Polymyalgia Rheumatica - Diffuse Connective Tissue Diseases

POLYMYALGIA RHEUMATICA

Pathophysiology

The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs predominately in Caucasians and often in first-degree relatives. An association with the genetic marker HLA-DR4 suggests a familial predisposition. Immuno-globulin deposits in the walls of inflamed temporal arteries also suggest an autoimmune process.

Clinical Manifestations

Polymyalgia rheumatica is characterized by severe proximal mus-cle discomfort with mild joint swelling. Severe aching in the neck, shoulder, and pelvic muscles is common. Stiffness is noticeable most often in the morning and after periods of inactivity. Systemic features include low-grade fever, weight loss, malaise, anorexia, and depression. Because polymyalgia rheumatica generally occurs in people 50 years of age and older, it may be confused with, or disregarded as, an inevitable consequence of aging.

Giant cell arteritis, sometimes associated with polymyalgia rheumatica, may cause headaches, changes in vision, and jaw claudication. These symptoms should be evaluated immediately because of the potential for a sudden and permanent loss of vision if untreated. Polymyalgia rheumatica and giant cell arteritis generally have a self-limited course, lasting several months to several years (Paget, 2001).

Assessment and Diagnostic Findings

Polymyalgia rheumatica and giant cell arteritis are found almost exclusively in people over 50 years of age. Giant cell arteritis has a reported incidence of 18 cases per 100,000, and polymyalgia rheumatica has an annual incidence rate of 52 cases per 100,000 over age 50 (Loeslie, 2000; Ruddy et al., 2001).

Assessment focuses on musculoskeletal tenderness, weakness, and decreased function. Careful attention should be directed to-ward assessing the head (for changes in vision, headaches, and jaw claudication).

Often diagnosis is difficult because of the lack of specificity of tests. A markedly high ESR is a screening test but is not defini-tive. Diagnosis is more likely to be made by eliminating other po-tential diagnoses, but this is highly dependent on the skills and experience of the diagnostician. The dramatic and immediate re-sponse to treatment with corticosteroids is considered by some to be diagnostic.

Medical Management

Polymyalgia rheumatica (without giant cell arteritis) is treated with moderate doses of corticosteroids. NSAIDs are sometimes used for mild disease. For patients with giant cell arteritis, rapid initiation of and strict adherence to a regimen of corticosteroids are essential to avoid the complication of blindness.

Nursing Management

The nursing care of the patient with polymyalgia rheumatica is based on the basic plan of nursing care presented earlier. The most common nursing diagnoses include pain and insufficient knowledge of the medication regimen.

A management concern is that the patient will take the pre-scribed medication, frequently corticosteroids, until symptoms improve and then discontinue the medication. The decision to dis-continue the medication should be based on clinical and laboratory findings. Nursing implications are related to helping the patient prevent and monitor side effects from medications (eg, infections, diabetes mellitus, gastrointestinal problems, and depression) and adjust to side effects that cannot be prevented (eg, increased appetite and altered body image).

The loss of bone mass with corticosteroid use increases the risk for osteoporosis in this already at-risk population. Interventions to promote bone health such as adequate dietary calcium and vitamin D, weight-bearing exercise, and smoking cessation, if in-dicated, should be emphasized (Buckley et al., 2001; Loeslie, 2000).