (p=0.010). Conclusion: Level of pain affects elderly women's functions and impaired their daily living activity. Full function was more prevalent among younger elderly women than older ones. Moderate function impairment was more prevalent among illiterate, not working or free business, urban, married women, and those who inadequate family income inadequate family income. Recommendations: Implementation educational program regarding coping in reducing pain and complications of osteoarthritis through directed program to persons in community.

Keywords: daily living activity elderly, women, knee osteoarthritis, socio-demographic characteristics

Received March 12, 2023; Revised April 17, 2023; Accepted April 26, 2023

Citation: Hanan Elzeblawy Hassan, Eman Mohamed Alsherbieny, Mariam Riad Fahmy, Daily Living Activity among Elderly Women with Knee Osteoarthritis Pain: Impact of Socio-demographic Characteristics. World Journal of Social Sciences and Humanities, 9 (1). 24-33. January 2023. doi:10.12691/wjssh-9-1-4

1. Introduction

Knee osteoarthritis (OA) is a common progressive multifactorial joint disease and is characterized by chronic pain and functional disability. Knee OA accounts for almost four-fifths of the burden of OA worldwide, and increases with obesity and age; Up to now, knee OA is incurable except knee arthroplasty which is considered as an effective treatment at an advanced stage of the disease, however, which is responsible for substantial health costs [1,2,3,4].

Physical examination of the knee should begin with a visual inspection. With the patient standing, look for periarticular erythema and swelling, quadriceps muscle atrophy, and varies or valgus deformities. Observe gait for signs of pain or abnormal motion of the knee joint that can indicate ligamentous instability. Next, inspect the surrounding skin for the presence and location of any scars from previous surgical procedures, overlying evidence of trauma, or any soft tissue lesions [5,6,7,8].

Range of motion (ROM) testing is an essential aspect of the knee exam. Active and passive ROM with regard to flexion and extension should be assessed and documented. Palpation along the bony and soft tissue structures is an essential part of any knee exam. The palpatory exam can be broken down into the medial, midline, and lateral structures of the knee [9,10,11,12].

Other knee tests may be performed, depending on the clinical suspicion based on the history as patella apprehension – patellar instability, J-sign called patellar maltracking, patella compression/grind – chondromalacia or patellofemoral arthritis, medial McMurray – a medial meniscus tear, lateral McMurray – lateral meniscus tear, thessaly test – a meniscus tear, lachman – anterior cruciate ligament (ACL) injury, anterior drawer – ACL injury, pivot shift – ACL injury, posterior drawer – posterior cruciate ligament (PCL) injury, posterior sag – PCL injury, quadriceps active test – PCL injury, valgus stress test – MCL injury and varus stress test – LCL injury [13,14,15].

Imaging can be used to assess the presence and severity of OA. Conventional radiography is the most widely used imaging modality in OA and allows for detection of characteristic features of OA including marginal osteophytes, joint space narrowing, subchondral sclerosis, and cysts. Radiographs can also be used to measure joint space narrowing, which is sometimes used as a surrogate measure of cartilage loss. However, radiographic changes in OA are insensitive, particularly with early disease [16,17,18].

Magnetic resonance imaging (MRI) is not necessary for most patients with symptoms suggestive of OA and/or typical radiographic features. However, MRI can identify OA at earlier stages of disease before radiographic changes become apparent. These changes include cartilage defects and bone marrow lesions. MRI can also be used to assess pathology in other structures of the joint not visualized by radiography such as effusions, synovium, and ligaments [5].

Ultrasonography is another imaging modality that can identify OA associated structural changes and is useful for detecting synovial inflammation, effusion, and osteophytosis. Limitations of ultrasound include that it is operatordependent and cannot be used to assess deeper articular structures and subchondral bone. Synovial fluid from OA joints is usually noninflammatory or mildly inflammatory with less than 2000 white blood cells/mm , predominantly mononuclear cells. Inflammatory effusion in OA may occur in the presence of calcium pyrophosphate crystals. Calcium pyrophosphate crystals may be present in as many as 30 to 60 percent of unselected OA patients [19,20,21].

