Understanding RA in the Elder

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Understanding RA in the Elder

• Veronica Southard

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Introduction

• 30-40 pts with RA seen in clinics for arthritis
  are gt60 yrs.
• Majority of these have onset before 60
• Elders with RA have jt. deform., mob restrict.,
  dec. strength.
• Functional limitations
• Great impact on ADLs and IADLs

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Clinical Classification

• Heterogeneous course? involvement of synovium,
  joints, and other bodily systems
• 20-30 of RA cases occur after age 60!

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Differential Dx

• Both OA and RA affect function
• RA causes fatique, OA does not.
• OA large joints (Locomotion)? IADLs
• RA small joints hands and wrists? ADLs

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EORA

• Elderly Onset Rheumatoid Arthritis
• Def RA occurs after age 60. Both sexes
• Sx gradual onset of pain, swelling, and
  stiffness in multiple joints.
• Synovitis is restricted to fewer and larger
  joints shoulders, hips, knees, and wrists.
• Seronegative arthritis with extraarticular
  manifestations (nodules)

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• More benign and less aggressive
• RF frequently absent.
• Morning stiffness may last 3-4 hours
• Significant increase in ESR

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Management of RA

• Education the more the better!!
• Treatment PT is indicated in all phases.
• Role of the PT is to help decrease pain and
  swelling, improve the ROM and strength and
  instruct pt in energy conservation and joint
  protection techniques.

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Phases of treatment

• Acute
• Chronic
• Pre/post surgical

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Different scenarios seen in elders

• RA before 60 the long duration becomes a factor
• EORA reduce active inflammation, look at
  functional mobility and altered independence?
  emphasis on functional training. Independence in
  ADLs

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Education

• Pt has to play an active role in recovery
• Explain to pt. about their condition, what
  happens and why.
• Teach pt. when to exercise, when to rest, how to
  control pain
• Explain the rationale for exercises, and
  modalities.
• Explain why they need assistive devices and home
  modifications

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Rest

• General body use caution because of rapid
  decline potential. Establish a balance.
• Joint specific acute episodes

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Exercise

• Enhance physical and mental state.
• Moderate aerobic exercise has been shown to be
  beneficial. ( Prevention/Wellness)
• Individualized to address specific issues.
• Functional return is more important in this
  population.

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• During acute inflammation, 1 rep of complete Rom
  is required to maintain Jt. motion.
• Caution not to overstretch which can result in
  tears.
• ROM done in the evening has been shown to assist
  in decreasing the duration of morning stiffness

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• Passive ROM is not recommended. Instead use
  gentle stretching, positioning, and splints.
• Strengthening isometric or isotonic.
• Encourage the pt. to exercise indefinitely
• Aerobics should be 3-4x/wk for 20-40 minutes at
  60-70 max HR.

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Effects of Exercise on Elders with RA

• Effects of immobilization can be reversed to gain
  strength /gt than young.
• Prolonged stretching
• WB exercise
• Functional training

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Modalities

• Address Pain, stiffness, and weakness
• Commonly used heat, cold.
• Studies have shown no evidence of increased
  benefit if heat and exercise are combined.
• Cold can provide anesthetic effects. Move
  cooled joints very gradually

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Splinting and joint protection

• Rest and protection
• Explain and the patient will comply.

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Energy Conservation

• Principles of loading and unloading joints should
  be clearly understood by patients.
• 1. Clasp clothing in the front
• 2. Use velcro
• 3. Dec. reps to complete activity
• 4. Sit rather than stand
• 5. Walk more slowly
• 6. Carry smaller loads when stairclimbing

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Functional evaluation

• Not only the patient, but the home environment
  and needs of the caregiver have to be accounted
  for

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CASE STUDIES

• 1. 82 yo female, admitted to your facility s/p
  fall. R wrist fx. Closed reduction. PTA I ADLs
  lived alone. AO X 3. Mildly HOH, wears hearing
  aid. PMHx CHF, HTN, THR R x 10 yrs.
• Eval and treat Pt. will remain in your care 2
  days. Then Home health will commence

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• Case 2
• 65 yo male, living with wife and 1 son. Recent
  retiree, planning to travel. Fell in the sup
  kitchen that he volunteers at and fx R radius and
  ulna. Pins and plates were used. While
  recuperating from fx, developed R hip and knee
  pain making walking difficult. Seen by Ortho,
  who prescribed Voltaren and Tylenol. Gardually,
  in the next 6 months noticed hand tightness,
  being stiff all over in AMs. What is going on?

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• Sally is a 74 yo female with RA since her early
  50s. You have been seeing off and on over the
  last 2 years. You have successfully assisted her
  rehab after a knee replacement and hip
  replacement. Although see is independent without
  device or assist, today her cc is how hard
  everything is. What issues do you want to
  address this examination?