rheumatoid arthritis in the elderly
Introduction
Introduction to rheumatoid arthritis in the elderly Rheumatoid arthritis (RA) is a symmetrical, progressive and aggressive polyarthritis, mainly involving the small joints of the hands and feet, showing joint pain, swelling and dysfunction, and the disease is repeated. It is a chronic systemic autoimmune disease characterized by joint synovial inflammation. The main pathological changes are chronic inflammation of the synovial membrane, vasospasm formation, destruction of cartilage and subchondral bone, and ultimately joint deformity and rigidity. Lost. Genetics, infection, random factors, sex hormones, environmental factors, psychological factors, the sin of Chinese medicine, evil invasion, phlegm and stasis, may all be due to this disease. basic knowledge The proportion of illness: the probability of illness in the elderly is 5.3% Susceptible people: the elderly Mode of infection: non-infectious Complications: constrictive pericarditis myocarditis pneumothorax choroiditis iritis osteoarthritis rheumatoid arthritis arthritis
Cause
The cause of rheumatoid arthritis in the elderly
Genetic factors (20%):
The results of rheumatoid arthritis patients, family and identical twins and non-identical twins support the conclusion that genetic factors play an important role in the pathogenesis of rheumatoid arthritis. RA is similar to other rheumatism in genetics. The aspect has its own characteristics, the family aggregation of RA is relatively low (Table 1). Secondly, there are many different genes involved in the pathogenesis of RA, but none of the specific genes are necessary for the disease or can cause disease alone. Each plays a small part, so that the probability of disease occurrence increases slightly, which is the low explicit or incomplete appearance of heredity. Third, genetic factors not only determine the susceptibility of the disease, but also the severity and clinical development of the disease. Performance-related, which provides us with genetic markers for predicting disease progression, and in recent years genome-wide scanning and candidate gene approaches have led to a deeper understanding of the genetics of RA genes.
(1) HLA-related alleles: The human major histocompatibility complex (MHC) possesses a polymorphic locus, and a person who inherits a specific gene expressed at the MHC locus is susceptible to RA. This particular gene is called an allele associated with the disease.
(2) Non-HLA-related pathogenic genes: Recently, the focus of research has gradually shifted to non-HLA genes (Table 4), as more and more studies have found that it has a non-negligible role in the pathogenesis of RA. Currently, microsatellite markers and single nucleotide polymorphisms are used for genome-wide linkage analysis to analyze complex genes associated with disease, UK, Japan, USA and The use of this genetics technology in many European countries to detect RA-susceptible populations worldwide, and to study families with at least two siblings with RA, confirmed the linkage between HLA and RA, and found Non-HLA loci located on chromosomes 1, 3, 4, 5, 6, 12, 16, 17 and 18 are associated with RA, although the role of HLA allele RA plays an important role, but the role of non-HLA genes Can not be ignored.
Infection factor (20%):
Since the discovery of hemolytic streptococcal infections caused by rheumatic fever 30 years ago, attempts have been made to confirm that infection is a major cause of rheumatoid arthritis by various theories and experiments. Many microorganisms are considered to be the pathogens of chronic synovitis, including many. Bacteria, mycoplasma, chlamydia, viruses (such as cytomegalovirus, parvovirus B19, EB virus, etc.), infection factors have long been suspected as a direct cause of RA, with the development of molecular biology techniques, especially PCR The application provides a more advanced means of finding the source of infection, but unfortunately, no specific infection factor has been found, whether it is the application of separation methods, the use of electron microscopy, or modern molecular biology techniques.
Random factor (10%):
With the deepening of the understanding of RA, people are increasingly aware of the role of stochastic factors in the pathogenesis of RA, and put it in a more important position, but the role of random factors is difficult to repeat through the test, these The factors mainly reflect their role in the pathogenesis of RA from the following three aspects, including somatic genetic mutation, epigenetic effects and random changes related to physiological processes.