Possible complications of osteoarthritis as rapid, complete breakdown of cartilage resulting in loose tissue material in the joint which called chondrolysis, bone death which called osteonecrosis, stress fractures by hairline crack in the bone that develops gradually in response to repeated injury or stress, bleeding inside the joint, infection in the joint, deterioration or rupture of the tendons and ligaments around the joint, leading to loss of stability and pinched nerve in osteoarthritis of the spine [22].

Primary prevention of OA would be most effective in a high-risk population free of structural and clinical OA, targeting modifiable risk factors over a prolonged period. To prevent OA development, either risk factors themselves need to be prevented as joint injury or occupational heavy lifting or the risk factors need to be reversed as low muscle strength, increased body weight or misalignment [23].

2. Aim of the Study

The current study is conducted to assess effect of socio-demographic characteristics on daily living activity among elderly women with knee osteoarthritis.

2.1. Research Questions

Are socio-demographic characteristics of elderly women with knee osteoarthritis having effect on daily living activity?

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. Subjects

3.2.2.1. Sample Size

A non-probability consecutive sampling technique was used to recruit elderly women according to the eligibility 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. Total sample was 300 women.

3.2.2.2. 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.

3.2.2.3. 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

Four tools were utilized to collect data of the current study.

A. Tool (1) Katz Scale:

It was adapted from (Katz et al., 1963). It aimed to assess independence among elderly women with knee osteoarthritis concerning daily living activities (ADL). It included the 6 items; shower, getting dressed, use the toilet, mobility, output control and nutrition [25].

v The scoring system:-

Total global score of 6 for 6 items, were rated on two ranks as (with supervision, guidance, and personal assistance or complete care = Zero and without supervision or direction or personal assistance=1).

The total score of this scale classified into three categories based on the following:

Full function = 6

Moderate impairment = 4-5

Severe functional impairment = ≤3

3.2.4. Validity and Reliability

• 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. The modification was done based the opinion of the expertise. 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 to test the clarity, applicability, feasibility and relevance of the tools used and to determine the needed time for the application of the study tools. The patients who were included in the pilot study were excluded from the sample because essential modifications were done after conducting pilot study.

3.2.6. Ethical Considerations

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. Researcher assured the anonymity and confidentiality of the patients included in the study. The patients in the study was informed that they are allowed to choose to participate or not in the study and they have the right to withdraw from the study at any time without any reasons.

3.2.7. Administrative Design

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.

3.2.8. Statistical Design

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. Chi-square (X²⁾ test of significance was used in order to compare proportions between qualitative parameters.

4. Results

Table 1 shows 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 governmental jobs. While, 70.3% of studied elderly women were married, 60.3% of them lived at rural areas, and 52% of them had inadequate monthly income.

Table 1. percentage distribution of demographic characteristics of the studied elderly women (n=300)

Figure 1 presents level of independence in activity of daily living among studied elderly women. It reveals that, most (90%) of studied elderly women used the toilet without supervision or direction or personal assistance. While 30% of them getting dress with supervision, guidance, and personal assistance or complete care.

Figure 1. level of independence in activity of daily living among studied elderly women (n=300)

Figure 2 presents total level of independence in activity of daily living among studied elderly women. It illustrates that more than one-third (47.7% & 49.3%) of studied elderly women had full function and moderate functional impairment, respectively, while 3% of them had severe functional impairment.

Figure 2. total level of independence in activity of daily living among studied elderly women (n=300)

Figure 3 portrays relationship between pain level and Katz scale for independence in the activities of daily living among studied elderly women. It reveals that women with severe pain documented sever functional impairment (71.4%) compared to who had moderate and no pain (50% & 0.0%), respectively. Statistically significant deference was found (p=0.000).

Figure 3. Relationship between pain level and Katz scale for independence in the activities of daily living among studied elderly women (n=300) (* Statistically significant at p≤0.05;** Highly statistical significant at p≤0.01)

Figure 4 presents relationship between studied elderly women's independency in daily living activities and their age. It reveals that, younger elderly adult women (65-70 years) had higher percentage of full function (32.7%) more than older ones (70-75 & more than 75 years) who had full function (26.3% & 1.7%), respectively. A statistically significant difference between elderly women’ level of independence in activity of daily living and their age was found (p=0.002).

