Rheumatoid Arthritis among Older Adults

Arthur Bookman, MD, FRCPC, Division of Rheumatology, Toronto Western Hospital/University Health Network, Toronto, ON.

Rheumatoid arthritis (RA) in older adults has a lower female-to-male ratio, and presents as either a rheumatoid factor positive typical case of RA, or an acute seronegative syndrome consisting of myalgia, fever, weight loss, and fatigue. Differentiating among systemic lupus erythematosus, polymyalgia rheumatica, and rheumatoid arthritis may initially be very difficult in older patients. Rheumatoid arthritis beginning in younger people can lead to earlier death, accelerated atherosclerosis, complicated polypharmaceutical management, debilitating deformity, osteoporosis, and more frequent infection as these patients enter their geriatric years.
Key words: rheumatoid arthritis, geriatrics, polypharmacy, chronic disease, inflammatory arthritis.

Prototype of the Geriatric Syndrome

I am writing this editorial after finishing our falls prevention clinic at the Toronto Western Hospital. Falls are the prototype of the classic geriatric syndrome, in which one cause is rarely the issue but rather a substantial number of possible contributing factors are found. However, it is a rare older patient who does not have some musculoskeletal disorder as one of the predisposing conditions for falls. One of my patients today had severe osteoarthritis of her knees as well as painful feet with bunions and corns that contributed to her falls. As I have mentioned before on these pages, mobility is an essential quality of life issue for older adults, and so I am always excited when our issue focuses on musculoskeletal disorders.

We have several superb articles on our theme in this issue. The common topic of “Crystal-induced Arthritis” is tackled by Dr. Ian Tsang and Dr. Simon Huang, while Dr. R. Martinez-Galliano, L. Burke, and Dr. Bob McCormack delineate “An Active Approach to the Treatment of Frozen Shoulder.” We seldom appreciate how much we rely on our shoulder’s range of motion until we lose it! Our continuing education article this month is on the most common of the inflammatory arthritides. The article “Rheumatoid Arthritis among Older Adults” is by the distinguished rheumatologist, Dr. Arthur Bookman. For a variety of reasons, some people get much better care for their arthritis than others, something which theoretically should not happen in a country with universal health care. The reasons for this disturbing occurrence are discussed in the article “How to Make Sure Your Patient with Osteoarthritis Gets the Best Care” by Dr. Cornelia Borkhoff and Dr. Gillian Hawker.

As usual, we have a range of articles on other geriatric topics. The article “An Update on Prostate Cancer among Older Men” is by Dr. Michel Carmel, a researcher with our partner association, the Canadian Society for the Study of the Aging Male. Our cardiovascular column is on “Treatment of Hypertension in Older Adults” by Dr. W.S. Aronow, a prolific contributor both to our journal and the peer reviewed medical literature. Our psychology of aging column this month is called “Personality Traits: Stability and Change with Age” and is written by Drs. Antonio Terraciano, Robert McCrae, and Paul Costa, Jr. Our dementia column is on a topic that has become an important topic both for stroke neurologists and dementia experts, namely “Post-stroke Dementia among Older Adults.” It is written by Dr. Aleksandra Klimkowicz-Mrowiec.

Enjoy this issue,
Barry Goldlist

Physical Therapy and Exercise for Arthritis: Do They Work?

Marie D.Westby, BSc(PT), PhD Candidate, Mary Pack Arthritis Program,Vancouver Coastal Health, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.
Linda Li, BSc(PT), PhD, Harold Robinson/Arthritis Society Chair, Assistant Professor, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.

Physiotherapy aims to prevent physical impairment and restore functional ability through the use of exercise, education, and physical modalities. While there is solid evidence supporting physical activities in the management of arthritis, inactivity continues to be a problem among both younger and older patients with arthritis as compared to the general population. Current evidence supports the effectiveness and safety of moderate- to highintensity aerobic and strengthening exercises for osteoarthritis and stable rheumatoid arthritis. Participation in recreational activities does not replace the need for therapeutic exercises. Physicians and health professionals should be equipped with strategies to overcome barriers and facilitate treatment adherence when prescribing exercise.
Keywords: osteoarthritis, rheumatoid arthritis, physical therapy, exercise, physical activity.