Sex hormones (10%):
In 1938, scholar Hench observed that pregnancy and jaundice can alleviate the symptoms of RA, so he boldly suggested that adrenal insufficiency can lead to the occurrence of RA. It is these important observations that prompted later generations to discover corticosteroids, which are adrenal cortex. The main product, and for a long time as a treatment for RA has a miraculous drug, however, although corticosteroids can not cure RA, but the impact of abnormal secretion of hormones in the occurrence and development of RA is still relentless Research, for more than half a century, for corticosteroids, estrogen, progesterone, prolactin, testosterone, dehydroepiandrosterone (DHEA), adrenocorticotropic hormone and corticotropin-releasing hormone in RA clinical The study found that the production and action of gonads and sympathetic adrenal hormone mediators in RA patients are abnormal, indicating that they play an important role in the occurrence and development of RA (Table 5). Like other autoimmune diseases, RA is more common in female patients. The ratio of the incidence of women to men is 2 to 4:1, although this ratio is not as good as some other High diseases, such as systemic lupus erythematosus 9 to 13:1, Hashimoto's thyroiditis 25 to 50:1 the like, but still reflects hormone have a role in the immune response.
Environmental factors (10%):
A large number of clinical practice has confirmed that the incidence of this disease is significantly higher in those who live in damp housing for a longer period of time or in a humid environment. The incidence in this cold area is significantly higher than that in plain plains, indicating that the disease is cold and humid. related.
Self-psychological factors (10%):
A large number of clinical data at home and abroad have shown that the incidence of this disease is higher than that of normal people, and the prevalence of this disease is more likely to occur after mental stimulation, indicating that the disease is related to its own psychological factors.
Prevention
Rheumatoid arthritis prevention in the elderly
Pay attention to rest, work and rest, life in an orderly manner, and maintaining an optimistic, positive and upward attitude towards life can be of great help in preventing diseases.
Complication
Elderly rheumatoid arthritis complications Complications constrictive pericarditis myocarditis pneumothorax choroiditis iritis osteoarthritis rheumatoid arthritis arthritis
1. Malignant rheumatoid arthritis (MRA) refers to arteritis can cause infarcted lesions, Raynaud's phenomenon, further development can cause fingertip necrosis, shedding, severe disease can occur inseparable from nodular polyarteritis, systemic necrosis Arteritis has a poor prognosis.
2. The disease invades the heart can cause pericarditis, myocarditis, heart valve inflammation, and some due to rheumatoid nodules caused by cardiac conduction disorders (especially bundle branch block), individual cases may have constrictive pericarditis.
3. Patients with severe disease have elevated eosinophils. Some patients may have renal damage. Most of them have drug-induced digestive tract mucosal lesions. Spinal cord lesions are often secondary to cervical synovial joint disease, sometimes secondary to neuroinflammatory muscle atrophy. The rheumatoid thoracic exudate may be complicated by pleurisy. If the lesion develops, the nodules may merge into a cavity, sometimes causing pneumothorax or chronic bronchopleural fistula.
4. A small number of painless nodular lesions cause eyeball perforation after collapse, and some also have iritis, choroiditis, and dry keratoconjunctivitis.
Symptom
Symptoms of rheumatoid arthritis in the elderly Common symptoms Joint pain Osteoporosis Morning zombie rheumatism Cold dampness Rheumatic polymyalgia Subcutaneous nodules Perforation of the atlantoaxial joint instability
1. Diagnostic criteria and their applications
The American College of Rheumatology began to develop a classification standard for rheumatoid arthritis in 1956, which was revised in 1958. This standard provides objective criteria for the diagnosis and treatment of rheumatoid arthritis, and people continue to understand the disease. In addition, new inspection methods have emerged, and many diseases originally attributed to rheumatoid arthritis have gradually become independent.
(1) Classical method: The American College of Rheumatology revised the classification standard in 1987. The revised diagnostic standard is also the RA diagnostic standard widely used in China, and its contents include 7 articles:
1 morning stiffness: morning stiffness in or around the joint, lasting at least 1 hour per day for at least 6 weeks.
23 or more arthritis: at least 3 of the 14 joint areas have both swelling or effusion (not simple bone hyperplasia) for at least 6 weeks. These 14 joint areas are: bilateral proximal interphalangeal Joints, metacarpophalangeal joints, wrists, elbows, knees, ankles, and metatarsophalangeal joints.
3 hand arthritis: at least 1 swelling of the wrist, metacarpophalangeal joint and proximal interphalangeal joint for at least 6 weeks.
4 Symmetrical arthritis: The same joint area on both sides of the body is involved at the same time (the proximal interphalangeal joint / metacarpophalangeal joint / metatarsophalangeal joint area may not be completely symmetrical).
Category 5 rheumatoid nodules: subcutaneous nodules around the joint, around the joint or at the bone.
6 types of rheumatoid factor: positive.
