Arthritis in the later years.
When she finally made the dreaded visit, Lucille was surprised that her doctor spent more time asking questions than drawing blood or taking X-rays. She was even more surprised and relieved when she learned the problem was not in her joints, but was caused by a muscular condition called polymyalgia rheumatica that was treatable with medication,
Lucille, 77, is not unusual. Studies show that almost half of all people age 65 and over suffer from some kind of musculoskeletal condition. Yet many don't seek treatmentpossibly fearing tests and treatments, possibly believing their pain is a part of aging for which nothing can be done.
Fortunately, many such fears are unfounded. Most forms of arthritis can be treated - often noninvasively. But the actual treatment an older person receives, as well as the diagnostic process that leads to that treatment, may be different from those for young adults with seemingly similar conditions. Making a Diagnosis
Diagnosing a rheumatic condition in an older patient takes a special approach, says Dr. Evan Calkins, professor of medicine and family medicine at the State University of New York at Buffalo. Because older people are likely to suffer from several health problems, identifying the cause of a particular symptom or set of symptoms can take some work.
"Most older people are going to show some osteoporosis in a spinal X-ray, they're going to have some degree of degenerative changes in the discs, they're going to have some degree of osteoarthritis of the hip or knee, and it takes a much more intense clinical assessment to decide what's going on with that patient," says Dr. Leo M. Cooney Jr., a rheumatologist at Yale University School of Medicine.
The physical history and a functional exam, which are important in diagnosing people of any age, take on particular importance in older patients.
"If doctors were to use every kind of diagnostic tool to explore each possibility, that could run into vast sums of money - plus patients get worn out," Dr. Calkins says, "so the details of the history and physical get to be very important.
To get to the root of a painful problem, Dr. Cooney asks his older patients a lot of questions, such as, "Is your pain usually worse when you re going up stairs? " or, " Is your pain worse when you're walking or when you're sitting?" He also observes his patients walking a few steps, getting up and down from a chair and, if possible, ascending and descending stairs. Such simple demonstrations can tell him a lot about the origin or cause of pain.
Pain when ascending stairs may indicate the pain is coming from the hip, because climbing stairs involves flexing the hip, he says. Pain when walking or sitting might indicate a problem originating in the spine.
Laboratory tests remain an important part of the diagnostic procedure for people of all ages. But when diagnosing older people, there are some factors doctors must take into account. For one, most people have an increase in sedimentation rate (a blood test indicating inflammation) as they age, so a test showing an elevated sedimentation rate may not be as significant as in a younger person, according to Dr. Arnold L. Katz, clinical director of the Arthritis Centers at Liberty Hospital in Liberty, Mo., and at MidAmerica Rehabilitation Hospital in Overland Park, Kan.
The same is true of antinuclear antibodies (ANAS) and rheumatoid factor, two types of autoantibodies that are common in people with certain autoimmune diseases. "The percentage of individuals who have positive ANAs and rheumatoid factor gets higher as they age," says Dr. Katz. Exactly why that occurs is not known, he adds. However, some researchers believe environmental factors - perhaps exposure to different medications or to viruses - may have a role in it.
"Doctors must take the patient's age into account when diagnosing a medical condition," Dr. Katz says. "A positive test in itself may not have clinical significance. A careful history and physical examination are always important." Different Forms and Manifestations
Some types of arthritis, such as polymyalgia rheumatica (PMR) and calcium pyrophosphate deposition disease (pseudogout), affect older people almost exclusively. PMR is a muscular condition that causes pain with movement, especially in the shoulder and hip areas. Pseudogout is an acute inflammation, usually of a single joint, caused by an accumulation of pyrophosphate crystals in the joint fluid.
Other forms occur in people of all ages, but manifest themselves differently in older people. Lupus, for example, is more likely to affect the joints, lungs and skin of older people. It is less likely to involve the kidneys and nervous system or to cause Raynaud's phenomenon as it often does in younger people.
Older people also are more likely to develop drug-induced lupus, a lupuslike syndrome that can be caused by the use of certain cardiovascular and hypertensive medications.
Gout, too, can affect older people differently. For example, podagra, an inflammation of the big toe which is the most common symptom of gout in younger people, is fairly rare in older patients - particularly women. Older women who have gout usually have a more diffuse form of tendinitis, Dr. Calkins says.
