Rheumatic Diseases in the Elderly

Recent demographic trends have revealed a new phenomenon occurring globally. People of the older age group are progressively increasing in numbers. In most countries the fastest growing segment of the population is the oldest. All the same time, mortality rates change at later ages. When plotted against age, the graph of the log of morality rate for each year gives a straight line.

The overlap between geriatrics and rheumatology becomes increasingly obvious because of two factors. First, when an increasingly fraction of the population belongs to the geriatric age group, an increasing component of practice of all physicians including rheumatologists, will cater to the needs of geriatric patients. Secondly, musculoskeletal problems, especially arthritis, are most troublesome for the elederly.¹ In this article the salient features of various rheumatic disorders in the elderly will be briefly outlined.

A multiplicity of short lasting joint pains and stiffness are associated with aging. However, it is important to appreciate that some disorders like polymyalgia rheumatica and giant cell arteritis occur mainly in the older age.^2,3 Clinical manifestations of some disorders in the older age are different from those seen in the young.⁴ Finally, the type and dosage of drugs may have to be altered due to different kinetics and increased risk of side effects. ⁵

One of the basic tenets of geriatric medicine is that the clinical profile of several disease states in the elderly is vastly different from that seen in people in the middle age. Consequently, classically described presentations are often absent. This is especially true of Sjogren’s syndrome, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and osteoarthritis (OA). ^6-9

Osteoarthritis and Crystal Induced Arthropathies

Even though OA and aging are not synonymous, there is a permissive element in the aging human cartilage that facilitates the development of OA in a disproportionately higher percentage of individuals belonging to the geriatric population.¹⁰ The incidence of OA from age 40 onwards is roughly equal to or slightly more than the numerical age group (e.g. 40% after age 40-55 and up to 85% after age 70).¹¹ In addition, in several cases OA may be secondary to other conditions like crystal induced arthritis caused by monosodium urate (gout) arthritis or calcium pyrophosphate deposition disease (CPPD).¹² If OA is suspected but there are signs of inflammation in the joint (e.g. swelling and tenderness ) the OA may have been complicated by crystals, infection or both. ^13,14 OA most often involves knees and hips. At times it may be generalized. There is usually deep active pain with motion that is relieved by rest, short lasting stiffness and limitation of motion. Eventually the joint space may be completely lost. At this stage the only modality of therapy left could be joint replacement.

Degenerative changes in the spine

These occur increasingly with advancing age and almost all individuals over the age of 70 years have one or more of this degenerative conditions. Arthritis of the facet or apohyseal joints: This involves the inferior articular process of one vertebra and the superior articular process of the one below it. It occurs almost universally in those over 60 years of age. Sclerosis occurring as a reaction may result in osteophyte formation and may eventually narrow the intervertebral foramina that could compress nerve roots exiting from there. The spectrum of symptoms may vary from mild low back pain to nerve root compression to spinal “claudication”. The common site in the lumbar region is the L4-5 level and if the cervical region is involved then the most common sites are C5-6 and C6-7.¹⁵

Lumbar canal stenosis: The clinical hallmarks of this disorder are pseudo-claudication, spinal claudication or neuropathic claudication.¹⁶ In one series these were present in 94% of 68 patients reported. Numbness or tingling was reported in 63% and weakness in 43%.¹⁷ Lateral spinal x-ray could show the canal size to be less than 15 mm wide.¹⁸ However, CT can with myelography or MRI are better modalities for diagnosis. Surgical decompression at the appropriate levels can produce partial or complete resolution of symptoms in over 80% of patients.¹⁸

Diffuse Idiopathic Skeletal Hyperostosis (DISH) : This occurs mainly in the middle and older age group. The diagnostic hallmark is the radiological changes showing “dripping wax candle” calcification of the anterior and lateral ligaments involving four adjacent vertebra. The thoracic region is usually affected and these findings closely resemble those seen in fluorosis. Treatment is symptomatic.¹⁹

Vertebral Crush and Wedge Fractures: These affect postmenopausal women and are a consequence of senile osteoporosis.²⁰ The presentation is with acute onset of pain in the area of affected vertebra, worsens on motion and becomes relieved on lying flat. Treatment is symptomatic. Atlantoaxial subluxation (AAS) secondary to OA of the cervical spine has been described in patients with severe cervical OA. Thus, OA should be added to the causes of AAS, and conversely AAS should be assessed in cases with severe OA of the upper cervical spine.²¹

Rheumatoid arthritis

RA in the elderly individuals is often manifested by stiffness, limb girdle pain and diffuse boggy swelling of the hands, wrists and forearms. Onset of RA after age 60 has lesser chances of subcutaneous nodules or rheumatoid factor (RF). There is generally a more benign course than younger patients, lower frequency of RF positivity and a higher frequency of HLA-DR4 phenotype.²² The onset of disease is generally slow but inactivity stiffness may be incapacitating. In other characteristics the disease presentation is similar to that seen in the younger individuals. However, if for some reason there is stroke or paralysis of one side for some reason there may be a striking asymmetry or even unilateral involvement because of the disease. Joints may be spared on the paralyzed side and the degree of protection roughly parallels the extent of paralysis. However, if there is preexisting RA the protective effect is less.

