Your SlideShare is downloading. ×
0
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Geriatric Rheumatology
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Geriatric Rheumatology

2,649

Published on

A talk about Geriatric Rheumatology

A talk about Geriatric Rheumatology

0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
2,649
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
0
Likes
3
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Transcript

    • 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 <ul><li>Bone mass </li></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><li>Joint </li></ul><ul><ul><li>Wear & tear </li></ul></ul><ul><ul><li>Cartilage changes (CPPD) </li></ul></ul><ul><ul><li>Bony overgrowth </li></ul></ul><ul><li>Surrounding soft tissue </li></ul><ul><ul><li>Wear & tear </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><li>Muscle mass </li></ul><ul><ul><li>Synthesis of heavy chain </li></ul></ul><ul><ul><li>Break down of myocyte </li></ul></ul><ul><ul><li>Loss of motor neuros </li></ul></ul><ul><ul><li>Force & Fatigability </li></ul></ul><ul><ul><ul><li>Fatty infiltrate </li></ul></ul></ul>
    • 5. <ul><li>Young people </li></ul><ul><ul><li>30% of body weight is muscle, 20% is adipose tissue </li></ul></ul><ul><ul><li>10% is bone. </li></ul></ul><ul><ul><li>Muscle ~ 50% of lean body mass & ~50% of the total amount of body nitrogen. </li></ul></ul><ul><li>Age 75 </li></ul><ul><ul><li>½ the muscle mass has disappeared; </li></ul></ul><ul><ul><li>15% of body weight is muscle, 40% is adipose tissue, and 8% is bone. </li></ul></ul>
    • 6. Aging Process - Immune System <ul><li>Cellular immunity v </li></ul><ul><ul><li>Delayed type hypersensitivity v </li></ul></ul><ul><ul><li>Cellular proliferation to mitogen v </li></ul></ul><ul><ul><li>Atrophy of thymus & loss of thymic hormones </li></ul></ul><ul><li>Humoral immunity v/^ </li></ul><ul><ul><li>Lower affinity antibody </li></ul></ul><ul><ul><li>Increased autoantibodies </li></ul></ul><ul><ul><li>B cell production v </li></ul></ul><ul><li>Innate immunity - Macrophage function v </li></ul><ul><li>Cytokines </li></ul><ul><ul><li>^ INF-γ, TGF-β, TNF, IL-6, IL-1 </li></ul></ul><ul><ul><li>v IL-2 </li></ul></ul>
    • 7. Case Study <ul><li>Arthralgia / Arthritis </li></ul><ul><ul><li>Hand (rheumatoid arthritis) </li></ul></ul><ul><ul><li>Knee </li></ul></ul><ul><li>Systemic Rheumatic Disease </li></ul><ul><ul><li>Lupus </li></ul></ul><ul><ul><li>Sjogren </li></ul></ul><ul><li>Treatment </li></ul>
    • 8. Arthralgia vs Arthritis <ul><li>Arthralgia </li></ul><ul><ul><li>subjective , may not be real joint inflammation. </li></ul></ul><ul><ul><li>may involve the joint itself or peri-articular tissues , such as ligament, tendon, bone, muscle, … etc. </li></ul></ul><ul><li>Arthritis </li></ul><ul><ul><li>real joint inflammation or synovitis. </li></ul></ul><ul><ul><li>joint swelling or two or more of the following: </li></ul></ul><ul><ul><ul><li>Erythema; local heat; tenderness; </li></ul></ul></ul><ul><ul><ul><li>Limited range of motion (ROM) </li></ul></ul></ul>
    • 9. Anatomy of Joint Joint Pain: http://www.nlm.nih.gov/medlineplus/ency/article/003261.htm
