Background The number of elderly individuals with rheumatoid arthritis (RA) is expanding in Europe, mainly due to an increase in life expectancy. As a result, management of these patients, e.g. the application of the treat-to-target and tight control principles, shall have to account for frailty and comorbidity. However, knowledge about how rheumatologists perceive and manage RA in the elderly patient population is limited.
Objectives To explore the viewpoints of rheumatologists on management goals in elderly RA patients and the influence of factors such as age, frailty and comorbidity on these goals. Furthermore, experiences of rheumatologists with regard to outcome instruments to guide management in elderly patients were assessed.
Methods A qualitative study involving semi-structured interviews with rheumatologists was conducted. Two readers independently annotated the transcripts of the interviews. Important concepts were taxonomically categorized and later combined in overarching themes by using NVivo 11.
Results Seventeen rheumatologists were purposively sampled from nine medical centres (mean age: 44.8 years (SD 7.7 years); 29% male). High levels of frailty and comorbidity frequently influenced management goals of rheumatologists: in these cases, preserving an acceptable functional status prevailed over the treat-to-target and tight control principles. For instance, most rheumatologists accepted the presence of tender and swollen joints when overall functioning and social participation were not or only minimally impaired. In patients ≥80 years, age instead of frailty and comorbidity was the most prominent factor that steered management. On that line, almost all rheumatologists admitted that their management strategy is less driven by the result of the Disease Activity Score-28 (DAS28), since comorbidity (e.g. osteoarthritis) and an age-related physiological Erythrocyte Sedimentation Rate (ESR)-elevation might distort the DAS28 value. Instead, before adapting anti-rheumatic therapy, rheumatologists weighted the frailty and comorbidity levels of a patient and the functional consequences of these factors such as cognitive and physical decline, dependency and polypharmacy (quote 1, Table 1). This frequently resulted in a less future-oriented management approach that was not aimed at the maximal prevention of joint erosions and deformities (quote 2, Table 1). Rheumatologists reported that a lack of time to evaluate all comorbid conditions, as well as contradictory advices of other medical specialists often complicated the management of elderly RA patients.
Conclusions Commonly accepted RA treatment paradigms such as treat-to-target and tight control are not automatically adopted in the elderly patient population. Maintaining a patient acceptable functional status prevails. Future RA management recommendations for elderly RA patients are needed and should account for factors such as frailty and comorbidity.
Disclosure of Interest None declared
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