Arthur Bookman, MD, FRCPC, Division of Rheumatology, Toronto Western Hospital/University Health Network, Toronto, ON.

Rheumatoid arthritis (RA) in older adults has a lower female-to-male ratio, and presents as either a rheumatoid factor positive typical case of RA, or an acute seronegative syndrome consisting of myalgia, fever, weight loss, and fatigue. Differentiating among systemic lupus erythematosus, polymyalgia rheumatica, and rheumatoid arthritis may initially be very difficult in older patients. Rheumatoid arthritis beginning in younger people can lead to earlier death, accelerated atherosclerosis, complicated polypharmaceutical management, debilitating deformity, osteoporosis, and more frequent infection as these patients enter their geriatric years.
Key words: rheumatoid arthritis, geriatrics, polypharmacy, chronic disease, inflammatory arthritis.

Kristine E. Pringle, Ph.D., Health Care Consultant, First Health Services Corporation/PAPACE, Harrisburg, PA, USA.
Frank M. Ahern, Ph.D., Senior Research Associate, Department of Biobehavioral Health, Pennsylvania State University, University Park, PA, USA.
Debra A. Heller, Ph.D., Senior Health Care Consultant, First Health Services Corporation/PA-PACE, Harrisburg, PA, USA.

Many medications have the potential to interact with alcohol, and older patients may be at greater risk of experiencing adverse effects due to issues of comorbidity and polypharmacy. Even small amounts of alcohol consumed by an older person who is taking multiple medications can have serious consequences. A retrospective analysis linked prescription claim records with self-reported alcohol use. Results showed that 77% of older adults used at least one alcohol-interactive medication, and 19% of alcohol-interactive drug users reported concomitant alcohol use. Because many individuals are unaware of the risks posed by alcohol and medications, it is important for clinicians to warn patients about potential interactions.
Keywords: older adults, alcohol, prescription drug use, alcohol-drug interactions, concomitant use of alcohol and prescription drugs.

Marie D.Westby, BSc(PT), PhD Candidate, Mary Pack Arthritis Program,Vancouver Coastal Health, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.
Linda Li, BSc(PT), PhD, Harold Robinson/Arthritis Society Chair, Assistant Professor, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.

Physiotherapy aims to prevent physical impairment and restore functional ability through the use of exercise, education, and physical modalities. While there is solid evidence supporting physical activities in the management of arthritis, inactivity continues to be a problem among both younger and older patients with arthritis as compared to the general population. Current evidence supports the effectiveness and safety of moderate- to highintensity aerobic and strengthening exercises for osteoarthritis and stable rheumatoid arthritis. Participation in recreational activities does not replace the need for therapeutic exercises. Physicians and health professionals should be equipped with strategies to overcome barriers and facilitate treatment adherence when prescribing exercise.
Keywords: osteoarthritis, rheumatoid arthritis, physical therapy, exercise, physical activity.

Tara Snelgrove BSc, MSc, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL.
Proton Rahman MD, MSc, FRCPC, Associate Professor of Medicine, Department of Medicine, Division of Rheumatology, Memorial University of Newfoundland, St. John’s, NL.

Rheumatoid arthritis is the most common etiology for inflammatory arthritis in the older population, with an estimated prevalence of 2%. An older individual with inflammatory polyarthritis usually falls into one of two categories. The first consists of patients with well-established long-standing disease, whose course is often confounded by end organ damage and toxicity related to antirheumatic drugs. The other category comprises patients with late-onset inflammatory polyarthritis, whose presentation is often nonspecific and, thus, more elusive to diagnose. Systemic lupus erythematous can also occur in the older adult; it is less prevalent than rheumatoid arthritis and is associated with multiple organ involvement, including musculoskeletal symptoms.
Key words: rheumatoid arthritis, systemic lupus erythematosus, inflammatory polyarthritis, late-onset disease.

Richard Long, MD, Professor, Department of Medicine, University of Alberta, Edmonton, AB; Chairman, Tuberculosis Committee, Canadian Thoracic Society.

