Sint Maartenskliniek, Department of Rheumatology, Nijmegen, The Netherlands
Correspondence to: W. van Lankveld, Sint Maartenskliniek Research, P.O. Box 9011, 6500 GM Nijmegen, The Netherlands. E-mail: w.vanlankveld{at}maartenskliniek.nl
The aim of this editorial is to keep the needs of the elderly with musculoskeletal conditions a rheumatological priority. The number of older patients with musculoskeletal conditions will double in the near future. Pitfalls in diagnostics will be described, as well as possible limitations in treatment. These difficulties in diagnostics and treatment underline the need for specific attention for this group of patients. The gerontorheumatological outpatient service in the Netherlands is described, as an example of a way in which special attention to the problems of the elderly with musculoskeletal conditions is given. Experimental studies on the effect of gerontorheumatological interventions are non-existent. Therefore, evidence from geriatric studies showing the positive effect of similar services for the frail elderly is given. Finally, important topics in future research on gerontorheumatology are suggested.
In Western society, the percentage of elderly people in the population has increased dramatically during recent decades and is likely to increase further in the coming decades. Many elderly patients are functioning well without any assistance. However, a large proportion of older people are confronted with one or more disabilities [1]. Musculoskeletal conditions are the most frequently reported disorders in the elderly in the community [25]. Because the number of people over 65 is likely to increase in the Western population, it is estimated that the number of older patients with musculoskeletal conditions will double in the coming decades [6, 7].
As a result, rheumatology will be challenged to meet the health-care demands of increasing numbers of patients. Furthermore, the number of elderly patients with complex rheumatological conditions in need of specialized care will also increase [8]. There is a lack of attention for this group of patients, as existing special care for the elderly is most often focused on patients with primarily cognitive problems [9].
Due to the low incidence of rheumatic conditions in an average general practice, as well as the complexity of these conditions, the general practitioner may experience difficulties in diagnostics and treatment of the symptoms presented [10, 11]. The rheumatologist seems most able to address the problems of these patients. Rheumatology is a specialism rooted in internal medicine; therefore the rheumatologist is not only able to diagnose and treat the patient's medical condition but is also able to take the wider consequences of the disease into account.
Symptom presentation, disease manifestation and comorbidity in older people can pose diagnostic problems. Presented symptoms may be the result of a wide range of musculoskeletal, endocrine, metabolic, traumatic and psychological conditions [12, 13]. Furthermore, intellectual and cognitive function in some patients may be impaired, affecting the ability of the patient to communicate symptoms.
Disease manifestations may pose another diagnostic problem. The incidence and prevalence of some musculoskeletal conditions increases with age. However, the clinical picture and diseases manifestations of some well-known conditions can differ depending on the age of onset [14, 15]. On the other hand, longstanding conditions may pose new problems as the patient gets older. For instance, ankylosing spondylitis is unlikely to become manifest at an older age [3]. However, the impact of this condition may increase with age due to the slow progression of impairment over time. As a result, some older patients may be confronted with new limitations when they get older.
Finally, comorbidity may interfere with accurate diagnostics. Only in recent years has comorbidity in the musculoskeletal conditions received proper attention. Comorbidity in the population of patients with rheumatic diseases is high. At least 50% of all patients with RA are diagnosed with one or more additional chronic condition [16, 17]. In particular, it has been shown that the coexistence of multiple musculoskeletal conditions is high [2], and quality of life is seriously impaired in people with multiple musculoskeletal diseases [18].
