Addressing Ageism in Rheumatology

Ageism in healthcare not only is frustrating and demoralizing for older patients but also negatively affects care. In rheumatology, patients with rheumatoid arthritis (RA) diagnosed later in life are less likely to be prescribed disease-modifying antirheumatic drugs (DMARDs).

With adults aged 65 years or older representing an increasing proportion of the US population, understanding how to best care for these patients is key. Medscape Medical News spoke with Jiha Lee, MD, MHS, a rheumatologist and assistant professor of internal medicine at the University of Michigan, Ann Arbor, on addressing ageism in rheumatologic care. She was the lead author in a recent editorial on the subject, published on March 10 in Arthritis Care & Research.

What are the geriatric 5Ms, and how do they apply to rheumatology care?

The “Five Ms” is a geriatric framework developed and supported by the American Geriatrics Society (AGS), which stands for Multicomplexity, Medications, Mind, Mobility, and what Matters Most. It’s a framework to help better understand the older adult as a whole, including all the complexities that they have. Ultimately, we want to be able to understand the goals and preferences of older adults and help to make shared decisions that consider their complexities so that they can have the best outcomes possible.

How does ageism contribute to inadequate treatment?

My research is about late-onset RA. One of the things I was very surprised to find is that only about 30% of older adults with a new diagnosis of late-onset RA are started on any kind of DMARD within the first year, despite the fact that DMARDs are the standard of care. This includes any DMARD, including methotrexate, hydroxychloroquine, or sulfasalazine, which are relatively safe and effective in older adults as well.

In comparison, about 80% of younger adults diagnosed with RA are started on DMARDs after diagnosis. On top of that, even though physicians have some hesitancy in initiating DMARDs in this older population, adults with late-onset RA are still getting striking amounts of steroids. How we perceive the risk-benefit ratio in older adults seems to be very different from the younger population, and I think part of that is ageism. One of my colleagues and co-authors, Una Makris of UT Southwestern Medical Center, Dallas, did a survey of rheumatologists, and there was a lot of hesitancy because of the unknowns around how older adults are going to react. There’s a lack of information because older adults simply aren’t included in the clinical trials.

Some patients struggle with internalized ageism, feeling they might not be “worth” receiving treatment or questioning whether it’s worthwhile because of their age. They may also have greater fear about potential side effects. I think how we perceive age certainly plays into how we make treatment choices.

How have age limits in clinical trials contributed to these knowns and potentially ageism in medicine?

There was a paper by Palmowski and colleagues in 2019 that looked at this exact question. What they found is that in clinical trials, the average age for patients with RA is 53 years. However, in the American College of Rheumatology (ACR) RISE registry, which is a pretty comprehensive look at private and academic/university patients with rheumatic diseases in the United States, patients with RA are, on average, 63-64 years old. That’s a decade difference.

There’s no rationale provided for most of these trials on why they exclude older adults. About one third of clinical trials had age-based exclusion with no clear explanation, and then another third excluded older patients on the basis of the number of medical conditions or comorbidities that they had.

But the reality is that 50% of our patients, young or old, have two or more conditions. If those patients are being excluded, we don’t have the information on how best to prescribe these high-risk medications.

Our knowledge around how older populations respond to DMARDs is mostly based on population-based studies using Medicare data, RA registries, and other patient registries. The ACR RISE registry is also helping to fill that gap, but it would be helpful to have firsthand data from the clinical trials as well.

What is being done to include older adults in clinical studies?

There is a movement to promote the inclusion of older adults by the National Institutes of Health. C. Barrett Bowling, a geriatrician, has provided a framework called the Five Ts (Target population, Team, Tools, Time, and Tips to accommodate) to help avoid barriers to the inclusion of older adults in research.

Patients want to be involved, but they also emphasize that they need accommodation sometimes to be able to participate, such as longer study visits, trial information given with bigger fonts or changes in volume, a team approach, and even transportation assistance.

The first T stands for target population, meaning understand the patients that you’re actually treating. For our patients with RA, that would mean a population with an average age of 63-64 years. For late onset, that includes adults 70+ years old. Second, having a team approach with rheumatologists, geriatricians, pharmacists, and whoever else is involved in the care process. It’s important to make sure older participants have enough time to complete the necessary assessments in a study and provide tips for accommodation as needed. For example, if a test is running long and a patient has multimorbidity and needs to take their meds, there needs to be some thought into that process. Tools include changes in fonts, hearing aids, if needed, and additional accommodations to make participating in clinical trials a more involved and pleasant process for older adults.

What are some common misconceptions healthcare providers may have about caring for older patients, particularly in rheumatology?

I think one misconception is that older adults won’t benefit from treatment. Japan, for example, has been facing the challenges of a rapidly aging population — larger in size and occurring earlier than in the United States. They’ve conducted more studies comparing patients with late-onset and younger-onset RA, showing similar success in achieving remission or meeting treat-to-target goals with DMARDs.

Older adults may have more side effects — most predominantly infection and some with atypical presentations — that are treatable and preventable. There was a study in the United States that showed that comorbidities were associated with reduced responsiveness to DMARDs. But I don’t think that means we don’t treat these patients. It means we’re just more thoughtful about how we combine medications and how we manage comorbidities.

Another misconception is that pain and reduced functionality are a natural part of aging. Assuming all older adults have the same levels of pain or reduced function overlooks individual differences, and that kind of generalization can negatively affect health outcomes.

What are some unique aspects of providing rheumatology care to older adults? What should providers keep in mind?

It’s important not to overlook a patient as a person. We need to understand the whole person and to make sure that they’re involved in the care decision-making. That’s where the 5 Ms come in.

We see these patients for 1 hour out of every couple of months, but they’re living with this day-to-day. It’s important to understand how the disease affects them every day and what barriers they have. They may have stairs that they need to navigate at home, or they may have difficulty using the bathroom. Making sure that they can be connected with assistive devices or home assessments as needed, leveraging community resources, is one important part of the conversation.

Would you advise that providers block off more time for patients who are older?

Ideally, yes, to better assess and appreciate the complexity of older adults. There are ways to do comprehensive geriatric assessments, but that is not necessarily within a rheumatologist’s scope of practice. And so, a team approach is very important for older adults. I will often send my patients to geriatricians for those comprehensive assessments for functionality and cognitive impairment and communicate with these colleagues to inform care decisions. Similarly, I’ll reach out to my pharmacy colleagues if I have concerns about medications interacting with certain conditions or medications, and they’ll provide helpful insight.

What should providers keep in mind when communicating with elderly patients?

The language you use is very important, and the World Health Organization had a campaign related to this in 2021. Number 1 is to avoid problem framing such as catastrophizing what aging looks like or using terms like “silver tsunami.” Try to use a neutral language when speaking to these adults to avoid what’s called othering: Viewing older adults as separate community or entity. In the United States as a whole, we need to be to be self-aware of our own perceptions about age and how we manifest that. This is where education is important, so that we have better training and understanding on how to communicate best with our older adults.

What are some resources that healthcare professionals can seek out to learn more about caring for older adults?

The World Health Organization is a great resource, as well as the AGS and the Gerontological Society of America. I would also encourage them to look for local resources at their own institutions.

I also hope to see the ACR and other rheumatology professional societies and communities start providing and integrating education on ageism so that we can improve care for our older adults. Looking ahead, there’s an exciting opportunity for rheumatologic professional societies and communities to integrate ageism education into our professional development, helping to shape a future where older adults receive the respectful, high-quality care they deserve.

Lee is supported by the National Institutes of Health and the National Institute on Aging.