Advancing Rheumatologic Care in Older Adults: Highlights from the 2024 American Geriatrics Society Annual Scientific Meeting

Graphical Abstract

Rheumatologists are caring for a rapidly increasing older adult population. Aging introduces certain complexities in rheumatology care, including: accumulation of comorbid conditions influences treatment choices and response, polypharmacy increases the risk and burden of treatments, and late-onset rheumatic diseases can have atypical presentations.^1,2 Patient preferences and goals of care, which often change over an individual’s lifespan, impact therapeutic decision-making.

The American Geriatrics Society (AGS) stands at the forefront of addressing best practices for the care of older adults and can serve as an important partner to the American College of Rheumatology (ACR) and the rheumatology community at large. The AGS, founded in 1942, is a nationwide, not-for-profit society of geriatrics healthcare professionals dedicated to improving the health, independence, and quality of life of older people. In response to the growing population of older adults, the AGS has set out to provide support in education, training, dissemination, and implementation of geriatric care principles in medical and surgical specialties.³ Several medical and surgical societies, including those representing emergency medicine,⁴ oncology,^5,6 and cardiology^7–10 have embraced the integration of geriatric principles¹¹ and successfully developed national clinical and research networks to advance the care of older adults.⁴ Given that the aging population will require rheumatology care, the need for comprehensive training in aging principles for rheumatologists has never been more urgent.

In this article, we provide an update from the 2024 AGS Annual Scientific Meeting (AGS 2024) that emphasizes key geriatric principles and concepts pertinent to rheumatologists. The coauthors believe that these sessions highlight opportunities to enhance clinical care for older adults with rheumatic diseases. Overall, the aim of this article is to raise awareness and disseminate knowledge gained from AGS 2024 to encourage dialogue on integrating comprehensive age-friendly rheumatologic care.

Approach

For this article, we selected material of highest relevance to the rheumatology community, including content related to clinical care, education, and research and anchored it on the Geriatrics 5Ms framework (Figure 1).¹² The Geriatric 5Ms, developed and endorsed by the AGS, Institute for Healthcare Improvement, and the John A Hartford Foundation, supports the goal of delivering age-friendly healthcare by emphasizing mind, mobility, medications, what matters most, and multicomplexity.^12,13 We also highlight potential barriers to adopting aging-friendly practices in rheumatology. This summary concludes with a case study on how another specialty has integrated many of these principles into practice.

Figure 1:

Summary of AGS 2024 clinical, education, research highlights that align with the Geriatric 5Ms and promote age-friendly patient centered care. Also listed are potential barriers (clouds) to implementing these programs into the field of rheumatology.

Clinical Highlights: practical strategies incorporating a biopsychosocial approach to assessing and managing what matters most to older adults

Fall assessment and prevention

In older adults, falls are associated with an increased risk of fracture, disability, and mortality.¹⁴ Individuals with rheumatic diseases may have an even higher fall risk due to joint pain and deformities, deconditioning, and medications.¹⁵ Given the impact on both patient outcomes and healthcare costs, geriatricians consider falls a chronic health condition requiring focused management similar to any other chronic disease state.¹⁶ Falls and instability are underreported by patients both due to under-recognition, especially near-misses where injuries do not occur, as well as stigma (i.e., concern that reporting falls may lead to clinical interventions that limit independence).¹⁷

In a session led by Elizabeth Eckstrom MD, MPH and entitled “Safe Mobility: The Role of Falls Assessment and Prevention in Clinical Practice,” presenters suggested that fall assessment and prevention should be communicated to patients as “safe mobility,” with an emphasis on reaching mobility goals and preserving independence.¹⁸ The speakers in this session discussed the implementation of fall prevention programs in primary care settings and telemedicine visits using the STEADI framework: Screening (patients at risk), Assessing (modifiable risk factors), and Intervention (to reduce identified risk factors).¹⁹ This framework can be implemented readily in clinical practice with three brief questions: 1) Do you feel unsteady when standing or walking?; 2) Do you have any worries about falling?; 3) Have you fallen in the past year?. A “yes” to any of those questions highlights the need for fall assessment and introduction of intervention strategies. We believe this simple approach to fall screening would add value to the care of older adults with rheumatic diseases, promoting improved patient reporting of fall behaviors and allowing for important clinical interventions or referrals focused on maintaining and improving mobility.

