As of 2022, it is safe to say, that while the numbers of scientific reports on this topic are promising, the disease is often neglected as a serious health condition, for example, it was not considered relevant to a high degree in the face of multiple COVID-19 restrictions and service cuts in 2019 and for extended periods thereafter, even though COVID-19 was observed to impact aging adults in particular, along with those who are obese and often suffer from osteoarthritis, quite markedly and significantly 1. As a result, predicting that the multiple COVID pandemic restrictions would largely protect against this infectious disease, but failing to consider the fact that these public health strategies could worsen chronic health conditions such as osteoarthritis and its burden and costs at all disease stages quite adversely, which was indeed apparent on later reflection, this oversight has clearly placed many older adults at risk for excess osteoarthritis disability, as well as a probable heightened COVID-19 infection risk 10 and possible increases in pain, muscle weakness, wasting, and frailty 10. In addition to the multiple needs of the community dwelling older adult under such circumstances, those suffering from osteoarthritis may have had concerns about what to do as a whole, and were expected to be digitally literate, and receive information via remote mechanisms that may have provoked confusion, or fear of undertaking recommended steps because they did not understand the instructions provided 11.

This possible lack of understanding as to how to manage their disease in the absence of their usual face to face services and that occurred widely in 2019 and for extended periods thereafter, may well have exacerbated both the structural features of the disease, as well as probable ongoing or reactive emergent consequences, such as anxiety and fear, while rendering the ability to comprehend complex self-care messages more challenging than ever, even among the literate 12. These include problems in their ability to control their weight, sleep deficits, fatigue, and high levels of distress and widespread pain. In addition, a role for worsening socioeconomic circumstances since 2019 as far as fostering their disease progression goes cannot be ruled out 4. In addition, the impact of poor past educational opportunities may have compounded this series of events, especially in the face of confusing media and public health messages 131415. 

To reverse any untoward disease repercussions enumerated above, it appears that providers and clinicians themselves now have added obligations to not only consider the currently diverse pathological manifestations of the disease that may prevail, and what treatments are indicated, but must carefully weight the past and recent experiences of the patient, including their ability to comprehend any recommended treatment paradigm. Moreover, in the face of unremitting osteoarthritis disability and accompanying extended periods of immobility due to pain, which is reactive and intractable, providers need to try and encourage their older clients to be partners in averting a probable downward spiral of overall well-being, along with a heightened need for costly health services through their attention to carrying out favorable rather than unfavorable health behaviors.

Alternately, although not usually fatal, poorly treated osteoarthritis as a result of a lack of disease insights on behalf of the sufferer, may well lessen both their motivation as well as their ability to undertake desired and essential activities of daily living independently and without undue distress. In particular, the older adult suffering from disabling osteoarthritis and who has experienced and continues to experience any form of discrimination or perceptions thereof, and that impacts their ability to access needed resources and services may undoubtedly be worse off than those who have received quality services and continue to have access to these. As well, a host of other overlooked epigenetic factors that may impact treatment understandings, including, but not limited to poor past educational opportunities, educational access, and modes of employment that yield low health provider access opportunities rather than optimal provider access may prove collectively harmful. In addition, those osteoarthritis sufferers who fall into the higher age ranges and who are already a group likely to be more intently affected by health illiteracy in general may be especially negatively impacted if they are poorly informed about their role in fostering their well being and avoiding health risks. The quality of available education programs when currently reviewed, even if accessible, also appears to have multiple shortcomings that may well deter those with limited literacy in adverse, rather than favorable ways 1617181920. Features of osteoarthritis that may be especially important to possibly mitigate are those of joint inflammation, excess weight gain or loss, muscle and bone attrition, nerve damage and impairments of those sensory mechanisms designed to foster joint protection and avert injury, common in vulnerable older adult osteoarthritis populations 23242526272829303132. As put forth by Hunter et al. 33, the appropriate selection and use of evidence-based management options is critical in this regard, but for helping the osteoarthritis client to obtain the full benefits from their treatment recommendations, they have to understand what is needed, and be able to act on these imperatives.

In short, without a salient osteoarthritis disease understanding and knowledge about best choices in the self-care realm, unsafe behaviours, as well as uncontrollable eating behaviours, and a failure to appreciate the importance of sleep and stress reduction along with a failure to contain the pain associated with osteoarthritis and its disease progression disease are likely to heighten the need for high levels of dangerous narcotics as well as medications to counter reactive depression. As well, multiple additional self-management challenges may arise including fears of moving, as well as limitations in health seeking behaviours, poor adherence to recommendations, and an inability to function physically without undue fatigue, pain and immense distress 34.