Inflammatory Polyarthritis in the Older Adult

Tara Snelgrove BSc, MSc, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL.
Proton Rahman MD, MSc, FRCPC, Associate Professor of Medicine, Department of Medicine, Division of Rheumatology, Memorial University of Newfoundland, St. John’s, NL.

Rheumatoid arthritis is the most common etiology for inflammatory arthritis in the older population, with an estimated prevalence of 2%. An older individual with inflammatory polyarthritis usually falls into one of two categories. The first consists of patients with well-established long-standing disease, whose course is often confounded by end organ damage and toxicity related to antirheumatic drugs. The other category comprises patients with late-onset inflammatory polyarthritis, whose presentation is often nonspecific and, thus, more elusive to diagnose. Systemic lupus erythematous can also occur in the older adult; it is less prevalent than rheumatoid arthritis and is associated with multiple organ involvement, including musculoskeletal symptoms.
Key words: rheumatoid arthritis, systemic lupus erythematosus, inflammatory polyarthritis, late-onset disease.

Total Hip Arthroplasty in the Older Population

Peter G. Passias, MD, 4th year resident, Tufts Affiliated Hospitals Orthopedic Surgery Residency Program, Medford, MA, USA.
James V. Bono, MD, Clinical Professor of Orthopedics, Tufts University School of Medicine; Director of Education, New England Baptist Hospital, Medford, MA, USA.

Total hip arthroplasty (THA) is one of the most commonly performed and successful operations in orthopedic surgery in terms of clinical outcome, implant survivorship, and cost-effectiveness. The average age for a patient undergoing a THA is 66 years. As life expectancy continues to increase in developed nations and the percentage of the population that is older than 65 years rises, THA surgery will be more frequently performed. This change in demographics is clinically relevant as the indications, risks involved, and outcomes are not identical to those of younger THA candidates. Osteoarthritis is by far the most common diagnosis among patients undergoing primary elective THA. Other common diagnoses include rheumatoid arthritis, other types of inflammatory arthritis, post-traumatic arthritis, and osteonecrosis of the femoral head. Patients that are candidates for THA have radiographic evidence of hip joint degeneration together with the clinical symptoms of disabling pain and functional limitation despite adequate nonsurgical management. The following article attempts to summarize some of the key issues regarding THA in an older population.
Key words: total hip arthroplasty, osteoarthritis, avascular necrosis, hip fracture, older population.

Osteoarthritis of the Knee

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Kevin D. Gross PT, PhD, Boston University Clinical Epidemiology Research and Training Unit, and the Department of Medicine at Boston Medical Center, Boston, MA, U.S.A.
David J. Hunter MBBS, PhD, Boston University Clinical Epidemiology Research and Training Unit, and the Department of Medicine at Boston Medical Center, Boston, MA, U.S.A.

Despite the increasing prevalence of symptomatic knee osteoarthritis, many uncertainties exist pertaining to its management. Many putative risk factors are characterized by excessive loading of vulnerable joint structures. Clinical examination includes assessment of knee function and the influence of modifiable risks such as malalignment, muscle strength, and obesity. Knee braces, footwear, exercises, and dieting are prescribed for the purpose of improving the distribution of loads on the knee, and reducing the likelihood that osteoarthritis (OA) and its symptoms will worsen. In this conservative approach, pharmaceuticals of low toxicity are preferred and given only when other methods fail to achieve functional improvement.
Key words: knee osteoarthritis, mechanical risk factors, nonpharmacologic management, physiotherapy, joint replacement.

