Our understanding of the pathogenesis and approach to treatment of autoimmune diseases continue to evolve. However, key questions concerning the epidemiology, pathogenesis and optimal treatment of these diseases in the elderly population remain unanswered. Despite the many exciting new therapeutic advances, immunosuppression in elderly patients with autoimmune diseases continues to pose a dilemma. Changing population demographics and the advent of biologics, coupled with the lack of the availability of a rheumatologist in many smaller communities, will significantly impact the geriatrician's role in the care of older adults with autoimmune diseases in the coming years. This chapter summarizes key recent advances, with specific references to the geriatric population.
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that preferentially affects diarthrodial joints. The current and most widely used classification criteria for RA were developed in 1987 by the American College of Rheumatology (ACR), based on the study of predominantly middle-aged patients attending hospital outpatient clinics (Table 120-1). While the criteria set is useful for diagnosing established and active disease in younger patients, its usefulness in detecting early disease and elderly-onset (>60 years old) rheumatoid arthritis (EORA) has not been established. This is important because the disease presentation in EORA may be distinct from that of young-onset RA (YORA).
Table 120-1 Classification Criteria for Rheumatoid Arthritis* (R3A4) |Favorite Table|Download (.pdf)
Table 120-1 Classification Criteria for Rheumatoid Arthritis* (R3A4)
Using a method with positive results in <5% of normal controls
Subcutaneous nodules over bony prominences, extensor surfaces, or in juxta-articular regions
Typical changes of RA on hand and wrist radiographs, including erosions or unequivocal bony decalcification localized in or adjacent to the involved joints
Arthritis of the hand joints
Swelling of wrist, metacarpal phalangeal (MCP), or proximal phalangeal (PIP) joints for at least 6 weeks
Arthritis in three or more joints
Soft-tissue swelling or fluid present simultaneously for at least 6 weeks. Possible areas include PIP, MCP, wrist, elbow, knee, ankle, and metatarsal phalangeal joints
Arthritis that is symmetrical
Simultaneous involvement of the same joint areas on both sides of the body for at least 6 weeks
am (morning) stiffness
Morning stiffness in and around the joints, lasting at least 1 h before maximal improvement at anytime in the disease course
One important advance that may lead to the eventual modification of the ACR classification criteria for RA is the discovery that the majority (70–90%, depending on the assay) of patients with RA has in their blood circulating anticyclic citrullinated peptide (anti-CCP) antibodies. Citrullination is a posttranslational modification of protein-bound arginine into the nonstandard amino acid citrulline, and many citrullinated proteins ...