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Rheumatic problems in elderly

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some important musculoskeletal affliction in elderly

some important musculoskeletal affliction in elderly

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  • 1. Rheumatic problems in Elderly
  • 2. Rheumatology 101:What you need to know foryour ambulatory medicine experience Kevin Latinis, M.D./Ph.D. Division of Rheumatology Dept. of Internal Medicine klatinis@kumc.edu
  • 3. Rheumatology 101 Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA) Lupus Fibromyalgia Low back pain and other peri-articularcomplaints General musculoskeletal exam (timepermitting)
  • 4. Mechanical vs. Inflammatory Arthritis Latinis, K., et al The Washingto n Manual Rheumatol ogy Subspecial ty
  • 5. Osteoarthritis-Background Very common-2nd leading cause for disability in USA-In patients 60 and older: affects 17% of menand 30% of women-Estimated that 59.4 million patients will haveOA by the year 2020 Etiology-primary idiopathic-secondary
  • 6. Osteoarthritis-Distribution Bouchard’s Heberden’s Latinis, K., Dao, K, Shepherd, R, Guti errez, E, Velazque z, C. The Washington Manual Rheumatology Subspecialty
  • 7. Osteoarthritis-DiagnosisClinicalSupported by X-raysNon-inflammatory lab data, if any
  • 8. 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
  • 9. Osteoarthritis-TreatmentJoint Replacement Surgery-Primarily of knee and hip, but also available in hands, shoulders,& elbows-Indications: 1. pain at rest 2. instability-patients benefit from aggressive PT before & after surgeryOther surgical procedures
  • 10. Clinical Pearl: Arthritis of the DIP jointPsoriatic Arthritis (inflammatory) OA (non-inflammatory)
  • 11. Inflammatory ArthritisRheumatoid arthritisSpondyloarthropathies-Undifferentiated-Ankylosing spondylitis-Psoriatic arthritis-Reactive arthritis (formerly Reiter’s syndrome)-Enteropathic arthritisSLE, Sjogrens, Scleroderma, Polymyalgiarheumatica, Vasculitis, Infectious(bacterial, viral, other), Undifferentiated connectivetissue disease
  • 12. Latinis, K.,et al TheWashington ManualRheumatologySubspecialty
  • 13. Rheumatoid Arthritis-Background Symmetric, inflammatory polyarthritis Affects ~1% of our population Occurs in women 3x more than men Etiology-Genetic, class II molecules (HLA-DRB1)-Autoimmune-?Environmental
  • 14. Rheumatoid Arthritis-Distribution Latinis, K., et al The Washington Manual Rheumatolog y Subspecialty
  • 15. Latinis, K.,et al TheWashington ManualRheumatologySubspecialty
  • 16. Systemic Lupus Erythematosus (Lupus)-BackgroundDefinition-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.
  • 17. Systemic Lupus Erythematosus (Lupus)-BackgroundClinical 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.
  • 18. Systemic lupus erythematosus classification criteria (SOAP BRAIN MD) 1. Serositis: 5. Blood/Hematologic disorder: (a) pleuritis, or (a) hemolytic anemia or (b) pericarditis (b) leukopenia of < 4.0 x 109 2. Oral ulcers (c) lymphopenia of < 1.5 x 109 3. Arthritis (d) thrombocytopenia < 100 X 109 4. Photosensitivity 6. Renal disorder: (a) proteinuria > 0.5 gm/24 h or 3+ dipstick or (b) cellular casts 7. Antinuclear antibody (positive ANA) 10. Malar rash 8. Immunologic disorders: 11. Discoid rash (a) raised anti-native DNA antibody binding or (b) anti-Sm antibody or (c) positive anti-phospholipid antibody work-up". ..A person shall be said to have SLE if four or 9. Neurological disorder:more of the 11 criteria are present, serially or (a) seizures orsimultaneously, during any interval of (b) psychosisobservation."
  • 19. 53 yo BF with severe generalized weakness,weight loss, and chronic psychosis Alopecia Psychosis Malar rash Arthritis
  • 20. Laboratory Data139 106 16 7.7 101 3.9 2984.3 21 1.4 22.3 MCV=8324 hour urine Absolute lymph=0.5Protein=514ESR=119 ANA + 1:5280CH50=67 (118-226) Anti DNA +C3=31 (83-185) Direct & Indirect Coombs +C4=18 (12-54) Anti-IgG +
  • 21. Treatment of SLEArthritis, arthralgias, myalgias: Glomerulonephritis NSAIDS, anti-malarials (eg. steroids Plaquenil), Steroids- pulse cytotoxics injections, oral methotrexate mycophenylate mofetilPhotosensitivity, dermatitis avoid Sun CNS diseaseexposure topical anti-coagulants for thrombosissteroids Plaquenil steroids and cytotoxics forWeight loss and fatigue vasculitis steroids Infarction (secondary to vasculitis)Abortion, fetal loss steroids ASA cytotoxics immunosuppression prostacyclinThrombosis Cytopenias anti-coagulants steroids IVIG-short term for thrombocytopenia danazol cytotoxics-if bone marrow status is known
  • 22. Steroids in LupusSteroid responsive Dermatitis Steroid non-responsive(local) Thrombosis Polyarthritis Chronic renal damage Serositis Hypertension Vasculitis Steroid-induced Hematological psychosis Glomerulonephritis (most) Infection Myelopathies
  • 23. ANA-When to order and how to follow up K., Latinis, on a positive test et al The Washingto n Manual Rheumatol ogy Subspecial ty Consult., L WW, 2003.
  • 24. Latinis, K.,et al TheWashington ManualRheumatologySubspecialtyConsult., LWW, 2003.
  • 25. Fibromyalgia-BackgroundChronic musculoskeletal pain syndrome ofunknown etiologyCharacterized by diffuse pain, tenderpoints, fatigue, and sleep disturbancesPrevalence is 2-5% with a female to malepredominance of 8:1Mean age is 30-60
  • 26. Fibromyalgia-Diagnosis
  • 27. 4 3 1 2 6 578 9
  • 28. Fibromyalgia-Treatment
  • 29. Low back pain andother peri-articular complaints-background Very common, one of the most frequent reasons to visit primary care physicians Articular 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
  • 30. Latinis, K.,et al TheWashington ManualRheumatologySubspecialty
  • 31. Latinis, K., et al TheWashington ManualRheumatologySubspecialty
  • 32. Latinis, K., etal TheWashingtonManualRheumatologySubspecialty
  • 33. Muscles of the rotator cuff: Supraspinatus Infraspinatus Subscapularis Teres Minor
  • 34. Low back pain andother peri-articular complaints-Treatment RICE -Rest -Ice -Compression -Elevation NSAIDs and analgesics Time Other
  • 35. General Musculoskeletal Exam Underutilized by primary care providers Should be simple and quick Goal is to recognize signs of rheumatologicaldiseases and determine if it is appropriate torefer to a rheumatologist or manageindependently
  • 36. Summary Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA) Lupus Fibromyalgia Low back pain and other peri-articularcomplaints General musculoskeletal exam (timepermitting)