Inflammatory Polyarthritis in the Older Adult

Tara Snelgrove BSc, MSc; Proton Rahman MD, MSc, FRCPC

Disclosures

Geriatrics and Aging. 2006;9(8):544-550. 

In This Article

Systemic Lupus Erythematosus

Epidemiology

Systemic Lupus Erythematosus (SLE) is a prototypic autoimmune disorder that predominantly affects females of childbearing age and is involved with inflammation in multiple organ systems.

In the U.S., incidence of SLE has been estimated to be 15-124 cases per 100,000.[12] This incidence varies according to age and gender. Between the ages of 15-45 years, the female-to-male ratio is around 12:1. This ratio drops with age, though women are still at higher risk of developing the disorder. The female predominance is reduced to 4.4:1 in late-onset SLE, defined as the onset of SLE after the age of 50.[13]

Clinical Signs and Symptoms/Diagnosis

SLE can affect multiple organ systems and often has a varied and dynamic course. There are 11 criteria used to help diagnose SLE at which four must be present. Often early symptoms are nonspecific, and the disease is frequently incipient for many years. The diagnostic criteria for SLE are presented in Table 2 . These criteria are intended to separate SLE from other disorders and do not include many other common symptoms, such as fatigue, fever, weight loss, lymphadenopathy, and vasculitis. Thus, SLE can affect virtually any organ.

Lupus arthritis is usually characterized by a symmetrical polyarthritis of the small joints of the hands, the wrists, and the knees. Although the clinical presentation may resemble RA when viewed by a plain radiograph, the inflammatory synovitis tends not to be erosive.

Overall, late-onset SLE appears to be a milder disease than early-onset SLE. In a recent pooled analysis of 714 cases in the literature, late-onset SLE was characterized by higher occurrence of serositis and pulmonary involvement and lower occurrence of malar rash, photosensitivity, palpable purpura, alopecia, Raynaud's phenomenon, neuropsychiatric manifestations, renal involvement, and lymphadenopathy.[14] With respect to laboratory features, the analysis noted higher frequency of rheumatoid factor positivity, whereas antiribonucloprotein, anti-Sm, and serum complement abnormalities were less likely to occur when compared to young SLE patients.

Numerous studies have noted that the severity of SLE usually declines over time.[14] This decline in severity may be primarily attributed to less frequent kidney involvement (proteinuria, renal insufficiency, diffuse proliferative glomerulonephritis) in late-onset SLE. Because of the disease process this has led to less treatment with high-dose corticosteroids and immunosuppressive agents. Finally, although there is a reduced 10-year survival in late-onset SLE patients when compared to their younger counterparts, this is due to the consequences of aging rather than SLE related factors. Thus, overall, late-onset SLE tends to be a milder disease entity than young-onset SLE.

Treatment

Treatment of SLE varies depending on the severity of symptoms and the organ systems involved. An organ-specific approach is used to manage SLE. The management of inflammatory arthritis may just require NSAIDs or low-dose corticosteroids whereas cutaneous disease, such as discoid lupus, may be treated with topical corticosteroids or with antimalarial agents such as hydroxychloroquine. Long-term corticosteroids are the principle treatment modality for the management of SLE. High doses are usually reserved for significant renal and CNS disease. Small to moderate doses are used to treat the serositis and inflammatory arthritis.

The older population is more prone to developing corticosteroid toxicity, especially osteoporosis and glucose intolerance. Several common conditions among older adults are also side effects of long-term corticosteroid use, and thus their risk of adverse events is much higher. Osteoporosis, glaucoma, fragile skin, memory impairment, and increased risk of infection due to impaired immune function are all side effects of corticosteroid use.[10] Short-term side effects of high-dose steroids are weight gain, fluid retention, and insomnia, all of which have increased morbidity in aging individuals by adding strain to already weakening joints, kidney function, and mental acuity. Long-term high-dose corticosteroid use can result in peptic ulcer disease, worsening of hypertension, hyperglycemia, atherosclerosis, elevated serum lipids, and psychosis.[10] In older patients with cardiac comorbidities, these long-term effects are concerning, and patients with poor glycemic control must be vigilant with blood sugar testing to ensure proper dosing of diabetes medications. Thus, all efforts are made to minimize the dose of steroids in this population, including the concomitant use of DMARDs.

Conclusion

In conclusion, inflammatory polyarthritis is common in the older population. The diagnosis of such patients is often more elusive as "classic" symptoms are often less likely to occur. The management of these patients is confounded by end organ damage, treatment toxicity, and other comorbid illness. Thus a high index of suspicion is required for the diagnosis and the management plan should be carefully developed.

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