Older patients with musculoskeletal conditions are thus an extremely heterogeneous group. The rheumatologist has to consider a broad array of treatment possibilities. However, both pharmacological and non-pharmacological interventions that are effective in regular treatment may be less appropriate in some older patients. Age can influence the effect of medication in a number of ways. First, older patients seem to be more vulnerable to side-effects of medication [5, 11]. Secondly, the pharmacokinetics and pharmacodynamics of drugs, and their interactions, are affected by age-related changes in the major organs and metabolism [19]. Thirdly, older people experience greater comorbidity and are therefore more likely to need multiple drug prescriptions. This increases the risk of adverse effects as a result of drug interaction. Comorbidity also increases the risk of exposure to multiple prescribers, resulting in fragmentation of care [20, 21]. Finally, compliance to medication regimes is poor in older people [22]. Compliance is hard to improve [23], especially in older patients with cognitive impairments.
These cognitive impairments, and other limitations in physical, psychological and social functioning in some older patients, can limit non-pharmacological treatment possibilities as well. In rheumatology, there is a growing emphasis on active and intensive non-pharmaceutical treatment [2426]. These interventions emphasize the patient's active involvement, requiring highly developed motor and cognitive skills. However, some older people are unable to undergo relative complex treatment due to impaired motor and cognitive functioning [27]. In addition, social support and income both decline with age in some patients. These coping resources are important to cope with the disease and the demands of treatment.
To respond adequately to the needs of an ageing population with musculoskeletal problems, the Department of Rheumatology of the Sint Maartenskliniek in Nijmegen, The Netherlands, introduced a specialized service: the gerontorheumatological outpatient service. The aim of the service is similar to that of regular rheumatological care: to improve and preserve quality of life by preventing unnecessary impairment and disability, preserve independence, improve mobility, decrease pain, improve care quality and reduce the quantity of care. The gerontorheumatological outpatient service differs from regular rheumatological care in that it uses a problem-oriented approach tailored to the individual's specific needs and possibilities. It not only focuses on separate disease-related variables, but also uses a more holistic approach, taking age-related psychosocial and cultural issues into account.
Patients older than 75 yr with musculoskeletal problems can be referred to the outpatient service. Patients are scheduled for a dual appointment at the rheumatologist and a specialized nurse practitioner. The rheumatologist assesses disease and impairment variables and the nurse practitioner concentrates on the patient's functioning in activities of daily life. Furthermore, the nurse evaluates the patient's psychological, social and cognitive functioning as well as coping resources. At the same time, counsel and advice are given on a number of disease-related topics. Finally, the nurse practitioner assesses the patient's wishes and needs. The patient's problems and needs are thus assessed taking the patient's abilities and environment into account.
Directly after the dual appointment, the rheumatologist and nurse decide on a further course of action, tailored to the individual's health problems and possibilities. Three actions are possible. (i) The patient is dismissed from further treatment by the rheumatologist. Information related to diagnosis and/or treatment is sent to the general practitioner. The nurse practitioner can advise, inform, counsel and educate the elderly patient about diseases and diagnosis, home adaptations, aiding devices for activities of daily living, home-care possibilities, transport facilities and welfare organizations, and complementary community-based care. (ii) Further treatment may be given in primary care or community-based complementary care. (iii) Multidisciplinary treatment may be given in the hospital. All patients are rescheduled for a follow-up appointment. Patients are informed by the rheumatologist about the findings of the examination and treatment options are discussed with the patient.
The gerontorheumatological outpatient service was evaluated in 100 patients 75 yr of age or older (84 women and 16 men) [28]. Comorbidity was high in this sample (Table 1). In 100 patients 174 rheumatological conditions were diagnosed. Most predominant was osteoarthritis, which was found in over half of the patients, often in combination with another diagnosis. Only 25 patients were free of non-rheumatological chronic conditions. In 33 patients, one non-rheumatological condition was found and in 22 patients, there were two. Twenty patients suffered from three or four non-rheumatological conditions.
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Most patients (69) were referred back to the general practitioner with additional treatment advice after one to three visits to the outpatient clinic. The remaining 31 patients received further treatment by the rheumatologist; 19 of them received regular outpatient treatment by the rheumatologist alone. In 12 patients, the problems were deemed serious enough to warrant multidisciplinary treatment, either ambulatory, clinical or surgical.
