Why should rheumatologists care about aging? Save

As a herald to what was to come in Washington, the publication of the Lancet Rheumatology series on aging coming just days before ACR24 set the stage for the “grey tsunami” of geriatric rheumatology that was to follow.

As we are all aware, the global population is aging and none of our rheumatic diseases are immune to the impact of the complexities and so-called “geriatric syndromes”, including sarcopenia, frailty, falls and cognitive impairment, associated with the aging process.

Whilst we are increasingly aware of these syndromes, it is sometimes overwhelming to consider just how we may incorporate the unique needs of our older patients into our already busy clinical practice – or perhaps until now we were unsure of their significance and relevance.

Why should we care about aging?

We have increasing evidence to support the central role frailty plays in disease and health outcomes of those with rheumatic disease, including increased risk of serious infection, hospital readmission and mortality. 1 This year’s conference had multiple novel abstracts exploring the association between frailty status and cancer risk and outcomes.

Abstract 0486, a retrospective cohort study using the Veterans Affairs Rheumatoid Arthritis (VARA) registry examined frailty status in 2554 rheumatoid arthritis (RA) patients, and the risk of incident cancers and cancer-related mortality. The study confirmed previous findings of high rates of prefrailty (40%) and frailty (26%)  in those with RA. Interestingly, age-adjusted incidence rates of cancer events were higher in those who were frail, with an age-adjusted incidence rate of 19.93 per 1000 person-years compared with 15.45 for those who were pre-frail and 12.39 in those who were robust. Increased frailty status also showed a trend towards higher cancer-related mortality in these patients; prefrailty (HR 1.43 (95% CI:1.01,2.01)) and frailty (HR1.47 (95% CI:0.98, 2.18)).

This confirms the role of frailty in the risk stratification of patients with RA. Identifying frailty permits possible interventions for its reversal/ improvement, potentially mitigating risk and improving overall patient outcomes.

In abstract 1506, 362 patients with systemic lupus (SLE) and a mean age of 40.6 years were enrolled in a single-centre study assessing cognitive impairment (CI) using the ACR neuropsychological battery. Raw scores were compared to age and sex-matched normative data and the prevalence of  CI was 44.3% (the definition of CI was a  z score of ≤-1.5 in two or more cognitive domains) or 30.1% (the definition of CI was a z score of ≤-2 in two or more cognitive domains). The most frequently affected cognitive domains were visual-spatial function, learning and memory. This study emphasises that cognitive impairment can occur at any age, and indeed patients with rheumatic diseases are more susceptible to accelerated biological ageing and the appearance of geriatric syndromes at a younger chronological age. As Dr. Levinson masterfully emphasised in session 16S32 “Aging Strong: Managing older adults with rheumatic disease” the high prevalence of CI in all our rheumatic diseases impacts a patient's quality of life, adherence to medication regimens, ability to adequately report their symptomatology and can lead to frequently missed appointments, all of which impact their rheumatic disease outcomes. Therefore, one may argue it is our duty to identify the presence of CI in our patients.

Throughout ACR24, the message was clear. Our rheumatology patients, just like the rest of the population, are aging, and indeed our patients are even more susceptible to the complexities and syndromes associated with aging, and at a younger chronological age. By the early identification of these syndromes, we have the ability to intervene and engage in an interdisciplinary approach to halt or potentially reverse these processes resulting in not only better rheumatic disease outcomes, but overall improved quality of life in our patient population. Moreover, the identification of geriatric syndromes in our patients may facilitate a means of management risk stratification. 

How do we incorporate aging into our clinics?

The “Geriatric concerns for the rheumatologist” session as part of the review course addressed just this. Dr. Singh explored the relevance, and application of the geriatric “5Ms”  to provide us with a construct to identify and address the unique and essential needs of our older adults. 2

The first of the “5Ms” – mind – refers to cognition and mood. As Dr. Singh outlined, mood can be relatively quickly assessed in the  clinic using the PHQ-2 questionnaire, and similarly Dr. Levinson (session 16S32) outlined the “Mini-Cog” tool for the screening of cognition. The “Mini-Cog” consists of 3 simple steps – three word registration, clock drawing and three word recall. Despite our time constraints in the clinic, this is something that we can quickly implement, even on an annual basis.

The second “M”  - mobility – encourages us to enquire about falls, the need for mobility aids and screen for frailty. By garnering insight into this, again, we can engage our multidisciplinary team to improve muscle mass, provide appropriate aids and reduce falls. The sooner we identify deficits, the sooner we can intervene and prevent future complications.

The third “M” – medication – reminds us to review our patient's prescription in its entirety, consider polypharmacy and more importantly actively engage in “deprescribing” any potentially inappropriate medication (PIM).

The fourth “M” is perhaps my favourite – consider what matters most to the patient – and ask them! This short question can truly transform a patient's quality of life by ensuring our treatment plan is aligned with their own goals and preferences.

The final “M” – multi-complexity-  encourages us to view our patients rheumatic disease in the context of their other comorbid conditions and psychosocial needs. Ask about a patient's pain, their function including activities of daily living, and also enquire about their social support system and any loneliness.

I have outlined below my “ ACR24 take home” methods of incorporating the 5Ms into my time constrained rheumatology clinic, which I encourage everyone to consider. 

If an issue is identified using the 5Ms, we can engage in  a cross-disciplinary and multidisciplinary approach to management. We have a duty to be proactive when caring for older adults with rheumatic disease, and also those vulnerable to accelerated biological ageing.

“As you and I age, let’s make an effort to celebrate the journeys of our older adults and develop care interventions that are proactive rather than reactive.”

Dr. Singh ACR24

1. Lieber SB, Wysham KD, Sattui SE, Yung R, Misra D. Frailty and rheumatic diseases: evidence to date and lessons learned. The Lancet Rheumatology 2024.

2. Buehring B, van Onna M, Myasoedova E, Lee J, Makris UE. Understanding the multiple dimensions of ageing: 5Ms for the rheumatologist. The Lancet Rheumatology 2024.