Geriatric syndromes in elderly patients with rheumatoid arthritis

1. 2. 3. 4. Yi-Ming Chen1,2,3, Liang-Kung Chen3,4,5, Jong-Liang Lan1,2,3,6 and Der-Yuan Chen1,2,3,6 +Author Affiliations 1. 1Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, 2Center for Geriatrics and Gerontology, Taichung Veterans General Hospital, 3National Yang-Ming University, 4Center for Geriatrics and Gerontology, 5Department of Family Medicine, Taipei Veterans General Hospital and 6National Chung-Hsing University, Taichung, Taiwan. Der-Yuan Chen, Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung City, 40705, Taiwan. E-mail: dychen@vghtc.gov.tw Received January 30, 2009. Revision received June 8, 2009. Next Section

1.

Abstract
Objective. Geriatric syndromes (GSs), i.e. cognitive impairment, depression, fall, incontinence and malnutrition, are extensively used to highlight the unique features of common health problems in the frail elderly. Although GS is common in older RA patients, it is rarely reported earlier. We evaluate the prevalence of GS in elderly RA patients and explore the interrelationship between GS and RA. Methods. All enrolled RA patients were categorized into elderly RA (aged 65 years) and younger RA (aged <65 years). A comprehensive geriatric assessment was done to determine the presence of GS. HAQ score and disease activity of RA, including 28-joint disease activity score (DAS28), were assessed. Results. In total, 65 elderly and 25 younger RA patients were enrolled. The prevalence of GS in the elderly participants, especially cognitive impairment and fall, was significantly higher than that in the young. Older RA patients were more physically dependent than the young. Compared with subjects without GS, older RA patients with GS had longer disease duration, higher DAS28 scores, lower haemoglobin levels and more physical dependence. By using binary logistic regression, we found that a higher DAS28 score and a lower haemoglobin level were independent risk factors for GS. Conclusions. The prevalence of GS was higher in the elderly RA patients than that in the young. A higher DAS28 score and a lower haemoglobin level were independent risk factors for GS in older RA patients. Further study is needed to evaluate the prognostic role of GS.
Key words

Geriatric syndromes

Rheumatoid arthritis

Disability

Disease activity Elderly Previous SectionNext Section

Introduction

Geriatric syndromes (GSs), i.e. falls, intellectual failure, immobility, malnutrition, incontinence, etc., are extensively used to highlight the multi-factorial nature of health problems in frail older people [1]. GS per se is a better predictive factor for adverse clinical outcomes than disease diagnosis or comorbidity [2]. However, most previous studies that evaluated the impact of GS on health care outcomes were done mainly in acute care settings; few studies have been conducted in outpatient settings and in cases of chronic disease treatment [2]. Some chronic conditions, e.g. arthritis, are associated with substantial functional limitations, which are highly likely to be linked to GS [3]. Arthritis is an important contributing factor for physical disabilities in older people and 60% of elderly people may be affected by arthritis [4]. About 10% of elderly arthritis patients experience certain limitations in the activity of daily living (ADL) [5]. Moreover, impaired ADL in the elderly may predict acute hospital admission, longer hospital length of hospital stay and institutionalization or mortality [69], irrespective of the underlying medical diagnosis. Compared with arthritis of other aetiologies, RA is characterized by a chronic symmetrical polyarthritis with devastating joint damage and overwhelming inflammatory process, which causes a stronger adverse impact on patients. RA patients are associated with a >7-fold greater increased risk of disability than age- and sex-matched community-living people [10]. Moreover, RA is frequently associated with components of GS such as depression, cognitive impairment and falls or poor nutritional status [1114]. Compared with younger RA patients, elderly RA patients suffered from the disease for a longer period of time, which is associated with the presence of depression [11]. In addition, elderly RA patients with a history of falls, one essential element of GS, have a higher chance of developing impaired functional capacity [13]. Furthermore, malnutrition in RA patients was related to higher disease activity and poorer functional status [14]. Taken together, these findings show that there is a strong linkage between RA and GS. However, the success of modern RA treatment raises new challenges for health-care professionals, because RA patients are more likely to survive into old age and the prevalence of elderly onset RA patients may also increase along with the increase of the elderly population. Therefore, to explore the inter-relationship between elderly RA patients and GS is of great importance. This study evaluates the impact of GS on disease activities and disabilities in older RA patients.
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Patients and methods

