Rheumatoid arthritis (RA) is a chronic, systemic disease of unknown etiology that is dominated by inflammatory synovitis and is one of the most common rheumatic immune diseases. It is characterized by symmetric, aggressive arthritis of the wrist, metacarpophalangeal joints, proximal interphalangeal joints and small joints of the foot, and may be associated with extra-articular organ damage such as interstitial lung lesions and peripheral nerve damage.
The onset of RA may be related to genetics, infection, sex hormones, etc. RA can occur at any age, with more middle-aged women developing the disease, with a high incidence at 40-60 years of age and a female incidence two to three times that of men.
What are the clinical features of rheumatoid arthritis in the elderly? What is the difference between the Chinese medical treatment of RA in the elderly and that of young and middle-aged patients? In addition, what should be noted about the medication used in the treatment of RA in the elderly? Today I will talk about it.
A. Clinical characteristics of rheumatoid arthritis in the elderly
1, RA in middle-aged women onset for more, the high incidence of age 40 to 60 years old, the incidence of women for men 2 to 3 times.
The incidence ratio of rheumatoid arthritis in elderly men and women is different from that of young and middle-aged rheumatoid arthritis patients, the number of elderly RA men and women is roughly equal, closer to 1:1, in addition to the gradual increase in male patients in old age.
2, more elderly RA acute onset than chronic onset, many patients start similar to infectious diseases, the onset of the symptoms of redness, swelling, heat and pain of the joints, functional limitations, and other symptoms, and the symptoms are heavy.
3. The onset of the disease involves more large joints, such as the shoulder and knee joints, while the proximal interphalangeal joints, metacarpophalangeal joints, wrist joints (hand joints), plantar toe joints and other small joints are often less involved.
Therefore, if you encounter symmetric knee osteoarthritis in the elderly with a short history of onset, you should not preconceive that it is osteoarthritis of the knee, but should improve rheumatoid factor, anti-CCP antibodies, and X-ray of both knees to exclude the possibility of age-related RA.
4. The hands and/or feet are often accompanied by sunken edema.
RS3PE (mild seronegative symmetric synovitis with sunken edema syndrome) is considered to be a special type of RA with an acute onset and is more common in elderly males. It is clinically manifested as acute inflammation of the wrist, flexor tendon sheath and hand joints with sunken edema of the back of the hand, and bilateral elbow, shoulder, hip, knee, ankle and foot joints can be involved. The rheumatoid factor is negative, the X-ray is rarely seen bone erosive changes, the blood sedimentation is increased, hypoproteinemia and anemia, and the response to a variety of non-steroidal anti-inflammatory painkillers is poor, small doses of glucocorticoids have significant effect, some patients can self-limiting symptoms gradually disappear.
5.Often accompanied by fatigue, weight loss and other systemic symptoms.
6, often accompanied by systemic damage, such as heart, lung, kidney, nervous system and other damage is common.
The rate of rheumatoid factor positivity in elderly RA is low, while in the general population, the rate of rheumatoid factor positivity is about 5%, and in healthy elderly people, the rate of positivity has been reported to be as high as 10%-15%, but usually with low titers. Therefore, rheumatoid factor should be interpreted with caution in the elderly. If rheumatoid factor-positive elderly RA has more interstitial lung lesions, CRP, ESR-positive is more common.
8, anti-CCP antibody diagnostic RA specificity in more than 90%, sensitivity in 43% ~ 66%. Studies have shown that the positive rate of anti-CCP antibodies in elderly RA is 65%, which can be used as a differential diagnosis indicator with other diseases.
9, anti-keratin antibody (AKA) for general RA diagnosis sensitivity of 40% ~ 60%, specificity of 94% ~ 98%. Some studies have shown that the sensitivity of AKA detection in rheumatoid arthritis in the elderly is 31.4% and the specificity is 98%, suggesting that AKA has a high specificity in the diagnosis of RA in the elderly and is its specific antibody. Another study showed that the positive rate of AKA in early RA was 28%, suggesting that AKA has some early diagnostic value for RA in the elderly.