The incidence of tuberculosis increases with age in Canadians. The prevalence of latent tuberculosis infection (LTBI) may also increase with age in Canadians, though information on the age distribution of LTBI is less precise. Chronic inflammatory conditions that currently constitute the major indications for new biologic therapies (tumour necrosis factor inhibitors), such as Crohn's disease and rheumatoid arthritis, often have an older age onset. Biologic therapies have the potential to cause LTBI to progress to active tuberculosis disease. Their use in older Canadians or other populations that may have a higher than average prevalence of LTBI poses a challenge to tuberculosis control.
Key words: tuberculosis, tumour necrosis factor inhibitors, age, rheumatoid arthritis, Crohn's disease.

Arthur Bookman, MD, FRCPC, Senior Staff Physician, University Health Centre, Coordinator, Core Residency Rheumatology Program, University of Toronto, Toronto, ON.

Rheumatoid arthritis (RA), traditionally, has been a difficult and discouraging condition for medical practitioners to treat. In general, physicians have been taxed to contend with the overwhelming physical destruction, as well as the sometimes devastating medical complications, seen in the disease. Our medical schools do not provide sufficient preparation, giving us inadequate tools for recognition of joint disease in general and few tools for following and monitoring disease progression.

Only 10 years ago, the treatment plan for RA was a leisurely-paced pyramid of medications. It began with non-steroidal anti-inflammatory agents (NSAIDs), and flowed through empirical remedies such as gold salts and chloroquine, into newer empirical remedies co-opted from cancer treatment or transplantation, such as methotrexate or imuran in recent years.

Over the last five to 10 years, modern studies have contributed to an evolving understanding of the disease. It is now evident that the diagnosis of RA amounts to a prediction of joint inflammation that will inevitably evolve to joint damage, leading to X-ray evidence of erosion and joint space narrowing. Furthermore, these X-ray changes are markers for loss of function and disability. The evolution of X-ray change over time is constant (Figure 1).

Dr. Angela G. Juby, MBChB, Cert Geriatrics
Associate Clinical Professor, Division of Geriatrics,
Department of Medicine, University of Alberta, Edmonton, AB.

Dr. Paul Davis, MBChB, FRCP, FRCPC
Associate Dean, Faculty of Medicine, University of Alberta,
Professor, Division of Rheumatology,
Department of Medicine, University of Alberta, Edmonton, AB

Introduction
Rheumatoid arthritis most commonly presents in the 3rd and 4th decades of life; elderly patients with initial presentation and patients whose disease persists into the later decades of life can present interesting challenges. In particular, the differences in clinical presentations of rheumatoid disease in the elderly when compared to younger patients may lead to difficulty in making a definitive diagnosis. There may be diagnostic challenges related to the interpretation of laboratory findings, particularly serological tests. Elderly patients often have comorbidities; therefore, pharmacologic management of rheumatoid disease must be undertaken with caution to reduce interference with the stability of other organ system therapies, and the potential for drug-disease and drug-drug interaction and polypharmacy must be addressed. Finally, it is important to dispel the attitude that "arthritis" is a process associated with "normal aging.

Hand deformity typical of rtheumatoid arthiritis

Novel Biological Therapy for Rheumatoid Arthritis Looks Promising

Ruwaida Dhala, BSc, MSc

Rheumatoid arthritis (RA) is the most common autoimmune disease worldwide. RA primarily affects joints of the extremities, particularly the fingers. The disease is characterized by chronic inflammation of the synovial joints resulting in joint destruction and deformity. RA occurs both in children and adults. The peak incidence of RA is between the ages of 30 and 50 and occurs more frequently in women than in men.¹ The clinical manifestations of the disease include peri-articular soft tissue swelling, joint pain and joint stiffness. Like most autoimmune diseases, there is a genetic susceptibility to RA (see related article on Unravelling the Genetic Mystery of Arthritis). T cells appear to be important in disease initiation whereas monocytes are implicated in disease progression.