Why Being Older Can Complicate Treatment for RA
I read an interesting article the other day concerning the challenges that rheumatologists have treating an aging population. The topic actually surprised me because even though inflammatory diseases can affect people of all ages, the incidence of RA increases with age. Per the CDC the incidence for people 18 to 34 years old is only 8.7 per 100,000 vs. 89 per 100,000 for people 65 to 74 (more than 10 times as great). It would seem, then, that older people would be the primary patient population in a rheumatologist’s office and therefore, there would be a great deal known about treating this particular age group.
According to the article, the primary issue is not necessarily treating the RA, but treating patients with multiple health issues, or comorbidities. Comorbidities are actually fairly common. Things like Sjogren’s disease, depression, and certain cardiovascular and lung conditions are often seen with people who also have RA and are therefore known to the rheumatologist.
The problem is as we age, our immune and other systems change which not only makes us increasingly susceptible to RA but to other conditions not directly associated with RA. For example, the incidence of type 2 diabetes starts rising dramatically at age 45. While a rheumatologist can be quite skilled at treating inflammatory diseases, they would no doubt refer a patient who develops diabetes to a different specialist. The problem becomes in coordinating the care of the patient with two serious health conditions being treated by two different doctors. The rheumatologist might be inclined to prescribe a course of prednisone to help the patient manage RA symptoms. However, a known side effect of prednisone is high blood sugar, which is directly contrary to treating someone with diabetes.
While this is one example, the challenge of treating patients with multiple health issues becomes exponentially more complex. Lacking a full understanding of the patient’s conditions and the possible interaction with other drugs the patient is taking, the rheumatologist may be overly cautious in treating RA so as to minimize any complications. This may result in treating the RA at less-than-optimal levels.
A second issue with treating an older patient is there's less research data available for this age group. This is because research studies often exclude older patients with multiple health conditions just so the research data is more clearly associated with rheumatoid arthritis and not complicated by other issues. While this might be great for the particular research study, it actually leaves out one of the primary populations for which research needs to be done. This knowledge gap will only increase as the population ages. Currently there are about 10,000 people each day that turn 65 in the United States. Even if more research studies were to be expanded to include this age group, the results might still be compromised because older people tend to be less willing and/or less able to participate in the studies.
The final element is one of ageism both on the part of the rheumatologist and the patient. The word “ageism” describes stereotyping and/or discrimination against people on the basis of their age. The rheumatologist might dismiss certain symptoms or descriptions of pain as being part of the natural aging process rather than correlating it to disease activity. Similarly, the patient may underreport symptoms because they, themselves, dismiss them as age-related. Further, an older patient with a less-active lifestyle may have different expectations of what “healthy” means versus a more active, younger person. Therefore the rheumatologist might prescribe a less aggressive treatment plan for an older patient than a young patient with a more physically demanding existence.
The challenge is not only that the overall population is aging at a rapid rate; people (even those with RA) are living longer. Therefore the population of older RA patients will comprise a growing percentage of a rheumatologist’s practice. The good news is that there are more treatment options than ever before available. There just needs to be more work done to be sure the needs of this important group of patients are met.
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