Rheumatoid arthritis can appear so different in older people that some doctors suspect there is actually a different form of RA that occurs in people over 60. Referred to in the medical literature as "benign rheumatoid arthritis of the aged" or "central polyarthritis," this condition "tends to affect not the small joints of the hands and feet, but the large axial joints the hips, knees, neck and occasionally the shoulders and elbows," says Dr. Cooney.
Roughly 25 to 40 percent of people who develop inflammatory arthritis over the age of 60 fall into this category, he says. "People with this condition often have abrupt onset. Within 24 hours of being absolutely normal, they'll come in with a very significant presentation of the disease."
Unlike classic rheumatoid arthritis, which affects three women for every man affected, this form occurs in men and women equally, according to Dr. Cooney. At least half the people diagnosed with this condition can expect to have a spontaneous remission meaning symptoms of the disease go away on their own - within a couple of years of onset. Laboratory tests in people with the pattern usually show no rheumatoid factor.
Whether this is actually a different disease is a matter of controversy. But, in general, Dr. Calkins says, RA in the elderly is less severe than in younger people, who are more likely to have rapid development of destructive joint involvement. Treatment Differences
The treatment you receive for arthritis will depend on your age as well as on the particular form you have and the preference of your doctor. For the most part, the treatment prescribed for an older person will be similar to that for a young adult. However, most doctors make a few exceptions for their older patients.
Management techniques that rely on treatments other than drugs are particularly important in the elderly, says Dr. Calkins. Examples include the proper use of splints, crutches and other walking supports, muscle-building exercise, appropriately designed neck traction, local heat, transcutaneous electrical nerve stimulation (TENS) therapy and orthopaedic surgery.
Muscle-strengthening and stretching exercises are particularly effective in elderly persons in whom arthritis accentuates the normal age-related loss of muscle function, he adds. Exercises to strengthen abdominal muscles and improve posture can help relieve low back pain.
Rest, a cornerstone of conservative therapy in younger people, may be hazardous in the elderly, Dr. Calkins says. "If an older person, age 82 or 83, goes to bed for a week or two weeks, there's a chance they will lose their ability to walk. So with older people you really put a great priority on keeping them going to avoid a loss of their independence - even a temporary one."
When drugs are needed to control arthritis, doctors may prescribe a different regimen for their older patients, but opinions vary as to what that regimen should be. Dr. Cooney says he hesitates to prescribe nonsteroidal anti-inflammatory drugs (NSAIDS) for older patients because of their increased risk of developing gastric ulcers from NSAID use. For patients with RA Dr. Cooney is more likely to prescribe hydroxychloroquine and sulfasalazine. "My own belief is that if I can bring somebody under control with these drugs, they are much safer in the long term use than are daily nonsteroidals," he says.
Dr. Calkins agrees that NSAIDs are more likely to cause severe side effects in the elderly than in younger people. But he also points out difficulties with using remittive agents (drugs such as gold and methotrexate that are used in hopes of bringing on a remission), including the need for frequent laboratory tests and oftentimes immediate unpleasant side effects. For that reason he often chooses to prescribe very low doses of corticosteroids, which may take as long as 15 years to produce harmful side effects. "Therefore, if a patient is already 85, it's not likely that person will ever experience the drug's toxic side effects," he says.
Dr. Katz continues to prescribe NSAIDs for his older patients, but does so with special concern. "Doctors are extremely careful with anti-inflammatory drugs," he says. "NSAIDs are used with great caution, perhaps in lower dosages or with less frequency," he continues. "Based on personal experience, doctors may feel some drugs are better than others to use in a particular population."
Because older people are likely to have many different medical conditions that require medication, your doctor should take a careful look at your medical records, considering any conditions or medications that might interfere with arthritis treatment. The Importance of Getting Help
One point on which doctors do agree is the importance of getting help for any form of arthritis. There is no reason to assume that muscle or joint pain is just an inevitable sign of old age. In older people, as in their younger counterparts, treatment may be able to relieve the symptoms while preventing joint damage or other irreversible problems.
Before you give in to a life of aches, pains and diminishing function, see your doctor for a custom-tailored treatment plan, and show arthritis who's boss. Here's to a long - and healthy - life.
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|Author:||Dunkin, Mary Anne|
|Date:||Jan 1, 1992|
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