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U N I T 1 2
Musculoskeletal Function
High serum urate levels rarely occur in women before
menopause; initial attacks of clinical gout occur around
the age of 70 years, or 20 years after menopause. The
treatment of gout is often more difficult in the elderly.
Although colchicine may be effective in controlling the
symptoms of chronic gout, it may cause diarrhea in some
patients, limiting its effectiveness in maintenance therapy.
Pseudogout.
As part of the tissue aging process, OA
develops with associated cartilage degeneration and the
shedding of calcium pyrophosphate crystals into the
joint cavity. These crystals may produce a low-grade
chronic inflammation—the chronic pseudogout syn-
drome. The accumulation of calcium pyrophosphate
and related crystalline deposits in articular cartilage is
common in the elderly. There are no medications that
can remove the crystals from the joints. Although it may
be asymptomatic, presence of the crystals may contrib-
ute to more rapid cartilage deterioration. This condition
may coexist with severe OA. Calcium pyrophosphate
deposition disease may also present with proximal mus-
cle pain mimicking polymyalgia rheumatica.
Polymyalgia Rheumatica
Polymyalgia rheumatica is an inflammatory condition
of unknown origin characterized by aching and morn-
ing stiffness in the cervical regions and shoulder and pel-
vic girdle areas.
86–88
Of the forms of arthritis affecting
the elderly, it is one of the more difficult to diagnose and
one of the most important to identify. Elderly women
are especially at risk. Polymyalgia rheumatica is a com-
mon syndrome of older persons, rarely occurring before
50 years of age (and usually after age 60). The onset can
be abrupt, with the patient going to bed feeling well and
awakening with pain and stiffness in the neck, shoul-
ders, and hips.
Diagnosis and Treatment.
Diagnosis is based on the
pain and stiffness persisting for at least 1 month and
an elevated ESR. The diagnosis is confirmed when the
symptoms respond dramatically to a small dose of pred-
nisone, a corticosteroid. Biopsies have shown that the
muscles are normal, despite the name, but that a non-
specific inflammation affecting the synovial tissue is
present. It is possible that a number of patients are erro-
neously diagnosed as having RA or OA. For patients
with an elevated ESR, the diagnosis usually is based on
a 3-day trial of prednisone treatment.
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Patients with
polymyalgia rheumatica typically exhibit striking clini-
cal improvement on the second day. Patients with RA
also show improvement, although usually days later.
Treatment with NSAIDs provides relief for some
patients, but most require continuing therapy with
prednisone, with gradual reduction of the dose over
the course of 1.5 to 2 years, using the person’s symp-
toms as the primary guide. Patients need close moni-
toring during the maintenance phase with prednisone
therapy. Because their symptoms are relieved, they often
quit taking the prednisone and their symptoms recur, or
doses are missed and the decreased dosage leads to an
increase in symptoms. Unless careful assessment reveals
the frequency of missed doses, the physician may be
misled into increasing the dosage when it is not needed.
Because of the side effects of the corticosteroids, the goal
is to use the lowest dose of the drug necessary to control
the symptoms. Weaning patients off low-dose predni-
sone therapy after this length of time can be a difficult
and extended process.
Complications.
A certain percentage of patients with
polymyalgia rheumatica also develop
giant cell arteritis
(i.e., temporal arteritis) with involvement of the oph-
thalmic arteries.
89
The two conditions are considered to
represent different manifestations of the same disease.
Giant cell arteritis, a form of systemic vasculitis, is a sys-
temic inflammatory disease of large and medium-sized
arteries. The inflammatory response seems to be a T-cell
response to an antigen.
Clinical manifestations of giant cell arteritis usually
begin insidiously and may exist for some time before
being recognized.
89
It is potentially dangerous if missed
or mistreated, especially if the temporal artery or other
vessels supplying the eye are involved, in which case
blindness can ensue quickly without treatment. The
condition is responsive to appropriate therapy. For
those patients at risk, adherence to the medication pro-
gram is critical, with preservation of sight being the
goal. Because this complication can occur so quickly
and is relatively asymptomatic, it is vital that the patient
understand the importance of taking the correct dose
regularly as prescribed. Initial treatment consists of
large doses of prednisone. This dosage is continued for
4 to 6 weeks and then decreased gradually.
Management of Rheumatic Diseases in
the Elderly
In addition to diagnosis-specific treatment, the elderly
require special considerations.
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Management tech-
niques that rely on modalities other than drugs are
particularly important. These include splints, walking
aids, muscle-building exercise, and local heat. Muscle-
strengthening and stretching exercises are particularly
effective in the elderly person with age-related losses in
muscle function and should be instituted early. Rest, the
cornerstone of conservative therapy, is hazardous in the
elderly, who can rapidly lose muscle strength.
In terms of medications, the NSAIDs may be less
well tolerated by the elderly, and their side effects are
more likely to be serious. In addition to bleeding from
the gastrointestinal tract and renal insufficiency, there
may be cognitive dysfunction manifested by forgetful-
ness, inability to concentrate, sleeplessness, paranoid
ideation, and depression.
Joint arthroplasty can also be used for pain relief and
increased function. Chronologic age is not a contraindi-
cation to surgical treatment of arthritis. In appropriately
selected elderly candidates, survival and functional out-
come after surgery are equivalent to those in younger
age groups. The more sedentary activity level of the
elderly makes them even better candidates for joint
replacement because they put less stress and demand on
the new joint.