    • 10. Differential Diagnosis <ul><li>Is it articular? </li></ul><ul><li>Is it acute or chronic? </li></ul><ul><li>Is inflammation present? </li></ul><ul><li>How many/which joints are involved? </li></ul><ul><li>Aggravating factors </li></ul><ul><li>Associated symptoms & organs involved </li></ul>
    • 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. <ul><li>77 yo housewife </li></ul><ul><li>2/3 DIP, 5 PIP stiffness & arthralgia </li></ul><ul><li>Morning stiffness 30 min </li></ul>
    • 17. Osteoarthritis - hand <ul><li>Nodes - large & knobby </li></ul><ul><ul><li>Heberden's nodes at the DIP joints </li></ul></ul><ul><ul><li>Bouchard's nodes at the PIP joints </li></ul></ul><ul><ul><li>rarely cause pain, but decrease function of hands. </li></ul></ul><ul><li>Radiography - joint space narrowing, bony sclerosis, and osteophytes. </li></ul>
    • 18.    
    • 19. Prevalence of Hand OA (x-ray) <ul><li>Michigan </li></ul><ul><li>Black ~20% </li></ul><ul><li>White ~25% </li></ul><ul><li>Rotterdam </li></ul><ul><li>>= 55 yo </li></ul><ul><li>Male 55% </li></ul><ul><li>Female 67% </li></ul><ul><li>Uncommon in Chinese </li></ul>%
    • 20.  
    • 21. Idiopathic Osteoarthritis <ul><li>Hand </li></ul><ul><li>Hand pain, aching or stiffness </li></ul><ul><li>< 3 swollen MCPs </li></ul><ul><li>Hard tissue enlargement </li></ul><ul><ul><li>>=2/10 selected joints* </li></ul></ul><ul><ul><li>>=2 DIPs </li></ul></ul><ul><li>Deformity </li></ul><ul><ul><li>>=2/10 selected joints </li></ul></ul><ul><li>10 selected joints 2/3 DIP, 2/3 PIP, & 1 st CMC </li></ul><ul><li>Knee (Sen 91%, Spe 86%) </li></ul><ul><li>Knee pain & Radiologic changes </li></ul><ul><li>>= 1 of the following features </li></ul><ul><ul><li>Age > 50 years </li></ul></ul><ul><ul><li>Morning stiffness <30 min </li></ul></ul><ul><ul><li>Crepitus </li></ul></ul><ul><li>Hip (Sen 91%, Spe 89%) </li></ul><ul><li>Hip pain & </li></ul><ul><li>>= 2 of the following features </li></ul><ul><ul><li>ESR <20 mm 1st hr </li></ul></ul><ul><ul><li>Radiologic changes (x2) </li></ul></ul>
    • 22. Osteoarthritis <ul><li>Erosive osteoarthritis, an inflammatory form, often produces deforming bony overgrowth of the PIP and DIP joints. </li></ul>
    • 23.  
    • 24. <ul><li>91 yo housewife </li></ul><ul><li>2 DIP arthritis for 3 days with swelling, erythema and heat </li></ul><ul><li>Occasional swelling, tender and ROM limitation over DIP/PIP </li></ul><ul><li>Morning stiffness 10 min </li></ul>
    • 25.  
    • 26. Crystal-related Arthropathy <ul><li>Gout </li></ul><ul><ul><li>Prevalence 50-74 yo ~4% </li></ul></ul><ul><ul><li>Lower extremities </li></ul></ul><ul><ul><li>Hands - hypertensive women on diuretics </li></ul></ul><ul><li>Pseudogout (CPPD, calcium pyrophosphate dihydrate) </li></ul><ul><ul><li>Prevalence - 65-75 yo ~10-15%, >85 yo ~30-60% </li></ul></ul><ul><ul><li>Wrists, knees with chondrocalcinosis </li></ul></ul><ul><ul><li>Acromegaly , hyperparathyroidism , & hypothyroidism are predisposing factors. (v Mg/P) </li></ul></ul>
    • 27.  
    • 28.  
    • 29. Clinical Courses <ul><li>Gout </li></ul><ul><li>Acute, tophaceous gout </li></ul><ul><li>Acute onset of inflammatory arthritis, possibly after trauma, illness, or surgery. </li></ul><ul><li>small joints </li></ul><ul><ul><li>podagra (1st MTP) </li></ul></ul><ul><li>bursae (olecranonal/pre-patellar bursa) </li></ul><ul><li>Pseudogout </li></ul><ul><li>Acute, subacute, chronic </li></ul><ul><li>Usually in large joints, esp. the knee. (shoulder, hip, wrist, and elbow) </li></ul><ul><li>Chronic, asymmetric, inflammatory polyarthritis may mimic rheumatoid arthritis. </li></ul>