As such, even if research is limited, an older adult with osteoarthritis may arguably suffer unduly because they are challenged in understanding what they need to do or why in order to remain in the community, rather than residing in a nursing home where their self-care role will be of less importance. As such, it appears reasonable to assert that if providers fail to appreciate COVID-19 implications, as well as the past social histories and ability to comprehend health messages of their older osteoarthritis clients, the capacity of the client for carrying out home based remedial approaches effectively and safely may be jeopardized 333442. Moreover, the combined impacts of possible impaired cognitive processes, as well as having excess muscle weakness and pain if they have long COVID are likely to severely curtail the motivation for self-care especially if the older adult is too challenged to decipher their health recommendations, or to contact their providers and seek advice, for example if they have limited feelings of confidence, or limited English language skills 36. It appears therefore that a fair number of older adults with osteoarthritis may consequently fail to flourish even if they receive needed care if they fail to fully appreciate the importance of their lifestyle actions that are proven disease and disability predictors. As well, while laudable efforts have been put forth to bridge the service gap since 2019, following remotely staged exercise regimens or others-not designed for the particular client, as well exposure to media messages advocating technological appliances that may do little to stem the disease progression, may do more harm than good if the individual is unable to separate fact from fiction. In addition needed possible home based safety modifications, medication checks, and the purchase of assistive devices may be very challenging to undertake for many in the higher age ranges who not only have multiple affected joint sites and medical conditions, but are unable to articulate or access the help needed without appropriate assistance and guidance and discussions with the key provider 37.

In this regard, a one size fits all approach may fail unless if the older adult is guided thoughtfully by the provider in light of their prevailing health status, as well as any mediating or possibly moderating epigenetic factors 3738. These understandings might include explanations about the specific importance of energy conservation and desirable sleep hygiene practices including physical activity participation in efforts to relieve pain, fatigue, and stiffness, and lessening reliance on medications, particularly during the early disease stages 34. As well, heightened attention is currently indicated as far as creating personalized culturally relevant infection protection strategies, as well as nutritional and exercise approaches that respect affordability and access issues, along with their ability to act on these recommendations 37. That is, the clinician or team of providers must currently be in a position, as well as motivated to conduct and undertake a thorough medical history, a comprehensive physical examination, plus a detailed environmental assessment of the older adults’ key needs before ascertaining the precise intervention aims and design. Goals set must then be attainable, and actionable by an older adult who is in pain, who may be very anxious and fearful, and functionally, technologically, and socially as well as economically challenged, especially since the onset of COVID-19 39. They can also conduct a specific mental health screening test to examine whether depression, anxiety, or stress are likely to be factors requiring additional intervention attention, especially if any mental health challenges impact cognitive functions adversely. Ascertaining the disease magnitude and related prognostic factors, as well as examining the client’s general health status, along with their health beliefs, disease understandings, and self-efficacy perceptions may also help to assess lifestyle and behavioural factors that can contribute markedly to the osteoarthritis health burden 4041.

To specifically reduce potential feelings of helplessness, especially in cases where the osteoarthritis symptoms are possibly exacerbated by exposure to COVID-19 disease and long COVID infections 42434445, education directed towards fostering a clear understanding of their osteoarthritis condition and its potential both for worsening as well as for mitigation over time, especially among those adults with multiple morbidities, and breaking down what is needed to foster favourable outcomes into small doable steps is recommended. The provision of personalized levels of information and that is developed in conjunction with input from the older adult in question, as well as in consideration of their health literacy level, and degree of social support can also help to foster, rather than impede intervention adherence, while building a sense of control and a strong commitment to do all that is possible to minimize any further joint attrition or be placed at risk for a COVID infection.

To this end, written exercise and/or nutrition instructions and others with diagrams understandable by both the older adult and their significant others that are culturally and/or linguistically tailored as well as empathetic supportive therapeutic approaches appear desirable, especially if the older adult is not conversant with technology or has no access or skill or motivation for this approach in this regard. Finally, to mitigate the impact of depression due to the disease chronicity, helping to build the patient’s confidence, plus emotional support for both patients and caregivers, and efforts to offset obesity and joint injury, as well as possible excess frailty, are strongly recommended.

