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Geriatric Rheumatology
Thaddeus A. Osial, Jr. MC FACP, FACR
Margolis Rheumatology Assoc. UPMC
Goals
• Review selected rheumatic diseases commonly seen in the elderly
• Review unique presentations of rheumatic diseases as seen in the elderly
Rheumatic Diseases in the
Elderly
Diseases primarily seen in the elderly
• Polymyalgia Rheumatica
• Temporal Arteritis
• CPPD (calcium pyrophosphate depostion disease)
• Osteoarthritis
• RS3PE (Remitting Seronegative Symmetrical Synovitis with Pitting Edema
Diseases with variable manifestations in the elderly
• Gout
• Rheumatoid arthritis
• Lupus
Case Presentation
• 73 y.o. woman with gradual enlargement of her finger joints
• Concerned she has “crippling arthritis”
• Mother / sister had similar “deformities”
• Some are tender, others were tender in the past
• Also sore at the base of the thumb
• Some difficulty opening jars, turning knobs etc
Case
• 73 yo woman with gradual enlargement of her finger joints
• Concerned she has “crippling arthritis”
• Mother / sister had similar “deformities”
• Some are tender, others were tender
• Also sore at the base of the thumb
• Some difficulty opening jars, turning knobs etc
• Her knees are also painful when she walks
Osteoarthritis:
Typical symptoms
• Joint pain, often use-related
• Distribution often patchy and asymmetrical
• Gelling of joints after inactivity
• Loss of range of motion
• Bony enlargement, sometimes an effusion
• Absence of systemic features
• Non-inflammatory joint fluid
• Normal lab studies
Epidemiology of OA
• Estimates of the prevalence are imprecise because of difficulties in definition.
• 80% over 55 have x-ray evidence.
• 50 million (22%) of adults have self-reported doctor-diagnosed arthritis.
• 21 million (9% of all adults) have arthritis-attributable activity limitation
Center for Disease Control
Prevalence of arthritis by age group
Epidemiology of OA
Hootman JM, Jeffrey Sacks JJ, Helmick CG. Arth Rheum 2004
RA vs. OA
Patterns of Joint Involvement
Osteoarthritis of the Medial Side of the Knee.
Felson DT. N Engl J Med 2006;354:841-848.
Osteoarthritis
Osteoarthritis of the hands
Osteoarthritis: knees, medial and lateral cartilage
degeneration (radiographs)
Goals of OA Management
• Control pain and other symptoms.
• Correct functional limitations and
disability.
• Effective use of medications
Patient education Physical and occupational therapy
Weight reduction, exercise, assistive devices
OTC NSAIDs Acetaminophen
Prescription Oral and topical NSAIDs
IA steroids Hyaluronic acid
Surgery
Treatment of Osteoarthritis
? Topical analgesics ? Glucosamine, chondroitin
Severity of symptoms
Mild
Severe
Narcotics
Pharmacologic Treatment for Osteoarthritis of the Knee.
Felson DT. N Engl J Med 2006;354:841-848.
What drugs should be used
for osteoarthritis?
Efficacy & Safety Cost
Cartilage “re-growth”
Cartilgage “re-growth”
Inflammatory Osteoarthritis
Heberden’s Nodes
Subcutaneous Deposits (tophi)
GOUT
Crystalline Arthritis
•Gout
•Pseudogout
Gout in the Elderly
• Renal insufficiency
• Medications (eg diuretics)
• Comorbid conditions (eg myeloproliferative diseases)
• May be polyarticular (esp. in later stage disease) and involve less typical joints
Monosodium Urate Crystal
Diagnositic Points:
Gout
• Acute monoarthritis with intercritical periods
• Maximum inflammation within 24 hours
• Unilateral 1st MTP involvement
• Visible or palpable lesion suggestive of tophi
Gout: Massive Tophi
Diagnositic Points:
Gout
• Acute monoarthritis with intercritical periods
• Maximum inflammation within 24 hours
• Unilateral 1st MTP involvement
• Visible or palpable lesion suggestive of tophi
• Hyperuricemia
• Subcortical bone cyst on x-ray
Gout X-ray
Gout
Diagnositic Points:
Gout
• Acute monoarthritis with intercritical periods
• Maximum inflammation within 24 hours
• Unilateral 1st MTP involvement
• Visible or palpable lesion suggestive of tophi
• Hyperuricemia
• Subcortical bone cyst on x-ray
Treatment of Gout
• Care with use of NSAIDs and colchicine (re: renal insufficiency, risk of bone marrow toxicity)
• Corticosteroid injection remain an option for acute disease (and to confirm diagnosis) as do po steroids
• Long term treatment with goal of SUA <6 (or lower)
• Slow initiation of allopurinol, initially 50-100 mg/d (potential greater risk of hypersensitivity)
• Still may slowly increase dose to 300+mg/d to reach goal
Calcium Pyrophosphate
Crystal
CPPD (knee)
CPPD wrist
Pseudogout
• Acute/subacute mono or oligoarthritis
• Knee/wrist/ankle primarily involved
• Usually last up to 10 days, but may cluster
• Precipitated by trauma/illness/surgery
• May have systemic features (e.g. fever)
• May also present with a chronic, “pseudo- RA” picture
CPPD
• Asymptomatic radiographic finding
• Acute arthritis ie pseudogout
• Chronic arthritis ie pseudo RA
• Pyrophosphate arthropathy
Pyrophosphate arthropathy
Evaluation/Treatment of Pseudogout
• Acute episodes may respond to steroids, intra-articular steroids, NSAIDs and colchicine
• Prophylactic treatment with colchicine may be effective, but variable (0.6 mg daily or qod)
• Search for an underlying cause (hypercalcemia, hyperparathyroidism, hemochromatosis, hypothyroidism)
• Treatment of the underlying disease may not affect the arthritis
• Check Ca/P/Mg, ferritin, iron, TIBC, TSH
Regional Musculoskeletal
Problems
Milwaukee Shoulder
Psoriatic arthritis: hands, nail changes, rash, and
arthritis
INFECTION
(septic bursitis or arthritis?)
