Geriatric Rheumatology

Thaddeus A. Osial, Jr. MC FACP, FACR Margolis Rheumatology Assoc. UPMC Goals

• Review selected rheumatic diseases commonly seen in the elderly • Review unique presentations of rheumatic diseases as seen in the elderly Rheumatic Diseases in the Elderly Diseases primarily seen in the Diseases with variable elderly manifestations in the elderly

• Polymyalgia Rheumatica • Gout • Temporal Arteritis • Rheumatoid arthritis • CPPD (calcium pyrophosphate • Lupus depostion disease) • Osteoarthritis • RS3PE (Remitting Seronegative Symmetrical Synovitis with Pitting Edema

Case Presentation

• 73 y.o. woman with gradual enlargement of her finger joints • Concerned she has “crippling arthritis” • Mother / sister had similar “deformities” • Some are tender, others were tender in the past • Also sore at the base of the thumb • Some difficulty opening jars, turning knobs etc

Case

• 73 yo woman with gradual enlargement of her finger joints • Concerned she has “crippling arthritis” • Mother / sister had similar “deformities” • Some are tender, others were tender • Also sore at the base of the thumb • Some difficulty opening jars, turning knobs etc • Her knees are also painful when she walks

Osteoarthritis: Typical symptoms • Joint pain, often use-related • Distribution often patchy and asymmetrical • Gelling of joints after inactivity • Loss of range of motion • Bony enlargement, sometimes an effusion • Absence of systemic features • Non-inflammatory joint fluid • Normal lab studies

Epidemiology of OA

• Estimates of the prevalence are imprecise because of difficulties in definition. • 80% over 55 have x-ray evidence. • 50 million (22%) of adults have self- reported doctor-diagnosed arthritis. • 21 million (9% of all adults) have arthritis- attributable activity limitation

Center for Disease Control

Prevalence of arthritis by age group Epidemiology of OA

Hootman JM, Jeffrey Sacks JJ, Helmick CG. Arth Rheum 2004 RA vs. OA Patterns of Joint Involvement Osteoarthritis of the Medial Side of the Knee.

Felson DT. N Engl J Med 2006;354:841-848.

Osteoarthritis Osteoarthritis of the hands Osteoarthritis: knees, medial and lateral cartilage degeneration (radiographs)

Goals of OA Management

• Control pain and other symptoms. • Correct functional limitations and disability. • Effective use of medications

Treatment of Osteoarthritis

Severe

Surgery Narcotics IA steroids Hyaluronic acid Prescription Oral and topical NSAIDs OTC NSAIDs Acetaminophen

Patient education Physical and occupational therapy Weight reduction, exercise, assistive devices Mild ? Topical analgesics ? Glucosamine, chondroitin Severity of symptoms Pharmacologic Treatment for Osteoarthritis of the Knee.

Felson DT. N Engl J Med 2006;354:841-848. What drugs should be used for osteoarthritis?

Efficacy & Safety Cost

Cartilage “re-growth” Cartilgage “re-growth”

Inflammatory Osteoarthritis Heberden’s Nodes

Subcutaneous Deposits (tophi) GOUT Crystalline Arthritis

• Gout • Pseudogout

Gout in the Elderly

• Renal insufficiency • Medications (eg diuretics) • Comorbid conditions (eg myeloproliferative diseases) • May be polyarticular (esp. in later stage disease) and involve less typical joints Monosodium Urate Crystal Diagnositic Points: Gout • Acute monoarthritis with intercritical periods • Maximum inflammation within 24 hours • Unilateral 1st MTP involvement • Visible or palpable lesion suggestive of tophi Gout: Massive Tophi Diagnositic Points: Gout • Acute monoarthritis with intercritical periods • Maximum inflammation within 24 hours • Unilateral 1st MTP involvement • Visible or palpable lesion suggestive of tophi • Hyperuricemia • Subcortical bone cyst on x-ray Gout X-ray Gout Diagnositic Points: Gout

• Acute monoarthritis with intercritical periods • Maximum inflammation within 24 hours • Unilateral 1st MTP involvement • Visible or palpable lesion suggestive of tophi • Hyperuricemia • Subcortical bone cyst on x-ray

Treatment of Gout

• Care with use of NSAIDs and colchicine (re: renal insufficiency, risk of bone marrow toxicity) • Corticosteroid injection remain an option for acute disease (and to confirm diagnosis) as do po steroids • Long term treatment with goal of SUA <6 (or lower) • Slow initiation of allopurinol, initially 50-100 mg/d (potential greater risk of hypersensitivity) • Still may slowly increase dose to 300+mg/d to reach goal