7 Imaging changes: Bone erosion or osteoporosis in the front and back of the hand and wrist, which can be diagnosed as RA if it meets 4 of the above 7 items.
2. "Tree" classification method
In addition to the above classical classification methods, there is also a "tree" classification method.
3. Early diagnosis
Early diagnosis is the basis of early treatment. However, there is no satisfactory early diagnosis index. In clinical work, only good materials are synthesized. Various laboratory tests can be used to detect RA early, treat early, and control diseases. progress.
Examine
Examination of rheumatoid arthritis in the elderly
First, laboratory inspection:
1 mild to moderate anemia.
2 serum globulin increased, immunoglobulin IgG, IgA, IgM increased.
The three types of rheumatoid factor were 80% positive, the anti-rheumatoid arthritis synergistic nuclear antigen antibody (anti-RANA antibody) positive rate was 93% 95%, and the anti-nuclear antibody was 10% 20% positive.
Second, X-ray examination, early or active joint soft tissue swelling or associated with joint cavity effusion, later osteoporosis of joints, joint space reduction and bone erosion, late subluxation, dislocation, joint deformity to form bone Sexual rigidity.
Diagnosis
Diagnosis and diagnosis of rheumatoid arthritis in the elderly
Differential diagnosis
(a) proliferative osteoarthritis
The age of onset is more than 40 years old, no systemic disease, no redness and swelling in the joints, damaged joints with weight-bearing knees, spine and other common, no migration, muscle atrophy and joint deformity edge lip-like hyperplasia or callus formation , erythrocyte sedimentation rate, RF negative.
(two) rheumatoid arthritis
The disease is particularly confused with the onset of rheumatoid arthritis, the following points can be identified:
1 Onset is usually abrupt, with sore throat, fever and increased white blood cells.
2 It is more common in the joints of the extremities, which is swollen and painful in the migratory joints. There is no permanent damage after the joint symptoms disappear.
3 often have carditis at the same time.
4 serum anti-streptolysin "O", anti-streptokinase and anti-hyaluronidase were positive, and RF negative.
The efficacy of 5 salicylic acid preparations is often rapid and significant.
(three) tuberculous arthritis
Rheumatoid arthritis should be distinguished from this disease when it is limited to a single joint or a few joints. This disease may be associated with other areas of tuberculosis, such as spinal tuberculosis often with paraspinal abscess, more common in two or more joints, X-ray Early detection is not easy to distinguish, if there is local bone destruction or paravertebral abscess shadow, it is helpful to diagnose, joint cavity fluid is often positive for tuberculosis culture, anti-tuberculosis treatment is effective.
(4) Ankylosing spondylitis
The disease was previously considered to be a type of rheumatoid arthritis, but the disease begins with low ankle joints, non-extremity facets; joint synovitis is not obvious and calcification ossification is obvious; rheumatoid factor test is negative, not Subcutaneous rheumatoid nodules appear; aspirin and other drugs that are ineffective for rheumatoid arthritis can work.
(5) Other connective tissue diseases (both with multiple arthritis)
1. Systemic lupus erythematosus is indistinguishable from early rheumatoid arthritis. The former occurs mostly in young women. It can also occur in the proximal interphalangeal joint and metacarpophalangeal joint synovitis, but the joint symptoms are not heavy, generally no cartilage and bone. Quality damage, systemic symptoms are obvious, there are many organ damage, typical face appears butterfly or discoid erythema, lupus cells, anti-ds-DNA antibody, Sm antibody, lupus test positive can help diagnosis.
2. Scleroderma, occurs in women aged 20 to 50 years, symmetrical hand stiffness in the early stage of edema, refers to knee joint pain and swelling of surrounding soft tissue caused by joint synovitis, easily confused with RA, early in the disease Self-limiting, often a few weeks after the sudden swelling disappeared, the phenomenon of Raynaud's phenomenon, which is conducive to the diagnosis of this disease, hardening and atrophy of the skin hardening, showing a "chat smile" face is easy to identify.
3. The clinical symptoms of mixed connective tissue disease are similar to RA, but there is a high titer granular fluorescent anti-nuclear antibody, high titer anti-soluble ribonucleoprotein (RNP) antibody positive, and Sm antibody negative.
4. Muscle pain and edema of dermatomyositis are not limited to the vicinity of the joints, heart and kidney lesions are more common, and joint lesions are rare, ANA (+), anti-PM-1 antibody, anti-Jo-1 antibody positive.
