ACR CONVERGENCE 2021—At sessions on Nov. 6 and 8, experts discussed some of the skills and approaches needed for treating complex, aging patients with rheumatoid arthritis (RA). By using the 5M mnemonic—multicomplexity, mind, mobility, medications and matters most—practitioners can employ a multifaceted approach.1
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Multicomplexity in Older Patients with RA
Una E. Makris, MD, MSc, a clinical investigator at the Dallas VA Medical Center studying chronic musculoskeletal pain in older adults and an associate professor of internal medicine in the Division of Rheumatic Diseases at UT Southwestern Medical Center, Dallas, noted that the cases of many older adults seen in rheumatology clinics are quite complex. Dr. Makris participated in both the Multicomplexity in the Aging Patient with Rheumatoid Arthritis session and the Meet the Experts: The 5Ms of Aging panel as part of the Community Hub on Aging.
Dr. Makris explained that clinicians must consider not only the patient’s rheumatic disease but also many other factors that may complicate its management, including multimorbidity, polypharmacy, the patient’s functional status and ability to perform activities of daily living, mobility, risk for falls and mental health conditions. Clinicians must also think about the complexity of psychosocial situations as they relate both to pain and to mental health, two deeply interrelated components.
In the 5Ms of Aging panel, Raymond L. Yung, MB, ChB, Jeffrey B. Halter, MD, Collegiate Professor of Geriatric Medicine and director of the Geriatrics Center and Institute of Gerontology at the University of Michigan, Ann Arbor, explained that medicine has traditionally employed a reductionist approach. “Older patients with rheumatic diseases are more complex because of their changing physiology, immunosenescence, as well as their other chronic conditions. Multicomplexity [is] a more holistic approach that we need when we are taking care of older adults with rheumatic diseases.”
Barriers to Tackling Complexity
Dr. Makris acknowledged some of the perceived barriers in tackling this complexity as part of rheumatologic care. Some practitioners see the approach as time-consuming and impractical. However, by assessing and prioritizing issues, clinicians can address multicomplexity in a streamlined fashion, making referrals where needed and addressing less urgent issues at follow-up.
Dr. Makris also reported that clinicians are sometimes dismissive about pain in the elderly, considering it an unavoidable part of aging. But this stance is unproductive and potentially biased, she argued. “Agism can lead to inappropriate underassessment and undertreatment of symptoms,” she said.
Other rheumatologists may believe that these are issues that should be addressed by primary care physicians. It’s true that a team approach can be very helpful, and the more complex assessments may be more appropriate for a different setting, such as a geriatric clinic staffed by multiple types of providers, she noted.
However, rheumatologists can also play important roles in making initial assessments related to multicomplexity, Dr. Makris argued. “Managing these comorbidities can actually optimize outcomes for patients with rheumatic diseases,” she added.
Another participant in both sessions was Björn Bühring, MD, a rheumatologist and geriatrician at Ruhr-University Bochum, Germany. He noted that patients with a greater number of medical morbidities have worse daily functioning, whether their rheumatic disease is in a period of high or low disease activity.2 Better management of these other conditions may positively impact their daily functioning, which can then be detected on disease activity scores assessed in rheumatology.
Dr. Bühring said, “If you improve function and mobility, your HAQ [Health Assessment Questionnaire score] will go down without doing anything to the patient’s immunosuppressants. If you identify cognitive impairment and you help the patient, their adherence will get better.” So addressing these other issues can directly impact rheumatology outcomes.
Clinicians must consider not only the patient’s rheumatic disease, but also many other factors that may complicate its management.
Using the 5Ms
Dr. Makris and others in the Community Hub on Aging discussed the utility of the 5Ms in working with older patients with RA, an approach first presented by the gerontology community.1 This easily remembered mnemonic can help providers be systematic about caring for their elderly patients. One of the Ms—multicomplexity—is itself a reminder to think about comorbidities and psychosocial factors.
Another M, mind, serves as a cue to address the patient’s mentation and check for dementia, delirium and/or depression. Several different rheumatic conditions, including RA, systemic lupus erythematosus, Sjögren’s syndrome and systemic sclerosis, are thought to increase the risk of cognitive decline and dementia, perhaps via the activation of proinflammatory pathways.3
Mental health issues, such as depression, are also more common in people with RA and other rheumatic diseases than they are in the general population.4 Also, musculoskeletal pain is a risk factor for mental health conditions and vice versa, and each influences the other’s response to treatment.
