Similar physiologic declines occur in other systems in older adults, namely changes in the gastrointestinal tract, leading to altered absorption; changes in the hepatic system, leading to altered metabolism; and altered body composition, affecting drug distribution.
The 5 Ms
The need for aging-sensitive care led our colleagues in geriatrics to develop essential guiding principles to systematically identify and address the complexity of the rapidly growing older adult population: the 5 Ms—mind, mobility, multimorbidity, medications (i.e., polypharmacy) and what matters most (i.e., patient preference).8 The guiding principles of the 5 Ms can inform how we optimize DMARD use in older adults with RA and manage the greater burden of geriatric conditions that can impact outcomes.
Conditions of the mind (e.g., cognitive impairment and dementia) present unique challenges in DMARD utilization in older adults. Those with mild cognitive impairment living in the community may have difficulty managing their medications, coming in for follow-up visits and getting timely blood work to monitor for toxicity associated with DMARD use in RA.
Those with moderate to severe dementia pose practical and ethical dilemmas: Can we accurately assess disease activity when patients cannot communicate their symptoms? Can we really push for treat to target in RA patients with moderate to severe dementia?
Similarly, late-onset RA patients in the community with preexisting mild to moderate mobility limitations face challenges in managing DMARD therapy. Such patients need resources for medication management and transportation for follow-up visits. In addition to functional limitations, frailty, propagated by age and inflammation, can have an impact on mobility and health outcomes in older adults with late-onset RA, creating another dilemma for initiating aggressive DMARD therapy: multimorbidity and polypharmacy (medications), common in older adults and a natural consequence of aging, complicate the choice of DMARD due to increased risks of drug-drug and drug-disease interaction.
The final M, matters most, refers to patient preference. Often, patient preference is clouded by ageist biases toward themselves. An older adult may decline DMARD initiation stating, “I’m too old for aggressive treatment.” A patient’s family members and caregivers may share a similar philosophy and prefer a treatment that relieves pain rather than one that treats the underlying disease.
Physicians may also harbor ageist biases, mostly stemming from fear of causing harm. Some evidence suggests that DMARDs may be associated with increased toxicity in older adults, especially biologic DMARDs, fueling caution to avoid harming these patients.9 Of concern, despite growing evidence of the risks of glucocorticoid use, older adults with late-onset RA are commonly prescribed long-term glucocorticoids—with or without DMARDs.