Patients were asked to evaluate the service by mailed questionnaire 6 months after the first referral. Most patients (86%) indicated that they had used the information and advice given during the gerontorheumatological service. Most patients (89%) would recommend the service to other patients of their age with similar problems, while 92% of the patients gave an overall positive evaluation. At the same time, all referring general practitioners were contacted by mail. A total of 77 different general practitioners referred the 100 patients included in the study. A short questionnaire was sent with which they could evaluate the content of the service. Of these 77 practitioners, 53 returned the mailed questionnaire (response rate = 69%); 82% indicated that the service had a positive effect for this patient, 82% would recommend the gerontorheumatological service to colleagues with similar patients, and 89% indicated that a gerontorheumatological service aimed at patients with musculoskeletal conditions is a useful initiative. These qualitative data suggest that the gerontorheumatological outpatient services may have positive effects on the patient's quality of life.
As yet, there is no scientific evidence for the effectiveness of special services for older patients with musculoskeletal conditions, such as this gerontorheumatology outpatient service. Evidence for a potential positive effect can be found in geriatrics. In dealing with complex problems in the elderly, geriatric specialists have developed the Geriatric Assessment: a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, the need for services is assessed, and a coordinated care plan is developed to focus interventions on the person's problems [31].
Over recent decades, geriatric evaluation and management (GEM) has been studied in both outpatient clinics and inpatient units. In an outpatient setting, positive effects have been reported on a wide range of outcome variables, including mortality [32], satisfaction on the part of both the patient and the primary physician [33], functional decline [34], quality of health and social care [35], health perception, social interaction, general wellbeing, life satisfaction, depression [36] and health-care utilization [37]. GEM has also been used in clinical situations [38]. In patients admitted to a hospital for an acute illness, GEM in combination with postdischarge home intervention did improve functional status and reduced the length of hospital stay and subsequent readmissions, and it also reduced nursing home admissions, enabling patients to live longer at home [39].
In 1993, Boyer stated that geriatric rheumatology is a much-needed subspeciality [27]. One can argue about the extent to which such a subspeciality is necessary. However, as was true a decade ago, more efforts should be made to keep the needs of the elderly with musculoskeletal conditions a priority on the clinical and scientific agenda of rheumatologists. Ongoing efforts should be made to address a number of important questions (Table 2).
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Another broad area of development and research should focus on developing a clear conceptual framework to guide potential interventions. What kinds of interventions are feasible in which situations? Which interventions should receive priority? For instance, in the non-compliant elderly, improving compliance with medication will have positive effects on treatment outcome. Pharmacist interventions have been shown to be effective in improving patient compliance in drug prescription [42, 43]. Similar interventions should be studied in the elderly with musculoskeletal conditions. In a similar way, recognition and treatment of depression in the elderly may have larger beneficial effects on functioning than treatment of the comorbid physical condition [44]. Finally, ethical considerations should be carefully weighed. When should one abstain from further interventions in the patient's last years of life?
The efficacy of any intervention in the elderly depends on the continuation of care in the community. Complementary community-based care has to be achieved in the treatment of elderly people with musculoskeletal conditions. Comprehensive community-based care coordinated by a clinical nurse specialist is a promising alternative form of care in rheumatology [45]. As this care for the elderly is most often coordinated by geriatric specialists and nurses specializing in geriatrics, rheumatologists should form close alliances with geriatrists to ensure optimal treatment for the older patient with musculoskeletal conditions.
Finally, a challenging topic will be to evaluate interventions in elderly patients with musculoskeletal conditions. Cost analyses of interventions are needed to be able to determine and compare costs of different interventions. However, it is much harder to show the effect of these interventions on quality of life. As quality of life in the elderly may be determined by factors other than those operating in younger people (for instance, loneliness and anxiety), the effects of interventions on these variables have to be incorporated in future research.
The authors have declared no conflicts of interest.
References
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