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Challenges in the management of older patients with inflammatory rheumatic diseases

Nature Reviews Rheumatology volume 18, pages 326–334 (2022)Cite this article

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Abstract

The rise in the number of people aged 65 years and older living with inflammatory rheumatic diseases such as rheumatoid arthritis is causing considerable challenges for clinicians. As patients get older, they are at an increased risk of multiple chronic diseases, a situation termed multimorbidity. Multimorbidity inevitably drives polypharmacy, where by a patient requires treatment with multiple medications. In addition, advancing age, multimorbidity and polypharmacy all place a patient at an increased risk of developing geriatric syndromes, which are clinical conditions in older people that do not fit into disease categories and include malnutrition, sarcopenia and frailty. Geriatric syndromes further increase the risk of adverse outcomes, including the accrual of additional morbidity, nursing home admission and mortality. Patients with inflammatory rheumatic diseases are especially prone to developing geriatric syndromes. Some predisposing risk factors for geriatric syndromes, such as joint swelling and functional limitations, are also inherent to rheumatic inflammatory disease itself. The frequent coexistence of multimorbidity, polypharmacy and geriatric syndromes in this patient group requires individually tailored interventions to preserve patient independence and overall functioning. To prepare for the changing demography, rheumatologists should gain more insight into the implications of multimorbidity, polypharmacy and geriatric syndromes for the management of older patients with inflammatory rheumatic diseases.

Key points

  • Older people with inflammatory rheumatic diseases often have multimorbidity, polypharmacy and geriatric syndromes such as frailty.

  • The clinical phenotype of inflammatory rheumatic diseases can change as patients get older; late-onset rheumatoid arthritis is characterized by a more abrupt disease onset and an increased number of tender and swollen joints.

  • Characteristics of frailty often overlap with the rheumatic disease itself; notwithstanding, frailty should be considered a red flag as it is associated with many negative outcomes such as hospitalization.

  • Aberrant disease manifestations and the presence of multimorbidity, polypharmacy and geriatric syndromes in older people can all lead to challenges in diagnosis, pharmacological treatment, clinical research and outcome measurement.

  • Older people with inflammatory rheumatic diseases might need an alternative management approach, as single disease-oriented care can become burdensome because of inefficient care delivery.

  • Isolated geriatric care interventions are generally ineffective in older patients; comprehensive care programmes that target a specific patient group are more promising.

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Fig. 1: Example of a downward spiral that can be seen in patients with inflammatory rheumatic diseases who also suffer from multimorbidity, polypharmacy and geriatric syndromes.
Fig. 2: The ‘spaghetti model’ for the onset and progression of multimorbidity and geriatric syndromes in patients with inflammatory rheumatic diseases (rheumatoid arthritis in this example).

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Acknowledgements

The authors are grateful to T. Schoonbrood and B. Spaetgens for their valuable suggestions.

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  1. Department of Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands

    Marloes van Onna & Annelies Boonen

  2. Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands

    Marloes van Onna & Annelies Boonen

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Correspondence to Marloes van Onna or Annelies Boonen.

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M.v.O. has received consultancy fees from Novartis and Pfizer and a research grant from Pfizer. A.B. has received research grants to her department from AbbVie and Celgene and consultancy fees from UCB, Lilly, Novartis, Sandoz and Galapagos.

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van Onna, M., Boonen, A. Challenges in the management of older patients with inflammatory rheumatic diseases. Nat Rev Rheumatol 18, 326–334 (2022). https://doi.org/10.1038/s41584-022-00768-6

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