Edna P. Schwab, M.D. Associate Professor of Clinical Medicine. Philadelphia VAMC

Size: px

Start display at page:

Download "Edna P. Schwab, M.D. Associate Professor of Clinical Medicine. Philadelphia VAMC"

August Elliott
7 years ago
Views:

1 Impact of Arthritis in the Elderly l Edna P. Schwab, M.D. Associate Professor of Clinical Medicine Division of Geriatrics Philadelphia VAMC University of Pennsylvania Medical Center

3 Arthritis America s most common chronic condition in adults over 65 y.o. In 1995: 40 million persons were affected In 2020: 60 million people will be affected or 18.2% of population

4 Prevalence National Long Term Care Survey found arthritis to be most prevalent diagnosis Followed by dementia, athlerosclerosis Under 44 years 5.1%, years 36.5%, 45% years, 55.2% years and 57% > 85 years

dementia, athlerosclerosis Under 44 years 5.

5 Impact on Activities 78% limited it in one physical activity it 34% limited in 5 or more activities 36% limited in ADL abilities Many report poor self rated health When present with another co-morbid condition (CHF, COPD) and an ADL impairment, they are 5 times more likely to require nursing home placement

rated health When present with another co-morbid condition (CHF, COPD) and

6 Impact of Arthritis on Older Adult Decreasing independence Increasing falls/ unsteady gait Difficulty with self care Increase utilization of health care services ($140 Billion direct and indirect costs) Psychological impact: Depression, dependence, fear, anxiety

Increase utilization of health care services ($140 Billion direct

7 Diagnostic Dilemmas Pain may be under reported Cognitive impairment delays accurate history Atypical disease presentations (present with functional impairment) False positive serologies Multiple coexisting conditions may confound presentation Difficult to maneuver through the health care system

functional impairment) False positive serologies Multiple coexisting

8 Arthritis in the Elderly Osteoarthritis Crystal diseases Gout CPPD Hydroxyapatite disease (Milwaukee Shoulder) Treatment Special considerations in the elderly

9 Assessment of Arthritis History Physical examination Radiographs Weight bearing films Laboratory CBC, ESR,CRP, chemistry, uric acid level, l serologies Joint fluid crystal, cell count, culture

10 Osteoarthritis Etiology Pathology Natural History Risk Factors Features

12 Osteoarthritis Epidemiology Radiographically present in 83% men and 87% women over age 55 y.o. Joint pain present in 15% - 20% Severity of joint pain does not correlate with radiographic abnormalities

13 Joints Affected in Osteoarthritis Localized or generalized disease Hands Bouchard s and Heberden s nodes First CMC C-spine, L/S spine Hips Knees Feet

14 Features of Osteoarthritis Early morning stiffness less than 30 minutes Pain with activity and relieved with rest Limited range of motion, joint deformity, joint tenderness, crepitus, and effusion Inflammation is mild Lab findings normal, synovial fluid low WBC Radiographs joint space narrowing, osteophytes,subchondral t h sclerosis and subchondral cysts

tenderness, crepitus, and effusion Inflammation is mild Lab findings normal, synovial

15 Pathogenesis of OA Biochemical Breakdown Collagen/Proteoglycan Matrix Disrupted Trigger? Cell Injury Release of Destructive Enzymes (MMP. Aggrecanase, cathepsin B, plasminogen activator) Cartilage Breakdown Activation of Inflammatory Response Bone Remodeling

16 Risk Factors Age Female Genetic predisposition Obesity Previous injury Underlying arthropathy Congenital abnormalities Occupation Abnormal biomechanics and physical loading Menopausal status Bone density Quadriceps weakness

abnormalities Occupation Abnormal biomechanics and

21 Treatment Considerations in the Elderly Multiple morbidities - CHF, CKD, CVA, PUD Physiologic og alterations a in organ systems: s renal, hepatic function Altered drug distribution, metabolism and elimination Altered end organ sensitivity to certain drugs Drug-drug interactions Increased incidence of adverse effects

22 Physiologic Changes with Aging g that Affect Drug Distribution Absorption Distribution Elimination Hepatic metabolism Renal excretion Altered physiology increased gastric ph Decreased gastrointestinal blood flow Reduced cell mass in gastrointestinal mucosa Reduced total body water Decreased lean body mass Increased body fat Rd Reduced dserum albumin Decreased hepatic blood flow Decreased hepatic mass Reduced enzyme activity Decreased renal plasma flow Decreased glomerular filtration rate Decreased tubular function

23 Treatment Options Nonpharmacologic therapy Behavioral modification (weight loss), education Prevention, joint protection, bracing; subtalar strapping with lateral wedge insole (varus deformity) Relaxation techniques and psychological counselling Physical therapy-increase extensor/flexor strength Aerobic and aquatic exercise

24 Pharmacologic Treatment Non-narcotic Analgesics Topical Agents NSAIDs Assess risk factors for toxicity Monitor for toxicity Treat older high risk patients with gastroprotective agents Safety concerns with cox 2 inhibitor due to increased risk of MI Narcotics

25 Pharmacologic Treatment (continued) Intra-articular articular and soft tissue injections triamcinolone or methylprednisolone Adverse rx: septic arthritis: 5-50% crystal induced inflammation w/i 24h osteonecrosis local cutaneous atrophy/rash tendon rupture calcinosis steroid arthropathy Chondroprotective agents Sinvisc or hyalgan (?mechanism of action) Adverse rx: infection,post injection pain 1-27%

26 Complementary and Alternative Medicine Acupuncture studies equivocal Glucosamine- Chondroiten sulfate Lancet 2001 results of trial suggest efficacy in both limiting joint space narrowing and improved womac scores in treated patients 1500mg daily BMJ 2010: no benefit with glucosamine/chondroiten sulfate Other studies which were RCT s did not show efficacy when compared to placebo in reducing pain from OA of knee Toxicity-generally found to be safe w/few reports of insulin resistance theoretical concern for development of atherosclerosis

27 Invasive Therapy Arthroscopy Saline lavage Surgery Debridement Total Joint Replacement

Rheumatoid Arthritis. Nicole Klett,, M.D.

Rheumatoid Arthritis. Nicole Klett,, M.D. Rheumatoid Arthritis Nicole Klett,, M.D. Rheumatoid Arthritis Systemic Chronic Inflammatory Primarily targets the synovium of diarthrodial joints Etiology likely combination genetic and environmental Diarthrodial