Tackling Multicomplexity in Aging Patients with RA

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.

Dr. Bühring

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 patients’ daily functioning, which can then be detected on disease activity scores assessed in rheumatology.

“If you improve function and mobility, your HAQ [Health Assessment Questionnaire score] will go down without doing anything to the patient’s immunosuppressants,” Dr. Bühring said. “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.