Rheumatoid arthritis (RA) is a systemic autoimmune disease where a person’s immune system attacks the lining of the joints causing inflammation and pain. If untreated, it can lead to chronic damage and disability. Rheumatoid arthritis most commonly involves the joints of the hands, feet, wrists, elbows, shoulders, hips, knees, ankles and neck. It can involve one or more of these joints at the same time and can progress to include more joints over time. Symptoms include pain, swelling, and redness in affected joints, morning stiffness, reduced function, and severe fatigue.
Rheumatoid arthritis is diagnosed in approximately 1 in 100 people in Canada. The disease affects women twice as often as men. Usually, people are diagnosed between the ages of 20 and 50, though rheumatoid arthritis can start at any age, adulthood onwards. When rheumatoid arthritis starts after age 60, it is called elderly-onset or late-onset RA.
Late-onset RA usually affects larger joints, like shoulders. Symptoms include joint pain, fever, muscle pain, weight loss and anemia. Similarly to active RA, initial treatment should be aggressive to prevent further joint damage. However, a study published recently in ACR Open Rheumatology found that most people diagnosed with late-onset RA after age 65 are not getting optimal treatment.
The study used Medicare date from 2008 to 2017 to identify people with a new diagnosis of late-onset RA. Of the 33,000 people who had a new diagnosis of late-onset RA, despite current clinical practice guidelines, only 29% received a medication that can modify the disease within the first year after diagnosis.
In an interview with Harvard Health, Dr. Devyani Misra, a geriatrician, rheumatologist, and researcher at Harvard-affiliated Beth Israel Deaconess Hospital, said: “This is in contrast with 70% to 80% of younger adults with rheumatoid arthritis who receive disease-modifying medications soon after diagnosis.”
Reasons for treatment delays
There are many reasons why people with late-onset RA are not getting the most effective medications, including cost, considerations for side effects, coexisting conditions, perceived frailty, cognitive impairment, and accessibility to health care.
Cost
Arthritis Consumer Experts conducted a national Survey to address inequities and gaps in public and private drug plans. Challenges with accessing reimbursement coverage for arthritis medications include meeting and paying insurance deductibles, navigating and maximizing private and public drug plans, and determining how to get costly medications after retirement.
One respondent shared her concerns about retirement:
“I have private coverage until I am 65, I don’t know what it will be like when I no longer have that private insurance in another 3 and a half years from now. I do worry about that, and if it will be affordable at that time or not.”
Side effects and coexisting conditions
Like many medications, the arthritis medications used to treat RA have side effects, including fatigue, liver problems, an increased risk for infections, headaches, and diarrhea. Some people may decline these medications to avoid experiencing side effects. People with late-onset RA may have other health conditions that limit what medications they can take. If someone is cognitively impaired, it may also be harder to follow and monitor a particular treatment plan.
Frailty and access to health care
Health care providers might prescribe a less aggressive treatment because they are not sure how the side effects will impact someone who they perceive as frail. As people age, it may be harder for them to access health care. They may become dependent on family members to take them to medical appointments. If they have retired in a remote community, they would have to travel farther to access the health care and specialists they need.
What you can do
Explore treatment options with your rheumatologist, doctor, specialist, and healthcare team. Have an open conversation with your health care providers about your concerns. They may be able to tailor a treatment plan that address your concerns. To learn more about setting treatment goals and building a treatment plan with your health care provider, take lesson 3 of JointHealthTM Education’s course on rheumatoid arthritis here.
Ask for support from friends and family members. Explain what rheumatoid arthritis is and how it impacts your life. Let them know that you may need help with completing chores when you are experiencing a flare. If a friend or family member can take you to your medical appointments, come up with a schedule that works for both of you.