Gout, calcium pyrophosphate crystal disease (CPPD), and polymyalgia rheumatica are common conditions that can cause joint pain in geriatric patients. These conditions are discussed in this chapter.
General Principles in Older Adults
Gout was first described thousands of years ago. Major risks for gout and hyperuricemia include obesity and old age. One study suggests that the incidence of gout is increasing in the geriatric population. The strongest predictor for the development for gout is an elevated uric acid level. Levels between 6 and 8.99 mg/dL predict a 2-fold increase in gout flares and a level >9 predicts a 3-fold rise. Although gout more commonly affects males, male predominance is not seen in patients older than age 60 years, where the incidence of gout in men and women is about equal. Additional risks for gout include high purine diet (red meat, shellfish), alcohol (beer and spirits), high-fructose drinks, renal insufficiency, medications (thiazides), organ transplantation, lead exposure, and genetic factors. Certain diseases that are common in the elderly are also risk factors for gout and include hypertension, diabetes, hyperlipidemia, metabolic syndrome, and hematologic malignancies.
Gout is characterized by episodic self-limited oligoarticular joint pain. The presence of erythema and swelling is characteristic. A history of podagra (first metatarsal joint attack) and or tophi, which are deposits of uric acid crystals around the ear helix or joints, further increases the specificity of diagnosis. Most gout attacks are monoarticular, although recurrent attacks can affect more than 1 joint. Patients may also present with fevers and constitutional symptoms. The ear and lower extremities are common sites of attacks because lower temperatures favor uric acid deposition. Periarticular structures such as bursa and tendons can also be involved. Gout often develops in previously damaged joints or after a trauma. Gout typically resolves in 3–14 days if untreated; however, crystals remain in affected joints and recurrent attacks are common, ranging from 60% in 1 year to up to 84% in 3 years.
The gold standard for the diagnosis of gout is the finding of monosodium urate crystals from aspirated fluid from an inflamed joint or tophi. These crystals are needle shaped and seen inside of polymorphonuclear leukocytes from aspirated joint fluid. They are strongly birefringent when viewed under polarized microscopy. Crystals from tophi are seen alone because the tophus material is acellular. Joint fluid in gout is inflammatory, with elevated leukocyte counts, which can result in diagnostic confusion between septic arthritis and gout. Joint aspiration might not always be performed or be successful, and the American College of Rheumatology has developed additional criteria for diagnosis. Six of the following criteria are needed for diagnosis: recurrent acute arthritis; acute inflammation that develops over 1 day; monoarticular arthritis; redness of the joint; unilateral first metatarsal joint pain or swelling; unilateral tarsal joint swelling; suspected tophus; hyperuricemia; ...