Rheumatic disorders are common in old age: much of rheumatology is geriatric and much of geriatrics is rheumatology. DR FRANK DUDLEY HART1 1983
The clinical evaluation of the presentation of arthralgia (painful joints) or arthritis (inflammation of the joints) can be a difficult and challenging exercise because it can be a presentation of many systemic disorders, some of which are rare. Important considerations are sex, age, the pattern of joint involvement (monoarticular or polyarticular), immediate and more remote history, family history and drug use—all of which may provide important diagnostic clues. Polyarthritis, which implies the active inflammation of five or more joints, presents a more challenging diagnostic problem.
Key facts and checkpoints
In a UK National Morbidity Survey, joint symptoms composed just over 7% of all morbidity presenting to the family doctor.2
The commonest cause was osteoarthritis (OA), which affects 5–10% of the population.
Almost 2% of Australians report having rheumatoid arthritis (RA).3
There should be no systemic manifestations with OA.
One-quarter of disability in elderly people is due to severe joint disease.
Systemic diseases that may predispose to, or present with, an arthropathy include the connective tissue disorders, diabetes mellitus, a bleeding disorder, previous tuberculosis, the spondyloarthropathies such as psoriasis, SBE, hepatitis B, rheumatic fever, the various vasculitic or arteritic syndromes (the vasculitides) such as Wegener granulomatosis, HIV infection, lung cancer, haemochromatosis, sarcoidosis, hyperparathyroidism, Whipple disease and Paget disease.
The pain of inflammatory disease is worse at rest (e.g. on waking in the morning, also with stiffness) and improved by activity.
Early diagnosis and management of RA results in considerably better outcomes.
Causes of monoarthritis include crystal deposition disease, sepsis, osteoarthritis, trauma and spondyloarthritis.
Gout and septic arthritis have a recognised cause and cure.
Acute gout is 4–6 times more prevalent in men than women; however, it becomes more common in postmenopausal women, particularly those on thiazide diuretics.4
A DIAGNOSTIC APPROACH
A summary of the diagnostic strategy model is presented in TABLE 25.1.
Table Graphic Jump Location Table 25.1Arthralgia: diagnostic strategy model ||Download (.pdf) Table 25.1 Arthralgia: diagnostic strategy model
Viral polyarthritis (e.g. parvovirus)
Serious disorders not to be missed
rheumatoid arthritis (RA)
connective tissue disorders: SLE, scleroderma, polymyositis and dermatomyositis, psoriasis, other
Pitfalls (often missed)
Ross River virus
Other vasculitides (e.g. polyarteritis nodosa)
Familial Mediterranean fever
Pigmented villonodular synovitis
Seven masquerades checklist
Drugs (esp. narcotics)
Endocrine disorder (thyroid storm, Addison disease)
Spinal dysfunction (possible spondyloarthropathies)
Is the patient trying to tell me something?...