BMH Medical Journal

BMH Med. J. 2020; 7 (Suppl): Early Online. Geriatrics & Gerontology Initiative: International Workshop on Care of the Elderly

Introduction

Currently, more than 12% of the world's elderly population lives in India. Musculoskeletal disorders (MSKDs) are one of the major causes of morbidity in elderly population. Epidemiological studies in India indicate that the community based prevalence of MSKD is about 20% with low back pain being the commonest.

Low back pain

Low back pain (LBP) in older adults that causes considerable pain and disability. The majority of LBP among older adults has no definite pathology (e.g., fracture or inflammation) and is diagnosed as non-specific or mechanical LBP. Lumbar spondylosis with degenerated disc and altered facet joint alignment is the commonest cause. Majority of them improve with short periods of rest ,analgesics and other supportive therapy. Few of them may develop symptoms of radiculopathy due to compression of nerve roots and may need specific treatment.

However sinister causes of LBP like malignancy, infection and osteoporotic spinal fractures should always excluded if the back pain is severe and persistent. The presence of red flag symptoms and signs warrant urgent and extensive investigations and appropriate treatment (See Table 1) The incidence of all malignancies exponentially increases with age, although only less than 1% of the causes of LBP presented to primary care physicians are attributed to spinal tumors. Vast majority of these tumors are related to metastasis and only a handful of them are primary tumors. The common metastatic sources of LBP are prostate, kidney, breast and lungs although primary malignant tumors (e.g., Multiple myeloma or lymphoma) are also be found in older adults . Clinically, typical symptoms of spinal tumors are progressive, unremitting, localized or radiating pain that are aggravated by movement, worse at night, and cannot be eased by rest. Vertebral osteomyelitis is a life-threatening infectious musculoskeletal disease in older people caused by an infection of vertebral bones. Bacterial infections like Staphylococcus aureus and tuberculosis are the common agents in elderly.

Osteoporosis & Fractures

Fractures are frequent in the elderly and result mainly from the effects of falls and osteoporosis. Low-impact falls, even from standing height, are the most common cause of injury in geriatric patients. Falling is a multi-factorial problem due to both extrinsic (e.g., environmental and housing conditions) and intrinsic risk factors (e.g., impaired mobility, loss of muscular strength, poor visual acuity, and medication). Osteoporosis, which is characterized by qualitatively normal, but quantitatively deficient bone, leads to bone fragility and increased risk of fractures The general prevalence of osteoporosis in women is approximately 50% at the age of 85 years, while in men the prevalence is about 20% at that age Plain X-ray and DEXA scan are useful in making the diagnosis.

Table 1:   Red Flags of Low back pain in elderly

•    Back pain associated with fever & chills
•    Pain extending to the thoracic region
•    Nocturnal pain
•    Unexplained weight loss
•    Refractory pain in spite of proper medications
•    Loss of control of the bowel or bladder.
•    Weakness or numbness in the leg or arm.
•    Foot drop, disturbed gait.
•    Saddle anaesthesia
•    History of Malignancy (prostate, renal, breast or lung)
•    History of trauma
•    Steroids or Immuno suppressive use

Osteoarthritis

Osteoarthritis (OA) is the most common joint disease in persons 60 years of age and above, with a radiographic prevalence as high as approximately 90% in women and 80% in men. Its etiology is not fully understood, although there are several related factors such as female gender, genetics, metabolism, and excessive mechanical stress. It frequently leads to decreased function and loss of independence. Weight bearing joints like knee and hip are commonly involved. Although the joints of the hand are also commonly affected, they are less likely to be symptomatic. The diagnosis of OA is primarily based on clinical history and physical examination. Plain radiographs can help confirm both the diagnosis and grade the severity of the condition. The cardinal radiographic features of OA are focal / non uniform narrowing of the joint space in the areas subjected to the most pressure, subchondral cysts, subchondral sclerosis, and osteophytes. Even though there are no specific treatments are available for OA, analgesics Neutraceuticals, Duloxetine and intraarticular hyaluronic acid are all claimed with varying benefits. Weight reduction, muscle strengthening exercises and physiotherapy are definitely beneficial.

