It is not uncommon for an older adult patient to complain of pain, but it is important to ask questions about the location, severity, and duration of the pain. It is easy to dismiss pain in the geriatric population because both the patient and the clinician often feel pain is a normal part of aging.
Polymyalgia rheumatica (PMR) is an inflammatory disease that can also be associated with giant cell arteritis (GCA). Both illnesses affect patients aged 50 years and older, with a mean age of 70 years, and are probably a spectrum of one disease.
Having one illness does not mean that your patient will have the other, but both are often seen together. The important information to note is that undiagnosed GCA may lead to blindness.
Patients with PMR complain of muscle pain and stiffness in the upper arms, shoulders, thighs, and pelvic girdle. The stiffness is particularly severe when waking in the morning, possibly with some difficulty getting out of bed. The symptoms are usually bilateral and symmetric, and there may also be complaints of fatigue, weight loss, depression, and fever. Another common feature of PMR is inflammation of the synovial cavities and bursae in the shoulders.
Patients may complain of difficulty rising from their chair, combing their hair, or fastening or unhooking a bra. Some patients may also have mild joint swelling, especially of the wrists and knees. Females are twice as likely as males to experience PMR. If left untreated, muscle atrophy may be seen.
The laboratory finding, commonly asked on medical exams, is an erythrocyte sedimentation rate (ESR) of greater than 50. However, it is important to note that many PMR patients (7 to 20%) do not have an elevated ESR. If you practice medicine based entirely on what you see on labs, you may miss an important diagnosis!
GCA patients may complain of fatigue, headache, and tenderness of the scalp. There is often particular pain around the temporal and occipital arteries. Headache is the most common complaint and has been seen in over 67% of patients.
The pain from GCA is usually severe. If the disease has gone untreated, the vessels are often thickened and tender. On palpation there will be an absent or reduced pulse.
Visual disturbances may be seen in up to 50% of patients. Blindness is the most severe and is irreversible. The blindness is usually sudden and painless and is preventable if the disease is caught early.
If an older patients present with complaints of headache, this is one diagnosis that you don’t want to miss. Other symptoms may include pain with chewing, loss of taste, tingling of the tongue, and pain in the mouth or throat. These symptoms are believed to be due to the vascular insufficiency.
At present, the underlying pathology of PMR is unclear, although may patients report a distinct prodromal event resembling influenza or viral pneumonia before the muscle pain begins. There is some thought that Parvovirus B19 is linked to GCA. There have been studies showing a seasonal increase in PMR and GCA; however, other studies dispute this fact.
Initial treatment for PMR is with corticosteroids, which also helps prove the diagnosis. Patients will report a dramatic resolve of symptoms within 24 to 72 hours. For GCA, corticosteroids are mandatory.
Doses for PMR are between 10 to 20 mgs for one month, reducing by 2.5 mg every week to 10 mg daily, and 20 to 80 mg for GCA, depending on whether there is ocular involvement at diagnosis. Consulting or referring to a rheumatologist is wise.
The goal for PMR is to get symptoms under control and then decrease the steroids to the lowest possible dose to manage symptoms. However, care has to be given not to decrease too quickly since reducing the dose is associated with relapses.
Patients with GCA should be monitored for potential ophthalmic issues. Some patients are switched to methotrexate or anti-TNF medications at some point. Patients on average continue these medications for about 2 years. A few patients will need treatment indefinitely.
Next time one of your older patients complains of muscle pain, stop and take a minute to ask a few questions. Don’t assume advancing age means muscle pain and ignore their symptoms.
Sharon M. O’Brien, MPAS, PA-C, is a practicing clinician with an interest in helping patients understand the importance of sleep hygiene and the impact of sleep on health.
- McGraw-Hill Education, Current Medical Diagnosis and Treatment 2015, “Polymyalgia Rheumatica and Giant Cell Arteritis”, p 836-837.
- Hochberg, ed., Practical Rheumatology, Third Edition, “Polymyalgia rheumatica and giant cell arteritis”, p. 491-501.