Calcium Pyrophosphate Crystal CPPD (knee) CPPD wrist Pseudogout

• Acute/subacute mono or oligoarthritis • Knee/wrist/ankle primarily involved • Usually last up to 10 days, but may cluster • Precipitated by trauma/illness/surgery • May have systemic features (e.g. fever) • May also present with a chronic, “pseudo- RA” picture

CPPD

• Asymptomatic radiographic finding • Acute arthritis ie pseudogout • Chronic arthritis ie pseudo RA • Pyrophosphate arthropathy Pyrophosphate arthropathy Evaluation/Treatment of Pseudogout

• Acute episodes may respond to steroids, intra-articular steroids, NSAIDs and colchicine • Prophylactic treatment with colchicine may be effective, but variable (0.6 mg daily or qod) • Search for an underlying cause (hypercalcemia, hyperparathyroidism, hemochromatosis, hypothyroidism) • Treatment of the underlying disease may not affect the arthritis • Check Ca/P/Mg, ferritin, iron, TIBC, TSH

Regional Musculoskeletal Problems Milwaukee Shoulder

Psoriatic arthritis: hands, nail changes, rash, and arthritis

INFECTION (septic bursitis or arthritis?) Case (continued)

• Several months of increasing fatigue “getting older” • Pronounced AM stiffness for several hours, hard to get out of bed and get dressed • Shoulders painful, hips and neck somewhat less • Appetite isn’t a good • Mild swelling of the fingers and wrists • Limited findings on exam; some difficulty raising arms over head due to pain, equivocal MCP swelling and knee swelling

Possible diagnosis

Polymyalgia rheumatica • Age > 50, peaks between 70 and 80 • Bilateral aching and stiffness for >1 month, involving neck/shoulders (upper arms)/hips (upper thighs) • Morning stiffness > 1 hour • Elevated sedimentation rate (in most) or CRP • Rapid response to prednisone • EXCLUSION OF OTHER DISEASES • Due to synovitis of joints and surrounding structures (eg subdeltoid and subacromial bursitis)

The Hands of a Patient with Untreated Polymyalgia Rheumatica.

Salvarani C et al. N Engl J Med 2002;347:261-271. RS3PE (Remitting Seronegative Symmetrical Synovitis with Pitting Edema • Sudden onset of bilateral symmetrical synovitis of wrists, small hand joints, flexor tendon sheaths, and dorsal hand swelling • Distal not proximal symptoms predominate • Rheumatoid factor (-), elevated ESR • May respond to low dose steroids • If unresponsive, consider a malignancy (adenocarcinoma, lymphoma) • Non-erosive, possibly part of PMR spectrum

RS3PE

Possible diagnosis Giant Cell Arteritis (GCA)

• ~16-21% of PMR patients have GCA • ~40-60% of GCA patients have PMR sx • PMR sx may occur anywhere in the course of GCA • Classic symptoms: – Headaches – Temporal scalp tenderness

GCA: Head Pain

• Prominent • “Unlike any other headache” • Constant, severe, often nocturnal • Scalp tenderness (eg laying on the pillow hurts) • Temporal or frontal, occipital, parietal • Facial, ear, jaw , neck tenderness

Possible diagnosis Giant Cell Arteritis

• ~16-21% of PMR patients have GCA • ~40-60% of GCA patients have PMR sx • PMR sx may occur anywhere in the course of GCA • Classic symptoms: – Headaches – Temporal scalp tenderness – Visual changes

GCA:Visual

• Diplopia • Blurring • Loss of part of visual fields • Visual aura • Ocular pain • Amaurosis fugax (high risk for permanent loss) • USUALLY due to anterior optic ischemia

Possible diagnosis Giant Cell Arteritis

• ~16-21% of PMR patients have GCA • ~40-60% of GCA patients have PMR sx • PMR sx may occur anywhere in the course of GCA • Classic symptoms: – Headaches – Temporal scalp tenderness – Visual changes – Jaw claudication (~35-50%) STRONGLY SUGGESTIVE SX

GCA: Jaw Claudication

• Pain after chewing for awhile relieved by rest (ie. Claudication) • May be episodic for weeks or months • NOT TMJ syndrome, etc • Less common: sore tongue, reduced opening of jaw • Less specific: jaw pain, tooth or gum pain • 50% or fewer of patients, but highly specific

Possible diagnosis Giant Cell Arteritis

• ~16-21% of PMR patients have GCA • ~40-60% of GCA patients have PMR sx • PMR sx may occur anywhere in the course of GCA • Classic symptoms: – Headaches – Temporal scalp tenderness – Visual changes – Jaw claudication (~35-50%) STRONGLY SUGGESTIVE SX – Misc: fever (cause of FUO, occ. Sepsis-like with high fevers, rigors, sweats), malaise, anorexia, sore throat/hoarseness, claudication of arms – Late thoracic aortic aneurysm

