A Blueprint to Inspire Older Patients to Thrive and Age Well

By Bryan D. Vargo | December 1, 2022

Demographic data predicts a huge growth in the number of older patients in the coming years. As such, inspiring older patients — especially those who have chronic conditions like arthritis — to thrive and age well is in all our best interests.

At the 2022 conference of the American College of Rheumatology (ACR) several researchers discussed how to inspire older patients to thrive using what clinicians call the 5Ms of aging. 

Presenting on behalf of Una Makris, MD, MSc, associate professor, UT Southwestern Medical Center, Bjoren Buehring, MD, focused on why the aging population matters — namely a very large increase in disability caused by increases in age-related disease such as arthritis and back pain — and how to implement the 5Ms of aging in rheumatology practice.

According to Dr. Buehring, chair of the Department of Rheumatology, Immunology and Osteology at Bergisches Rheuma-Zentrum, Krankenhaus St. Josef in Wuppertal, Germany, a shift in the approach to treating older adults is needed and by using the 5Ms, it can be achieved. Approved by the National Institutes of Health’s National Institute of Aging the 5Ms include:

• Multicomplexity describes the whole person, typically an older adult, living with multiple chronic conditions, advanced illness and /or with complicated biopsychosocial needs.
• Mind — When caring for older adults, all health professionals should consider mentation, dementia, delirium, depression.
• Mobility — When caring for older adults, all health professionals should consider amount of mobility/function, impaired gait and balance and fall injury prevention.
• Medications — When caring for older adults, all health professionals should consider polypharamacy and deprescribing, optimal prescribing and adverse medication effects and medication burden.
• What Matters Most — When caring for older adults, all health professionals should consider each individual’s own meaningful health outcome goals and care preferences.

The key to addressing all the patient’s issues — medical, psycho-social, financial, etc. — said Dr. Buehring, is not to be overwhelmed by taking them all on, but to focus on the one that’s most important to the patient and the provider and save the rest for another day. “Prioritize what matters most,” said Dr. Buehring. This multicomplexity approach is important because “multimorbidities are really common,” said Dr. Buehring. “We have good data that it is more common in inflammatory diseases, RA being one.”

The second presenter, Elena Myasoedova, MD, PhD, associate professor, Mayo Clinic, focused on the Mind aspect of the 5Ms. Key takeaways include:

• Cognitive impairment is a spectrum and neurocognitive domains include memory, executive function (daily activities), language, visuospatial skills, complex attention and social cognition.
• Cognition is difficult to study and measure.
• Risk factors include genetic, modifiable risk factors (lifestyle), unknown risk (effects of inflammation, which may be more pronounced in inflammatory disease patients).
• Cognitive impairment can be detected in about one-third of patients with rheumatoid arthritis.
• There’s about a 40% increase in risk of all-cause dementia in patients with RA as opposed to the general population, even accounting for age, sex and cardiovascular risk factors and cardiovascular disease. “So there’s definitely a signal that rheumatoid arthritis may contribute — somewhat independently — to this process,” said Dr. Myasoedova.
• Controlling inflammation in RA may help improve outcome of dementia.
• Variety of screening methods used to identify cognitive impairment.
• A multidisciplinary approach to treatment is best, incorporating general internal medicine, rheumatology, neurology, psychiatry, cardiology, geriatrics and collaboration with patient and caregiver.

The third presenter, Jiha Lee, MD, MS, University of Michigan, focused on the Medication aspect of the 5Ms. Key takeaways include:

• Consider polypharmacy, typically defined as the concurrent use of 5 or more medications. But was more important than the number is any potential of unnecessary, ineffective or possibly harmful prescribing.
• Polypharmacy affects 1 in 2 adults with RA age 65 or older and 3 out of 4 adults with lupus age 65 or older.
• Prescribing cascade — defined as prescribing medications to treat the adverse side effects of previously prescribed medications (misdiagnosed as new medical condition) — is a risk factor for polypharmacy.
• Desprescribing, which may help optimize medication use, is the thoughtful and systematic process of identifying problematic medications and either tapering, stopping, discontinuing or withdrawing these medications in a manner that is safe, effective and helps older adults maximize their wellness and goals of care.
• 40% of RA and lupus patients are using a potentially inappropriate medication (known as PIM use).
• Health care providers must provide ongoing and frequent assessment of risk-benefit ratio for older adults to minimize medication-related harm.

The final presenter, Daniel White, PT, ScD, associate professor, University of Delaware, focused on the Mobility or the 5Ms. Key takeaways include:

• Falls and fears of falling are common among older adults and patients with rheumatic diseases.
• Decreased activity due to falls or fear of falls can lead to a vicious cycle that increases the risk of future falls.
• Physical therapy for older adults is designed to break this cycle, e.g., assessing and improving balance.
• Assessing fear of falling — confidence of functioning in the home, e.g., taking a shower, climbing stairs, etc.
• Interventions include assessing goals, encouraging daily activity, addressing strength and balance training, patient/family education, adaptations (e.g., using a cane).