Rheumatic problems in elderly

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some important musculoskeletal affliction in elderly

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Rheumatic problems in elderly

  1. 1. Rheumatic problems in Elderly
  2. 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. 3. Rheumatology 101 Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA) Lupus Fibromyalgia Low back pain and other peri-articularcomplaints General musculoskeletal exam (timepermitting)
  4. 4. Mechanical vs. Inflammatory Arthritis Latinis, K., et al The Washingto n Manual Rheumatol ogy Subspecial ty
  5. 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. 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. 7. Osteoarthritis-DiagnosisClinicalSupported by X-raysNon-inflammatory lab data, if any
  8. 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. 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. 10. Clinical Pearl: Arthritis of the DIP jointPsoriatic Arthritis (inflammatory) OA (non-inflammatory)
  11. 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. 12. Latinis, K.,et al TheWashington ManualRheumatologySubspecialty
  13. 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. 14. Rheumatoid Arthritis-Distribution Latinis, K., et al The Washington Manual Rheumatolog y Subspecialty
  15. 15. Latinis, K.,et al TheWashington ManualRheumatologySubspecialty
  16. 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. 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. 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. 19. 53 yo BF with severe generalized weakness,weight loss, and chronic psychosis Alopecia Psychosis Malar rash Arthritis
  20. 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. 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. 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. 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. 24. Latinis, K.,et al TheWashington ManualRheumatologySubspecialtyConsult., LWW, 2003.
  25. 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. 26. Fibromyalgia-Diagnosis
  27. 27. 4 3 1 2 6 578 9
  28. 28. Fibromyalgia-Treatment
  29. 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. 30. Latinis, K.,et al TheWashington ManualRheumatologySubspecialty
  31. 31. Latinis, K., et al TheWashington ManualRheumatologySubspecialty
  32. 32. Latinis, K., etal TheWashingtonManualRheumatologySubspecialty
  33. 33. Muscles of the rotator cuff: Supraspinatus Infraspinatus Subscapularis Teres Minor
  34. 34. Low back pain andother peri-articular complaints-Treatment RICE -Rest -Ice -Compression -Elevation NSAIDs and analgesics Time Other
  35. 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. 36. Summary Arthritis-Inflammatory (RA, spondyloarthropathies)-Mechanical (OA) Lupus Fibromyalgia Low back pain and other peri-articularcomplaints General musculoskeletal exam (timepermitting)

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