Jill Nawrot1,2, Annelies Boonen3,4, Ralph Peeters3,4, Mirian Starmans3,4, Marloes van Onna3,4. 1. From the Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht; Department of Rheumatology, Zuyderland Medical Center, Heerlen, the Netherlands. j.nawrot@student.maastrichtuniversity.nl. 2. J.Nawrot, medical student, Division of Rheumatology, Maastricht University Medical Center; A. Boonen, MD, PhD, Division of Rheumatology, Maastricht University Medical Center; R. Peeters, MD, PhD, Department of Rheumatology, Zuyderland Medical Center; M. Starmans, MD, PhD, Department of Rheumatology, Zuyderland Medical Center; M. van Onna, MD, PhD, Division of Rheumatology, Maastricht University Medical Center. j.nawrot@student.maastrichtuniversity.nl. 3. From the Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht; Department of Rheumatology, Zuyderland Medical Center, Heerlen, the Netherlands. 4. J.Nawrot, medical student, Division of Rheumatology, Maastricht University Medical Center; A. Boonen, MD, PhD, Division of Rheumatology, Maastricht University Medical Center; R. Peeters, MD, PhD, Department of Rheumatology, Zuyderland Medical Center; M. Starmans, MD, PhD, Department of Rheumatology, Zuyderland Medical Center; M. van Onna, MD, PhD, Division of Rheumatology, Maastricht University Medical Center.
Abstract
OBJECTIVE: In this qualitative study we analyzed the (1) influence of age, comorbidity, and frailty on management goals in elderly patients with RA; (2) experiences of rheumatologists regarding the use of the Disease Activity Score at 28 joints (DAS28) to monitor disease activity; and (3) differences in management strategies in elderly patients with RA compared to their younger counterparts. METHODS: Rheumatologists were purposively sampled for a semistructured interview. Two readers independently read and coded the interview transcripts. Important concepts were taxonomically categorized and combined in overarching themes by using NVivo 11 software. RESULTS: Seventeen rheumatologists (mean age 44.8 yrs, SD 7.7 yrs; 29% male) from 9 medical centers were interviewed. Preserving an acceptable level of functioning was the most important management goal in patients ≥ 80 years and in patients with high levels of comorbidity and frailty. The DAS28 score less frequently steered the management strategy, because rheumatologists commented that comorbidity and an age-related erythrocyte sedimentation rate elevation might distort the DAS28 score. Instead, management of elderly patients highly depended on comorbidity, frailty, and their subsequent effects such as cognitive and physical decline, dependency, and polypharmacy. Presence of 1 or more of these factors frequently resulted in a less future-oriented management approach with less emphasis on the maximal prevention of joint erosions. CONCLUSION: The treat-to-target model is not automatically adopted in the elderly patient population. Future evidence-based RA management recommendations for elderly patients with RA are needed and should account for factors such as comorbidity and frailty.
OBJECTIVE: In this qualitative study we analyzed the (1) influence of age, comorbidity, and frailty on management goals in elderly patients with RA; (2) experiences of rheumatologists regarding the use of the Disease Activity Score at 28 joints (DAS28) to monitor disease activity; and (3) differences in management strategies in elderly patients with RA compared to their younger counterparts. METHODS: Rheumatologists were purposively sampled for a semistructured interview. Two readers independently read and coded the interview transcripts. Important concepts were taxonomically categorized and combined in overarching themes by using NVivo 11 software. RESULTS: Seventeen rheumatologists (mean age 44.8 yrs, SD 7.7 yrs; 29% male) from 9 medical centers were interviewed. Preserving an acceptable level of functioning was the most important management goal in patients ≥ 80 years and in patients with high levels of comorbidity and frailty. The DAS28 score less frequently steered the management strategy, because rheumatologists commented that comorbidity and an age-related erythrocyte sedimentation rate elevation might distort the DAS28 score. Instead, management of elderly patients highly depended on comorbidity, frailty, and their subsequent effects such as cognitive and physical decline, dependency, and polypharmacy. Presence of 1 or more of these factors frequently resulted in a less future-oriented management approach with less emphasis on the maximal prevention of joint erosions. CONCLUSION: The treat-to-target model is not automatically adopted in the elderly patient population. Future evidence-based RA management recommendations for elderly patients with RA are needed and should account for factors such as comorbidity and frailty.