Although geriatric patients can be among the most challenging to treat, there is a dearth of research-backed data on which to base diagnosis and treatment decisions, Dr. Makris says.
“Usually, older persons who have certain comorbidities and are ‘higher risk’ are excluded from clinical trials,” Dr. Makris says. “Therefore, our ability to make evidence-based decisions for these patients can be limited.”
Diagnostic Challenges
Diagnosing rheumatic disease in the geriatric population requires a keen ability to distinguish between actual disease and side effects from a medication, says Dr. Nakasato. This can be addressed, at least in part, with a thorough medication history, reminding patients to disclose over-the-counter supplementation as well as prescription drugs that they take, Dr. Yung says.
Discussing with patients the goal of treatment is also crucial, says Dr. Makris. “We should make an effort to talk to each of our older patients about what means most to them at this stage in their life—what are their priorities as far as outcomes we should be aiming for together,” she says.
For instance, the goal of treating back pain in a younger patient might be so they can return to work quickly. In a geriatric patient, their goal may be grocery shopping independently, gardening, or cooking, explains Dr. Makris.
At the same time, rheumatologists should not assume anything about what the patient can or cannot do. To truly assess function, ask repeated questions of both the patient and any caregivers who are present during the appointment, says Barbara Resnick, RN, PhD, Sonya Ziporkin Gershowitz Chair in Gerontology at the University of Maryland School of Nursing in Baltimore and chair of the board of directors for the American Geriatric Society.
“You sometimes have to ask the same question five different ways,” she says. “You might ask the patient if they are able to get their groceries on their own and they say it’s no problem. Yet their caregiver will tell you the patient hasn’t gone alone for six years.”
In addition to questioning, a thorough physical exam is also crucial, as older patients sometimes downplay their symptoms, says Roy D. Altman, MD, professor emeritus at UCLA Rheumatology in Los Angeles. “They may not understand their symptoms, or they don’t want to worry their families. There is also a lot of denial,” he says.
Older patients sometimes downplay pain or do not even report it to their physicians because they’ve been told, “it is just a normal part of aging,” says Dr. Makris. It is important for healthcare providers to be aware of their own biases. “When we get that pain scale rating, we should be doing a pain assessment to find out more about their pain and how it interferes [with] or affects their daily life. By acknowledging that our patients have pain that interferes with daily activities, we have the potential to really help our older patients,” she says.
