Introduction:
More and more elderly people are being diagnosed with chronic inflammatory rheumatic diseases. These conditions can have various effects on their health, and they may also have other medical conditions at the same time. This makes them more vulnerable to complications related to the heart, cancer, infections, and side effects from medications. New treatments called biotherapies have been developed, but they can also have their own risks. The management of an elderly patient's condition can be improved by conducting a thorough assessment of their health from a variety of perspectives and developing a treatment plan that takes many factors into account. This method, also referred to as a multidimensional health assessment leading to an integrated therapeutic strategy, has been noted as a significant area of research in order to improve the care of elderly patients.
What Are the Different Factors That Need to Be Taken Into Account When Managing Rheumatic Conditions in the Elderly?
- Treatment Effectiveness in the Elderly - Limited research on elderly patients with rheumatoid arthritis (RA) suggests that conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) combined with glucocorticoids (GCs) are the initial treatment approach, similar to younger patients. Studies show that csDMARDs like Methotrexate (MTX) and Leflunomide (LEF) maintain their effectiveness in the elderly. Biotherapies, particularly TNFα (tumor necrosis factor-alpha) inhibitors (TNFi), have demonstrated benefits in clinical response and radiographic progression in the elderly population with RA. However, some studies suggest slightly lower effectiveness of TNFi in older patients, while others show comparable outcomes in younger patients. Further research is needed to better understand the impact of treatments on elderly individuals with RA.
- Adverse Reactions in the Elderly - Determining the role of treatment in the occurrence of complications associated with cardiovascular disease, malignancies, osteoporosis, and infections in both rheumatoid arthritis (RA) and aging can be challenging. In elderly individuals, the risk of serious infections is reported to be two to three times higher compared to younger age groups. The use of Methotrexate (MTX) in RA has been associated with significant adverse effects, including major infections, liver failure, bone marrow suppression, and inflammatory pneumonitis. Age-related factors, such as kidney failure and low albumin levels, increase the risk of severe MTX toxicity, often requiring dose adjustments for elderly patients. Studies have shown that increasing age is linked to a higher tendency to discontinue MTX in newly diagnosed RA patients. For Leflunomide (LEF), a retrospective study of RA patients showed that the occurrence of adverse events and survival rates were comparable between patients aged 65 and below and those over 65. However, hypertension and unintended weight loss associated with Leflunomide are particular concerns in the elderly.
Regarding tumor necrosis factor inhibitors (TNFi), multiple studies have highlighted a higher risk of infections in the elderly, especially in cases of high comorbidity, elevated disease severity markers, and previous infections. Retrospective cohorts of RA patients treated with TNFi medications have shown similar rates of drug discontinuation between different age groups, with adverse events (specifically infections) being the primary reason for discontinuation in the elderly, while treatment ineffectiveness is the main reason for younger patients.
What Are the Management Strategies for Inflammatory Rheumatic Conditions in the Elderly?
- Comprehensive Geriatric Assessment: When managing elderly patients with inflammatory rheumatic conditions, a comprehensive geriatric assessment is crucial. This multidimensional evaluation includes assessing physical function, cognitive status, comorbidities, medication review, and social support systems. It aids in identifying individual needs, tailoring interventions, and minimizing the risk of adverse events.
- Multidisciplinary Approach: Inflammatory rheumatic conditions require a collaborative approach involving rheumatologists, geriatricians, physiotherapists, occupational therapists, nurses, and social workers. Such multidisciplinary teams ensure holistic care, addressing diverse aspects of the patient's well-being, including pain management, functional independence, and psychosocial support.
- Pain Management: Pain is a common and debilitating symptom in inflammatory rheumatic conditions. Elderly patients may face challenges in reporting pain, necessitating careful assessment and proactive management. Pharmacological interventions, such as nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and Corticosteroids, should be cautiously prescribed, considering the patient's comorbidities, renal function, and risk of adverse effects. Non-pharmacological approaches can complement pain management strategies, including physical therapy, heat/cold therapy, and assistive devices.
