Many rheumatic conditions, such as rheumatoid arthritis or lupus, develop when patients are in their 20s to 50s. As a result, most therapies are developed with the needs of these younger adults in mind.
Many older patients have been either living for years with a rheumatic disease or are getting newly diagnosed with a rheumatic condition. Rheumatic conditions are often lifelong diseases that involve the immune system and inflammation. As a patient’s health and body change with age, therapies that managed symptoms earlier in life may no longer be effective or might cause problems as new conditions develop.
Identifying and treating rheumatic conditions can be challenging in older adults for several reasons:
- Rheumatic symptoms such as inflammation, joint pain, limited mobility, and fatigue might overlap with age-related conditions and be overlooked.
- Patients might believe aging itself is causing them to feel worse.
- Health care professionals might assume a rheumatic condition is controlled if the patient does not mention ongoing or new symptoms.
When important changes go undiscussed, pain and inflammation can get worse. This contributes to decreased mobility, social isolation, increased risks of frailty, and reduced quality of life in our growing aging population.
By 2050, nearly 23% of patients with arthritis will be 65 and older, compared to just 17% in 2022. Now is the time to integrate geriatric principles into rheumatology care.
In geriatrics, experts in the care of older adults lean into the Geriatric 5Ms – mind, medication, multicomplexity, mobility, and what matters most – a conversation guide designed in 2017 to help plan care based on a patient’s goals and overall health.
In rheumatology, these core geriatric principles have not yet been applied or used routinely – but they should be. By expanding these conversations, we can help aging patients live the way they want to, with less frailty, more vibrancy, and a better chance to contribute in ways that matter most to them.
In a series of studies published in The Lancet Rheumatology in November 2024, I collaborated with rheumatologists from around the world to expand the Geriatric 5Ms through the lens of rheumatology, with the goal of helping more older adults with rheumatic disease enjoy a higher quality of life.
The Geriatric 5Ms for older adults with rheumatic conditions
✔️ Matters Most
At any stage of life, a care plan is most successful when it is built around a patient’s goals. While “feeling better” may be a decent motivator, setting personal goals – such as holding their new grandbaby without pain, weeding their garden, or biking and walking with friends – can move a patient to active participation and engagement in their care.
“Matters most” discussions involve patients, their family members, and their interdisciplinary care team for a holistic perspective. Consider open-ended questions such as:
- What matters most to you right now?
- What brings you the most joy in life?
- What feelings or health problems keep you from doing what you love?
Together, we talk through strategies to improve their function from “good enough” to doing what they love. This could lead to changes such as overhauling their medications to better control rheumatic symptoms, talking with a therapist to manage anxiety or depression, or launching a new diet and exercise program to improve strength, mobility, and independence.
When older adults are active in discussions about their vitality, care plans become truly personalized. Older patients can stay vibrant longer when we move rheumatic care from a one-size-fits-all approach to an individualized, holistic approach.
I had a wonderful discussion with a patient who said something that I will always carry with me. He said, ‘I want you to guard against good enough. Just because I’m older, don’t assume that my function is good enough. Ask me what matters most.’
✔️ Multicomplexity
With age, many older adults tend to develop compounding health conditions such as high blood pressure, diabetes, and osteoarthritis. Research shows that as more conditions occur, rheumatic symptoms can become more difficult to treat due to effects from chronic inflammation, co-existing conditions, and multiple medications.
Inflammation can contribute to a higher risk (and earlier onset) of age-related conditions such as coronary artery disease, Alzheimer’s disease, and frailty. Frailty is a state of reduced health and function that is associated with worse outcomes in rheumatic diseases. It leaves older adults vulnerable to falls, fractures, hospitalization, and disability.
Waning health can lead to loneliness and social isolation, which research shows can significantly affect health and recovery. But older patients may not proactively bring up new symptoms – they don’t want to be a burden, and they may fear getting more tests and medications or losing independence.
Having regular, nonjudgmental discussions about all health conditions and emotions is key in caring for older adults. The care team, which may include rheumatologists, geriatricians, primary care physicians, or other specialists as well as families and caregivers should work to keep dialogue with older adults open and nonconfrontational. There are appropriate, effective treatment combinations for every patient. Achieving the best outcomes starts with honest conversations.
