Table Of ContentGeriatric Rheumatology
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Yuri Nakasato • Raymond L. Yung
Editors
Geriatric Rheumatology
A Comprehensive Approach
Editors
Yuri Nakasato Raymond L. Yung
Sanford Health Systems Department of Internal Medicine
Fargo, ND, USA University of Michigan
[email protected] Ann Arbor, Michigan, USA
[email protected]
ISBN 978-1-4419-5791-7 e-ISBN 978-1-4419-5792-4
DOI 10.1007/978-1-4419-5792-4
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011928680
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Preface
It is our pleasure to introduce an exciting new textbook that provides a much-needed and
different perspective on rheumatology. Our outstanding contributors have put in a lot of effort
and thought delving into the aging process per se, the older population, and how they affect the
future of rheumatology.
Let face it, our patient population is aging. Although patients over 65 years of age still
compose around 15% of the total population, they are consuming about 50% of rheumatology
resources. Innovative ways of doing research, patient care, education, and policy need to be
addressed in order to improve quality of care, patient satisfaction, and the safety of our older
population.
Multi-disciplinary teams have always been the hallmark of geriatrics but they are cost-
prohibitive in times of healthcare system reforms and social changes. As the age of retirement
increases, it is crucial to keep the older patient with rheumatic conditions functional or – even
better – active in the work force. We invite you to continue thinking in new terms and adapt to
their needs, considering new models that are economically sustainable.
Patients with rheumatic diseases are getting older and attaining closer-to-normal popula-
tion life expectancies. On the other hand, patients without rheumatic diseases are living longer
too, thanks to improved therapies and advances in public health. This allows the development
of a variety of elderly onset rheumatic diseases with often atypical presentations. Furthermore,
immunosenescence complicates the geriatric rheumatology panorama with a combination of
suppressed immune responses, low-grade chronic inflammatory reactions (also called inflamm-
aging), and clinically non-significant autoantibodies that raise questions and puzzle even the
more reputable experts. Moreover, uncontrolled inflammatory autoimmune conditions accele-
rate atherosclerosis and may give the false impression of an equally accelerated intrinsic aging,
since morbidity and aging both decrease the physiological reserves.
Older patients present to rheumatologists with a milieu of baseline co-morbidities. This
fact has highlighted the need to group rheumatologic with non-rheumatologic diseases such as
diabetes, hypertension, atrial fibrillation, and cardiovascular diseases in the future. For exam-
ple, it is starkly different to treat a patient with polymyalgia rheumatica and uncontrolled
diabetes than a patient without diabetes. Until older rheumatic disease patients with multiple
co-morbid conditions are included in clinical trials, it will be impossible to have high quality
evidence-based treatment guidelines for the older arthritis patients.
Different specialists have created a pharmacological vicious cycle by prescribing increas-
ingly more medications; once the number of medications reaches the double digits, sophisti-
cated drug inventory management techniques may be required. Older patients are known to
have voluntary or involuntary compliance problems; drug cost, dementia, and visual problems
are the main issues. Medications are justified but at times, they are not withdrawn promptly
when the acute problem subsides, creating a list of necessary and unnecessary medications.
As a consequence, the cycle is closed by a new round of problems attributed to medications,
such as peptic ulcer disease (due to nonsteroidal anti-inflammatory agents [NSAIDs]), gas-
trointestinal bleeding (due to medications interacting with Coumadin), falls with fractures
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vi Preface
(due to narcotics or psychotropic medications), infections (due to immunosuppressive therapy),
or heart diseases (related to NSAIDs or anti-TNF [tumor necrosis factor] agents).
The cache of biological therapies available to rheumatologists is ever expanding.
Simultaneously, they are creating reactivation of old diseases (such as fungal invasive infec-
tions and tuberculosis or herpes zoster), malignancies such as lymphoma, or new autoimmune
diseases (drug-induced lupus). Surveillance, vaccination, and early diagnosis are becoming
the rule rather than the exception. The question rheumatologists constantly face is whether to
be aggressive or more conservative when treating the older patient. The focus of elder care is
on cure (if possible), improvement in quality of life, rehabilitation, and palliative care. Some
older patients and their families are coming to the clinic with new expectations of cure as they are
better-informed, but they may also be confused due to the overwhelming amount of unfiltered
internet information.
