As the population of the United States ages, rheumatologic disease is quickly becoming one of the more common diagnoses encountered in the geriatric population. According to a recent study, more than 67 million Americans will have arthritis by 2030. In addition to increasing prevalence, disability associated with musculoskeletal disorders is increasing. A recent evaluation of the burden of disease found that worldwide disability associated with musculoskeletal disorders had more than tripled since 2004. With this increased burden of disease, there is a necessity for these diseases to be managed with an interdisciplinary approach. Through appropriate partnership of physical therapists, occupational therapists, physiatrists, orthopedic surgeons, and pain specialists, rheumatologic disease in the elderly can be effectively managed.
Osteoarthritis is the most common type of arthritis. According to 2005 US census data, approximately 27 million Americans suffer from osteoarthritis. Although osteoarthritis was once thought to be a normal consequence of aging, it is now felt to have more of a multifactorial etiology. It results from a complex interplay of a patient’s age, genetics, bone mass, hormonal influences, occupation, physical activity, and injuries.
Patients with osteoarthritis classically report joint pain that increases at night and with use. They may also have increasing stiffness after prolonged immobility; however, this stiffness should last for 30 minutes or less. Patients may suffer from primary and/or secondary osteoarthritis. Primary osteoarthritis most commonly affects the hands, spine, hips, knees and feet. Secondary osteoarthritis can affect any joint. Secondary osteoarthritis results from an underlying condition such as previous trauma, congenital disorders, endocrinology disorders (diabetes mellitus, acromegaly, hypothyroidism, hemachromatosis), or inflammatory arthritis (calcium pyrophosphate dehydrate deposition disease, rheumatoid arthritis, gout).
The physical examination of a patient with osteoarthritis is likely to reveal tender joints. Patients may also have enlarged joints from bony osteophyte formation or from joint effusions; however, the joints are neither warm nor erythematous. Warmth or erythema should lead to an evaluation for inflammatory causes of the patient’s joint pain. Aspiration of joint fluid can sometimes be helpful in making the diagnosis. Synovial fluid from a joint with osteoarthritis will be noninflammatory with less than 2,000 WBC/mm3. There are no laboratory tests or biomarkers that are helpful in establishing the diagnosis of osteoarthritis. Although osteoarthritis is primarily a clinical diagnosis, radiographs can be helpful to confirm the diagnosis and rule out more serious causes of pain such as fracture or malignancy.
Elderly women are at higher risk for development of hand osteoarthritis. Patients with osteoarthritis of the hands commonly have bony enlargement of the joints. The most commonly affected joints are the proximal interphalangeal (PIP) joints, distal interphalangeal (DIP) joints, and first carpometacarpal joints. Patients often report that the symptoms are increased in their dominant hand. Pain may significantly interfere with performance of the activities of daily living. A significant proportion of patients with hand osteoarthritis may have erosive disease. These patients may have striking bony proliferation, erythema, or warmth on physical examination. This presentation may often be confused with an inflammatory arthritis but is degenerative in its pathophysiology. Radiographs can sometimes be helpful in differentiating between these diagnoses. Radiographs of patients with hand osteoarthritis classically show joint space narrowing with subchondral sclerosis and marginal osteophytes. Radiographs of erosive osteoarthrits may also show subchondral erosions or a “gull wing” appearance of the distal interphalangeal joints.
The cervical and lumbar spine are the most common sites of spine osteoarthritis. Patients may relate pain, stiffness, and difficulty with movement of these areas. They may also have radicular symptoms if nerve root impingement or spinal stenosis exists. Imaging of the spine may show osteophytes resulting in foraminal narrowing, spinal stenosis, or spondylothesis.
Hip osteoarthritis classically presents as referred pain to the groin and thigh but the pain can also radiate to the buttock and knee. Patients usually report that the pain increases with walking but also with prolonged immobility. As the disease progresses, patients may demonstrate decreased range of motion. Radiographs of the hip in osteoarthritis will often show joint space narrowing with osteophyte formation.