II. TCM classification and treatment of RA in the elderly
Some scholars have divided the TCM evidence of RA in the elderly into three types, and believe that RA in the elderly is always a combination of positive deficiency and evil reality, and the general treatment principle should be to support the positive and guarding the root, and to attack and supplement at the same time. Clinical treatment should be based on the difference between deficiency and actuality and the different sensation of evil. We should also pay attention to the role of phlegm and stasis in the pathogenesis of the disease, as phlegm is not separated from spleen deficiency and stasis is not separated from qi deficiency.
Therefore, the treatment should strengthen the spleen and benefit the qi, remove phlegm and eliminate stasis. The treatment should be to harmonize Ying and Wei, eliminate external evil, benefit Qi and nourish Blood, nourish Liver and Kidney, strengthen the Spleen, resolve Phlegm and activate Blood circulation.
1.Discordance of Ying and Wei, invasion of external evil
As the elderly are weak, the Ying and Wei are out of balance, the Wei Yang is not solid, more likely to feel the external evil, wind, cold and damp evil invade the body, stay in the meridians and joints, paralysis of Qi and blood obstruction and paralysis; or external damp heat, or the body is wet, heat, or feel wind heat, and wet combined, or the body is Yin deficiency, external heat, damp heat in the limbs and meridians, contain congestion and obstruction and paralysis.
Paralysis of movement.
Pain in the joints of the extremities, waist and back, soreness, and indefinite pain, mostly in the shoulders and upper extremities, with the initial appearance of fear of wind and fever, light tongue, thin white tongue coating, and floating or slow pulse.
② Painful paralysis.
Pain in the joints of the limbs and waist, back and shoulders, pain does not move, aggravated by cold, warmth is reduced, the joints flexion and extension is not conducive, cold form and limbs, light day and night, white tongue coating, pulse floating tight, this is painful paralysis, the law when the warming and dispersing cold, dispel wind and remove dampness, Wu Tang plus or minus.
(3) Paralysis.
The pain in the muscles and joints of the extremities is fixed, or the pain in the waist and back is acute and unfavorable, the skin is numb, the affected area is swollen, the movement is difficult, the tongue is pale and fat, the moss is white, the pulse is moist and slow, this is paralysis, the method should be to remove dampness, dispel wind and dispel cold, Coix Seed Tang with addition.
Heat paralysis.
Pain in the limbs, waist and hip joints, fever in the painful area, increased pain in the rainy season or summer humid weather, or redness and swelling of the limb joints, slightly relieved by cold, pain is not palpable or the joints are accompanied by skin erythema, nodules, with fever, dry mouth, irritability, red tongue with yellow or dry or greasy coating, moist and scattered pulse, this is heat paralysis, the method should be clearing heat, clearing the channels, dispelling wind and dampness, Xuan Piao Tang plus reduction.
2.Qi and blood deficiency, liver and kidney deficiency type
The body is deficient in old age, the vital energy is insufficient, or the heart and spleen are damaged due to emotional and mental disorders, the Qi and blood are not enough, or the wind, cold, dampness and heat stay for a long time, consuming the Qi and hurting the essence, the essence is insufficient, the liver and kidney are deficient, the tendons and bones are not nourished, the deficiency is real and the evil is false paralysis. Insufficient qi and blood should be treated by nourishing qi and blood, dispelling evil and relieving pain, using the formula of Three Paralysis Soup; deficiency of liver and kidney: treatment: nourishing liver and kidney, strengthening tendons and bones, relieving paralysis and pain, using the formula of Tiger Qian Wan plus reduction.
3.Dampness and stagnation, phlegm and stagnation of each other
In old age, the spleen and stomach are weak, or the external dampness injures the spleen and stomach, the function of transportation and digestion is abnormal, water and dampness accumulate, and it is easy to be caught with wind, cold and heat. The treatment is to invigorate blood circulation, resolve phlegm and clear the channels, and the formula is to add and subtract from Body Pain and Stasis Soup with Dampness and Palsy Removal Soup.