Ultrasound technology controlled by rheumatologists is already at full swing in Europe,
and it is becoming the new joint-stethoscope for rheumatologists around the world. Providers
are enhancing their physical examination skills and becoming more precise and efficient doing
procedures. Older patients with dementia, or those unable to talk due to hospitalization or
delirium, can be examined by use of ultrasound for synovitis or fluid in unexpected areas for
diagnostic arthrocentesis to allow prompt therapy and prevent unnecessary treatments.
The health-care landscape is rapidly changing and the average age of rheumatologists is
also rising. Much of rheumatology practice takes place in the outpatient setting. Instead of see-
ing the patient in the hospital for a secondary consultation, patients may be discharged home
with the expectation that they will be seen promptly in the rheumatology clinic. While Internal
Medicine is undergoing a hospitalist movement, primary care overall is shifting to advanced
practice providers, increasing demand for rheumatology consultations. The older patient is
trapped in the midst of all these changes; our book Geriatric Rheumatology: A Comprehensive
Approach encourages you to think from the older patient’s perspective.
Fargo, ND Yuri Nakasato
Ann Arbor, MI Raymond L. Yung
Contents
Part I Aging and Comorbidity in Rheumatology
1 The Immune System in Aging ................................................................................. 3
Anjali Desai and Raymond L. Yung
2 Bone Aging ................................................................................................................ 11
Arthur N. Lau and Jonathan D. Adachi
3 Atherosclerosis in the Rheumatic Diseases: Compounding the Age Risk .......... 17
Naoto Yokogawa and Joan M. Von Feldt
4 Neuropsychiatric Manifestations of Rheumatic Diseases in the Elderly ............ 27
Jamal A. Mikdashi
5 Tuberculosis and Rheumatoid Arthritis in the Elderly ........................................ 35
Eduardo M. Acevedo-Vásquez, Darío Ponce de León,
and Rocío V. Gamboa-Cárdenas
6 Widespread Pain in Older Adults ........................................................................... 45
Cheryl D. Bernstein, Jordan F. Karp, and Debra K. Weiner
Part II Multidisciplinary Approach to Geriatric Rheumatology
7 Pharmacotherapy Considerations Unique to the Older Patient .......................... 59
Keith A. Swanson and Mark A. Stratton
8 Rheumatic Disease in the Nursing Home Patient ................................................. 73
Joanne Sandberg-Cook
9 Post-acute Care for Rheumatologists ..................................................................... 79
Deborah W. Robin
10 The Gerontorheumatology Outpatient Service: Toward an International
Classification of Function-Based Health Care Provision for the Elderly
with Musculoskeletal Conditions ............................................................................ 85
Wim Van Lankveld, Josien Goossens, and Marcel Franssen
11 Health Policy, Public Health, and Arthritis Among Older Adults ...................... 93
Kristina A. Theis, Debra R. Lubar, and Teresa J. Brady
12 Physical Therapy Management of Select Rheumatic Conditions
in Older Adults ......................................................................................................... 101
Maura Daly Iversen and Madhuri K. Kale
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13 Arthrocentesis in the Elderly .................................................................................. 113
Ahmed S. Zayat and Richard J. Wakefield
14 Physical Activity in Older Adults with Arthritis................................................... 125
Dorothy D. Dunlop, Pamela Semanik, and Rowland W. Chang
Part III Rheumatic Diseases in the Elderly
15 Systemic Lupus Erythematosus in Elderly Populations ....................................... 135
Ana M. Bertoli, Guillermo J. Pons-Estel, Paula I. Burgos,
and Graciela S. Alarcón
16 Elderly Onset Rheumatoid Arthritis ...................................................................... 145
Venkata Sri Cherukumilli and Arthur Kavanaugh
