1. Multicomplexity. This describes the whole person, typically an older adult, living with multiple chronic conditions, advanced illness, and/or complicated biopsychosocial needs. So we need to think about the big picture and understand our patients’ rheumatic disease in the context of comorbid conditions and psychosocial needs.
First, assess and prioritize pain and function. Can your patient complete activities of daily living? Do they need a mobility device? Second, assess and prioritize psychosocial needs. Are there comorbid depressive symptoms? Is social isolation or access to adequate nutrition an issue? Are the patient’s recent no-shows because they couldn’t afford transportation or medication refills? “Interdisciplinary teams are key here,” Dr. Singh said.
2. Mind. Cognitive concerns are common in patients with rheumatic diseases, especially when it comes to older patients. Dr. Singh encouraged us to be aware of the three Ds: dementia, delirium and depression. We can recognize and correct things that are reversible or modifiable, like cardiovascular risk factors, uncontrolled inflammation due to rheumatic disease, depression and chronic pain.
3. Mobility. Counseling on fall prevention and optimizing muscle strength and endurance are crucial components of managing mobility in older adults with rheumatic diseases, especially since they’re at particularly high risk of developing sarcopenia and functional limitations. Think about physical activity, fall risk, the need for assistive devices like canes, and home safety. Also consider bone health, nutrition and potentially inappropriate medication use (see below).
4. Medications. The main take-home concept here is deprescribing—the thoughtful and systematic process of identifying problematic medications and either tapering or stopping these in a safe way to help older adults maximize their wellness and goals of care.
So try to identify problem medications and ask yourself if the patient truly needs them. A good place to start is the American Geriatric Society Beers Criteria, which is updated every three years and gives us information on potentially inappropriate medications that are to be avoided in older adults. Examples include antidepressants, opioids, benzodiazepines, neuropathic pain medications (eg pregabalin, gabapentin) and muscle relaxants.7
5. What Matters Most. “A mother shouldn’t pick a favorite child,” joked Dr. Singh, “but I have a favorite ‘M.’” She said that one of the most powerful questions you can ask a patient is “what matters most to you right now?” That’s because every person’s meaningful health outcome goals and care preferences are different.
So list and rank your patient’s values and outcomes of interest in order of importance, and remember that this list can shift over time. Does increased survival matter most? Or is it instead comfort or physical function? Then, ask yourself if the plan you’re discussing is aligned with the patient’s goals and preferences.
