The risk of developing tuberculosis in elderly individuals with autoimmune disorders, particularly RA, is higher than in other age groups. Such risk increases with the use of bio- logic therapy, especially anti-TNFa(alpha) agents.
The clinical and radiographic features of tuberculosis in the older adult include extra-pulmonary and oligosymptom- atic disease, which makes its diagnosis more difficult. The rational use of less conventional diagnostic methods could be justified in this age group.
The diagnostic tests to detect LTBI in elderly RA patients do not have an adequate sensitivity (TST, and also QFT-IT);
therefore the onset of biologic therapy in this group of patients, particularly in areas highly endemic for tuberculo- sis, must be done very carefully.
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Y. Nakasato and R.L. Yung (eds.), Geriatric Rheumatology: A Comprehensive Approach, 45 DOI 10.1007/978-1-4419-5792-4_6, © Springer Science+Business Media, LLC 2011
Abstract The differential diagnosis of widespread pain in older adults is broad, with fibromyaglia syndrome (FMS) leading the list. While the exact pathogenesis of FMS is not clear, recent studies suggest that abnormal pain processing and central sensitization contribute to the development of chronic muscle pain and tender points. Precise diagnosis of FMS requires a targeted history and physical examination.
A multimodal treatment approach combining pharmacologic management, physical therapy, and cognitive behavioral techniques is effective for reducing pain and improving function and overall well-being. Antidepressant and anti- convulsant medications are widely used for FMS treatment.
Depression and anxiety are common psychiatric comor- bidities in older FMS patients that also require treatment to optimize outcomes.
Keywords Fibromyalgia syndrome • Myofascial pain syndrome • Tender points • Trigger points • Older adults
• Central sensitization • Depression • Anxiety • Serotonin
• Norepinephrine • Duloxetine • Milnacipran • Pregabalin
• Physical therapy • Cognitive behavioral therapy
Introduction
Chronic pain is under-recognized and under-treated in older adults. It is estimated that 25–50% of community dwelling older adults [1–3] and as many as 80% of nursing home resi- dents suffer from chronic pain [4]. The treatment of older adults has become a major public health concern as this group represents the fastest growing segment of the American popu- lation. By the year 2050, it is estimated that those over 65 years of age will comprise up to 20% of all US residents [5].
Older adults suffer from a wide variety of painful condi- tions with osteoarthritis, low back pain, and peripheral
neuropathies leading the list. Practitioners readily identify these conditions by eliciting a history and performing a physical examination and other diagnostic testing. For many practitioners, however, determining the cause of wide- spread pain is elusive. Diagnosing fibromyalgia syndrome (FMS), the most common cause of widespread pain in older adults, relies entirely on history and physical examination.
Practitioners are prone to discount the significance of wide- spread pain complaints especially when they occur in the setting of more acute medical issues. The consequences of failing to diagnose and provide effective treatment include continued suffering, impaired daily function, physical decon- ditioning, and psychological distress. This chapter will review the epidemiology, pathophysiology, diagnosis, dif- ferential diagnosis, and effective treatment of FMS in older patients. In addition, we will review the relevant psychologi- cal comorbidity such as depression and anxiety frequently encountered in older adults with FMS.