Case (continued)
• Several months of increasing fatigue “getting older”
• Pronounced AM stiffness for several hours, hard to get out of bed and get dressed
• Shoulders painful, hips and neck somewhat less
• Appetite isn’t a good
• Mild swelling of the fingers and wrists
• Limited findings on exam; some difficulty raising arms over head due to pain, equivocal MCP swelling and knee swelling
Possible diagnosis
Polymyalgia rheumatica • Age > 50, peaks between 70 and 80
• Bilateral aching and stiffness for >1 month, involving neck/shoulders (upper arms)/hips (upper thighs)
• Morning stiffness > 1 hour
• Elevated sedimentation rate (in most) or CRP
• Rapid response to prednisone
• EXCLUSION OF OTHER DISEASES
• Due to synovitis of joints and surrounding structures
(eg subdeltoid and subacromial bursitis)
The Hands of a Patient with Untreated Polymyalgia Rheumatica.
Salvarani C et al. N Engl J Med 2002;347:261-271.
RS3PE
(Remitting Seronegative Symmetrical Synovitis with
Pitting Edema
• Sudden onset of bilateral symmetrical synovitis of wrists, small hand joints, flexor tendon sheaths, and dorsal hand swelling
• Distal not proximal symptoms predominate
• Rheumatoid factor (-), elevated ESR
• May respond to low dose steroids
• If unresponsive, consider a malignancy (adenocarcinoma, lymphoma)
• Non-erosive, possibly part of PMR spectrum
RS3PE
Possible diagnosis
Giant Cell Arteritis (GCA)
• ~16-21% of PMR patients have GCA
• ~40-60% of GCA patients have PMR sx
• PMR sx may occur anywhere in the course of GCA
• Classic symptoms: – Headaches
– Temporal scalp tenderness
GCA: Head Pain
• Prominent
• “Unlike any other headache”
• Constant, severe, often nocturnal
• Scalp tenderness (eg laying on the pillow hurts)
• Temporal or frontal, occipital, parietal
• Facial, ear, jaw , neck tenderness
Possible diagnosis
Giant Cell Arteritis
• ~16-21% of PMR patients have GCA
• ~40-60% of GCA patients have PMR sx
• PMR sx may occur anywhere in the course of GCA
• Classic symptoms: – Headaches
– Temporal scalp tenderness
– Visual changes
GCA:Visual
• Diplopia
• Blurring
• Loss of part of visual fields
• Visual aura
• Ocular pain
• Amaurosis fugax (high risk for permanent loss)
• USUALLY due to anterior optic ischemia
Possible diagnosis
Giant Cell Arteritis
• ~16-21% of PMR patients have GCA
• ~40-60% of GCA patients have PMR sx
• PMR sx may occur anywhere in the course of GCA
• Classic symptoms: – Headaches
– Temporal scalp tenderness
– Visual changes
– Jaw claudication (~35-50%) STRONGLY SUGGESTIVE SX
GCA: Jaw Claudication
• Pain after chewing for awhile relieved by rest (ie. Claudication)
• May be episodic for weeks or months
• NOT TMJ syndrome, etc
• Less common: sore tongue, reduced opening of jaw
• Less specific: jaw pain, tooth or gum pain
• 50% or fewer of patients, but highly specific
Possible diagnosis
Giant Cell Arteritis
• ~16-21% of PMR patients have GCA
• ~40-60% of GCA patients have PMR sx
• PMR sx may occur anywhere in the course of GCA
• Classic symptoms: – Headaches
– Temporal scalp tenderness
– Visual changes
– Jaw claudication (~35-50%) STRONGLY SUGGESTIVE SX
– Misc: fever (cause of FUO, occ. Sepsis-like with high fevers, rigors, sweats), malaise, anorexia, sore throat/hoarseness, claudication of arms
– Late thoracic aortic aneurysm
Thoracic aortic aneurysm in
GCA
Possible diagnosis
Giant Cell Arteritis • Elevated ESR >40-50 in most GCA and PMR • ~10% with normal ESR in GCA and PMR • Elevated CRP, mild NCNC anemia, mild alkaline
phosphatase elevation • Who to biopsy??? - suspected TA - patient with cranial nerve signs or sx • Can be positive up to 2 weeks after initiation of Rx • Adequate biopsy (3-5 cm), occasionally contralateral side
Temporal Artery Biopsy GCA
Treatment
• PMR: Prednisone 15-20 mg/d
Begin taper in several weeks
Example: 2.5/d. every month to 10 mg
Then 1mg/month