Another M, mobility, reminds the provider to think about gait and balance issues, and address fall prevention. It’s important to ask about patients’ baseline physical activity, including their activities of daily living. It’s also important to think about how these factors may be contributing to social isolation, which further impacts comorbid health conditions.
With another M, medications, the provider remembers to consider possible medication adverse events, optimal prescribing and deprescribing, as needed. Published by the American Geriatric Society, the Beers criteria provide a helpful list of medications to consider avoiding in older adults (now also available as an app).5
A fifth critical M is matters most, which reminds providers to adapt their care to an individual’s specific healthcare goals and care preferences. Through identifying what matters most to a patient, Dr. Makris helps the patient identify specific, achievable goals that align with those values. Often these targetable goals focus on psychosocial aspects that are important to the patient (e.g., having a low enough level of pain to go to church using a cane).
“Older people have different priorities,” Dr. Yung added. “Understanding that is helpful, not just for the patient and for us [clinicians], but also for the family, so they can understand what their loved one actually wants.” Clarifying these priorities and values leads to better patient rapport, improved compliance and better all-around care.
Dr. Bühring pointed out that although a comprehensive geriatric assessment can be very helpful in a geriatric clinic, it can be time intensive, and it may not be practical to do as a rheumatologist in a busy practice. In many cases, shorter assessments can provide what is needed in that setting.
The rheumatologist needs to assess disease activity level, and a patient’s pain and how it is affecting a patient’s activities of daily living: walking, eating, performing housework, etc. For this, a PEG3, which assigns scores to the disease’s impact on a patient’s pain, enjoyment and general activity levels, can be helpful.6 “I find that understanding how the pain impacts function is more important than the pain intensity score alone,” said Dr. Makris.
Delirium, Dementia & Depression Screening
The cognitive assessment (mind) is also important, especially in a patient who appears to be confused or in a patient with a relevant past medical history. Clinicians can employ a number of different tools in this context. For example, physicians can use a tool like the Confusion Assessment Method (CAM) to quickly screen for delirium and a brief instrument, such as the Mini-Cog, to screen for cognitive impairment.7,8
Another part of mind is screening for mental health challenges, such as depression. Quick, validated tools, such as the Patient Health Questionnaire-2 (PHQ-2), can provide some preliminary information, as can the short-form version of the Geriatric Depression Scale (GDS-15).9,10
Frailty & Sarcopenia Screening
Dr. Bühring also recommended other tools that can be helpful for assessing frailty and sarcopenia. Sarcopenia is much more common in people with rheumatoid arthritis than in people in the general population. And, like multimorbidity, sarcopenia and consequent poor muscle function negatively impact daily functioning as measured by the Health Assessment Questionnaire (HAQ).11
Practitioners can choose among several approaches to screen for sarcopenia, including the SARC-F questionnaire and the Short Physical Performance Battery.12,13 The recent European Consensus guidelines on sarcopenia provide even more detail about the steps needed to make a formal diagnosis.14
A related but somewhat different parameter, frailty, also negatively impacts daily functioning and HAQ scores.15 The Fried Index is a validated measure that is easy to perform in a clinical setting, as is the Simple FRAIL Questionnaire Tool (Fatigue, Resistance, Aerobic, Illnesses, Loss of Weight).16,17 Because one component of frailty is muscle weakness, assessing for frailty somewhat captures sarcopenia status as well.
Dr. Bühring emphasized that regular and systematic use is much more important than the specific tools employed. “Pick a tool that you are comfortable with and go with it,” he said. “The key is that you know what your tools are, and you know them well enough that you don’t have to look up how to do them on the spot.”
Treatment & Interdisciplinary Collaboration
Both Dr. Bühring and Dr. Makris emphasized the need for interdisciplinary collaboration when dealing with these complex patients. When a rheumatologist identifies a potential issue, such as impaired cognition, it doesn’t mean that they alone are responsible for formal diagnosis and treatment. Rheumatologists should have a network of people they can ask for consultations and refer patients to, ideally others with experience working with older patients with rheumatic disease.