Related reading: Medical therapy for fragility fractures improves patient mobility, reduces recurrence
✔️ Medication
In the U.S., 34.5% of people ages 60-79 have polypharmacy, which means taking five or more prescription medications. As more drugs are added, the risk of side effects and medication errors increases, while the effectiveness against rheumatic conditions may decline.
Because of these nuances, older adults with existing or suspected rheumatic conditions should meet with their health care providers and if available, a Doctor of Pharmacy (PharmD) to:
- Review medications and dosages
- Determine the risks of interactions
- Identify side effects that may mask or worsen rheumatic symptoms
- Adjust dosages, timing, or types of medications for optimal outcomes
As new medications are recommended, families and health care professionals should discuss why and how the new drug may interact with current therapies. We also want to understand patients’ preferences, such as “I am anxious about doing injections” or “I know I won't take a pill three times a day.” With this knowledge, we can prescribe options that work and that the patient will be more likely to adhere to.
Related reading: Geriatrics COVE team makes house calls for older people
✔️ Mind
Having a rheumatic disease may increase the risk of cognitive impairment. Screening tools are available for the general public, but there is no specific measure that considers the effects of rheumatic diseases.
Older adults, caregivers, or health care professionals may downplay mood or memory changes as a normal part of aging. This makes conversations about even subtle emotional, cognitive, and personality changes in older adults important to their health and livelihood.
There are also many other conditions that can contribute to confusion, memory loss, or trouble concentrating. Some include:
- Mental health conditions: These include anxiety, depression, and post-traumatic stress disorder. Depression is twice as common in people with rheumatic diseases as in the general population and can co-exist with cognitive impairment.
- Medication side effects: Polypharmacy can lead to drug interactions and unexpected issues such as drowsiness or overstimulation.
- Delirium: Events such as hospitalization can cause temporary confusion and delirium that may mimic dementia.
- Reaction to pain: Low mood or irritability is a natural response when something hurts or when someone isn’t sleeping enough or feels generally uncomfortable.
Based on conversations with the patient and family, as well as exams and imaging, a rheumatologist, geriatric psychiatrist, neuropsychologist, behavioral neurologist, geriatric specialist, and primary care physician can make a thorough, personalized treatment plan that covers mind-related concerns and rheumatic disease activity.
✔️ Mobility
As we age, our muscle volume naturally declines (sarcopenia). Having a rheumatic disease can increase the risk of sarcopenia and mobility problems due to inflammation, muscle and joint pain, and resultant decreased movement. Reduced muscle strength negatively affects balance, gait, and the ability to perform daily activities, like bathing or preparing meals.
Reduced mobility also increases the risk of falling, which is the leading cause of injury-related death among older adults. One third of adults have fallen due to issues such as low mobility, medication interactions, and vision problems. Serious health issues such as a concussion or a fragility fracture can result in hospitalization, the need for long-term care assistance, or even death.
The way to counter this is to keep moving – if you don’t use it, you lose it! Older adults with rheumatic conditions can be assessed for mobility and function by health care professionals in rheumatology, geriatrics, physical medicine and rehabilitation, physical therapy, neurology, and orthopedics as well as primary care providers. Assessments can include:
- Chair-rise time (moving from sitting to standing)
- Balance
- Walking speed
- Hand-grip strength
- Climbing stairs
Every older patient needs to take fall prevention seriously to avoid traumatic brain injury and life-altering fractures. Some older adults feel embarrassed about having grab bars installed at home or using aids such as canes or walkers. Talk with loved ones and health care providers about ways to personalize these safety features.
The Geriatric 5Ms framework can be a powerful resource to bring geriatric principles into rheumatology practice. Providing optimal care involves teaming up with specialists and experts in various fields along with primary care physicians while communicating clearly and focusing on the values and goals the older patient sets forth.
Older adults with rheumatic diseases are living longer, healthier, more vibrant lives when underlying and comorbid conditions are recognized and treated appropriately. By bringing together older adults, families, and health care providers, patients can get the knowledge and support they need to make informed decisions about their care.
To schedule an appointment, call 214-645-2800 or request an appointment online.
