Geriatric Rheumatology
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This document discusses rheumatological conditions that commonly affect the elderly. It notes that osteoarthritis is prevalent in the hands and knees, with crystal arthropathies like gout and pseudogout also impacting older adults. Septic arthritis and bursitis are other joint issues seen. Systemic autoimmune diseases like rheumatoid arthritis, SLE, and Sjögren's syndrome may have an elderly onset. Treatment can be complicated by drug interactions and adverse effects. Careful consideration of comorbidities is important when managing rheumatological problems in geriatric patients.
Geriatric Rheumatology
- 1. Geriatric Rheumatology 楊宗翰 11/19, 2008
- 2. < 45 ≥ 75 (old old) 45-59 60-74 (young old) 13.1% 22.1% 32.6% 32.2% 18.1% 21.6% 29.1% 31.3% 15.3% 21.9% 31.0% 31.7% Total World Health Organization (1963) 2004/12 – 2008/10 ≥ 65 27.9% 33.0% <65 72.1% 67.0%
- 3. 1923 1949 (26) vs 2008 (75)
- 4. Aging Process - CTD Bone mass Osteoporosis Joint Wear & tear Cartilage changes (CPPD) Bony overgrowth Surrounding soft tissue Wear & tear Weakness Muscle mass Synthesis of heavy chain Break down of myocyte Loss of motor neuros Force & Fatigability Fatty infiltrate
- 5. Young people 30% of body weight is muscle, 20% is adipose tissue 10% is bone. Muscle ~ 50% of lean body mass & ~50% of the total amount of body nitrogen. Age 75 ½ the muscle mass has disappeared; 15% of body weight is muscle, 40% is adipose tissue, and 8% is bone.
- 6. Aging Process - Immune System Cellular immunity v Delayed type hypersensitivity v Cellular proliferation to mitogen v Atrophy of thymus & loss of thymic hormones Humoral immunity v/^ Lower affinity antibody Increased autoantibodies B cell production v Innate immunity - Macrophage function v Cytokines ^ INF-γ, TGF-β, TNF, IL-6, IL-1 v IL-2
- 7. Case Study Arthralgia / Arthritis Hand (rheumatoid arthritis) Knee Systemic Rheumatic Disease Lupus Sjogren Treatment
- 8. Arthralgia vs Arthritis Arthralgia subjective , may not be real joint inflammation. may involve the joint itself or peri-articular tissues , such as ligament, tendon, bone, muscle, … etc. Arthritis real joint inflammation or synovitis. joint swelling or two or more of the following: Erythema; local heat; tenderness; Limited range of motion (ROM)
- 9. Anatomy of Joint Joint Pain: http://www.nlm.nih.gov/medlineplus/ency/article/003261.htm
- 10. Differential Diagnosis Is it articular? Is it acute or chronic? Is inflammation present? How many/which joints are involved? Aggravating factors Associated symptoms & organs involved
- 11. Hand
- 12. 40 – 50 – 60 – 70 – 80 - 90
- 13. 40 – 50 – 60 – 70 – 80 - 90
- 14. 40 – 50 – 60 – 70 – 80 - 90
- 15. 40 – 50 – 60 – 70 – 80 - 90
- 16. 77 yo housewife 2/3 DIP, 5 PIP stiffness & arthralgia Morning stiffness 30 min
- 17. Osteoarthritis - hand Nodes - large & knobby Heberden's nodes at the DIP joints Bouchard's nodes at the PIP joints rarely cause pain, but decrease function of hands. Radiography - joint space narrowing, bony sclerosis, and osteophytes.
- 19. Prevalence of Hand OA (x-ray) Michigan Black ~20% White ~25% Rotterdam >= 55 yo Male 55% Female 67% Uncommon in Chinese %
- 21. Idiopathic Osteoarthritis Hand Hand pain, aching or stiffness < 3 swollen MCPs Hard tissue enlargement >=2/10 selected joints* >=2 DIPs Deformity >=2/10 selected joints 10 selected joints 2/3 DIP, 2/3 PIP, & 1 st CMC Knee (Sen 91%, Spe 86%) Knee pain & Radiologic changes >= 1 of the following features Age > 50 years Morning stiffness <30 min Crepitus Hip (Sen 91%, Spe 89%) Hip pain & >= 2 of the following features ESR <20 mm 1st hr Radiologic changes (x2)
- 22. Osteoarthritis Erosive osteoarthritis, an inflammatory form, often produces deforming bony overgrowth of the PIP and DIP joints.