Crystal Arthritis

Gout in the elderly differs from classical gout found in middle-aged men in several respects: it has a more equal gender distribution, frequent polyarticular presentation with involvement of the joints of the upper extremities, fewer acute gouty episodes, a more indolent chronic clinical course and an increased incidence of tophi. Long term diuretic use in patients with hypertension or congestive cardiac failure, renal insufficiency, prophylactic low dose aspirin and alcohol abuse are factors associated with the development of hyperuricaemia and gout in the elderly. Extreme caution is necessary when prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute gouty arthritis in the elderly. NSAIDs with short plasma half-life (such as diclofenac and naproxen) are preferred, but these drugs are not recommended in patients with peptic ulcer disease, renal failure, uncontrolled hypertension or cardiac failure. Colchicine is poorly tolerated in the elderly and is best avoided. Intra-articular and systemic corticosteroids are increasingly being used for treating acute gouty flares in aged patients with medical disorders contraindicating NSAID therapy. Urate-lowering drugs are indicated for the treatment of hyperuricaemia and chronic gouty arthritis.. Allopurinol is the urate-lowering drug of choice, but its use in the aged is associated with an increased incidence of both cutaneous and severe hypersensitivity reactions. To minimise this risk, allopurinol dose must be kept low. A starting dose of allopurinal 50 to 100mg on alternate days, to a maximum daily dose of about 100 to 300mgis often sufficient. Febuxostat is the other choice of drug in Allopurinol hypersensitivity, Asymptomatic hyperuricaemia is not an indication for long term urate-lowering therapy as the risks of drug toxicity often outweigh any benefit.

Pseudogout due to calcium pyrophosphate crystal deposition is also common in elderly, often presents with acute arthritis of knee joint. Calcific periarthritis of shoulder due to basic calcium phosphate deposition can also occur in elderly.

Rheumatoid Arthritis (RA)

Even though RA often starts in 3rd or 4th decade of life, 2-5% have onset after 60yrs In elderly onset RA the female predominance is less marked, disease onset more abrupt, morning stiffness is prolonged and constitutional symptoms more severe. Rheumatoid factor & anti CCP are often negative in elderly onset RA The differential diagnosis with polymyalgia rheumatica, (see Table 2) microcrystalline arthritis, and paraneoplastic manifestation of undiagnosed malignancy are more challenging.

Spondyloarthritis

Only 5% of Spondyloarthritis (SpA) patients are above 50 years of age. These late-onset SpA cases may present distinctive characteristics: constitutional signs, cervical involvement, predominant peripheral arthropathy of the upper and lower limbs or a mixed form of axial and peripheral joint involvement.

Polymyalgia rheumatica

Polymyalgia rheumatica is the most common inflammatory rheumatic disease in elderly people, and it is a common indication for long term treatment with glucocorticosteroids. The most characteristic presenting feature of polymyalgia rheumatica is bilateral shoulder pain and stiffness of acute or subacute onset with bilateral upper arm tenderness. Patients often develop concomitant hip girdle pain and stiffness, as well as pain and stiffness in the posterior neck musculature. Muscle weakness is not a feature of the disease, although this can be difficult to assess in the presence of muscle pain; when symptoms are protracted and untreated, disuse atrophy can occur. Stiffness after periods of rest and morning stiffness of more than one hour are typical. The stiffness may be so profound that patients have great difficulty turning over in bed, rising from a bed or a chair, or raising their arms above shoulder height - for example, to comb their hair. Mild synovitis may be seen in the wrists and knees, but the feet and ankles are only rarely affected. Especially at the onset of the disease, most patients have systemic symptoms including fatigue, loss of appetite, weight loss, low grade fever, and sometimes depression. Patients are always over the age of 50yrs often above 65yrs.

Table 2

Vasculitis

30% people with Polymyalgia Rheumatica in the western world is associated with temporal arteritis. However temporal arteritis is an uncommon large vessel vasculitis in India. When an elderly male presents with unilateral lancinating headache, jaw claudication, blurring of vision and tender temporal artery with high ESR and CRP the diagnosis is most likely and to be started on high dose steroids to prevent permanent blindness. Polyarteritis nodosa can also start in elderly population.Vasculitis secondary to malignancies and drugs should also be considered in elderly patients with vasculitis.

Endocrinopathies and metabolic bone disease

Hyperthyroidism, hypothyroidism, hyperparathyroidism and osteomalacia are all can present with musculoskeletal symptoms. Predominant bone or muscle pain, fatigue, absence of joint involvement; abnormalities of Thyroid function ,parathyroid hormone, calcium, phosphorus, vitamin D concentrations, are always helpful to arrive at the correct diagnosis.

Musculoskeletal Problems in Elderly