    • 30. Inflammatory … <ul><li>Fever (up to 39° C) </li></ul><ul><li>Leukocytosis, high CRP/ESR </li></ul><ul><li>Delirium, conscious change </li></ul>
    • 31. 74 yo female RA for 30 yrs
    • 32. Rheumatoid Arthritis <ul><li>Elderly-onset (>60 yo) </li></ul><ul><li>Clinical </li></ul><ul><ul><li>Mild arthritis, but large joint more freq (e.g. shoulders) </li></ul></ul><ul><ul><li>Lack rheumatoid nodules </li></ul></ul><ul><ul><li>RF+ in 32-58% </li></ul></ul><ul><ul><li>Onset: gradual / acute </li></ul></ul><ul><li>DDx: </li></ul><ul><ul><li>PMR, RS3PE, Lupus </li></ul></ul><ul><ul><li>Gout, CPPD </li></ul></ul><ul><ul><li>Para-neoplastic </li></ul></ul><ul><li>Prognosis: variable </li></ul><ul><li>Typical </li></ul><ul><ul><li>Onset: 30-50 decades </li></ul></ul><ul><ul><li>Sex: F/M 2-3x </li></ul></ul><ul><ul><li>Prevalence: 0.3-3% </li></ul></ul><ul><li>Age ^ </li></ul><ul><ul><li>F/M v </li></ul></ul><ul><ul><li>Prevalence ^ </li></ul></ul><ul><li>Late complication </li></ul><ul><ul><li>Joint </li></ul></ul><ul><ul><li>Extra-articular </li></ul></ul>
    • 33.  
    • 34.  
    • 35.  
    • 36. Biologics era (TNF, CD20, …) The complication of treatment …
    • 37. Knee
    • 38. 3 6
    • 39. 7 8
    • 40.  
    • 41. Knee arthritis <ul><li>Diagnostic approach </li></ul><ul><ul><li>History & Physical exam </li></ul></ul><ul><ul><li>Arthrocentesis </li></ul></ul><ul><ul><li>Radiography </li></ul></ul><ul><ul><ul><li>Standing AP view </li></ul></ul></ul>
    • 42.  
    • 43.  
    • 44. Septic arthritis <ul><li>>60 year-old: 25-40% / all septic arthritis </li></ul><ul><ul><li>Mortality 19-33% vs 10 in general population </li></ul></ul><ul><li>Complication </li></ul><ul><ul><li>Joint destruction in 1-2 days if untreated </li></ul></ul><ul><ul><ul><li>Osteoarthritis and loss joint function </li></ul></ul></ul><ul><ul><li>Osteomyelitis </li></ul></ul><ul><li>Diagnosis – </li></ul><ul><ul><li>Gram’s stain – sen (GPC 75%, GNB 50%) </li></ul></ul><ul><ul><li>Culture – SYN & B (sen 25-78%) </li></ul></ul>
    • 45.  
    • 46. Bursitis <ul><li>Location </li></ul><ul><ul><li>Subdeltoid (subacromial) bursitis </li></ul></ul><ul><ul><li>Olecranon bursitis </li></ul></ul><ul><ul><li>Pre-patellar bursitis </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Trauma (bloody) </li></ul></ul><ul><ul><li>Crystal (MSU, CPPD, apatite) </li></ul></ul><ul><ul><li>Septic (GPC - Staphylococcus aureus & group A streptococci) </li></ul></ul><ul><li>Diagnosis - aspiration </li></ul>
    • 47. Systemic Rheumatic Disease (SRD) Connective Tissue Disease (CTD)
    • 48. 20% of elderly patients (48-55%)
    • 49. Systemic Lupus Erythromatosus <ul><li>Elderly-onset (>60 yo) </li></ul><ul><ul><li>15-20% all lupus </li></ul></ul><ul><ul><li>F/M ~2-3x </li></ul></ul><ul><li>Clinical - Milder </li></ul><ul><ul><li>Serositis, ILD </li></ul></ul><ul><ul><li>Arthralgia, sicca </li></ul></ul><ul><ul><li>Less freq: CNS/Renal </li></ul></ul><ul><li>DDx </li></ul><ul><ul><li>Drug induced lupus </li></ul></ul><ul><ul><li>Infection (TB…) </li></ul></ul><ul><li>Typical </li></ul><ul><ul><li>Onset: 20-30 yo </li></ul></ul><ul><ul><li>F/M 5-9x </li></ul></ul><ul><li>Clinical </li></ul><ul><ul><li>Nephritis ~50% </li></ul></ul><ul><ul><li>CNS </li></ul></ul><ul><ul><li>Blood </li></ul></ul>