Figure 4. Relationship between studied elderly women's independency in daily living activities and their age (* Statistically significant at p≤0.05; ** Highly statistical significant at p≤0.01)

Figure 5 shows relationship between studied elderly women's independency in daily living activities and their educational level. It presents that, illiterate elderly adult women expressed moderate function impairment (18%) than other educated ones (17%, 11.4% & 3%), respectively. A high statistically significant difference between elderly women’ level of independence in activity of daily living and their level of education was found (p=0.000).

Figure 5. Relationship between elderly women's independency in daily living activities and educational level (* Statistically significant at p≤0.05; ** Highly statistical significant at p≤0.01)

Figure 6 shows relationship between studied elderly women's independency in daily living activities and their occupational status. It reveals that, retired elderly adult women were had full function (36%) than other ones who not working and had free business (16.4% & 0,0%), respectively. A high statistically significant difference between elderly women’ level of independence in activity of daily living and their occupation was found (p=0.000).

Figure 6. Relationship between elderly women's independency in daily living activities and occupational status (* Statistically significant at p≤0.05; ** Highly statistical significant at p≤0.01)

Figure 7 presents relationship between studied elderly women's independency in daily living activities and their marital status. It reveals that, moderate functional impairment was more prevalent among married elderly adult women (35%) than widows (14.3%). There was no statistically significant difference between elderly women’ level of independence in activity of daily living and their marital status (p=0.119).

Figure 7. Relationship between elderly women's independency in daily living activities and marital status (* Statistically significant at p≤0.05; ** Highly statistical significant at p≤0.01)

Figure 8 presents relationship between studied elderly women's independency in daily living activities and their residence. It shows that, full functional was more prevalent among rural elderly adult women (32.7%) than rural ones (15%). A statistically significant difference between elderly women’ level of independence in activity of daily living and their age was found (p=0.010).

Figure 8. Relationship between studied elderly women's independency in daily living activities and residence (* Statistically significant at p≤0.05; ** Highly statistical significant at p≤0.01)

Figure 9 portrays relationship between studied elderly women's independency in daily living activities and their income. It shows that, moderate functional impairment was more prevalent among elderly adult women who had inadequate family income (27.3%) than other ones (22%) who had adequate family income. There was no statistically significant difference between elderly women’ level of independence in activity of daily living and their marital status (p=0.133).

Figure 9. Relationship between studied elderly women's independency in daily living activities and income (* Statistically significant at p≤0.05; ** Highly statistical significant at p≤0.01)

5. Discussion

Pain in Osteoarthritis (OA) can be unrelated to joint damage and even occur before the onset of local inflammation and swelling in the synovium, OA patients with a higher degree of pain reported a higher reduction in QoL [26].

The findings of the present study revealed that the severity of arthritis pain varies in its intensity from moderate to severe, and the more than two third of studied women had a severe pain intensity. Furthermore, a report from the World Health Organization (WHO) highlights the strong relationships between painful musculoskeletal conditions and reduced physical activity, functional capacity and well-being [27,28,29,30,31]. These findings are in accordance with Driban et al., (2020) who added that the majority of the studied women had a degree of sever degree of pain.

As regarding the effect of OA on studied elderly women’ independence in the activities of daily living, the present study revealed that near half of studied women had a moderate functional impairment in generally. Moreover, nearly half of the studied women are independent regarding getting dressed (and needed for supervision, guidance, and personal assistance or complete care. These findings may be due to that fatigue be able to have a substantial impact on patients’ daily living activities and overall quality of life [32]. It is often identified as one of the most challenging aspects of chronic rheumatic diseases. The causes of fatigue appear multi-factorial in arthritis; disease activity plays a role but additional factors such as psychological distress and treatments may be additional causes of fatigue [33].

The results of the current study showed that the most of the studied older women had moderate functional immurement, which was related to the influence of OA diseases on the Katz scale for independence in daily living activities. These findings may be connected to the fact that synovial joints are the primary targets of rheumatoid arthritis, a chronic systemic inflammatory disease that also damages cartilage. Many patients experience diminished functional status and impairment as a result of this. OA may potentially present as an extra-articular condition.

