Social Security Disability and Lupus and other Immune System Disorders

Social Security Disability and Lupus and other Immune System Disorders Arthur Weinstein, MD Washington Hospital Center April, 2007 Disorders of “immune dysregulation” • CTD’s • Systemic vasculitis • Inflammatory arthritis – RA, ankylosing spondylitis • HIV 2 Connective Tissue Disorders SLE Scleroderma Dermatomyositis Undifferentiated CTD Polymyositis Sjogren’s syndrome 3 Connective Tissue Disorders Clinical Features related to disability • Constitutional and multisystem effects • Chronic, no cure • Exacerbations (flares) and remissions unpredictable but usually treatable • Treated with immunosuppressive medications – side effects • Comorbidities due to organ damage, to medication side effects, to long term disease/treatment effects and to other factors (eg psychological) 4 SLE Major Features of Active Disease • Constitutional – fatigue, malaise, fever, arthralgia, myalgia • Variable organ involvement – Arthritis – Mucocutaneous – rashes, oral ulcers – Kidney – Neuropsychiatric – psychosis, seizures – Pleurisy, pericarditis • Variable abnormalities in laboratory testing – High ESR, CRP, anemia, low WBC, platelets, abnormal urinalysis – High anti-DNA, low complement levels (C3, C4) 5 Case • Middle aged married female (husband retired) with SLE of about 10 years duration. No prior CNS involvement or renal disease. Her symptoms over the years have been constitutional (malaise, fever, joint pains), skin rashes, anemia, low white blood count. She has had flares consisting of joint and muscle pains, fever, malaise and fatigue. These would last about 3 weeks and would subside with an increase in prednisone dose to about 20mg/day which she would take for about 4 weeks with gradual weaning to her maintenance dose of 5mg/day. She has flares about 2 times yearly. • Other medications include plaquenil (hydroxychloroquine) 200mg bid, vasotec 20mg/day. • She has worked as an administrator for the Postal Service for the past 15 years. 6 Case (2) • Over the past year she has had increasing difficulty with her job. She is unable to complete her tasks and to handle more than a few tasks at one time. She complains of a decrease in memory and cognitive abilities. Her supervisor has recently given her a poor work performance rating. She has had 3 flares of SLE as above this past year but this deterioration seems independent of those flares. The only other symptoms she has are chronic muscle and joint aching and fatigue worse than in the past. Her current prednisone dose is 10mg/day. She has been missing more work lately because of these symptoms. disability. She has been told that there is no other suitable job for her at the Post Office. facial rash and BP 140/85, there were no objective physical findings. In particular, there was no arthritis or extremity weakness. Lab testing revealed mild anemia, WBC 4000 (nl>4500), ESR 20 (nl), ANA positive, anti-DNA positive. Brain MRI showed some nonspecific findings but no evidence of stroke or inflammation. 7 • She feels that she can no longer handle her job and is applying for • She went to see her rheumatologist who found that except for a mild • He referred her for formal neurocognitive testing. Case (3) • The testing took 6 hours which she found exhausting. The results revealed that she had trouble remembering large quantities of information and had difficulty with problem solving and multi-tasking. • Her initial application for disability was denied on the basis that she was not totally disabled and could do work of some kind. • She was sent an appeal package, but has had a psychological block about attempting to get all the information an appeal requires. She receives some pension from the military and assumes she may not be financially qualified to get disability. • She has not sought legal advice. 8 Medical Aspects of Case • No prolonged clinical flares to account for symptoms • Mildly abnormal laboratory tests not suggestive of acute lupus flare • Subjective constitutional symptoms without objective clinical findings (fever, weight loss) • Joint and muscle pains without objective arthritis or muscle weakness • Subjective changes in cognitive function without a history of neuropsychiatric lupus flare and nonspecific abnormalities on brain MRI • Poor work performance and abnormalities of higher cognitive function on formal testing. 