Rheumatic problems in elderly

Rheumatic problems in Elderly

Kevin Latinis, M.D./Ph.D.Division of RheumatologyDept. of Internal [email protected]

Rheumatology 101: What you need to know for your ambulatory medicine

experience

Rheumatology 101

Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA)LupusFibromyalgiaLow back pain and other peri-articular complaintsGeneral musculoskeletal exam (time permitting)

Mechanical vs. Inflammatory Arthritis

Latinis, K., et al The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003.

Osteoarthritis-Background

Very common-2nd leading cause for disability in USA-In patients 60 and older: affects 17% of men and 30% of women-Estimated that 59.4 million patients will have OA by the year 2020Etiology-primary idiopathic-secondary

Osteoarthritis-Distribution

Latinis, K., Dao, K, Shepherd, R, Gutierrez, E, Velazquez, C. The Washington Manual Rheumatology Subspecialty Consult., LWW, 2003.

Bouchard’s

Heberden’s

Osteoarthritis-Diagnosis

ClinicalSupported by X-raysNon-inflammatory lab data, if any

Osteoarthritis-TreatmentPain relief-Analgesics and NSAIDs/Cox-2 InhibitorsSMOADs (structure modifying osteoarthritis drugs)-Glucosamine Sulfate -see meta-analysis McAlindon et al. JAMA, 283: 3/2000, p. 1469-many under developmentNon-pharmacologic approaches-Reduce stress/load on joint-Strengthen surrounding muscles-PT/OT-Weight reduction-Patient educationLimit disability and improve quality of life

Osteoarthritis-Treatment

Joint Replacement Surgery-Primarily of knee and hip, but also available in hands, shoulders,& elbows-Indications:

1. pain at rest2. instability

-patients benefit from aggressive PT before & after surgeryOther surgical procedures

Clinical Pearl:Arthritis of the DIP joint

OA (non-inflammatory)Psoriatic Arthritis (inflammatory)

Inflammatory Arthritis

Rheumatoid arthritisSpondyloarthropathies-Undifferentiated-Ankylosing spondylitis-Psoriatic arthritis-Reactive arthritis (formerly Reiter’s syndrome)-Enteropathic arthritisSLE, Sjogrens, Scleroderma, Polymyalgia rheumatica, Vasculitis, Infectious (bacterial, viral, other), Undifferentiated connective tissue disease

Rheumatoid Arthritis-Background

Symmetric, inflammatory polyarthritisAffects ~1% of our populationOccurs in women 3x more than menEtiology-Genetic, class II molecules (HLA-DRB1)-Autoimmune-?Environmental

Rheumatoid Arthritis-Distribution


Definition-An inflammatory multisystem disease of unknown etiologywith protean clinical and laboratory manifestations and avariable course and prognosis.-Immunologic aberrations give rise to excessive autoantibodyproduction, some of which cause cytotoxic damage, whileothers participate in immune complex formation resulting inimmune inflammation.

Systemic Lupus Erythematosus (Lupus)-Background

Clinical features-Clinical manifestations may be constitutional or result frominflammation in various organ systems including skin andmucous membranes, joints, kidney, brain, serous membranes,lung, heart and occasionally gastrointestinal tract.-Organ systems may be involved singly or in any combination.-Involvement of vital organs, particularly the kidneys andcentral nervous system, accounts for significant morbidityand mortality.-Morbidity and mortality result from tissue damage due tothe disease process or its therapy.

Systemic Lupus Erythematosus (Lupus)-Background

Systemic lupus erythematosus classification criteria(SOAP BRAIN MD)

1. Serositis: (a) pleuritis, or (b) pericarditis

2. Oral ulcers3. Arthritis4. Photosensitivity

10. Malar rash11. Discoid rash

5. Blood/Hematologic disorder: (a) hemolytic anemia or(b) leukopenia of < 4.0 x 109 (c) lymphopenia of < 1.5 x 109 (d) thrombocytopenia < 100 X 109

6. Renal disorder: (a) proteinuria > 0.5 gm/24 h or 3+ dipstick or(b) cellular casts

7. Antinuclear antibody (positive ANA) 8. Immunologic disorders:

(a) raised anti-native DNA antibody binding or(b) anti-Sm antibody or (c) positive anti-phospholipid antibody work-up

9. Neurological disorder: (a) seizures or (b) psychosis

". ..A person shall be said to have SLE if four or more of the 11 criteria are present, serially or simultaneously, during any interval of observation."

53 yo BF with severe generalized weakness, weight loss, and chronic psychosis

Alopecia

Malar rash

Arthritis

Psychosis

Laboratory Data

1394.3

10621

161.4

101 7.7

22.33.9

Absolute lymph=0.5

298

MCV=83

ESR=119CH50=67 (118-226)C3=31 (83-185)C4=18 (12-54)

ANA + 1:5280Anti DNA +Direct & Indirect Coombs +

Anti-IgG +

24 hour urineProtein=514

Treatment of SLEArthritis, arthralgias, myalgias:NSAIDS, anti-malarials (eg. Plaquenil), Steroids- injections, oral methotrexatePhotosensitivity, dermatitis avoid Sun exposuretopical steroidsPlaquenilWeight loss and fatigue

steroidsAbortion, fetal loss ASA

immunosuppressionThrombosis

anti-coagulants

Glomerulonephritis steroidspulse

cytotoxicsmycophenylate mofetil

CNS diseaseanti-coagulants for thrombosissteroids and cytotoxics for

vasculitisInfarction (secondary to vasculitis)

steroidscytotoxicsprostacyclin

Cytopenias steroidsIVIG-short

term for thrombocytopenia danazol

cytotoxics-if bone marrow status is known

Steroids in Lupus

Steroid responsive Dermatitis (local)

PolyarthritisSerositisVasculitisHematological Glomerulonephritis (most)Myelopathies

Steroid non-responsiveThrombosisChronic renal damageHypertension Steroid-induced psychosis

Infection


ANA-When to order and how to follow up on a positive test

Fibromyalgia-Background

Chronic musculoskeletal pain syndrome of unknown etiologyCharacterized by diffuse pain, tender points, fatigue, and sleep disturbancesPrevalence is 2-5% with a female to male predominance of 8:1Mean age is 30-60

Fibromyalgia-Diagnosis

1

2

34

5

6

7

89

Fibromyalgia-Treatment

Low back pain and other peri-articular complaints-background

Very common, one of the most frequent reasons to visit primary care physiciansArticular vs peri-articular problems-Articular pain is generally deep or diffuse and worsens with active and passive motion-Periarticular pain usually exibits point tenderness and increased tenderness with active, but NOT passive motion

Muscles of the rotator cuff:SupraspinatusInfraspinatusSubscapularisTeres Minor

Low back pain and other peri-articular complaints-Treatment

RICE-Rest-Ice-Compression-ElevationNSAIDs and analgesicsTimeOther

General Musculoskeletal Exam

Underutilized by primary care providersShould be simple and quickGoal is to recognize signs of rheumatological diseases and determine if it is appropriate to refer to a rheumatologist or manage independently

Summary

Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA)LupusFibromyalgiaLow back pain and other peri-articular complaintsGeneral musculoskeletal exam (time permitting)

Rheumatic problems in elderly

Health & Medicine

Transcript of Rheumatic problems in elderly