In short, a significant proportion of those older adults who wish to continue live independently in the community rather than the nursing home and who may suffer many challenges due to their osteoarthritis may yet tend to be better off in response to active efforts to optimize joint biomechanics and life quality and self-efficacy than not. However, they may be worse off if they cannot comprehend what they need to do and why, and have multiple associated social challenges as well as economic challenges, even if surgery is forthcoming 3738. A role for prior educational inequities that may heighten the disease burden should also be borne in mind by the provider in this respect. Past research further indicates that providers commonly have many issues to deal with, and limited time frames for doing this, and may not truly consider the impact of their patient’s ability to understand or act on their well meaning instructions without due consideration as regards instructional material readability and other issues. Moreover, more commonly than not, they may assume their patients have the competency to make sound health affirming decisions and will duly carry out their recommendations, even though this expectation is often unrealistic. In addition, health literacy in medical settings is often diminished in the face of illness and complex health instructions, and can be expected to be greatly compounded by COVID-19 issues, but the forms and paperwork that must be completed to receive services in some instances, and divergent modes of advice and misinformation, may be overwhelming at the outset for the older adult. Older individuals may also have cognitive challenges that require carefully construed instructions as well as empathetic support regarding their health recommendations, along with fostering access to needed resources, and an educational approach that takes both health literacy as well as memory issues into account 464748495051.

However, even if this topic is not well studied or highlighted in the mainstream literature, it is clear that more dedicated research as well as educational efforts by providers serving aging societies and others may be instrumental in securing those health opportunities that underpin independent living and that are desired by many older adults with disabling osteoarthritis. Since many health service restrictions in the community remain consequent to COVID-19 and home based living appears to be advocated for fostering a higher life quality than a long term care facility, helping to simplify and clarify oftentimes very complex health recommendations, personal misunderstandings about the disease, and the key importance of optimal self-care or assisted care, along with the ability to make sound decisions may prove to reduce both the individual disease burden as well as burgeoning health care costs. As well, if the client understands what is needed and is helped through policy makers and others to access needed resources, outcomes will predictably be optimal at best on many levels.

This current mini review, which was restricted to examining literacy issues and their underpinnings and implications for older adult osteoarthritis care was premised on the basis that osteoarthritis, a common painful disabling disease affecting older populations, while not usually life threatening, remains highly challenging and costly to treat effectively without the partnership of the patient. A disease demanding considerable self management by the sufferer, especially if they wish to continue to reside in the community, is fraught with challenges, in general, as well as the emergent fallout and exposure to multiple COVID-19 associated health provision changes and infection risks that persist in 2022

In this regard, those with poor health literacy skills, as well as possible past and persistent exposures to multiple health inequities, especially those impacting educational attainment are likely to be more negatively impacted than not. However, it is apparent that careful and insightful patient specific assessments and treatment plans may permit those older vulnerable adults to continue to reside in their own homes if they desire, rather than in a nursing homes, despite any possible deficits in their educational and literacy skills. That is, sufficient research indicates that tailored and personalized intervention approaches delivered and designed and carefully communicated in light of the extent of prevailing joint and cognitive status, as well as the patient s ability to act on any desirable health recommendations will be more successful in multiple spheres than not- in all likelihood.

In particular, despite a lack of sound data, educating the patient in accord with their overall disease presentation and socioeconomic status, may be paramount in helping them to assert some degree of control over their disease, plus the adoption of realistic treatment goals and expectations and ability to make careful decisions. This approach in turn, may not only help to empower them, but to minimize the degree of any excess preventable joint destruction and associated pain provoking inflammatory processes they might encounter inadvertently, as well as fostering more desirable overall long term outcomes, while improving life quality, even if surgery is eventually indicated. As well, narcotic use may be averted, along with the high risks of the side-effects of antidepressants, weight issues may be mitigated, with more favourable long-term overall health outcomes, and lower health service requirements and monetary costs.

It is also the author s view that even if such an approach does not prevent the progression of the disease or reverse it, health status as a whole is likely to be more positively impacted than not by employing a carefully construed set of tailored self-management directives that account for differing starting points and life events that each individual brings to the clinic. As outlined in the literature, the ability to function physically and socially in meaningful activities not only promises to be life affirming in its own right as well as mitigating preventable degrees of disability and despair, but to allay multiple health costs and immense intervention needs. While it may also be vital for providers to encourage more resources to eliminate literacy discrepancies that impact health understandings in the future, and develop their expertise in this realm despite a lack of any strong evidence based contemporary studies, targeted in the interim should be those who are most vulnerable and that are likely to encounter multiple hurdles to managing their osteoarthritis condition. These cases may be expected to include, but are not limited to: those in the highest age groups, those living in low income areas, those who cannot readily decode misinformation, and those with limited education, language and numeracy skills, especially if they are not speakers or readers of the mainstream language. This added time commitment to carefully design informational messages that are understandable and accessible and do not rely on memory may yet provide a sound long term investment, even among those who are highly challenged to effectively translate complex messages and others, especially those at high risk for joint damage that could be averted by adopting sound joint protection techniques 5253545556575859.