Musculoskeletal Problems: An Under-recognized Determinant of Quality of Life

There is nothing like waking up in the morning with a stiff back and difficulty moving to remind oneself that arthritic disorders are an important factor in the quality of our everyday lives. Over the years I have frequently reminded our readers that among older adults living in the community, musculoskeletal problems are a more important determinant of quality of life than are cardiac diseases such as angina. The high prevalence of arthritic complaints among older adults makes arthritis the single most important medical factor in determining the quality of life for older adults. Fortunately, the once nihilistic approach to arthritis in older people is changing with newer therapeutic modalities and surgical options. Hopefully, the days of older patients simply being told, “You’re 90 years old: what do you expect?” are being phased out and replaced by, “You’re 90 years old: we will have to see what can help with your problems.”

Our CME article this month concerns probably the most common arthritic condition among older people, “Osteoarthritis of the Knee.” This learning module has been created by Drs. Kevin D. Gross and David J. Hunter. Dr. Peter G. Passias and Dr. James V. Bono review one of the most successful modern surgical procedures in their article “Total Hip Arthroplasty in the Older Population.” Although we usually think that inflammatory arthritis is a syndrome of younger adults, it can be an important cause of morbidity in older adults as well. Tara Snelgrove and Dr. Proton Rahman review this important topic in their article “Inflammatory Polyarthritis in the Older Adult.”

We also have our usual collection of diverse articles. The interesting area of gender difference in medicine is explored in this issue’s Cardiovascular column and addresses “Gender and Congestive Heart Failure” by Dr. Silja Majahalme. An internationally renowned group from the Centre for Research in Neurodegenerative Diseases at the University of Toronto, Drs. Yosuke Wakutani, Peter St. George-Hyslop, and Ekaterina Rogaeva discuss “The Genetic Profile of Dementia.”

Our cancer column addresses “Cancer Chemotherapy in the Older Cancer Patient” and is contributed by Dr. Lodovico Balducci. Finally, the cancer theme is continued in the article “Epidemiology of Colorectal Cancer and Aging” by Dr. Maida J. Sewitch and Caroline Fournier.

Enjoy this issue,
Barry Goldlist

Management of the At-Risk Patient with Osteoarthritis

Alan D. Bell, MD, Department of Family and Community Medicine, Humber River Regional Hospital, Toronto, ON.

Douglas C. Conaway, MD, Section of Rheumatology, Carolina Health Specialists, Myrtle Beach, SC, USA.

Recent disclosures of cardiovascular safety issues with medications that have become mainstays of osteoarthritis management have compelled clinicians to reconsider treatment approaches. This new information must be taken into account along with the well-known risk of gastrointestinal complications associated with nonsteroidal anti-inflammatory drugs. Consequently, clinical management of osteoarthritis pain in older patients requires careful evaluation and consideration of the individual patient’s risk factors. Co-therapy with proton pump inhibitors has demonstrated reductions in endoscopic gastropathy, but clinical outcome trials are lacking. For all treatment decisions, monitoring of patients’ responses to therapy is crucial for optimizing long-term safety and efficacy outcomes.

Key words: osteoarthritis, drug therapy, nonsteroidal anti-inflammatory drugs, cyclo-oxygenase-2 inhibitors.

Stenosis in the Lumbar Spine: Diagnosis and Treatment

Charles D. Ray, MD, FACS, FRSH (Lond.), President, American College of Spine Surgery; President, International Spine Arthroplasty Society; Past President, North American Spine Society, Yorktown, VA, USA.

Stenoses, or nerve entrapment, can occur at several sites. The focus here is on lumbar spine segments. Compression by stenosis can exist wherever nerve tissue is protectively covered by bone or where thick ligaments are located adjacent to nerve. Overgrowth of bone by spurs is the most common cause of compression producing disability and pain. Neurologic changes are rare. Diagnostic radiological imaging is needed, sometimes aided by selective injections of medications. Due to the limitations of non-surgical treatment, surgical decompression is common with generally good results.
Key words: spinal stenosis, vertebral bone spurs, claudication, surgical decompression, nerve injections.