Polymyalgia Rheumatica

Noleen Smith, 4th-year Medical Studentt, Guy's King's and St Thomas' Medical School, London, UK.
Mark Harding, MD, MBBCH(Wits), FRACGP, Dip Occ Health, BSc (QS) Hons, General Practitioner, Inverell, New South Wales, Australia.

Polymyalgia rheumatica (PMR) has a female predominance and typically occurs in people over 50 years of age. PMR usually presents as pain and stiffness in the neck, shoulder, and pelvic areas. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are used to determine disease activity. PMR is thought to be a systemic component of giant cell arteritis with aborted vasculitis. Other studies have looked at infectious agents as a causative factor. PMR is treated using a corticosteroid regime that, in turn, causes many unwanted side effects. Various methods to decrease these unwanted effects have been studied, including the addition of methotrexate as a steroid-sparing agent and intramuscular injection of methylprednisolone rather than oral prednisolone.
Key words: erythrocyte sedimentation rate, C-reactive protein, vasculitis, corticosteroids, side effects.

Lumbar Spinal Stenosis: Evidence for Treatment

David L. Snyder, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
David Doggett, PhD, Senior Research Analyst, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.
Charles Turkelson, PhD, Chief Research Analyst and Director, Evidence-Based Practice Center, ECRI, Plymouth Meeting, PA, USA.

Degenerative lumbar spinal stenosis is a common problem among older adults. Stenotic compression of spinal nerves can result in low back pain, disabling leg pain, and greatly restricted walking capacity. Conservative therapies are usually prescribed for mild symptoms and surgery is prescribed for severe symptoms, while patients with moderate symptoms may not have an obvious treatment choice. The clinical evidence supporting these treatment options has been criticized because of problems with study design and quality that complicate their assessment. Despite the poor quality of most of the literature, recent studies provide better information and a means of starting to judge the effectiveness of treatment.

Key words: lumbar spinal stenosis, neurogenic claudication, conservative therapy, surgical intervention.

The Evaluation and Treatment of Low Back Pain in Older Adults

Arto Herno, MD, PhD, Senior Consultant, Department of Physical and Rehabilitation Medicine, Kuopio University Hospital, Kuopio, Finland.

The degeneration of the lumbar spine is strongly associated with aging, but this does not mean that pain is an unavoidable accompaniment (though the recorded incidence of low back pain suggests otherwise). Recently, more attention has been drawn to the problem of changes related to the aging of our musculoskeletal system and the associated socioeconomic implications. We now have advanced equipment to examine patients and our store of knowledge is enormous, but the application of this knowledge to a working practical plan at the individual level is problematic. Understanding the automatism of the normal function of the lumbar spine is essential for treating mechanical low back pain because the main goal is to correct this functional disorder. However, the long-term goal of treatment should be to involve patients in their back disorder management.

Key words: aging, degeneration, lumbar spine, low back pain, exercise.

Inflammatory Musculoskeletal Conditions in Older Adults

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

Jerry Tenenbaum, MD, FRCPC, Professor of Medicine, University of Toronto; Consultant in Rheumatology, Mount Sinai Hospital, University Health Network, Baycrest Geriatric Centre, Toronto, ON.

Musculoskeletal inflammatory conditions in the older patient cover the spectrum of those conditions affecting all age groups to those that are associated with advanced age. Polymyalgia rheumatica and pseudogout are two conditions which are seen predominately in older adults. While gout occurs more often in males in younger patients, both genders may present in the older population. Myositis in an older patient is more likely to be associated with neoplasia, so a search for common tumours should comprise part of the workup of that patient. Hypertrophic pulmonary osteoarthropathy associated with malignancy should be considered in the older patient who presents with arthritis, long bone pain, and clubbing. Osteoarthritis is by far the most common arthritis in the older population. It is important to identify those patients who have clinical features of inflammation in order to provide that subgroup with appropriate anti-inflammatory treatment.

Key words: polymyalgia rheumatica, pseudogout, synovitis, osteoarthritis, myositis.

Musculoskeletal Pain: the Curse of Aging

The focus of this month’s edition of Geriatrics & Aging is musculoskeletal disease. This heterogeneous collection of disorders is the biggest factor in quality of life for old and frail adults who are surveyed in the community. It is easy to understand why. If every step causes pain, or if sleeping is impossible because of hip disease, life can be very unpleasant indeed. Yet arthritis (and by extension those physicians who are interested in caring for patients with arthritis) never seems to get the amount of attention it deserves. Making life pain-free and more enjoyable seems less of a public and medical concern than saving lives.

The study and management of musculoskeletal disease has been revolutionized in recent times by the advent of magnetic resonance imaging (MRI). At times, however, the pictures are better than the science of what to do with those pictures. Spinal stenosis is a good example of how our diagnostic ability has forged ahead of our therapeutic knowledge. However, this is now an active area of investigation, and Drs. David Snyder, David Doggett, and Charles Turkelson tackle the issue in their article, “Lumbar Spinal Stenosis: Evidence for Treatment.” Dr. Arto Herno discusses an issue that is ubiquitous in older adults (and often younger ones as well) in his article entitled “The Evaluation and Treatment of Low Back Pain in Older Adults.” Although not as common as osteoarthritis, inflammatory conditions can be devastating in the older population. Dr. Jerry Tenenbaum reviews this topic in his article, “Inflammatory Musculoskeletal Conditions in Older Adults.”

As well, we have our usual assortment of geriatric articles. Drs. Kristopher Cunningham, Sharmi Shafi, Mellitta Mezony, Molly Thangaroopan, and Jagdish Butany outline the “Diagnosis and Treatment of Pericarditis in the Aged.” This can be a difficult and often overlooked diagnosis. Drs. Nages Nagaratnam and Kujan Nagaratnam review the topic of “Screaming in Dementia,” an issue which is very distressing for family and caregivers. Our Medical Director of CME, Dr. D’Arcy Little, reviews the topic of “Skin Manifestations of Internal Disease,” while Drs. Andrew Kertesz and David Munoz discuss “Frontotemporal Disease,” also known as Pick’s Disease, for our Drugs & Aging column. In our Lung Disease column, Drs. Max Huang and Lianne Singer review “Surgical Interventions for COPD.”

It’s not too much of a stretch of the imagination to realize that telemedicine will soon be a common way for patients to access a health professional. To this end, our Technology in Medicine column, entitled “Getting into Telemedicine: Information for Physicians” and written by Drs. Peter McCracken and Darryl Rolfson, is a valuable overview of the advantages of telemedicine for physicians and barriers to its application.

Finally, Dr. Paul Arnold provides an enjoyable and practical review of a recently published book, “The Medical Professional’s Guide to Handheld Computing.”

Enjoy this issue,
Barry Goldlist

Diagnosis and Management of Asymptomatic Hyperuricemia and Gout in Older Adults

Ian K. Tsang, MB, FRCPC, Clinical Professor, Division of Rheumatology, Faculty of Medicine, University of British Columbia, Vancouver, BC.

Gout is more prevalent in older adults than middle-age adults, and it affects women almost as commonly as men. An important clinical consideration regarding gout is that while hyperuricemia is commonly associated with gouty arthritis, a diagnosis of asymptomatic hyperuricemia does not generally require treatment. In addition, the clinical presentation and course of gout in older patients differ from the typical cases of middle-aged patients. Moreover, older gout patients present a challenge for physicians who manage them because of the high incidence of comorbid conditions and the likely occurrence of reduced renal function among this age group. This article reviews the diagnosis and management of asymptomatic hyperuricemia and gout in the older adult.
Key words: gout, hyperuricemia, NSAID, allopurinol, arthritis.