Joint Pain in Older Adults: An Age-Friendly Approach with Dr. Una Makris

Approach to Joint Pain in Older Adults

• 💡 Listen carefully to the patient's history, noting if pain is acute or chronic, gradual or abrupt in onset, and considering factors like trauma or falls.
• 🎯 Pay attention to the distribution of joint pain and swelling, as monoarticular pain with warmth may suggest crystal arthritis, while hand pain distribution can clue into RA or osteoarthritis.
• 🔑 Emphasize function and interference with daily life over pain intensity, as high-impact pain is more likely to lead to worse outcomes.
• 🧠 Understand that fibromyalgia is a separate entity and not necessarily a consequence of long-standing other types of joint pain.

Osteoarthritis (OA) Diagnosis and Management

• 🩺 Osteoarthritis is often a clinical diagnosis based on history and exam, with key findings including age, minimal morning stiffness, pain worsening throughout the day, bony hypertrophy, and crepitus.
• 🚫 Imaging is often not necessary to confirm OA unless there's a change in clinical presentation, suspicion of another diagnosis, or referral to orthopedics.
• 🚶‍♀️ Non-pharmacologic approaches are foundational, including education, weight management, nutrition, and mind-body movements like tai chi and yoga.
• 🗣️ Reframe OA discussions using terms like "breakdown of cartilage" and focus on improving function through strengthening, especially quadriceps, rather than "wear and tear" or "bone on bone."
• 🧴 Topical diclofenac is highly recommended due to limited systemic absorption, especially in patients with comorbidities like kidney disease or those on anticoagulation.
• 🧊 Hot and cold modalities can be helpful, with ice packs being a common preference.
• 🩹 Knee braces may be recommended if a patient feels unstable, but their effectiveness is often patient-dependent.
• 💊 For supplements like glucosamine and chondroitin, advise patients to discontinue if they are not effective or affordable; focus on high-quality data and regulated products.
• ⚖️ For Mr. Carter with CKD stage 3A, acetaminophen (up to 2 grams/day) and topicals are safer options than NSAIDs.

Late-Onset Rheumatoid Arthritis (RA) and Polymyalgia Rheumatica (PMR)

• ⚠️ A new presentation of acute onset, widespread joint pain, fatigue, and systemic symptoms in an older adult warrants suspicion for late-onset RA (LORA) or PMR.
• 🔍 Key features of LORA include acute onset, systemic symptoms, PMR-like symptoms, and potential for large joint involvement, especially shoulders. Patients may be seronegative for RF and anti-CCP.
• 🩺 Physical exam findings for inflammatory arthritis include bogginess, warmth, tenderness, and pain with motion, particularly in the MCPs, wrists, and elbows.
• 🩸 Labs to consider include ESR, CRP, rheumatoid factor, and anti-CCP antibodies. ANA is generally not needed unless lupus is suspected.
• 🏥 Early referral to rheumatology is crucial for diagnosis and initiation of disease-modifying therapy.

Geriatric 5Ms Framework for RA Management

• 🧩 The geriatric 5Ms (Mobility, Medications, Mind, Multicomplexity, What Matters Most) provide a framework for age-friendly care in older adults with RA.
• 🤝 Multicomplexity involves understanding and managing multiple concurrent conditions (e.g., RA, OA, CKD, cardiac disease) and their psychosocial impacts.
• 🎯 What Matters Most focuses on patient priorities and aligning care with their values and goals.
• 💊 Medications require careful review for polypharmacy, using tools like Beers criteria to identify potentially inappropriate medications and avoiding undertreatment.
• 🧠 The Mind component addresses cognitive health, including depression, delirium, and dementia, recognizing the potential link between chronic inflammation and cognitive decline.
• 🚶‍♀️ Mobility focuses on fall prevention, fracture risk, frailty, body composition (sarcopenia, osteoporosis), and promoting strength, balance, and physical activity.

Case Resolution and Takeaways

• 🚀 Successful management of LORA with a TNF inhibitor (etanercept) led to symptom resolution and weaning off prednisone, demonstrating the importance of aggressive treatment.
• ⚠️ Avoid ageism and assumptions about functional status in older adults; always ask about their goals and current function.
• 🤝 Interdisciplinary collaboration between primary care and rheumatology is vital for optimal patient outcomes.
• 🌟 Focus on treat-to-target strategies that include disease activity measures, functional goals, and patient-reported outcomes.