Participants

Patients who visited the rheumatology clinic of Taichung Veterans General Hospital were invited for study. Diagnosis of RA was made according to the 1987 ACR revised criteria for RA [15]. All participants were categorized into elderly RA (aged 65 years) and younger RA (aged <65 years) groups. Elderly onset RA (EORA) is defined as RA arising after the age of 60 years [16]. Patients who had a history of a stroke, malignancy or had been admitted because of acute illness in the previous 3 months were excluded from the study. A geriatrician, a rheumatologist and a nurse specialist carried out the structured interview, clinical examinations and comprehensive geriatric assessment of each participant. This study was approved by the Ethics Committee of Clinical Research, Taichung Veterans General Hospital, and informed consent was obtained from each participant according to the Declaration of Helsinki.
Components of the comprehensive geriatric assessment
Cognitive impairment

The mini-mental state exam was used to screen cognitive integrity [17], and cognitive impairment was defined as 24/26 for subjects with 6 and >6 years of education, respectively [18].
Depressive symptoms

A five-item geriatric depression scale (GDS) was used to screen depressive symptoms in the elderly RA patients, and a score of 2 marked the cut-off for the presence of depressive symptoms [19]. For the younger RA group, depressive mood was rated by Beck Depression Inventory, which was a self-administered scale of 21 items with a total possible score ranging from 0 to 63 [20]. Scores between 0 and 13 are interpreted as no depression, whereas scores >14 are considered as depressive.
Falls

Participants were asked if they had had two or more falls in the past year, including falls that did not result in any injury [21].

Malnutrition

Malnutrition risk was defined as unintentional body weight loss of 10% in the past 6 months [22].
Urinary incontinence

Subjects reporting loss of urine 2 weeks before interview were considered to have urinary incontinence [2].
Selected GSs

Individuals were classified in the GS group if they had at least one of the following selected GS (cognitive impairment, depressive symptoms, falls, malnutrition and urinary incontinence) [23, 24].
Scale of GSs

Scale of GSs (range 05) is a quantitative measure of GS defined by assigning and adding one point for each of the following GSs: cognitive impairment, depressive symptoms, falls, malnutrition and urinary incontinence.
Disease activity

The 28-joint disease activity score (DAS28) [25], serum CRP and ESR were utilized to assess disease activity of RA.
Disability

Assessment of disability in terms of disease impact was determined by an HAQ [26], which is a 20-item selfreported functional questionnaire with items rated from 0 to 3 and increasing in steps of 0.125 U.
Statistical analysis

Data in the text and tables are expressed as mean S.D. Statistical Package for the Social Sciences (SPSS) version 13.0 software (SPSS, Chicago, IL, USA) was used to perform all statistical analyses. Student's t-tests were used for comparisons between continuous variables when appropriate. Categorical variables were compared by chi-square test or Fisher's exact test when appropriate. The statistically significant factors in the single variable analysis, including DAS28, haemoglobin, HAQ, EORA and disease duration, were listed as independent variables, whereas GS was regarded as the dependent variable. Binary logistic regressions with backward Wald method were used to determine independent risk factors for GS. For all tests, a P-value < 0.05 was considered statistically significant.
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Results
Comparison between the young and elderly RA patients