Life-space Mobility

Mobility in all individuals, but especially older adults, has implications beyond physical activity itself, including an impact on social participation. The ability to engage in social activities and events is often reported as a key part of older adults’ health goals.²⁰ Life-space mobility (i.e., an individual’s multi-dimensional engagement with their environment over time)²¹ is not captured by standard measures of activities of daily living. At AGS 2024, C. Barrett Bowling MD, MSPH²² discussed ongoing research on measurement of life-space mobility captured through the Life-Space Assessment. Life-Space Assessment measures community mobility and social participation, yielding a summative quantitative measure of how far an individual tends to go, how often they go there, and how much help they need to get there.²³ In community-dwelling older adults, life-space mobility is independently associated with mortality²¹ and has been shown to decline in people with chronic conditions (e.g., chronic kidney disease) or in the setting of acute events.²⁴ Life-space mobility is an innovative measure that could prove to be relevant in older adults living with rheumatic diseases, allowing for improved assessment of functional mobility and incorporating a measure of “what matters most” to our patients.

Social Isolation

Social isolation and loneliness are common among older adults and are associated with numerous adverse health outcomes, including incident cardiovascular disease, stroke, and mortality.²⁵ Recognizing the significant impact of social isolation and loneliness, further intensified by the COVID-19 pandemic, the US Surgeon General issued an advisory on the epidemic of loneliness and social isolation in 2023.²⁶ Although social isolation and loneliness have received limited attention to date in rheumatology, they may be amplified in individuals with rheumatic diseases, due to functional limitations, fatigue, and chronic pain,²⁷ and are expected to have a clinical impact, especially on physical functioning and medication adherence.²⁸

A practical approach to loneliness and social isolation was presented at AGS 2024 by Ashwin Kotwal, MD, MS,²⁹ beginning with (1) identifying loneliness and social isolation through the use of existing tools (e.g., UCLA 3-Item Loneliness Scale³⁰ and Berkman-Syme Social Network Index³¹) and conversation; (2) discussing contributions to loneliness and providing support for emotional processing; (3) formulating individualized solutions through shared decision-making, including clinical (e.g., addressing pain) and social (e.g., social support) interventions; (4) directing attention to related medical needs (e.g., advanced care planning and psychosocial support).³² While these efforts should be situated within a multidisciplinary team and engage loved ones and caregivers, awareness of this approach is needed among rheumatologists and allied rheumatology professionals, who often play a prominent role in the care of adults with rheumatic conditions at risk for social isolation.

Educational Highlights: fostering the next generation of clinician-scientists

Rheumatology fellowship programs are crucial for expanding the workforce and cultivating clinician-scientists to address the needs of the aging population. However, barriers such as lack of dedicated time, funding, and training in analytic skills hinder research among trainees.³³ This issue affects various medical specialties, including geriatrics.³⁴ As part of a session focused on how junior investigators can engage with education, health systems, and community partners to successfully conduct studies with older adults, Ashna Rajan, MD, discussed the GEri-pall Research and Mentorship program at Brown University, designed to equip fellows with mentorship and resources to pursue scholarly work within the timeframe of their fellowship.³⁵ In its first 3 years, 95% of fellows had abstracts selected for poster presentation at a national conference, and 30% of these abstracts resulted in manuscripts. Notably, the opportunity to develop mentorship skills and build collaborative networks benefited both the fellows and the faculty involved.

Mentorship programs similarly could help the rheumatology community overcome barriers to academic careers.³³ The Brown GEri-pall Research and Mentoring program begins in the first month of fellowship, providing dedicated time for identifying a hypothesis-driven original research interest. Fellows also are paired with faculty mentors early in the program for regular meetings to set and meet milestones. Additionally, the program provides tangible resources such as a Data Sandbox, a dedicated analyst, and a Continuing Medical Education (CME) allowance. The Data Sandbox is innovative because a program-specific IRB enables fellows to access data from the beginning of their fellowship, eliminating what is often a rate-limiting step in research.