- 24. 91 yo housewife 2 DIP arthritis for 3 days with swelling, erythema and heat Occasional swelling, tender and ROM limitation over DIP/PIP Morning stiffness 10 min
- 26. Crystal-related Arthropathy Gout Prevalence 50-74 yo ~4% Lower extremities Hands - hypertensive women on diuretics Pseudogout (CPPD, calcium pyrophosphate dihydrate) Prevalence - 65-75 yo ~10-15%, >85 yo ~30-60% Wrists, knees with chondrocalcinosis Acromegaly , hyperparathyroidism , & hypothyroidism are predisposing factors. (v Mg/P)
- 29. Clinical Courses Gout Acute, tophaceous gout Acute onset of inflammatory arthritis, possibly after trauma, illness, or surgery. small joints podagra (1st MTP) bursae (olecranonal/pre-patellar bursa) Pseudogout Acute, subacute, chronic Usually in large joints, esp. the knee. (shoulder, hip, wrist, and elbow) Chronic, asymmetric, inflammatory polyarthritis may mimic rheumatoid arthritis.
- 30. Inflammatory … Fever (up to 39° C) Leukocytosis, high CRP/ESR Delirium, conscious change
- 31. 74 yo female RA for 30 yrs
- 32. Rheumatoid Arthritis Elderly-onset (>60 yo) Clinical Mild arthritis, but large joint more freq (e.g. shoulders) Lack rheumatoid nodules RF+ in 32-58% Onset: gradual / acute DDx: PMR, RS3PE, Lupus Gout, CPPD Para-neoplastic Prognosis: variable Typical Onset: 30-50 decades Sex: F/M 2-3x Prevalence: 0.3-3% Age ^ F/M v Prevalence ^ Late complication Joint Extra-articular
- 36. Biologics era (TNF, CD20, …) The complication of treatment …
- 37. Knee
- 38. 3 6
- 39. 7 8
- 41. Knee arthritis Diagnostic approach History & Physical exam Arthrocentesis Radiography Standing AP view
- 44. Septic arthritis >60 year-old: 25-40% / all septic arthritis Mortality 19-33% vs 10 in general population Complication Joint destruction in 1-2 days if untreated Osteoarthritis and loss joint function Osteomyelitis Diagnosis – Gram’s stain – sen (GPC 75%, GNB 50%) Culture – SYN & B (sen 25-78%)
- 46. Bursitis Location Subdeltoid (subacromial) bursitis Olecranon bursitis Pre-patellar bursitis Causes Trauma (bloody) Crystal (MSU, CPPD, apatite) Septic (GPC - Staphylococcus aureus & group A streptococci) Diagnosis - aspiration
- 47. Systemic Rheumatic Disease (SRD) Connective Tissue Disease (CTD)
- 48. 20% of elderly patients (48-55%)
- 49. Systemic Lupus Erythromatosus Elderly-onset (>60 yo) 15-20% all lupus F/M ~2-3x Clinical - Milder Serositis, ILD Arthralgia, sicca Less freq: CNS/Renal DDx Drug induced lupus Infection (TB…) Typical Onset: 20-30 yo F/M 5-9x Clinical Nephritis ~50% CNS Blood
- 50. Drugs … Definite procainamide, hydralazine, chlorpromazine, methyldopa, isoniazid penicillamine, quinidine, sulfasalazine Suspects Captopril, beta-blockers, nifedipine, lithium, anticonvulsants, propylthiouracil, levodopa Diangosis Anti-histone Ab (70-95%)
- 52. Sicca … The most common signs, xerophthalmia (dry eyes) and xerostomia (dry mouth) , are reported in up to 25% of elderly patients. However, most persons with such symptoms have atrophic mucus-producing cells rather than an autoimmune disease.
- 53. Drugs - anticholinergic effects tricyclic and other antidepressants antihistamines certain antiarrhythmic blood pressure medications ( diuretics ) certain antiepileptic drugs.
- 54. Infection & inflammation … Chronic viral infections, particularly hepatitis C virus and HIV Tuberculosis Paraneoplastic syndrome
- 55. Sicca … Systemic manifestations Raynaud's phenomenon, interstitial pneumonitis, polyarthritis, vasculitis, neurologic and psychiatric
- 56. Sjögren's syndrome Exocrine function v with age interfere with drugs Elderly-onset (? yo) Dry eye/mouth Arthralgia/arthritis Myalgia, fever, fatigue Vasculitis, ILD, CNS Interstital nephritis Raynaud, hypothryoid
- 58. Treatment … Drug-drug interaction azathioprine (AZA) and allopurinol methotrexate (MTX) and cotrimmoxazole (Baktar, SMZ/TMP) NSAIDs COX-2 inhibitors GI or CV adverse events
- 59. Summary Arthralgia or arthritis Hand & Knee Osteoarthritis, Crystal-related arthropathy Septic arthritis, Bursitis Rheumatoid arthritis Systemic rheumatic disease (SRD/CTD) SLE & Sicca Drug related, chronic infection, cancer Treatment NSAIDs Drug-drug interaction (MTX, AZA, …)
- 60. Resources The Merck Manual of Geriatrics, 3/e 2006 http://www.merck.com/mkgr/mmg/sec7/sec7.jsp Duthie: Practice of Geriatrics, 4/e 2007 MD Consult