Rheumatoid Arthritis in the Elderly

Older age of rheumatoid arthritis onset is associated with higher activation status of peripheral blood CD4(+) T cells and disease activity

Rheumatoid arthritis (RA) is a chronic inflammatory disease, with a clinical manifestation both systemic and in joints. It has been suggested that age at disease onset and/or patients' age have influence on disease activity and clinical outcome. The reasons for the different course of RA in older people are not known; however, the activation status of peripheral blood lymphocytes could be responsible. Our aim was to relate expression of activation markers in peripheral blood CD4(+) T cells of RA patients with patients' age and/or onset age and disease activity measured by DAS28. Seventy RA patients were included into the immunological study. Two separation criteria were performed: based on age of RA onset and on the biological age of patients. We examined different activation markers, CD69, CD25, CD95 and human leucocyte antigen D-related (HLA-DR), on the CD4(+) T cell surface. Division of RA patients in 10-year intervals at 40, 50 and 60 years revealed that RA patients with later disease onset were characterized by higher DAS28. This phenomenon was not limited to the division at 60 years of age but, surprisingly, the major differences were found for the 40-year onset division. Analysis of all four components of DAS28 revealed that disease activity in older disease onset was dependent on all components. Older-onset RA patients had a higher percentage of CD4(+) CD25(+) and CD4(+) CD95(+) T cells. Summarizing the major differences in DAS28 and activation status of CD4(+) T cells observed for onset of disease at 40 years seems to be the most informative about the immunological status of RA patients.

Rheumatoid arthritis in the elderly: is it a different disease?

Controversy has surrounded the question of whether rheumatoid arthritis (RA) afflicting the elderly is a different disease than RA in younger patients. Resolution of this complex question requires careful consideration of the pathogenesis of the disease and its diagnosis and prognosis. Meaningful analysis of these factors optimally derives from a critical review of all relevant medical literature (i.e., an evidence-based approach); however, methodologic inconsistencies and other difficulties with the literature on this subject largely preclude definitive interpretation. This review examines the evidence concerning various aspects of RA in the elderly population.

Increased numbers of CD5+ B cells and T cell receptor (TCR) gamma delta+ T cells are associated with younger age of onset in rheumatoid arthritis (RA)

Patients presenting with RA before the age of 45 years (younger onset) are known to have more aggressive disease compared with patients presenting after the age of 65 years (older onset). Coordinated expansion of circulating CD5+ B cell and TCR gamma delta+ T cell levels has been reported in patients with RA. This study assesses the peripheral blood levels of these two cell types in RA patients with younger and older onset of disease. CD5+ B cell levels were significantly elevated in the younger onset RA group (26.6+/-4.5%) compared with the older onset RA group (14.2+/-1.2%; P<0.01). TCR gamma delta+ T cell levels were also significantly raised in the young patients (4.0+/-0.9%) compared with elderly patients (1.6+/-0.2%; P<0.01). T cell levels (CD3+) were similar in both groups (young 66.4+/-3.3%; old 74.3+/-3.4% (mean+/-s.e.m.); NS). Total B cell levels (CD19+) were also similar in these groups (7.7+/-0.7% versus 8.9+/-1.8%; NS). A significant positive correlation was observed between the CD5+ B and TCR gamma delta+ T cell types in the patients (r=0.72, P<0.05). Compared with age-matched normal controls, the younger onset patients had similar CD5+ B cell and TCR gamma delta+ T cell levels to the elderly controls (CD5+ B cells 30.2+/-3.0%; TCR gamma delta+ T cells 3.0+/-0.8%). Conversely, older onset RA patients had CD5+ B cell levels similar to the young controls (12.3+/-1.9%). Spontaneous in vitro synthesis of immunoglobulins (IgM, IgA and IgG) and rheumatoid factors (IgM and IgA isotypes) were not significantly different in both patient groups. The coordinate expansion of circulating CD5+ B cells and gamma delta+ T cells seen in patients with RA presenting before 45 years of age and not after 65 years of age may suggest a potential role for these cells in more aggressive disease states.

Second-line agents for rheumatoid arthritis

Second-line agents (disease-modifying agents or slow-acting antirheumatoid drugs) are well established for synovitis that persists despite treatment with non-steroidal anti-inflammatory agents. Indications for their use in the elderly are similar to those in younger people, but the elderly are at higher risk of adverse reactions. Therefore, lower doses, more cautious patient selection and more frequent monitoring for adverse reactions are recommended. Low dose corticosteroids are often effective in the elderly and obviate the need for second-line agents.

Preventive aspects of mobility and functional disability

Among bone and joint diseases, frequent causes of disability include (a) fractures from falls and osteoporosis, (b) osteoarthritis of hips, knees, and lumbar spine, (c) painful feet, (d) back pain, and (e) intractable rheumatoid arthritis. Risk factors for falling may arise from factors intrinsic to the patient and from hazards in the environment. The prevention and management of osteoporosis are controversial. Most experts endorse the use of estrogens in postmenopausal women and the need for continuing physical activity, particularly walking, in both elderly men and women. To preserve independent living, conservative management of osteoarthritis of hip, knee, and low back consists of properly balancing rest, non-weight-bearing exercises, and the use of walking aids. In rheumatoid arthritis, the clinician should emphasize (a) exercises to maintain range of motion and (b) muscle strength, both to prevent flexion contractures and to maintain the ability to carry on activities of daily living.

Polymyalgia rheumatica: a syndrome associated with HLA-DR4 antigen

HLA class II antigens were determined in 65 patients with biopsy-proven giant cell arteritis (GCA). An increase in DR4 antigen frequency was found in the patients (40%) compared with that in 200 healthy controls (20%) (Pcorr less than 0.05). DR4 was significantly more frequent in GCA patients with polymyalgia rheumatica (PMR) than in those without PMR (58.8% versus 19.3%) (P less than 0.005). HLA-DR4 frequency in GCA patients without PMR was similar to that in the control population (20%). Patients with severe, disabling PMR had DR4 more frequently (90%) than did those with moderate symptoms who required medical care because of cranial arteritis manifestations (41.6%) (P less than 0.05). We conclude that, in GCA patients, association with DR4 is mainly related to the manifestation of the disease as PMR. We discuss clinical and immunogenetic similarities between PMR and other DR4-associated rheumatic disorders. Common immunopathogenic mechanisms leading to clinical overlap among them are suggested.