“Doctor, this medication isn’t working! My hands are still swollen and painful, I can’t lift my arms and I have difficulty walking. I know you’ve done your best but there must be something more than this methotrexate. I retire in January and my daughter just can’t take care of me and my wife.”
Elderly-onset rheumatoid arthritis (EORA) is defined as RA starting after 60 years of age. Compared to RA in younger patients, it’s characterized by a lower female/male ratio and frequently has an acute onset accompanied by constitutional symptoms. There are two overlapping subsets of RA in the elderly: the first has the classical RA clinical picture while the other has a polymyalgia rheumatica-like appearance (Table 1). Anti-cyclic citrullinated peptide antibodies can differentiate this last subset from true polymyalgia rheumatica.1
Treatment of RA in the elderly requires prudence because of the increase in age-related risks pertaining principally to the renal, cardiovascular and gastrointestinal systems. The risk/benefit ratio of medication must be accurately evaluated for every single patient.2 Therapeutic goals, however, take on more urgency because the potential for immobility places the elderly at high risk for permanent loss of their independence, increasing the social burden of the disease in this age group.
The guidelines and the reality
The American College of Rheumatology recommended, in their 2002 guidelines for the treatment of RA, early aggressive treatment with disease modifying anti-rheumatic drugs (DMARDs). Close monitoring of the response is key, and if control of the disease isn’t adequate, the guidelines suggest a change of DMARD, combination therapy or the use of biologic agents. These recommendations were reinforced in the 2008 guidelines available on line at www.rheumatology.org.
The U.S. National Committee on Quality Assurance has also determined that all patients with RA should be treated with DMARDs.3 Furthermore, of 204 rheumatologists who filled a survey on the treatment of RA, (80%) supported this early aggressive DMARD approach.4
And yet, current, real-life management of RA of the elderly may be based more on assumptions than evidence. Older patients receive lower doses of methotrexate (MTX). They’re less likely to be treated with DMARD combinations, more likely to be taking prednisone, and are less often treated with biologics.5 A survey of patients in the community, with full prescription drug coverage, also showed that older patients and those not seeing a rheumatologist were less likely to receive a DMARD and may provide a target for quality improvement interventions.3 Olivieri et al have recommended that no group of molecules be excluded, a priori, from the care of older RA subjects.2
Let’s now look, more specifically, at the prescription of biologics in older subjects. In one report, 215 (44%) of 487 RA patients were prescribed an anti-TNF.6 Age had a significant influence on the decision to prescribe and on its timing. For the same period of observation, elderly patients received fewer biologics, if one considers the duration of disease and the co-morbidities. Their score on the DAS28 had to be significantly higher, on average, than that of younger patients before a biologic was considered. The literature, however, has documented that both infliximab and etanercept are no less effective and no more toxic in RA patients over 65 than they are in the younger age group.
Negative stereotypes are costly
Frankel et al have recommended that future CME efforts raise physician awareness of this possible bias so that equal care be provided in all age groups.4
The term ageism was coined in 1969 by the Pulitzer prize-winning gerontologist Dr. Robert N. Butler, to define prejudice against older adults based solely on chronological age or associated disability. It’s maintained in the form of primarily negative stereotypes and myths concerning the older adult. In Butler’s words: “Ageism reflects a deep-seated uneasiness on the part of the young and middle-aged — a personal revulsion to and distaste for growing old, disease, disability; and a fear of powerlessness, ‘uselessness’, and death.” Our culture of youth and productivity, our fear of death, and past biomedical research based on the 5% of institutionalized elders all lead us to this bias. Known consequences of ageism include less preventive care, less screening and diagnostic testing, and care gaps with insufficient and possibly inappropriate treatment. Both the U.K. and U.S. government have embarked on programs to limit the problems related to pervasive ageism in healthcare.
Following Frankel’s recommendation for CME efforts, and to empower elderly patients,4 we have engineered, with an unrestricted educational grant from Amgen and Wyeth, an interactive workshop on Ageism in the Treatment of RA. We hope to teach physicians that ageism and scapegoating aren’t the solution. Chronic diseases account for $3 out of each $4 spent on healthcare. Much of the strain they put on our system could be relieved by better care. The societal cost of disease is more than that of medications. By applying the 2008 ACR guidelines to all patients regardless of age with proper consideration to the risk-benefit ratio, physicians could decrease the personal, familial and societal burden of this potentially crippling disease.