9 Features of SLE which can lead to work disability • Related to disease activity – constitutional – structural organ effects malaise, fatigue, fever renal insufficiency/failure, deforming arthritis, disfiguring skin rash acute and chronic infections, bone and joint damage, mood swings, weight gain, hypertension, diabetes • Related to medication effects • Functional changes “related to **common SLE” but not to active disease** chronic fatigue, chronic muscle and joint pains, neurocognitive dysfunction, depression 10 Comorbidities and SLE (various causes, independent of disease activity) • Organ damage from SLE (prior activity) – kidney, brain (neurocognitive, stroke-extremity weakness) • Medication effects (corticosteroids) – obesity, hypertension, diabetes – osteoporosis, avascular necrosis • Premature atherosclerotic disease – heart attack, stroke, heart failure • Other – Fibromyalgia – Cognitive dysfunction – Depression – Chronic fatigue 11 Work Disability in SLE Extent of the Problem • Cohort of 159 patients with SLE working since diagnosis (Partridge et al: Arthritis Rheum 1997; 40:2199) – 40% quit work completely average of 3.4 years after diagnosis – substantial job modifications – predictors of early work disability – lower education status (no college), health insurance status, physical rather than mental job, low income, greater disease activity at time of diagnosis • Inception cohort of 273 SLE patients (C, AA, H) (Bertoli et al: Ann Rheum Dis 2007; 66:12) - 19% self-report of disability at 5 years (25% in AA) - predictors – age*, longer disease duration, male, poverty*, less social support, higher disease activity and damage index 12 Work Disability in SLE The Important Issues • Disease and non-disease factors contribute to overall poor health (Alarcon et al, 2005) • Disease factors are characterized by intermittency of activity, variability of organ involvement in an individual patient and from patient to patient and side effects of treatment • Non-disease factors include education status, nature of employment, income level • Fibromyalgia, cognitive dysfunction, depression and fatigue are often related and require special attention 13 Work Disability in SLE fibromyalgia, subjective cognitive impairment, depression, chronic fatigue • Fibromyalgia (by American College of Rheumatology criteria) is common in SLE - up to 30% and may correlate with overall disease severity (Katz et, 2005) - associated with widespread chronic MSK pain, fatigue, subjective problems with memory and concentration • Subjective Cognitive Impairment is extremely common in SLE (up to 80% in some studies) - can be associated with active neuropsychiatric lupus but is usually not - neurocognitive impairment (and chronic fatigue) correlate with work disability (Utset et al: J Rheumatol 2006, 33:531, Panopolis et al: 2006) - neurocognitive testing may or may not be abnormal (higher executive function) - other performance tests may be abnormal – Assessment of Motor Processing Skills (AMPS) (Poole et al: Dis Rehabil 2006;28:653) - brain MRI may show (nonspecific) abnormalities 14 Work Disability in SLE fibromyalgia, subjective cognitive impairment, depression, chronic fatigue, • Depression is common with major depression occurring in up to 30% of patients – may correlate with active lupus and functional disability Comp Psych 2007;48:14) (Nery et al: – often associated with cognitive symptoms (Julian et al et al, 2006, Naqibuddin et al, 2006) – can be associated with chronic fatigue • Chronic Fatigue can have multiple causes as above (as but active SLE is associated with acute fatigue which usually remits with disease suppression) 15 Other Systemic Autoimmune Conditions • Scleroderma – Raynaud’s, cardiorespiratory disease, renal disease • Dermato/polymyositis – muscle weakness (from disease and high dose corticosteroids), respiratory disease • Sjogren’s syndrome – ocular, oral dryness, systemic organ involvement • Vasculitic disorders – many types - highly variable in organ involvement - structural damage and objective findings predominate 16 Role of the Physician • Can help with elucidation of diagnostic features and severity of organ involvement, medications used, comorbidities in SLE and other CTDs and vasculitic disorders • Better to ask to supply records than to provide a comprehensive summary • It would be very helpful to have MD fill out a directed questionnaire about the case rather than a free flow evaluation Please be respectful of physician’s limited time 17