Table 1 shows the demographic data and clinical characteristics. A total of 65 elderly patients (48 females and 17 males; mean age S.D. 72 5 years old) and 25 young patients (21 females and 4 males; mean age S.D. 50.6 9.2 years old) were enrolled. The clinical manifestations including gender, disease duration, haemoglobin and disease activities determined by ESR, CRP, DAS28 were indistinguishable in both groups. However, the elderly group had more chance of developing GS than the young group (55.4 vs 24.0%, P = 0.008). Moreover, the elderly RA patients had more cognitive impairment (16.9 vs 0%, P= 0.026) and fall (29.2 vs 4%, P = 0.010). Scale of GSs determined by summation of each components of GS was higher in the elderly group than the young group (1.12 1.13 vs 0.36 0.70, P = 0.002). The elderly RA patients were more disabled in terms of HAQ than the young patients (1.35 1.02 vs 0.78 0.79, P= 0.021).
TABLE 1.
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Demographic data, clinical characteristics, laboratory findings and components of GSs in 65 elderly and 25 young patients with RA
Comparisons between subjects with and without GSs

Overall, elderly RA patients with GS had a longer disease duration than GS-free subjects (13.72 8.70 vs 8.95 6.68, P = 0.029). Compared with subjects without GS, those who had GS had higher DAS28 scores (4.78 1.62 vs 3.38 1.36, P = 0.001) and lower haemoglobin levels (11.94 1.47 vs 12.74 1.45 g/l, P = 0.024) (Table 2). Moreover, RA patients with GS were more prone to be physically dependent (HAQ score 1.69 0.90 vs 0.97 1.02, P = 0.003).
TABLE 2.
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Comparisons between subjects with and without GSs in a cohort of 65 elderly patients with RA
Risk factors for GSs

By using binary logistic regression (backward Wald method), we found that a higher DAS28 score [odds ratio (OR) = 2.05; 95% CI 1.04, 4.02; P = 0.037] and a lower haemoglobin level (OR = 0.46; 95% CI 0.22, 0.98; P = 0.043) were both independent risk factors for the presence of GS in elderly RA patients (Table 3).
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TABLE 3.

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Independent risk factors for GSs in 65 elderly patients with RA

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Discussion
RA is one of the most disabling types of inflammatory arthritis, which leads to various levels of morbidity and disability. Owing to advances in RA treatment, more patients may survive into old age and consequently the prevalence of EORA may also be increased due to the longer life expectancy. Traditionally, rheumatologists treated RA patients mainly according to the considerations of controlling disease activity. However, rheumatologists now need to deal with more complicated situations in treating elderly RA patients, such as cognitive impairment, depression, falls or poor nutritional status, which are all cornerstones of GS. To the best of our knowledge, this is the first study to evaluate the complex interrelationship between GS, disease activity and disability in elderly RA patients. The term geriatric syndromes, including fall, urinary incontinence, delirium, dementia, osteoporosis, pressure ulcers and malnutrition etc., is commonly used to describe those clinical manifestations in the frail elderly that cannot be sorely explained by single disease entity [23, 24]. Nevertheless, the concept of GS remained poorly defined and there was no generally accepted and quantitative measure of GS in the literature [1]. Developing a formal criterion for selected GS by working committees of professional organizations had been proposed to facilitate clinical practice and research studies [1]. In this study, we chose selected components of GS, including cognitive impairment, depressive symptoms, fall, urinary incontinence and risk of malnutrition. It may not be possible to cover all GSs ever reported in the literature, but we believed that due to the nature of shared risk factors in GS, the selected constituents in our study represented multiple pathologies of frail elderly RA patients. We also attempted to quantitatively measure GS by creating a new assessment tool, scale of geriatric syndromes, which was significantly higher in the elderly RA than in the young RA patients. Our findings suggested that the components of GS, especially cognitive impairment and fall, were more age related than disease related in RA patients. The DAS28, which assesses joint tenderness, swelling, inflammatory biomarkers and the patient's perceived general health, is a surrogate indicator of RA severity and the association with functional capability has been confirmed [27]. Dunlopet al. [28] reported that in elderly patients with arthritis, disabilities were associated with older age, cognitive dysfunction and depressive symptoms, which are essential elements of GS. A recent study of 100 RA patients has shown that longer disease duration was positively associated with functional disability [29], which may result in GS. In this study, we found that older RA patients with higher disease activity (defined by DAS28), longer disease duration and physical function impairment (defined by higher HAQ score) were more prone to develop GS. However, only higher DAS28 and lower haemoglobin were independent risk factors for GS. In RA patients, chronic inflammation was considered as the leading cause of low haemoglobin level [30], and anaemia was also known to be associated with adverse impact on physical function, cognitive status and further functional deterioration [31].