These results are consistent with those of Mirzaei et al. (2017), who stated that rheumatoid arthritis can impact the majority of the body's organs and cause greater rates of death and morbidity [34]. Also, Jeihooni et al. (2021) who noted that OA is the cause of a significant decline in physical activity came to the conclusion that physical exercise has numerous advantages for RA patients and ought to be widely practiced. One of the goals of therapeutic patient education for OA should be to encourage physical activity [35].

Concerning level of independence in activity of daily living among studied elderly women, the present study findings revealed that the It reveals that, most (90%) of studied elderly women used the toilet without supervision or direction or personal assistance. While 30% of them getting dress with supervision, guidance, and personal assistance or complete care. The impact of cytokines Mueller et al., (2021) has been widely used to explain the genesis of fatigue [36]. Also, these results support Pope's (2020) claim that fatigue is a prevalent symptom of rheumatic and musculoskeletal illnesses (RMDs), with significant weariness reported by 41–80% of rheumatoid arthritis patients (OA). El-Sayed & Hassanein (2021) also noted that women with osteoarthritis and fibromyalgia reported a prevalence of fatigue ranging from 40% to 76%, respectively, while those with axial spondylo arthritis reported a prevalence of weariness ranging from 60 %to 74% [37].

Regarding total the level of independence in activity of daily living among studied elderly women, it illustrates that more than one-third of studied elderly women had full function and moderate functional impairment, respectively, while 3% of them had severe functional impairment. These results are consistent with Saffari et al (2018) observation that many OA patients experience stress due to their diminished mobility, increased disability, and diminished independence [38]. People with RA are more likely to experience depressive symptoms, job loss, financial difficulties, social and relationship problems, and changes in relationship status [35].

Concerning relationship between pain level and Katz scale for independence in the activities of daily living among studied elderly women. The result of the current study a statistically significant deference was found. It is observed that severe pain lead to sever functional impairment. This is in line with Chen et al., (2019); their study denoted that pain in osteoarthritis (OA) can be unrelated to joint damage and even occur before the onset of local inflammation and swelling in the synovium, OA patients with a higher degree of pain reported a higher reduction in QoL [26].

Concerning the relation between studied women level of independence in activity of daily living and their personnel characteristics including “age and residence, there was a highly statistically significant difference between elderly women’ level of independence in activity of daily living and their educational level and occupational status. This is in agreement with Lazaridou et al., (2018) who stated that there was a statistically significant relation between patients’ level of independency in ADLs and their age, residence, educational level, gender and occupational status [38].

It is expected that elderly women's independency in daily living activities depend on their age, level of education. Illiterate elderly adult women expressed moderate function impairment (18%) than other educated ones. Of course, younger women will have higher percentage of full function more than older ones, as older age are more susceptible to musculoskeletal change which imparted its function. Moreover, level of education affects level of knowledge for prevention, management of OA, they will can apply primary and secondary prevention. This in line with Runhaar & Zhang, (2018) and Conrozier & Lohse (2022) [23,24]

Also, the results of the current study reveal that moderate functional impairment was more prevalent among urban married elderly adult women than rural widows. This may attributed to married and urban ones have more household responsibility and duties [39].

In addition, the results highlighted a relationship between studied elderly women's independency in daily living activities and their income. Moderate functional impairment was more prevalent among elderly adult women who had inadequate family income than other ones. It is not surprising as low income ones will not have the same equal chances for good food, exercise, medical care and services.

6. Conclusion

Based on the result of the current study it can be concluded that:

Level of pain affects elderly women's functions and impaired their daily living activity. Full function was more prevalent among younger elderly women than older ones. Moderate function impairment was more prevalent among illiterate, not working or free business, urban, married women, and those who inadequate family income inadequate family income. There was a statistically significant difference between elderly women’ level of independence in activity of daily living and their age and residence. Moreover, there was a highly statistically significant difference between elderly women’ level of independence in activity of daily living and their educational level and occupational status. However, there were no statistically significant differences between elderly women’ level of independence in activity of daily living and their marital status and monthly income.

7. Recommendation

The important recommendation inferred from the study results was implementation educational program regarding coping in reducing pain and complications of osteoarthritis through directed program to persons in community.

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