The knee is the most common site of joint pain in the older adult. Risk factors for osteoarthritis of the knee include increased BMI, previous knee injury, smoking, older age, intensive physical activity, female gender, and presence of hand osteoarthritis. Patients with osteoarthritis of the knee usually report pain that is increased with ambulation, but they can also have stiffness after prolonged immobility. It may also lead to other joint strain secondary to an abnormal gait. Other sources of pain of the knee such as mechanical derangement, anserine bursitis, fracture, or referred pain from the hip or spine should be considered before making a diagnosis of osteoarthritis. Physical examination of a knee affected by osteoarthritis may show crepitus, bony proliferation, and valgus or varus deformity. It may also reveal joint swelling, but the synovial fluid will be noninflammatory with a white blood cell count less than 2,000 WBC/mm3. Radiographs may show joint space narrowing that is present more often in the medial joint compartment. They are also likely to show osteophytes.
While any joint of the feet can be affected by osteoarthritis, the first metatarsophalangeal (MTP) joint is most commonly involved. Older age and female sex are independent risk factors for developing arthritis of this joint. Patients classically have the physical finding of hallux valgus with lateral deviation at the first MTP joint. Hallux valgus may also result in formation of an inflamed bunion at the site, which may be confused with gout. Radiographs can help differentiate between the two with osteoarthritis of the first MTP showing the classic joint space narrowing and osteophytes.
Patients with osteoarthritis are treated with a combination of non-pharmacologic and pharmacologic modalities. Exercise should be encouraged, especially with knee osteoarthritis, as recent studies suggest that exercise, in combination with weight loss, is more effective in pain reduction than weight loss alone. Involvement of occupational and physical therapists is encouraged. Splints, taping, orthotics, and wedged insoles can be helpful adjuncts in treatment.
Pharmacologic treatments for osteoarthritis do not change the natural history of the disease; rather, they focus on management of pain. Acetaminophen is the first-line treatment for osteoarthritis with doses up to 4,000 mg daily showing significant reduction in osteoarthritis pain when compared to placebo. More recent recommendations suggest a maximum of 3,250 mg of acetaminophen daily. The efficacy of this dose in osteoarthritis has not been studied in a large randomized controlled trial. If nonpharmacologic treatments and acetaminophen do not help with the pain, topical nonsteroidal anti-inflammatory medications (NSAIDs) are often preferred in the elderly over oral NSAIDs. Oral NSAIDs can be used in the elderly with careful attention to the possible side effects such as gastrointestinal bleeding and hypercoagulability. Treatment with opioid analgesics may be necessary but should be used sparingly in the elderly due to increased falls and fractures. Supplementation with glucosamine and chondroitin sulfate remains controversial as large-scale studies have shown conflicting results.
Intra-articular injections of corticosteroids or hyaluronic acid often provide relief for patients who have failed nonpharmacologic and pharmacologic treatment. Any joint can be injected with corticosteroid, but the knee is the most common site. Studies have demonstrated that a large majority of patients will have relief with intra-articular steroid injections to their knee. Unfortunately, intra-articular injection with steroids is not curative, and the pain is likely to return. Injection of hyaluronic acid is primarily performed in the knee joint. Results from trials regarding the efficacy of viscosupplementation to the knee with hyaluronic acid have been conflicting with some trials suggesting benefit and others finding it no more effective than intra-articular placebo.
Surgery is an option for some patients who have failed nonoperative treatments. Joint replacement of the knee and the hip are the most common surgical treatments of osteoarthritis. As these are complicated surgeries associated with significant perioperative morbidity, elderly patients must be fully medically evaluated before joint replacement surgery is performed.
Rheumatoid arthritis (RA) affects approximately 1% of the world’s population. Recent studies suggest that, in patients older than 60, the overall prevalence may be as high as 2%. It is estimated that there are currently 1.3 million Americans living with RA. Females are affected more often than males.