In rheumatology, national mentorship matching programs like CARMA (Creating Adult Rheumatology Mentorship in Academia) and AMIGO (ACR/CARRA Mentoring Interest Group) developed by the ACR and Childhood Arthritis and Rheumatology Research Alliance (CARRA) support both trainees and junior faculty. However, access to data and analytic support is a significant barrier to research success during training.^33,36 The vast majority of existing rheumatology-focused datasets that have been leveraged in trainee-led research suffer from limited accessibility. The ACR’s Rheumatology Information System for Effectiveness (RISE),³⁷ for example, does not provide for “hands-on training” in data management or analysis as all data manipulation and analyses using RISE data are conducted centrally at analytic centers with aggregate output shared with researchers. Although collectively demonstrating substantial value in prior mentored rheumatology research, other national datasets such as those from the Veterans’ Affairs Rheumatoid Arthritis Registry (VARA) registry, FORWARD, or CorEvitas (among others) are also limited in terms of access and/or analytic support available to trainees and mentors alike.³⁸ We encourage the rheumatology community to be creative and proactive (seeking institutional support or creating new opportunities at ACR, Rheumatology Research Foundation (RRF), and other rheumatology-focused funding organizations) to enhance training and research by expanding grant funding with access to and analytic support for rheumatology-focused datasets for trainees and/or early career investigators. Emulating the Brown GEri-pall program by making research resources more accessible will support the next generation of clinician-scientists to inform the care of the aging population with rheumatic diseases.

Research Highlights: building towards an age-inclusive evidence-based care model

Despite being the most frequent consumers of medications, devices, and healthcare services, older adults are underrepresented in clinical trials.³⁹ In rheumatology, one-third of clinical trials focused on rheumatoid arthritis and osteoarthritis included an upper age limit for enrollment without providing clear justification.⁴⁰ Consequently, clinical practice guidelines are developed based on studies involving mostly middle-aged adults, which is not representative of the rheumatology patient population as a whole. To address this inclusivity gap, the NIH enacted the Inclusions Across the Lifespan Policy⁴¹ which requires investigators to include individuals of all ages, unless there is a scientific or ethical reason not to include a specific age group.

At AGS 2024, challenges related to and innovative approaches for “geriatricizing” research to build age-inclusive evidence-based clinical care were discussed by C. Barrett Bowling, MD, MSPH.²² The 5T framework (Target population, Team, Time, Tools, Tips for accommodation)⁴² was highlighted as a framework to adapt research efforts to promote the inclusion of older adults in studies.⁴³ The 5Ts, outlined in Figure 2, were designed to enhance research inclusive of people across the lifespan in general and likely would enhance rheumatology-based research specifically.

Figure 2:

Rationale and points to consider when implementing the 5Ts in rheumatology research to ensure representation of older adults. Adapted from Bowling CB, et al. J Am Geriatr Soc. 2019;67(2):342–6. PRO = patient-reported outcomes

The 5Ts framework can be tailored to support recruitment, enrollment, and retention of older adults in clinical trials and the inclusion of outcome measures that “matter most” to older patients. We believe that adoption of age-friendly frameworks by rheumatology funders, similar to that promoted by the NIA, will enhance inclusion of older adults and improve the relevance and quality of rheumatic disease research. We suggest that including a plan for recruiting and accommodating adults across the age-span should be required in all proposals submitted to rheumatology funders (similar to sex as a biologic variable) and considered when scoring.⁴⁴ As it will take time to adopt new grant funding policies, we feel that in the interim funders should consider research supplements for ongoing studies to expand recruitment to include older adults. These efforts are likely to result in improved care delivery to the aging rheumatology patient population.

A Case Study on Implementing Geriatric Principles to Surgical Practice: The Geriatric Surgery Verification Program

The American College of Surgeons, AGS, and the John A. Hartford Foundation joined efforts and created the Geriatric Surgery Verification (GSV) program to improve surgical care for older adults by developing a structured program that addresses the goals and needs of older adults. This program targets frail adults 75 years of age or older who are considering in-hospital surgery and aims to optimize their surgical care through pre-habilitative interventions based on comprehensive geriatric assessments. The GSV program was developed based on the geriatric 4/5M principles and focuses on improving outcomes in four main domains: 1) goals of care and decision-making, 2) cognition screening and delirium, 3) maintenance of function and mobility, and 4) nutrition and hydration optimization. To maximize impact, detailed protocols on patient care, governance, resource allocation, and data surveillance were developed based on expert consensus. These standards enable real-time quality monitoring and improvement in implementation, promote research advancements, and facilitate scaling across surgical specialties and hospital environments.

