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.