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Learning Objectives

  • To relate the consequence of aging to the clinical manifestations of rheumatoid arthritis (RA) and other autoimmune diseases.

  • To understand the effects of age-associated physiologic changes and comorbidities on the use of common anti-rheumatic disease drugs.

  • To identify the use and limitations of current rheumatic disease classification and treatment guidelines in older patients with autoimmune diseases.

Key Clinical Points

  1. Patients with various autoimmune diseases exhibit evidence of accelerated aging.

  2. Recent rheumatoid arthritis classification criteria focus on early disease diagnosis; their usefulness is untested in older patients with the disease.

  3. Injectable and oral biologic therapies targeting multiple immune system pathways represent major advances in the treatment of autoimmune diseases, but these therapies are all associated with significant risk of side effects in older patients, particularly those with multiple comorbidities.

  4. Functional and social assessments are important components in the management of autoimmune diseases in older adults.

  5. It is important to exclude iatrogenic causes of rheumatic symptoms in older patients, as polypharmacy is a common issue in this age group.

  6. Paraneoplastic rheumatic syndromes occur in many malignancies prevalent in older patients.

The past decade has witnessed tremendous strides in our understanding of the pathogenesis and approach to treatment of autoimmune diseases. This is mirrored by a growing knowledge of the many immune system changes in aging, and clinicians’ experience in administration of biological therapies in older adults with rheumatic diseases. While the field of rheumatology continues to focus on individual rheumatic illnesses, there is also a greater appreciation of the corresponding risks and side effects of these powerful agents on older patients with multiple comorbid illnesses. This chapter summarizes recent key advances, with specific references to the geriatric population.



Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that preferentially affects diarthrodial joints. The American College of Rheumatology (ACR), in collaboration with the European League Against Rheumatism (EULAR), updated the classification criteria of RA in 2010 (Table 121-1). The impetus for updating the original 1987 criteria was the recognition of the importance of early diagnosis and treatment of this disease. The new classification criteria therefore no longer include late sequelae of RA such as rheumatoid nodules or radiographic evidence of bony erosions. The new set of criteria should allow the study and treatment of patients with earlier stages of the disease. It should be noted that the new classification criteria apply to patients with objective evidence of synovitis in at least one joint, and the synovitis is not better explained by another disease such as lupus, psoriatic arthritis, or crystal-associated arthritis. It is also important to understand that the mean age of patients in the nine arthritis cohorts used to develop the new classification criteria ranges from 46 to 58 years. While the criteria set is useful for diagnosing early and active disease in younger patients, its ...

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