Rheumatoid arthritis is a symmetric inflammatory polyarticular arthritis that classically affects the small joints of the hands and feet. It may also affect medium- and large-size joints; however, this is less typical than the small joint pattern. Patients usually describe stiffness that is increased in the morning, joint pain, and swelling, and, often, constitutional symptoms. Rheumatoid arthritis may present indolently over several months or may present acutely. The majority of patients with RA have a positive rheumatoid factor, but this is neither specific nor sensitive for the diagnosis of RA. Patients may also have a positive antibody to cyclic citrullinated peptide (CCP antibody). CCP antibody has high specificity for the diagnosis of RA but has a lower sensitivity. Radiographs early in RA may be normal. As the disease progresses, one may see periarticular osteopenia and juxta-articular erosions.
As rheumatoid arthritis often presents in younger people, many elderly with RA have been living with this disease for years. Patients without sustained access to disease modifying anti-rheumatic drugs may have serious morbidity from their RA. Patients with long-standing RA may have ulnar deviation of their hands, subluxation of numerous joints, swan neck and boutonniere deformities, joint contractures, and rheumatoid nodules. They may have undergone numerous orthopedic surgeries. With long-standing disease, patients may also suffer from extra-articular manifestations of RA such as: uveitis, scleritis, pulmonary fibrosis, and cardiovascular disease.
Elderly-onset RA occurs in patients older than 60 years of age and occurs equally among males and females. Symptoms are more likely to appear abruptly as opposed to insidiously. Large joints such as the shoulder are also more likely to be involved. Patients with elderly-onset RA are less likely to have a positive CCP antibody.
Oral medications are sometimes preferred by the geriatric patient. Nonsteroidal anti-inflammatory medications and corticosteroids may be used to help with pain; however, as these medications are not DMARDs, they should only be used as adjunctive therapy. Initial treatment with hydroxychloroquine or sulfasalazine may be considered for patients with very mild disease or for those with many comorbidities. The majority of patients with a new diagnosis of RA start with weekly oral methotrexate and daily folic acid supplementation. Methotrexate is generally well tolerated by the elderly; however, the weekly dosing schedule may sometimes be confusing to patients. If tight control of the rheumatoid arthritis is not achieved within the first 6 to 12 weeks, additional medications are added to the existing regimen. A recent trial of hydroxychloroquine, sulfasalazine, and methotrexate taken together has proven noninferior to methotrexate and etanercept together. Leflunomide is another oral medication that is often used by itself or in combination with other medications for RA. Tofacitinib was also recently approved for treatment of RA but data in the elderly is limited.
If oral medications do not control the disease or if they cannot be tolerated, biologic medications should be considered. The majority of biologic medications work best when used in combination with oral medications. Vaccinations such as pneumococcal, influenza, hepatitis B, and herpes zoster should be initiated, if possible, before the biologic medications are prescribed. Screening for tuberculosis should also occur before initiation of a biologic medication as these medications are associated with reactivation of latent tuberculosis. Tumor necrosis factor (TNF) alpha inhibitors are the most commonly used biologic medications for RA. Adalimumab, certolizumab, etanercept, golimumab, and infliximab are FDA approved for the treatment of RA. These medications have never been directly compared but seem to have similar efficacy in the treatment of RA. Choice between these medications is usually made based on patient preference and includes issues such as: route of administration, frequency of administration, and cost. Although elderly patients may seem to be at higher risk for adverse events, recent studies have demonstrated that these medications are as safe in the elderly as they are in the general population. Other options for patients who fail or cannot take TNF alpha inhibitors include rituximab, abatacept, and tocilizumab, although none of these medications have been studied specifically in the elderly.
Deposition of monosodium urate crystals (gout) or calcium pyrophosphate crystals (pseudogout) are the most common causes of crystal-induced arthritis. Another cause of crystal-induced arthritis in the elderly, albeit less common, is that induced by calcium phosphate hydroxyapatite crystals.