Thoracic aortic aneurysm in GCA Possible diagnosis

Giant Cell Arteritis

• Elevated ESR >40-50 in most GCA and PMR • ~10% with normal ESR in GCA and PMR • Elevated CRP, mild NCNC anemia, mild alkaline phosphatase elevation • Who to biopsy??? - suspected TA - patient with cranial nerve signs or sx • Can be positive up to 2 weeks after initiation of Rx • Adequate biopsy (3-5 cm), occasionally contralateral side

Temporal Artery Biopsy GCA Treatment

• PMR: Prednisone 15-20 mg/d Begin taper in several weeks Example: 2.5/d. every month to 10 mg Then 1mg/month Consider osteoporosis prophylaxis

• Persisting elevated ESR, poor response: ?GCA, ?malignancy, ?infection • Watch for peripheral arthritis as prednisone is tapered (e.g. late onset RA) Treatment

• GCA: Prednisone 40-60 mg/day Prednisone 60mg/d. if ischemic symptoms IV methylprednisolone (500mg) x 2-3 days if acute visual changes or loss

• Begin to taper at 1 month if stable (by 5 mg/d every few weeks to 20 then more slowly • Watch ESR more closely than with PMR • Rare for further visual problems after treatment begun • Consider “flare” being other problems (eg OA that responded to prednisone in both GCA and PMR RA in the elderly Clinical Presentation of RA: Key Presenting Signs and Symptoms

• Joint pain • Symmetric swelling of small peripheral joints • Morning joint stiffness of prolonged duration Rheumatoid Arthritis: Key Features • Symptoms >6 weeks’ duration • Often lasts the remainder of the patient’s life • Inflammatory synovitis • Palpable synovial swelling • Morning stiffness >1 hour, fatigue • Symmetrical and polyarticular (>3 joints) • Typically involves wrists, MCP, and PIP joints • Typically spares certain joints • Thoracolumbar spine • DIPs of the fingers and IPs of the toes

RA: fusiform swelling RA: Late Stage Deformities Signs and Symptoms of Early RA: Screening

• 3 swollen joints • MTP/MCP involvement – Squeeze test positive • Morning stiffness  30 min

Emery P et al. Ann Rheum Dis. 2002;61:290-297. Possible diagnosis

Elderly onset RA

• More equal gender distribution • Higher frequency of acute onset • More frequent shoulder girdle involvement (ie PMR-like presentation) than a younger population • More frequent constitutional symptoms (fever, weight loss, fatigue) • Consider seronegative inflammatory arthritis • Remember (+) RF occurs more commonly in the elderly even without RA and also with hepatitis C

Elderly onset RA special considerations

• Prognosis probably worse than younger patients with seropositive RA • May reflect comorbidities, poorer tolerance of medications, some with longer term disease • Therapy considerations: Risks of NSAID gi toxicity, renal insufficiency, exacerbations of HBP and CHP, CNS effects and concerns re: CAD Risks of DMARDs: myelosuppression, infections, coexisting renal insufficiency Insurance/$$ issues especially regarding biological agents

Seronegative arthritis of the elderly

• May begin with PMR-like picture, but have or develop more distal joint involvement • May follow a benign course, although erosive disease may occur • Seems to part of the spectrum of PMR in some cases

Paraneoplastic syndromes

• Dermatomyositis: 3-7x increase, ~10-15% -Age –typical: adenocarcinomas of the lung, breast, ovaries, pancreas, bladder, stomach -Eval: H/P, labs (CBC, ESR, R&M, CMP, ?PSA, ?CA125, stool guiac) -Consider colonoscopy, CT scans, pelvic sonography -Lower risk after 2 years from diagnosis

Paraneoplastic syndromes

• Atypical RA/PMR: explosive onset, asymetrical, RF negative • Palmar fasciitis: associated with ovarian cancer (and less commonly pancreas, lung, colon Palmar fasciitis Hypertrophic Pulmonary Osteoarthropathy Paraneoplastic syndromes

• Atypical RA/PMR: explosive onset, RF (-) asymmetrical • Palmar fasciitis: associated with ovarian cancer (and less commonly pancreas, lung, colon • Hypertrophic osteoarthropathy (clubbing) ------• Aromatase inhibitors: arthralgias, joint stiffness, frank inflammatory arthritis, tenosynovitis esp. in older women

Rheumatological Medications in the Elderly

• NSAIDs: concerns re: GI, HBP, CAD, fluid retention, confusion. • Corticosteroids: osteoporosis, AVN, glucose intolerance, risk of infections, cataracts • Methotrexate: hematological suppression (esp with renal insufficiency and malnutrition) • Colchicine: heme risks with CRF • Biological agents: infection risks • Bisphosphonates: contraindicated with CRF