вход по аккаунту


Geriatric rheumatology.

код для вставкиСкачать
Arthritis & Rheumatism
Official Journal of the American College of Rheumatology
In most medical specialties, subspecialties in
geriatrics are being developed. Rheumatology should
be no exception. Answers to important questions on
the epidemiology of aging, the aging process itself,
specific rheumatic diseases in the elderly, and the
delivery of health care to older individuals with rheumatic diseases are waiting to be discovered. The
medical research involved and the effect it will have on
rheumatologic practice is at once interesting and compelling, and eventually will greatly change the way
rheumatologists care for patients. It is important for
the members of our profession to support these new
efforts, which will impact on so many people and will
inevitably change our way of doing things in the
future. I am writing this, however, not just to endorse
the extension of our profession’s interest in classic
rheumatology to an interest in rheumatologic care of
patients who are in later life, but also to point out
important new goals for practicing rheumatologists in
the care of the elderly-at the present time, without
awaiting the evolution of the subspecialty.
Several years ago I resolved to become a geriatrician, seeking out the elderly and their medical
problems not just in the clinic and acute care hospital,
but wherever they might be, including the home and
the nursing home. I was surprised to learn how different geriatric rheumatology is when one goes out looking for it, rather than waiting for it to come to the
office. While it is clear that rheumatologists, if they are
to remain at the top of their specialty, cannot serve in
the variety of arenas required of the geriatrician, it is
also clear that primary care physicians are not likely to
acquire this expertise until rheumatologists begin
teaching it. For the most part, primary care physicians
and geriatricians see relatively little late-life rheumatoid arthritis, polymyalgia rheumatica, temporal arteritis, gout, or pseudogout. And while they see a fair
amount of osteoarthritis, they are usually not particularly puzzled by its management and do not perceive a
need for referral.
Here are several examples of the geriatric problems I am repeatedly confronted with as a geriatrician,
which were rarely referred to me as a rheumatologist.
Interestingly, while these all involve the musculoskeletal system, primary care physicians are not in the
habit of asking the advice of rheumatologists. This
seems unfortunate to me, for 1believe we could make
major contributions to improved care by our clinical
experience, by new research initiatives, and by involvement of our teaching programs.
From the Arizona Center on Aging, University of Arizona
College of Medicine, Tucson.
Supported in part by a grant from The Flinn Foundation.
John T. Boyer, MD: Director.
Address reprint requests to John T. Boyer, MD, Arizona
Center on Aging, University of Arizona College of Medicine, 1821
East Elm Street, Tucson, AZ 85719.
The fractured hip
Rheumatologists generally do not become involved with the acute care of a fractured hip and are
generally omitted from long-term management as well.
The orthopedist manages the easier cases from begin-
Arthritis and Rheumatism, Vol. 36, No. 8 (August 1993)
ning to end: the diagnosis, the surgery, and followup
supervision in the office. Patients with more complicated cases are rapidly moved from the acute care
hospital to the nursing home or convalescent hospital,
where they fall under the care of primary care physicians. Rehabilitation units are activated for a given
patient for a short period of time, but may not be
involved in the lengthy effort that is so often required.
Hip fracture occurring in a nursing home is associated
with a 44% rate of mortality within 1 year after the
event ( I ) , much of which may be due to the patient’s
failure to regain mobility. As experts in musculoskeletal disease and the maintenance of mobility, rheumatologists can make a great contribution to this important area.
The collapsing spine
Research on the prevention of osteoporosis is
under way and shows considerable promise. Meanwhile, however, the elderly continue to have an overwhelming problem with shortening of the spine and
associated pain, loss of mobility, loss of positive
self-image, and rising morbidity. It is of interest that
patients with these common problems are rarely referred to the rheumatologist by the primary care
physician, perhaps because there is so little expectation of help. In fact, however, there is much that can
be done through the use of exercise, postural assistance, local injections or massage, skillful use of
analgesics, retraining in activities of daily living, and
attention to clothing, appearance, and psychological
support. Heaven knows, if we rheumatologists can
care for a patient who has crippling rheumatoid arthritis over a lifetime and feel that we are contributing in
a positive way, we can do the same thing for the
dowager’s hump!
Extraarticular pain
In old age, too many things are cheaply branded
as “arthritis.” Our patients start this process for us,
aided by their friends and well-wishers. Physicians
tend to legitimize this diagnosis, perhaps because it
leaves so little to do and, after all, “what do you
expect at your age?” In fact, a great deal of the “pain
of old age” is extraarticular in nature and, as such, is
highly receptive to treatment through local measures
and exercises. Primary care physicians tend not to
make this important distinction between intraarticular
and extraarticular pain. Rheumatologists should point
the way, especially when treatment for extraarticular
pain can be so successful. Even when true arthritis is
present, there is frequently an element of extraarticular pain that remains responsive to simple therapy.
Pain syndromes
Yes, the middle-aged individual with fibromyalgia grows old and still has the fibromyalgia. Patients
with this pain syndrome are joined by many others:
Shoulder-hand syndromes following atrophy of the
rotator cuff are frequently attributed to “pressure on a
nerve.” Dystrophic pain is common as a primary
disease in the elderly, frequently complicates fractured wrist or fractured hip, and is highly responsive to
treatment. Post-zoster neuritis, another scourge of the
elderly, frequently finds its way to specialists in musculoskeletal disease. Here, too, one can help the
patient or the referring physician through a multifaceted approach to the management of pain.
Weakness and unsteadiness
Many elderly persons are simply unsteady on
their feet. A wide variety of problems, often more than
one per patient, account for this. Neurologic and
cardiovascular approaches are widely used, but attention to the musculoskeletal system all too often lags
behind. Enthusiasm for power-building exercises in
the elderly, gait retraining, and attention to assistive
devices are important items for the rheumatologist’s
Care of the elderly psyche
Many of my elderly patients tell me, “I don’t
want a doctor who does not have grey hair.” This
speaks directly to one of the major problems in all
geriatrics, not just geriatric rheumatology . However, it
behooves our specialty to become more familiar with
the problems of image of the deformed elderly, the
frustrations caused by the poor service and communication when one moves and thinks slowly, and the
depression that comes for the majority of those who
find that their sense of control is slipping. The average
75-year-old speaks 130 words per minute, down 18%
from the 155-word-per-minute average of youth and
middle age (2), and clinic appointment times may need
to be increased proportionately. We must also be more
flexible in our treatment decisions. Gold and methotrexate are highly practical and effective treatments in
the elderly, but sometimes one must compromise by
prescribing low-dose steroids from the very beginning,
simply because our patients may not be able to comply
with more complex programs.
Geriatric rheumatology is a much-needed subspecialty. We should Support it not only with new
research and education programs, but also with shifts
in our own practice patterns.
1. Reuben AB: Hip fracture, Geriatric Review Syllabus: A Core
Curriculum in Geriatric Medicine. Edited by JC Beck. The
American Geriatrics Society, 1989
2. &,one DR: Communications Problems in Aging: A Manual of
Geriatric Care. Edited by RW Warne, DM Prinsley. Sydney,
Williams and Wilkens, 1988
Без категории
Размер файла
210 Кб
geriatrics, rheumatology
Пожаловаться на содержимое документа