A cross-sectional study disclosed that RA patients were more likely to have cognitive dysfunction [32], and it was significantly related to basic ADL limitation in older people [33]. A recent meta-analysis showed that patients with RA had an increased risk of cerebrovascular accidents, which may lead to vascular dementia [34] and pseudo-dementia [11]. Despite the strong association between RA and cognitive impairment, the prevalence of cognitive impairment in RA patients remained unclear before we conducted this study. Undiscovered cognitive deficit in RA patients may also influence the compliance for complex dosing of DMARDs administered to achieve fair disease control. Depression was reported to affect more than a quarter of RA patients [35] and it is related to a higher disease activity [36]. A previous study showed that depression was more frequently encountered in RA than OA patients [37]. However, it was not related to age, but related to disease [37]. In the present study, 36.9% of the older RA patients were depressed, whereas only 16% of the young individuals had depressive mood. Albeit that the screening tools for depression in the young RA patients (BDI) was different from that for the aged (five-item GDS), there was a trend towards more depression in our elderly participants, although not statistically significant. Another problem to be addressed is the overlap between RA-related symptoms and somatic manifestation of depression. In the present study, depressive mood in the elderly RA patients was assessed by five-item GDS. However, one question in this assessment tool Do you prefer to stay home rather than going out and doing new things? could be interfered by RA disease activity, le ading to overestimation of depression. Therefore, a cut-off of two in the five-item GDS may not be applicable in geriatric patients with RA. Urinary incontinence is a common but frequently neglected problem in patients with arthritis [38]. The high incidence of urinary incontinence (23.1%) in this study had strong clinical implications. Active RA patients are usually more disabled and hence may need more time to reach the bathroom. Due to older age, the urinary incontinence may be multi-factorial, so rheumatologists should be aware of the possibility of urinary incontinence and treat it appropriately. In addition to the aforementioned impact, malnutrition in elderly patients may lead to increased morbidity and mortality, [39] and older RA patients tend to have poorer nutritional status, unfavourable anthropometric parameters and hypoalbuminaemia [40]. We found that 16.9% of the subjects unintentionally lost >10% of their body weight in the past 6 months. In this study, there are several limitations. First, the sample size was small, which may limit the applicability. However, we believe the study results still can be applied to other elderly RA patients. Second, this study was a cross-sectional design that did not provide a chance to evaluate whether the presence of GS did influence clinical care outcomes. Third, there was no formal consensus of GS and selected components of GSs were evaluated in this study. Fourth, this was an observational study, so appropriate interventions for GS were lacking. Therefore, a prospective cohort study with intervention programs is needed to clarify the impact of GS in older RA patients. In conclusion, the prevalence of GS, especially impaired cognition and fall, was higher in the elderly RA patients than the young. For older RA patients, higher disease activity and lower haemoglobin were independent risk factors for the development of GSs, i.e. cognitive dysfunction, depression, falls, urinary incontinence and malnutrition. Rheumatologists should be aware of the impact of GSs on older RA patients. A prospective cohort study with an appropriate intervention programme is needed to clarify the complex interrelationship between elderly RA and GSs.

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Acknowledgement
The authors would like to thank Biostatistics Task Force of Taichung Veterans General Hospital, Taichung Taiwan for statistical analysis for this study. Disclosure statement: The authors have declared no conflicts of interest.
The Author 2009. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org Previous Section