17 Disease-Modifying Antirheumatic Drug Use in Older
Rheumatoid Arthritis Patients ................................................................................ 151
Sogol S. Amjadi, Veena K. Ranganath, and Daniel E. Furst
18 Epidemiology, Risk Factors, and Aging of Osteoarthritis .................................... 173
Crisostomo Bialog and Anthony M. Reginato
19 Osteoarthritis in the Elderly Population ................................................................ 187
Roy D. Altman
20 Medium- and Small-Vessel Vasculitis ..................................................................... 197
Rafael G. Grau
21 Management of Geriatric Gout .............................................................................. 209
Lan X. Chen
22 Calcium-Containing Crystal-Associated Arthropathies
in the Elderly Population ......................................................................................... 213
Elisabeth B. Matson and Anthony M. Reginato
23 Polymyalgia Rheumatica and Giant Cell Arteritis in the Elderly ....................... 225
Wolfgang A. Schmidt
24 Antiphospholipid Syndrome in the Older Population .......................................... 231
Silvia S. Pierangeli, Alan M. Seif, and Emilio B. González
25 Osteoporosis and Metabolic Bone Diseases of the Elderly ................................... 241
Lora Giangregorio and Alexandra Papaioannou
26 Infectious Arthritis in the Elderly .......................................................................... 251
Nicole Melendez and Luis R. Espinoza
27 Sarcopenia and Myopathies in the Elderly ............................................................ 259
Kenneth S. O’Rourke
28 Scleroderma in the Elderly Population .................................................................. 275
Rebecca L. Manno and Fredrick M. Wigley
29 Sjögren’s Syndrome in the Elderly ......................................................................... 287
Raymond L. Yung and Sheeja Francis
Index .................................................................................................................................. 293
Contributors
Eduardo M. Acevedo-Vásquez, MD
Professor, Department of Rheumatology, School of Medicine, Universidad Nacional
Mayor de San Marcos, Lima, Peru
Jonathan D. Adachi, BSc, MD, FRCP(C)
Professor, Department of Medicine, McMaster University/St. Joseph’s Healthcare
Hamilton, Ontario, Canada
Graciela S. Alarcón, MD, MPH
Jane Knight Low Chair of Medicine in Rheumatology (Emeritus),
Department of Medicine, Division of Clinical Immunology and Rheumatology,
The University of Alabama at Birmingham, Birmingham, Alabama, USA
Roy D. Altman, MD
Professor of Medicine, Department of Medicine, Division of Rheumatology,
University of California Los Angeles, Los Angeles, California, USA
Sogol S. Amjadi, MS
Clinical Research Assistant, Division of Rheumatology, Department of Medicine,
University of California Los Angeles, Los Angeles, California, USA
Cheryl D. Bernstein, MD
Assistant Professor, Department of Anesthesiology, University of Pittsburgh,
Pittsburgh, Pennsylvania, USA
Ana M. Bertoli, MD
Staff Member, Instituto Reumatológico Strusberg, Córdoba, Argentina
Crisostomo Bialog, MD
Rheumatology Fellow, Department of Rheumatology, Brown University,
Providence, Rhode Island, USA
Teresa J. Brady, PhD
Senior Behavioral Scientist, Arthritis Program, U.S. Centers for Disease Control
and Prevention, Atlanta, Georgia, USA
Paula I. Burgos, MD
Instructor, Department of Clinical Immunology and Rheumatology, School of Medicine,
Pontifica Universidad Católica de Chile, Santiago, Chile
Rowland W. Chang, BA, MD, MPH
Professor of Preventive Medicine, Medicine, and Physical Medicine and Rehabilitation;
Director, MPH Program; Senior Faculty Fellow, Institute Healthcare Studies;
Director, Multidisciplinary Clinical Research Center in Rheumatology’s Methodology
and Data Management Core Unit; Northwestern University Feinberg School of Medicine;
Attending Physician, Co-Director, Arthritis Program, Rehabilitation Institute of Chicago;
Department of Preventative Medicine, Northwestern University, Chicago, Illinois, USA
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