- Comorbidity Management: Elderly patients often present with multiple comorbidities alongside inflammatory rheumatic conditions. Effective management necessitates a careful balance between controlling inflammation and minimizing medication-related complications. Treatment plans should consider potential drug-drug interactions, contraindications, and cumulative toxicities. Collaboration between rheumatologists and other specialists is crucial to optimize therapy and ensure patient safety.
What Are the Common Rheumatic Conditions Present in the Elderly?
- Spondyloarthritis (SpA) - Among spondyloarthritis patients, only a small percentage (5 percent) are over the age of 50. Late-onset spondyloarthritis cases in this age group may exhibit distinct characteristics such as constitutional signs, cervical involvement, predominant peripheral joint pain in the upper and lower limbs, and a higher prevalence of mixed forms of the disease involving both axial and peripheral joint manifestations.
- Psoriatic Arthritis (PsA) - Studies primarily focus on elderly patients with psoriatic arthritis (PsA), which occurs in 6 to 42 percent of individuals with psoriasis. Psoriatic arthritis typically develops around 10 years after the onset of psoriasis. Elderly-onset psoriatic arthritis patients often experience a more severe disease onset and greater joint damage compared to younger individuals. They also tend to have higher rates of fatigue, pain, comorbidities, and acute phase reactants. However, they may exhibit less dactylitis (inflammation of the fingers or toes) and nail involvement compared to those with younger-onset PsA.
- Psoriatic arthritis is associated with increased mortality, primarily due to cardiovascular causes.
- Both psoriatic arthritis and aging, along with tobacco use, are independent risk factors for subclinical atherosclerosis.
- Elderly patients with psoriatic arthritis have a higher risk of developing osteopenia, osteoporosis, and pathological fractures.
- Screening for cardiovascular risk factors in PsA patients is often insufficient, leading to under-treatment.
- Infections and Malignancies - Elderly PsA patients have a higher risk of opportunistic infections and hematological cancers compared to their people without psoriatic arthritis. Immunosenescence (a decline in immune function with age) partly contributes to this increased risk. Incidence rates of overall malignancies and specific cancer subtypes are similar in psoriatic arthritis and rheumatoid arthritis (RA) patients, increasing with age. Treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic originator DMARDs (boDMARDs) does not significantly differ in terms of cancer risk.
What Steps Can Be Taken to Enhance Elderly Care?
- Ensure appropriate use of innovative treatments by addressing concerns about side effects and disease control to increase the use of effective therapies like biologics in the elderly, avoiding underuse or excessive reliance on older treatments.
- Promote access to biologics for elderly patients by addressing barriers. Common barriers include lower education, low income, living alone, and age-related biases to ensure that elderly patients with comparable disease severity receive appropriate biologic treatments.
- Reduce polypharmacy by minimizing the use of multiple medications, which can lead to complications, by educating prescribers, applying appropriate prescribing criteria, utilizing electronic prescribing, and fostering collaboration between pharmacists and physicians.
- Consider comorbidities in treatment planning by taking into account the impact of other medical conditions and functional limitations on treatment response, quality of life, dependency, and mortality in the elderly. Adjust treatment plans accordingly.
- Monitor and address the increased risk of adverse effects due to comorbidities and functional impairment, such as renal insufficiency, chronic pulmonary disease, and diabetes, to improve treatment outcomes.
- Evaluate prognostic factors like disability, low functional status, and concurrent medication use, which can influence treatment effectiveness and guide treatment decisions for elderly patients, leading to improved outcomes.
Conclusion:
Elderly patients with inflammatory rheumatic conditions must be treated with a comprehensive, interdisciplinary, and tailored approach. Healthcare providers can improve patient outcomes and quality of life by considering the special needs of elderly patients, such as comprehensive geriatric assessments, pain management techniques, comorbidity management, and falls prevention. Essential elements of treating inflammatory rheumatic conditions in the elderly include maintaining health and preventing disease.