    • 50. Drugs … <ul><li>Definite </li></ul><ul><ul><li>procainamide, hydralazine, chlorpromazine, methyldopa, isoniazid </li></ul></ul><ul><ul><li>penicillamine, quinidine, sulfasalazine </li></ul></ul><ul><li>Suspects </li></ul><ul><ul><li>Captopril, beta-blockers, nifedipine, lithium, anticonvulsants, propylthiouracil, levodopa </li></ul></ul><ul><li>Diangosis </li></ul><ul><ul><li>Anti-histone Ab (70-95%) </li></ul></ul>
    • 51.  
    • 52. Sicca … <ul><li>The most common signs, xerophthalmia (dry eyes) and xerostomia (dry mouth) , are reported in up to 25% of elderly patients. </li></ul><ul><li>However, most persons with such symptoms have atrophic mucus-producing cells rather than an autoimmune disease. </li></ul>
    • 53. Drugs - anticholinergic effects <ul><li>tricyclic and other antidepressants </li></ul><ul><li>antihistamines </li></ul><ul><li>certain antiarrhythmic </li></ul><ul><li>blood pressure medications ( diuretics ) </li></ul><ul><li>certain antiepileptic drugs. </li></ul>
    • 54. Infection & inflammation … <ul><li>Chronic viral infections, </li></ul><ul><ul><li>particularly hepatitis C virus and HIV </li></ul></ul><ul><li>Tuberculosis </li></ul><ul><li>Paraneoplastic syndrome </li></ul>
    • 55. Sicca … <ul><li>Systemic manifestations </li></ul><ul><ul><li>Raynaud's phenomenon, </li></ul></ul><ul><ul><li>interstitial pneumonitis, </li></ul></ul><ul><ul><li>polyarthritis, vasculitis, </li></ul></ul><ul><ul><li>neurologic and psychiatric </li></ul></ul>
    • 56. Sjögren's syndrome <ul><li>Exocrine function </li></ul><ul><ul><li>v with age </li></ul></ul><ul><ul><li>interfere with drugs </li></ul></ul><ul><li>Elderly-onset (? yo) </li></ul><ul><ul><li>Dry eye/mouth </li></ul></ul><ul><ul><li>Arthralgia/arthritis </li></ul></ul><ul><ul><li>Myalgia, fever, fatigue </li></ul></ul><ul><ul><li>Vasculitis, ILD, CNS </li></ul></ul><ul><ul><li>Interstital nephritis </li></ul></ul><ul><ul><li>Raynaud, hypothryoid </li></ul></ul>
    • 57.  
    • 58. Treatment … <ul><li>Drug-drug interaction </li></ul><ul><ul><li>azathioprine (AZA) and allopurinol </li></ul></ul><ul><ul><li>methotrexate (MTX) and cotrimmoxazole (Baktar, SMZ/TMP) </li></ul></ul><ul><li>NSAIDs </li></ul><ul><ul><li>COX-2 inhibitors </li></ul></ul><ul><ul><li>GI or CV adverse events </li></ul></ul>
    • 59. Summary <ul><li>Arthralgia or arthritis </li></ul><ul><ul><li>Hand & Knee </li></ul></ul><ul><ul><ul><li>Osteoarthritis, Crystal-related arthropathy </li></ul></ul></ul><ul><ul><ul><li>Septic arthritis, Bursitis </li></ul></ul></ul><ul><ul><ul><li>Rheumatoid arthritis </li></ul></ul></ul><ul><li>Systemic rheumatic disease (SRD/CTD) </li></ul><ul><ul><li>SLE & Sicca </li></ul></ul><ul><ul><li>Drug related, chronic infection, cancer </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>NSAIDs </li></ul></ul><ul><ul><li>Drug-drug interaction (MTX, AZA, …) </li></ul></ul>
    • 60. Resources <ul><li>The Merck Manual of Geriatrics, 3/e 2006 </li></ul><ul><ul><li>http://www.merck.com/mkgr/mmg/sec7/sec7.jsp </li></ul></ul><ul><li>Duthie: Practice of Geriatrics, 4/e 2007 </li></ul><ul><ul><li>MD Consult </li></ul></ul>
    • 61.  

    ×