Joint pain induced by monosodium urate crystals most commonly affects men and postmenopausal women older than 65 years of age. There is an increasing risk for gout as one grows older due to increased hyperuricemia. Hyperuricemia is defined as a uric acid level greater than 7 mg/dL. Etiologies of hyperuricemia are likely to be multifactorial but may stem from longevity, increased use of diuretics and aspirin, and a higher prevalence of comorbidities such as hypertension, congestive heart failure, and renal failure. Patients may remain asymptomatic with hyperuricemia for many years before their first attack of gout; however, the degree of the hyperuricemia is directly linked to their risk of gout. As the uric acid rises greater than 7 mg/dL, the uric acid crystals can become insoluble and deposit into the joints or soft tissues, initiating a gout attack.
The majority of first gout attacks present with involvement of the metatarsophalangeal joint, foot, or ankle. However, in the elderly, a first attack of gout may be polyarticular or involve the hands. Once the acute attack has resolved, patients enter into the intercritical period where they are asymptomatic from gout. A large majority of patients will eventually experience another acute attack of gout. Over time, if patients remain untreated, the intercritical period shortens and gout can become chronic. Elderly patients with chronic gout may have diffuse tophi, which are sometimes misinterpreted as osteoarthritis.
The definitive diagnosis of acute gout should be established by direct visualization of intracellular monosodium urate crystals under polarized microscopy. Polarized microscopy will demonstrate strongly negative birefringent crystals. In intercritical or chronic gout, the crystals may still be present but not intracellular. Imaging of early acute gout may only show soft tissue swelling or the presence of a joint effusion. Classic radiographic features such as erosions with sclerotic margins and overhanging edges may not be present until many years after the first attack of gout. Visualization of tophi on imaging may also take several years.
The treatment of gout in the elderly is essentially the same as that of the general population with the caveat that careful attention must be paid to medication side effects. Colchicine or NSAIDs are most commonly used for the acute episodes. Colchicine is usually prescribed according to renal function and provider discretion. NSAIDs may also help with the inflammation of gout; however, they must be used cautiously in the elderly population as geriatric patients are more likely to experience gastrointestinal, renal, and cardiovascular side effects from NSAIDs. If colchicine or NSAIDs are not tolerated or do not control the symptoms, intra-articular or oral corticosteroids can be used.
Patients who have chronic frequent gout attacks, a severe polyarticular presentation of acute gout, or tophaceous deposits will benefit from medications to lower their uric acid levels. A serum uric acid level below 6 mg/dL is associated with less frequent gout attacks. Allopurinol, febuxostat, probenecid, and pegloticase are FDA-approved treatments for lowering uric acid in gout. These medications should not be initiated nor should dosage be adjusted during an acute episode of gout as this may prolong the acute attack. Allopurinol and febuxostat both inhibit xanthine oxidase. Although rare, allopurinol (and not febuxostat) is associated with a severe hypersensitivity syndrome. This allergic reaction occurs more often in patients with renal insufficiency; however, the drug can still be used cautiously in renal insufficiency.[22, 23] Febuxostat is an option for those who are allergic to allopurinol. It is also approved for use in patients with renal dysfunction as long as the creatinine clearance is greater than 30 mL/min. Probenecid is an uricosuric agent; however, as it is associated with increased nephrolithiasis and cannot be used in patients with renal dysfunction, it is not often prescribed for the elderly. Pegloticase has been recently approved by the FDA. It effectively and rapidly lowers serum uric acid levels, but its use is limited by the development of antibodies to pegloticase and by its high cost.
Elderly patients with gout may also suffer from the effects of polypharmacy. As the use of diuretics may increase serum uric acid, efforts should be made by physicians to try to limit the use of these medications in gout patients. Aspirin can also increase serum uric acid levels; thus, it is important to ensure that patients with gout who are taking aspirin have a definite need for this medication.