Reconciling conflicting challenges in older rheumatology patients: remedies from geriatric-rheumatology clinics

With an aging population, the proportion of older adults with autoimmune and inflammatory rheumatic diseases (AIIRDs) is increasing. Rheumatologists are tasked with balancing potentially conflicting viewpoints in the care of their older patients, with rheumatology guidelines advocating strict treat-to-target approaches for controlling disease activity versus geriatric principles emphasizing holistic risk–benefit considerations that may lead to less aggressive management. To reconcile potentially differing priorities and provide age-friendly care, geriatric-rheumatology clinics have been established, often by dual-certified geriatrician-rheumatologists utilizing the geriatric 5Ms framework: (1) What Matters Most, (2) Mobility, (3) Mind, (4) Medications, and (5) Multicomplexity.

An illustrative example of the need to balance conflicting geriatric and rheumatology principles is deprescribing. Deprescribing, the reduction or withdrawal of medications, may be beneficial depending on clinical circumstances or in the setting of polypharmacy (⩾5 medications), yet it may seem contradictory to treat-to-target guidelines or with the use of prophylactic medications (e.g., PJP prophylaxis with glucocorticoids). In addition, risk aversion and implicit bias may lead to suboptimal medication selection when even non-steroidal anti-inflammatory drugs (NSAIDs), often the most benign option, are considered high-risk medications in geriatrics. ¹ To complicate matters further, the average age in rheumatology clinical trials is nearly a decade younger than that reported by national registries, indicating a lack of evidence for appropriate treatment strategies for older adults due to underrepresentation in trials, and thereby underrepresentation in treatment guidelines. ²

Aging leads to multisystem degeneration that impacts medication pharmacometrics, clustering of comorbid conditions, polypharmacy, cognitive dysfunction, and mobility constraints. ³ Older patients also have broader differential diagnoses, mimics, and can present atypically, causing diagnostic pitfalls. Late-onset rheumatoid arthritis (RA), defined as new-onset disease ⩾65 years, can present more acutely, with constitutional symptoms, less seropositivity, and in larger, proximal joints. ⁴ Osteoarthritis, crystalline arthritis, neoplastic, and polymyalgia rheumatica constitute just a short list of potential mimics. Elderly-onset Systemic Lupus Erythematosus (SLE) can present with more arthritis, less cutaneous, and less female predominance. ⁴ Therefore, the care of older adults involves unique challenges.

Ultimately, the onus remains on rheumatologists seeing older patients to make decisions in the context of limited evidence and guidance, necessitating inherent comfort with navigating age-friendly priorities. As with other medical specialties that have successfully integrated geriatrics (e.g., oncology and surgery), geriatric-rheumatology clinics use the Comprehensive Geriatric Assessment (CGA), incorporating measures of physical and cognitive status, comorbid conditions, and medication review.^5,6 Geriatric-rheumatology clinics have already demonstrated increased rates of polypharmacy assessment and referrals for memory testing, sleep studies, and physical therapy. ⁷ Here we present lessons from the CGA and 5Ms of geriatric-rheumatology clinics that can be integrated into standard rheumatology practice.

What matters most

Starting clinic visits with patient priorities and aligning goals accordingly can reframe medical care not simply as disease management but also as support for patient autonomy and quality of life. Centering care on “What Matters Most,” as part of a shared decision-making (SDM) framework in rheumatology, improves patient knowledge, self-efficacy, medication adherence, trust in clinicians, and overall satisfaction. ⁸ Many patients prioritize medication side effects, costs, and prescription logistics. SDM has been found to add <3 minutes to a visit while reducing unnecessary testing and increasing willingness to start appropriate medications. ⁹

“What Matters Most” can be elicited through open-ended questions about elements in a patient’s life, including hobbies, responsibilities, or relationships. ¹⁰ Patient-reported outcome measures, such as RAPID3 or PROMIS, can serve as conversation starters following completion in the waiting room. Geriatric-rheumatology models have integrated SDM tools (e.g., https://patientprioritiescare.org/) in minutes with substantial benefits. ¹¹

Mobility

While rheumatologists focus on joint pathology, geriatricians focus on function and capability by assessing mobility and frailty. Frailty and sarcopenia are prevalent in older adults with AIIRDs, resulting in reduced mobility and functional status, falls or fear of falling, social isolation, and decreased health-related quality of life. ³ Adults with RA and sarcopenia have an approximately 2-fold higher incidence of falls, 10-fold higher incidence of fractures, and lower bone mineral density than those with RA alone. ¹² As the risk of osteoporosis and associated fractures increases with age, treatment decisions, especially around long-term systemic glucocorticoid use in older adults, need to be weighed carefully against steroid-sparing agent use in older adults.

