Geriatric Rheumatology

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A talk about Geriatric Rheumatology

Geriatric Rheumatology

  1. 1. Geriatric Rheumatology 楊宗翰 11/19, 2008
  2. 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. 3. 1923 1949 (26) vs 2008 (75)
  4. 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. 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. 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. 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. 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. 9. Anatomy of Joint Joint Pain: http://www.nlm.nih.gov/medlineplus/ency/article/003261.htm
  10. 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. 11. Hand
  12. 12. 40 – 50 – 60 – 70 – 80 - 90
  13. 13. 40 – 50 – 60 – 70 – 80 - 90
  14. 14. 40 – 50 – 60 – 70 – 80 - 90
  15. 15. 40 – 50 – 60 – 70 – 80 - 90
  16. 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. 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. 18.    
  19. 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>
  21. 22. Osteoarthritis <ul><li>Erosive osteoarthritis, an inflammatory form, often produces deforming bony overgrowth of the PIP and DIP joints. </li></ul>
  22. 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>
  23. 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>
  24. 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>
  25. 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>
  26. 31. 74 yo female RA for 30 yrs
  27. 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>
  28. 36. Biologics era (TNF, CD20, …) The complication of treatment …
  29. 37. Knee
  30. 38. 3 6
  31. 39. 7 8
  32. 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>
  33. 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>
  34. 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>
  35. 47. Systemic Rheumatic Disease (SRD) Connective Tissue Disease (CTD)
  36. 48. 20% of elderly patients (48-55%)
  37. 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>
  38. 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>
  39. 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>
  40. 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>
  41. 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>
  42. 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>
  43. 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>
  44. 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>
  45. 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>
  46. 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>

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