Consider osteoporosis prophylaxis
• Persisting elevated ESR, poor response: ?GCA, ?malignancy, ?infection
• Watch for peripheral arthritis as prednisone is tapered (e.g. late onset RA)
Treatment
• GCA: Prednisone 40-60 mg/day
Prednisone 60mg/d. if ischemic symptoms
IV methylprednisolone (500mg) x 2-3 days
if acute visual changes or loss
• Begin to taper at 1 month if stable (by 5 mg/d every few weeks to 20 then more slowly
• Watch ESR more closely than with PMR
• Rare for further visual problems after treatment begun
• Consider “flare” being other problems (eg OA that responded to prednisone in both GCA and PMR
RA in the elderly
Clinical Presentation of RA:
Key Presenting Signs and Symptoms
• Joint pain
• Symmetric swelling of small peripheral joints
• Morning joint stiffness of prolonged duration
Rheumatoid Arthritis:
Key Features
• Symptoms >6 weeks’ duration • Often lasts the remainder of the patient’s life
• Inflammatory synovitis • Palpable synovial swelling
• Morning stiffness >1 hour, fatigue
• Symmetrical and polyarticular (>3 joints) • Typically involves wrists, MCP, and PIP joints
• Typically spares certain joints • Thoracolumbar spine
• DIPs of the fingers and IPs of the toes
RA: fusiform swelling
RA: Late Stage Deformities
Signs and Symptoms of Early
RA:
Screening
• 3 swollen joints
• MTP/MCP involvement
– Squeeze test positive
• Morning stiffness 30 min
Emery P et al. Ann Rheum Dis. 2002;61:290-297.
Possible diagnosis
Elderly onset RA
• More equal gender distribution
• Higher frequency of acute onset
• More frequent shoulder girdle involvement (ie PMR-like presentation) than a younger population
• More frequent constitutional symptoms (fever, weight loss, fatigue)
• Consider seronegative inflammatory arthritis
• Remember (+) RF occurs more commonly in the elderly even without RA and also with hepatitis C
Elderly onset RA special considerations
• Prognosis probably worse than younger patients with
seropositive RA • May reflect comorbidities, poorer tolerance of medications,
some with longer term disease • Therapy considerations: Risks of NSAID gi toxicity, renal insufficiency,
exacerbations of HBP and CHP, CNS effects and concerns re: CAD
Risks of DMARDs: myelosuppression, infections, coexisting renal insufficiency
Insurance/$$ issues especially regarding biological agents
Seronegative arthritis of the elderly
• May begin with PMR-like picture, but have or develop more distal joint involvement
• May follow a benign course, although erosive disease may occur
• Seems to part of the spectrum of PMR in some cases
Paraneoplastic syndromes
• Dermatomyositis: 3-7x increase, ~10-15%
-Age –typical: adenocarcinomas of the lung, breast, ovaries, pancreas, bladder, stomach
-Eval: H/P, labs (CBC, ESR, R&M, CMP, ?PSA, ?CA125, stool guiac)
-Consider colonoscopy, CT scans, pelvic sonography
-Lower risk after 2 years from diagnosis
Paraneoplastic syndromes
• Atypical RA/PMR: explosive onset, asymetrical, RF negative
• Palmar fasciitis: associated with ovarian cancer (and less commonly pancreas, lung, colon
Palmar fasciitis
Hypertrophic Pulmonary
Osteoarthropathy
Paraneoplastic syndromes
• Atypical RA/PMR: explosive onset, RF (-) asymmetrical
• Palmar fasciitis: associated with ovarian cancer (and less commonly pancreas, lung, colon
• Hypertrophic osteoarthropathy (clubbing)
-----------------------
• Aromatase inhibitors: arthralgias, joint stiffness, frank inflammatory arthritis, tenosynovitis esp. in older women
Rheumatological Medications in the
Elderly
• NSAIDs: concerns re: GI, HBP, CAD, fluid retention, confusion.
• Corticosteroids: osteoporosis, AVN, glucose intolerance, risk of infections, cataracts
• Methotrexate: hematological suppression (esp with renal insufficiency and malnutrition)
• Colchicine: heme risks with CRF
• Biological agents: infection risks
• Bisphosphonates: contraindicated with CRF