The Challenges of Treating RA in an Aging Population

July 5, 2016

Doctors find themselves increasingly juggling treatment for geriatric patients.

As the population ages and improved treatments extend the lifespan of people with rheumatoid arthritis, doctors may find themselves increasingly juggling the treatment of multiple conditions.

Comorbidities in rheumatoid arthritis are nothing new, of course. An international cross-sectional study published in the journal Annals of the Rheumatic Diseases in 2014 (the COMORA study) found that 15 percent of rheumatoid arthritis patients had depression and 6 percent had experienced cardiovascular events. Other comorbidities found included asthma (6.6 percent), solid malignancies (4.5 percent) and chronic obstructive pulmonary disease (3.5 percent). Osteoporosis and interstitial lung disease are also common RA comorbidities.  

Aging, however, can increase the chances that a person with rheumatoid arthritis will experience one or more of these comorbidities. Getting older also makes people more likely to develop medical conditions not necessarily linked to the autoimmune disease.

"Economically developed countries will be aging rapidly in the coming decades," said Marloes van Onna, a researcher in the division of rheumatology at Maastrict University Medical Center in the Netherlands.  As the majority of diseases are age dependent -  i.e. they occur more often in the elderly - the number of patients with RA with one or more comorbidities will increase in number."  [[{"type":"media","view_mode":"media_crop","fid":"49922","attributes":{"alt":"©OcskayBence/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_4957093594791","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6072","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©OcskayBence/Shutterstock.com","typeof":"foaf:Image"}}]]

Van Onna and her colleague Annelies Boonen, also of the Maastrict University Medical Center, highlighted these patients in an article published in April in the journal BMC Musculoskeletal Disorders. Despite the growing ranks of elderly patients with rheumatoid arthritis, older patients with multiple comorbidities are rarely featured in the research literature, van Onna said. And that means not enough is known about their needs.

Aging immune system

As the immune system ages, it becomes less effective at producing and activating T and B cells, van Onna and Boonen wrote. The senescence of the immune system seems to make it prone to intolerance and to a pro-inflammatory environment, with increased levels of tumor necrosis factor, C-reactive protein and interleukin-6. This immunosenescence may help explain why the prevalence of rheumatoid arthritis increases with age.

A pro-inflammatory environment raises the risk of heart and vascular disease as well as cachexia, which can, in turn, increase the risk of infection and put patients at risk of metabolic conditions, according to a 2011 review in the Journal of Rheumatology.

Rheumatologists typically anticipate common rheumatoid arthritis comorbidities like cardiovascular disease, said Gary Owens M.D., a pharmaceutical and technological consultant who has written about the costs of managing care for rheumatoid arthritis, but may be less primed to treat other diseases of aging, like diabetes or respiratory illness, that aren't necessarily linked to RA. It's a complex care scenario, he said.

"Like all other chronic diseases, physicians must balance the need to aggressively manage RA, yet be aware of comorbidities and either treat them appropriately or refer for appropriate care," Owens told Rheumatology Network. "Sometimes this care requires significant coordination effort in a system that is often fragmented with poor information-sharing capabilities."

Left out

The information gap starts with research. Elderly patients and patients with complex comorbidities are often excluded from intervention studies, van Onna told Rheumatology Network. Focusing on younger, simpler patients makes for clearer data on treatments, but leaves out a vast swath of people whose needs are more complicated. Older RA patients are also less likely than younger patients to participate in observational studies, van Onna said. Elderly patients may be less able to arrange transportation for study medical benefits, might be less willing or able to expend extra effort to participate and may be unfamiliar with technology-driven data-collection methods, she said.

"In fact, no good studies to explore this issue [of exclusion and reduced participation] exist," van Onna said.

In the clinic, age bias may influence the kind of treatment elderly or complex patients received. Rheumatologists may be uncertain about potential side effects, particularly when a patient is being treated for comorbid conditions, which can lead to less-intensive management of the rheumatoid arthritis, van Onna said. It can also be difficult to differentiate between RA-related disability and the aches, pains and reduced mobility of old age.

"Also, older patients themselves might have lower expectations from the medical care as they lead a less-active life and their notion of 'acceptable health state' is likely different," van Onna said.

Lagging research, the challenges of communication with other specialists and the basic medical complexities of patients with multiple conditions can add up to serious confusion for practicing rheumatologists. It's essential, van Onna said, to develop individual, realistic care plans - and to think of treatment in a different light.

"Today's rheumatologists should make a shift from a traditional, disease-centered approach to a goal-oriented approach," she said. "Maintaining maximal functional status and active social participation are essential components of a goal-oriented approach."

 

 

References:

Dougados M, Soubrier M, Antunez A, et al. "Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA)." Annals of the Rheumatic Diseases Ann Rheum Dis. 2013;73(1):62-68. doi:10.1136/annrheumdis-2013-204223.

Van Onna M, Boonen A. "The challenging interplay between rheumatoid arthritis, ageing and comorbidities." BMC Musculoskeletal Disorders. 2016;17:184. doi:10.1186/s12891-016-1038-3.

Owens, Gary M. "Managed Care Implications in Managing Rheumatoid Arthritis." American Journal of Managed Care. 2014;20(7):S145-S152). AJMC.com.

Lemmey AB, Jones J, Maddison PJ. "Rheumatoid Cachexia: What Is It and Why Is It Important?" The Journal of Rheumatology. 2011;38(9):2074-2074. doi:10.3899/jrheum.110308.