Systemic Lupus Erythematosus

In an elderly patient who present with polyarthritis, pleuropericarditis and positive antinuclear antibodies SLE should be suspected.²³ Less than 15% patients with SLE are above the age of 55 years. There could be fever skin rash, neurological and hematological abnormalities. However, the disease is generally milder with fewer renal and more serositis and joint manifestations and generally resembles lupus induced by drugs.

Vasculitic Disorders

Temporal arteritis is a prototype vasculitic disorder in the elderly. It is often associated with pain and stiffness in both shoulders and hips. ⁵ Subset of these patients may present with features of pyrexia of unknown origin.² In general, vasculitic disorders in the elderly are often diagnosed after a significant latency. For instance in a study of patients with Wegener’s granulomatosis there was delay by months to year in the older individuals as compared to the young.²⁴ Death occurred within 2 years of diagnosis in 85% patients more than 60 years old as compared to 10% of those who were less than 60 years old.²⁴

Associated occult neoplasia

The association of malignancy with certain rheumatic syndromes has been convincingly established, such as asymmetric polyarthritis presenting in the elderly with an explosive onset, rheumatoid arthritis with monoclonal gammopathy, Sjogren’s syndrome with monoclonality, hypertrophic osteoarthropathy, dermatomyositis, polymyalgia rheumatica with atypical features, Lambert-Eaton myasthenic syndrome, palmar fasciitis and arthritis, eosinophilic fasciitis poorly responsive to corticosteroid therapy, erythema nodosum lasting more than 6 months, and onset of Raynaud’s phenomenon or cutaneous leukocytoclastic vasculitis after age 50 years.²⁵ The list of cancer-associated rheumatic syndromes is extending by inclusion of additional entities such as benign edematous polysynovitis, sacroiliitis, adult-onset Still’s disease, dermatomyositis sine myositis, systemic sclerosis, Sweet’s syndrome, osteomalacia, skeletal hyperostosis, antiphospholipid syndrome, and essential mixed cryoglobulinemia. Certain long-standing rheumatic syndromes, in particular rheumatoid arthritis, Felty’s syndrome, Sjogren’s syndrome, dermatomyositis, systemic sclerosis, systemic lupus erythematosus, and temporal arteritis behave like “premalignant conditions.”

Practical Prescribing in the Elderly

With advancing age there is a general decrease in functional reserve of all organs and doses and frequency of dosing of several drugs have to be reduced.²⁶ According to one estimate gastropathy associated with nonsteroidal anti-inflammatory drug (NSAIDS) may be the most frequent drug side effect. There are several reasons for the occurrence of increased side effects among older individuals. These include inherent toxicity of the drug itself. Pharmacodynamics may be altered due to the aging process and changes in binding of drugs to albumin.^25,27 Nutritional deficiency often occurs in the elderly. Several other drugs may be consumed simultaneously because of other concomitant disorders. The risk of drug interactions goes up correspondingly. There may be errors in complying with the instructions resulting in overdose of one more drugs.

In order to reduce the risk of adverse reactions in older individuals certain guidelines need to be followed.²⁷ The drugs history is important. Knowledge of dose modifications for the elderly is essential. As far as possible a diagnosis should be established before starting therapy. Smaller dose should be used initially and subsequently dose adjusted according to the patient’s response. Simplify treatment requirement as far as possible because of side effect due to drug.

In subspecialty practice patterns, referral to rheumatologists, and utilization of aspiration and injection procedures in a population-based sample of elderly individuals was quite inadequate in an analysis made in the West.²⁸ For most rheumatic disorders in the elderly what is more important is to restore to the individuals a state of physical functioning that keep him/her independent of the help of her relatives. Treatment has to be adjusted to the patients need and functional reserve. Therapy should be monitored closely for toxicity.

Acknowledgement:

The author wishes to thank the Editor of Journal of Indian Rheumatism Association. This article will appear soon in this Journal

References

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A Wanchu, M.D, D.M
Assistant Professor, Department of Internal Medicine
Postgraduate Institute of Medical Education and Research, Chandigarh

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