A geriatric-rheumatology mobility assessment includes inquiry about recent falls, physical steadiness, activities of daily living (ADLs), instrumental ADLs, and need for assistive devices. Objective measures of physical performance, such as Timed-Up-And-Go test, Chair-Stand test, or simply observation of the walk to the check-out desk, can be elicited in <30 seconds. ¹³ Brief collateral history from caregivers or patient report of daily chores may identify subtle declines. Early interventions include physical therapy, occupational therapy, or nutrition referrals to prevent falls and preserve independence.

Mind

Impaired cognition occurs commonly in AIIRDs and can hinder medication adherence, leading to medication errors and related health consequences, including hospitalization, loss of independence, and increased healthcare costs. ¹⁴ Approximately one-third of older adults with RA or SLE are reported to experience cognitive impairment, with cardiovascular disease, diabetes mellitus, depression, and antiphospholipid syndrome serving as risk factors. ¹⁵

While time remains a barrier to thorough evaluation in the clinic, simple screening tools can identify those with signs of cognitive dysfunction. The Mini-Cog is a quick test, asking patients to remember and recall three words (e.g., banana, sunrise, chair) after drawing a clock with “hands to 10 past 11,” and can be administered by clinic staff to identify patients in need of further assessment. ¹⁶ An error in ⩾2 elements, including words (each 1 point), clock numbering (1 point), or clock hand positioning (1 point), indicates the need for further evaluation. ¹⁶ Clinicians also may wish to keep in mind potentially modifiable risk factors for cognitive dysfunction, including sleep apnea, depression, anxiety, and sedating medications or glucocorticoids. Recognizing the inherent risk of impaired cognition in AIIRDs, geriatric-rheumatology clinics are well-positioned to integrate cognitive screening, address reversible contributors, and coordinate timely interventions to optimize outcomes.

Medications

While a guiding geriatric principle is the “low and slow” approach to prescribing, this does not imply the need to avoid appropriate treatment escalation altogether. Older adults with RA have been found to be managed longer on chronic glucocorticoids and receive lower methotrexate dosages and fewer biologic therapies than younger adults.^17,18 While low-dose glucocorticoids play an important role as bridging therapy, older adults receive cumulatively more glucocorticoids than younger adults, the consequences of which are not well understood. ¹⁸ Thus, a primary goal in caring for older adults is to minimize polypharmacy, reducing the prescribing cascade: fewer glucocorticoids means fewer secondary medications for prophylaxis or treatment of side effects, such as for gastritis, osteoporosis, or hypertension. Furthermore, in a British RA registry study evaluating polypharmacy, each additional medication or supplement reduced the odds of response to a biologic therapy by 8% and increased the risk of adverse drug events (ADEs) by 6%. ¹⁹

Conversely, older adults are more susceptible to ADEs related to disease-modifying antirheumatic drugs (DMARDs) due to age-related physiological changes impacting absorption, excretion, drug distribution, and metabolism. Geriatric-rheumatology clinics utilize tools and decision aids developed in the geriatrics context (e.g., Beers Criteria), pill organizers and blister packs, digital tools or apps, and simplified regimens (e.g., use of infusions vs injections or daily vs weekly options). Ultimately, interventions should target patient education, ease of dosing, multidisciplinary evaluation by pharmacy, and drug interactions consistent with a “What Matters Most” approach.

Multicomplexity

Multicomplexity is defined as the interplay of multiple interconnected health considerations, including comorbid conditions, functional impairments, and psychosocial factors. The biological age, as reflected in functional status, may diverge from the chronological age in years, as seen when an older patient can be an avid tennis hobbyist while another patient of the same age may be wheelchair-bound. AIIRD patients with multimorbidity, or ⩾2 chronic conditions, have a lower likelihood of achieving disease improvement or remission, suggesting that comorbid conditions should not be seen as a deterrent but rather an incentive to pursue treat-to-target care. ²⁰ Paradoxically, selection of pharmacotherapy can be challenging in multimorbidity and multicomplexity (e.g., kidney or liver disease), necessitating alignment with patient priorities and inclusion of older patients in pharmacologic trials and AIIRD guidelines. Rheumatologists often play a central role in multidisciplinary care, which may be all the more critical in the case of older adults with AIIRDs and multicomplexity.

Conclusion

Rheumatologists may face contradictory considerations in the care of complex older patients with AIIRDs, whether due to higher risk of side effects and frailty, challenges in pursuing a treat-to-target approach, or given a paucity of evidence-based guidance due to limited age-friendly inclusion in trials and guidelines. Increased national focus on age-friendly care has led to geriatric-rheumatology clinics integrating the Geriatric 5Ms framework, guided by “What Matters Most” to enhance patient satisfaction, autonomy, and adherence. Just as with other multispecialty clinics (e.g., dermatology-rheumatology), geriatric-rheumatology clinics provide an essential platform for integrating and refining age-friendly care practices. Future directions include disseminating geriatric principles, guidelines, and CGA initiatives to the broader community of rheumatologists and allied rheumatology health professionals, as well as increasing the inclusion of older patients in clinical trials.