This document provides an overview of common rheumatic problems seen in elderly patients. It discusses osteoarthritis, including its prevalence, risk factors, clinical presentation, diagnosis, and treatment options including joint replacement surgery. The document also briefly summarizes rheumatoid arthritis, systemic lupus erythematosus, fibromyalgia, and low back pain.

1. Rheumatic problems in Elderly

59. Rheumatology 101:
What you need to know for
your ambulatory medicine
experience
Kevin Latinis, M.D./Ph.D.
Division of Rheumatology
Dept. of Internal Medicine
klatinis@kumc.edu

60. Rheumatology 101
Arthritis
-Inflammatory (RA, spondyloarthropathies)
-Mechanical (OA)
Lupus
Fibromyalgia
Low back pain and other peri-articular
complaints
General musculoskeletal exam (time
permitting)

61. Mechanical vs. Inflammatory Arthritis
Latinis, K.,
et al The
Washingto
n Manual
Rheumatol
ogy
Subspecial
ty

62. 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 2020
Etiology
-primary idiopathic
-secondary

63. Osteoarthritis-Distribution
Bouchard’s
Heberden’s
Latinis, K., Dao, K,
Shepherd, R, Guti
errez, E, Velazque
z, C. The
Washington
Manual
Rheumatology
Subspecialty

65. Osteoarthritis-Diagnosis
Clinical
Supported by X-rays
Non-inflammatory lab data, if any

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

67. Osteoarthritis-Treatment
Joint 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 surgery
Other surgical procedures

68. Clinical Pearl:
Arthritis of the DIP joint
Psoriatic Arthritis (inflammatory) OA (non-inflammatory)

69. Inflammatory Arthritis
Rheumatoid arthritis
Spondyloarthropathies
-Undifferentiated
-Ankylosing spondylitis
-Psoriatic arthritis
-Reactive arthritis (formerly Reiter’s syndrome)
-Enteropathic arthritis
SLE, Sjogrens, Scleroderma, Polymyalgia
rheumatica, Vasculitis, Infectious
(bacterial, viral, other), Undifferentiated connective
tissue disease

70. Latinis, K.,
et al The
Washingto
n Manual
Rheumatol
ogy
Subspecial
ty

71. 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

72. Rheumatoid Arthritis-Distribution
Latinis, K., et
al
The
Washington
Manual
Rheumatolog
y Subspecialty

73. Latinis, K.,
et al The
Washingto
n Manual
Rheumatol
ogy
Subspecial
ty

74. Systemic Lupus Erythematosus
(Lupus)-Background
Definition
-An inflammatory multisystem disease of unknown etiology
with protean clinical and laboratory manifestations and a
variable course and prognosis.
-Immunologic aberrations give rise to excessive autoantibody
production, some of which cause cytotoxic damage, while
others participate in immune complex formation resulting in
immune inflammation.

75. Systemic Lupus Erythematosus
(Lupus)-Background
Clinical features
-Clinical manifestations may be constitutional or result from
inflammation in various organ systems including skin and
mucous 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 and
central nervous system, accounts for significant morbidity
and mortality.
-Morbidity and mortality result from tissue damage due to
the disease process or its therapy.

76. 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 or
simultaneously, during any interval of (b) psychosis
observation."

77. 53 yo BF with severe generalized weakness,
weight loss, and chronic psychosis
Alopecia Psychosis
Malar rash
Arthritis

78. Laboratory Data
139 106 16 7.7
101 3.9 298
4.3 21 1.4
22.3
MCV=83
24 hour urine Absolute lymph=0.5
Protein=514
ESR=119 ANA + 1:5280
CH50=67 (118-226) Anti DNA +
C3=31 (83-185) Direct & Indirect Coombs +
C4=18 (12-54) Anti-IgG +

80. Treatment of SLE
Arthritis, arthralgias, myalgias: Glomerulonephritis
NSAIDS, anti-malarials (eg. steroids
Plaquenil), Steroids- pulse cytotoxics
injections, oral methotrexate mycophenylate mofetil
Photosensitivity, dermatitis avoid Sun CNS disease
exposure topical anti-coagulants for thrombosis
steroids Plaquenil steroids and cytotoxics for
Weight loss and fatigue vasculitis
steroids Infarction (secondary to vasculitis)
Abortion, fetal loss steroids
ASA cytotoxics
immunosuppression prostacyclin
Thrombosis Cytopenias
anti-coagulants steroids
IVIG-short term for
thrombocytopenia
danazol
cytotoxics-if bone marrow status is
known

81. Steroids in Lupus
Steroid responsive Dermatitis Steroid non-responsive
(local) Thrombosis
Polyarthritis Chronic renal damage
Serositis Hypertension
Vasculitis Steroid-induced
Hematological psychosis
Glomerulonephritis (most) Infection
Myelopathies

82. 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.

83. Latinis, K.,
et al The
Washingto
n Manual
Rheumatol
ogy
Subspecial
ty
Consult., L
WW, 2003.

84. Fibromyalgia-Background
Chronic musculoskeletal pain syndrome of
unknown etiology
Characterized by diffuse pain, tender
points, fatigue, and sleep disturbances
Prevalence is 2-5% with a female to male
predominance of 8:1
Mean age is 30-60

85. Fibromyalgia-Diagnosis

86. 4
3
1
2
6
5
7
8
9

88. Fibromyalgia-Treatment

89. Low back pain and
other 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

90. Latinis, K.,
et al The
Washingto
n Manual
Rheumatol
ogy
Subspecial
ty

91. Latinis, K., et al The
Washington Manual
Rheumatology
Subspecialty

92. Latinis, K., et
al The
Washington
Manual
Rheumatolog
y
Subspecialty

93. Muscles of the rotator cuff:
Supraspinatus
Infraspinatus
Subscapularis
Teres Minor

95. Low back pain and
other peri-articular complaints-Treatment
RICE
-Rest
-Ice
-Compression
-Elevation
NSAIDs and
analgesics
Time
Other

96. General Musculoskeletal Exam
Underutilized by primary care providers
Should be simple and quick
Goal is to recognize signs of rheumatological
diseases and determine if it is appropriate to
refer to a rheumatologist or manage
independently

98. Summary
Arthritis
-Inflammatory (RA, spondyloarthropathies)
-Mechanical (OA)
Lupus
Fibromyalgia
Low back pain and other peri-articular
complaints
General musculoskeletal exam (time
permitting)