Depending on the context, this may mean other doctors (e.g., rehabilitation specialists, geriatricians, orthopedists, psychiatrists) or other professionals, such as physical therapists, occupational therapists, clinical psychologists, social workers or others.18 “It’s always worth picking up the phone to introduce yourself and also to [learn about] their approach to patient care,” said Dr. Makris.
Dr. Makris argued that for many of these older adults with complex conditions, nonpharmacological modalities can play a key role in augmenting treatment. She explained that multiple non-pharmacological interventions now have enough evidence behind them that rheumatologists can use them with their patients, although no single approach works for everyone.
Dr. Makris said, “I typically focus on these movement therapies [such as walking programs, tai chi, yoga, aquatic therapy]. I think that all of our older adult patients could benefit from increasing physical activity, and that could improve both the pain and the mental health comorbidities.” Other approaches, like mindfulness techniques or many others, may be appropriate for other patients.18
Using adjunct therapies in patients with pain is especially important because non-steroidal anti-inflammatory drugs (NSAIDs) are on the Beers list and should be avoided, if possible, by older adults, especially those with liver or kidney problems or those at risk of a gastrointestinal bleed.5
Dr. Makris recommended acetaminophen for patients who respond well to it, or topical NSAIDs, because they are safer than oral NSAIDs. Duloxetine or a similar agent may be helpful in the right context to also help with comorbid depressive symptoms.
However, NSAIDs may be the right choice for some patients if their pain can’t be well managed through other methods and if they are educated about the risks. Some patients may prefer to assume these risks if using an NSAID significantly improves their quality of life. To make the best decisions with respect to this and many other topics, it is critical to discuss with patients their needs, preferences and priorities.
Dr. Bühring pointed out, “It is about finding the safest drug, because none of these medications is going to be completely side effect free.”
Because calculating renal function can be less reliable in older adults, practitioners must diligently monitor for adverse effects from NSAIDs, even if patients have creatinine and glomerular filtration rate values in the normal range. Practitioners should aim for the lowest effective dose at the shortest duration feasible if an NSAID is prescribed.
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical and science writer living in Bloomington, Ind.
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- Radner H. Multimorbidity in rheumatic conditions. Wien Klin Wochenschr. 2016 Nov;128(21–22):786–790.
- Wotton CJ, Goldacre MJ. Associations between specific autoimmune diseases and subsequent dementia: Retrospective record-linkage cohort study, UK. J Epidemiol Community Health. 2017 Jun;71(6):576–583.
- Lwin MN, Serhal L, Holroyd C, Edwards CJ. Rheumatoid arthritis: The impact of mental health on disease: A narrative review. Rheumatol Ther. 2020 Sep;7(3):457–471.
- The 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Apr;67(4):674–694.
- Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009 Jun;24(6):733–738.
- Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990 Dec;113(12):941–948.
- Mini-Cog. Quick screening for early detection of dementia. https://mini-cog.com/.
- Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care. 2003 Nov;41(11):1284–1292.
- Marc LG, Raue PJ, Bruce ML. Screening performance of the 15-item geriatric depression scale in a diverse elderly home care population. Am J Geriatr Psychiatry. 2008 Nov;16(11):914–921.
- An HJ, Tizaoui K, Terrazzino S, et al. Sarcopenia in autoimmune and rheumatic diseases: A comprehensive review. Int J Mol Sci. 2020 Aug 7;21(16):5678.
- Malmstrom TK, Miller DK, Simonsick EM, et al. SARC-F: A symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016 Mar;7(1):28–36.
- Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994 Mar;49(2):M85–94.
- Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age Ageing. 2019 Jan 1;48(1):16–31.
- Andrews JS, Trupin L, Yelin EH, et al. Frailty and reduced physical function go hand in hand in adults with rheumatoid arthritis: A US observational cohort study. Clin Rheumatol. 2017 May;36(5):1031–1039.
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146–156.
- Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc. 2013 Jun;14(6):392–397.
- Welsh TP, Yang AE, Makris UE. Musculoskeletal pain in older adults: A clinical review. Med Clin North Am. 2020 Sep;104(5):855–872.