The success of the GSV program demonstrates the value and potential of multidisciplinary collaboration to develop and disseminate innovative models to improve the care of older adults. Importantly, several health care systems and specialties, such as the Veterans Health Administration, emergency medicine, and cardiology, also have developed age-friendly or age-focused care models.⁴⁵ They are primed to meet a new quality measure that CMS will introduce in 2025, based on age-friendly principles, to ensure that hospitals align care with older adults’ goals and preferences.⁴⁶ How this can be adapted to ambulatory care for older patients with rheumatic conditions has yet to be explored. Further, the rheumatology field is recognizing a shift in quality measurement from assessment of solely disease specific metrics (e.g., focused on RA or SLE) toward development of cross-cutting, universal quality metrics that reflect what matters most to patients across disease states -- also consistent with age-friendly care.^47,48

Conclusion

Individuals with rheumatic conditions accumulate age-related comorbidities and become frail at a younger age than the general population,⁴⁹ heightening the need for age-friendly care.⁵⁰ Moreover, older adults with rheumatic diseases have higher healthcare resource utilization and a greater burden of functional impairment and disability.⁵¹ Hence, it is timely and imperative that we as rheumatologists consider how to adopt geriatric principles and leverage multidisciplinary expertise to develop comprehensive standards of care and move towards value-based care for older adults with rheumatic diseases.

A recent survey conducted by the Hartford Foundation revealed that about 8 in 10 older adults (not all with rheumatic diseases) “feel the health care system is not prepared for the growing and changing needs of our country’s aging population.”⁵²Older adults strongly desired a person-centered holistic approach to care with more frequent discussion of “what matters most to you” that would enable them to stay independent and age in place. Those who received age-friendly care reported better healthcare relationships and outcomes. Further work is needed in clinical and research settings to implement this care model in rheumatology.

In the last decade, an interest group of rheumatologists dedicated to improving the care of older adults has grown steadily. The group aims to bridge the fields of rheumatology and geriatrics and has collaborated in multiple forums to disseminate geriatric principles to the rheumatology community. To date, the ACR has hosted aging-related sessions on mobility, physical function^53,54, inflammaging, frailty, multimorbidity, body composition⁵⁵, cognitive impairment, and palliative care^56,57 at ACR Convergence national meetings. Recently, “the intersection between aging and rheumatic disease and the complexities of caring for older adults” was recognized as a topic of interest by the Annual Meeting Planning Committee⁵⁸ for ACR 2025 Convergence. The ACR also sponsored an initiative to include measures relevant to aging populations in a special issue of Arthritis Care & Research devoted to Patient Outcomes in Rheumatology.⁵⁹ The ACR’s initiatives and recognition of the importance of improving the care for the aging rheumatology patient population highlights the potential for further collaborative initiatives between the ACR and aging experts. For those interested in pursuing aging research, the AGS and NIH/NIA have educational and funding opportunities that focus on developing investigators at the intersection of specialty care and geriatrics. The community of investigators, leaders, and mentors in aging has welcomed and supported specialists from both the medical and surgical fields.³

Caring for older adults with rheumatic disease is deeply rewarding because the approach is guided increasingly by the patient’s goals, preferences, and needs.³ Adopting the patient-centered and collaborative approaches presented at AGS will not only enrich our scientific knowledge, but also foster a holistic understanding of the aging process, ultimately improving patient outcomes and advancing the fields of both rheumatology and geriatrics. As the population with rheumatic diseases ages, delivery of evidence-based, safe, effective, and patient-centered care should be the standard of care, and ideally delivered in collaboration with geriatricians and other health professionals. Comprehensive training in aging principles for rheumatologists is now more relevant and timelier than ever to enhance the care of older adults with rheumatic diseases.

Significance & Innovation.

1. Incorporating geriatric principles, along with pursuing collaborative approaches with geriatricians and allied health professionals, can improve the care of older adults with rheumatic diseases.

2. Assessing falls and social isolation, in addition to traditional rheumatologic approaches focused on joint mobility and function, can enhance shared decision-making.

3. Applying the 5Ts framework (target population, team, time, tips to accommodate, tools) in research can enhance the inclusion of older adults in rheumatology research, which is essential for developing evidence-based age-friendly care.

4. Adopting innovative, patient-centered care models that include comprehensive geriatric assessments focused on what matters most to the patient will help transform rheumatology into a more age-friendly specialty, in alignment with recent healthcare policy developments and priorities.