"#493 Joint Pain in Older Adults with Dr. Una Makris" From The Curbsiders With A Link To The ACR Clinical Practice Guidelines

Note to myself: I have included the TRANSCRIPT below in this post because it is a great review of joint pain.

In addition to today’s resource, please review

American College Of Rheumatology Clinical Practice Guidelines:

Today, I review, link to, and excerpt from The Curbsiders’ #493 Joint Pain in Older Adults with Dr. Una Makris.*

*Young J, Witt LJ, Miller R, Makris UE, Williams PN, Watto MF. “#493 Joint Pain in Older Adults”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast July 28, 2025.

All that follows is from the above resource.

Audio:

Video:

Transcript available via YouTube

An age-friendly approach to arthralgias

Attack arthralgias with ease! Learn how to evaluate and manage common joint complaints in older adults. We’re joined by Dr Una Makris, @unamakris.bsky.social (UT Southwestern).

Claim CME for this episode at curbsiders.vcuhealth.org!

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Show Segments

Intro

Case 1 from Kashlak

General approach to joint pain in older adults

Diagnosing osteoarthritis

Management of osteoarthritis in older adults

Non-pharmacological interventions

Pharmacological interventions: topicals, orals, injectables

When to refer for joint replacement

Case 2 from Kashlak

Diagnosis of Late onset rheumatoid arthritis (LORA)

Differential Diagnosis and Distinguishing features

Lab work/Imaging

When to refer to rheumatology

Approach to managing LORA

The 5Ms framework

Initial treatment with glucocorticoids

Ageism as a driver of undertreatment in older adults

Treating to target

Key takeaways

Outro

TRASCRIPT

You know, Paul, I have some bad news. Um, I’m so sorry, Matt. Tell me. Tell me

more. Hackers brought down my online business, but I managed to keep the website

address. Is there is there more?

And you know what, Paul? That’s domain thing.

Jeez. Oh, boy. All right.

Matt, I noticed my my robotic vacuum cleaner. It’s just not cleaning as much as it

used to. It doesn’t seem to be getting around the house nearly as well as it has in the past. I’m a little afraid it has rheumatoid arthritis.

God, puns suck. Paul, why are we They really This show’s bad. Everything’s bad.

The Curbsiders podcast is for entertainment, education, and information purposes only. And the topics discussed should not be used solely to diagnose, treat, cure, or

prevent any diseases or conditions. For the more that views and statements expressed on this podcast are solely those of the host and should not be interpreted for official policy or position of any entity aside from

possibly cash or hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much we aren’t responsible if you screw up. You should always do your own home

and know when we’re [Music]

welcome back to the curbsiders. I’m Dr. Matthew Frank here with my great friend and someone who tells me he is the The

How dare you? Sorry. The primary care physician, America’s primary care physician, Dr.

Paul Nelson Williams. Hi, Paul. Hi, Matt. Thanks for that kind intro. How are you? You feeling humble tonight?

Humble’s the word. Okay. Well, uh, I’m excited. We had a great show, Joint Pain in Older Adults.

We talked some OA, we took some RA, we talked about differential diagnosis for joint pain, and then how to tailor the

approach to the older adult. Our guest was the great Dr. Una McCree. And uh

Paul, before we introduce our wonderful co-host, would you please remind people

why are we here, Paul? What are we doing? Yeah, existentially, Matt, I’m not sure. In terms of the podcast, we are the

internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. As you

alluded to, we are joined by super producer, frequent co-host, Dr. Leo Wit. Uh Dr. Wit, how are you tonight?

I’m great. Always happy to be back talking about geriatrics topics. And this topic is one in our series in our

collaboration with pen geriatrics and their ages smart geriatric workforce enhancement grant I think called a GUP

or a GWP led by Dr. Rachel Miller. So tonight we invited um Dr. Una McCree and

we had a fantastic conversation with her. She’s a professor of medicine in the division of rheumatic diseases at UT

Southwestern Medical Center and the Dallas VA. She’s always loved older adults and she’s passionate about

bridging the fields of rheatology and geriatrics. She spends a lot of her time outside of patient care and mentoring

focused on health service re research and improving outcomes that matter most for older adults with muscular skeletal

pain. So she joined us today to talk about her primary area of interest. So

pain joint pain and aging and how we can optimize our approach to improve outcomes for older adults with

arthritis. So without further ado, let’s get into it. A reminder that this and

most episodes will be available for CME credit for all health professionals through VCU Health at curbsiders.vcualth.org.

Una, we’ve been talking for a little bit. Thank you so much for joining us. The audience has heard your formal bio,

but they they want to know what’s a hobby or interest you currently have outside of medicine. Like what are you into these days?

Yeah. Um, thanks for having me, by the way. I’m really excited to chat with

everyone. Um, so at this stage of my life and my family life, my favorite

hobby is probably sitting on the sidelines, uh, cheering on my kids. I have two girls. I have a 16-year-old

competitive rower, so for her, I stand on the side of a river or a lake cheering her on. I have a 13-year-old

goalkeeper, so I love watching her protect her goal. Okay, that is uh I’m

glad you like doing that because I imagine you’re spending a lot of time doing that.

Absolutely. It’s it’s a complete pleasure while I have them at home to cheer them on.

Yeah. A lot of early mornings on the river, I’m sure. Yes.

Nope. Sounds like a great chance to brave the elements, too. So, that’s that’s good. Um I guess my follow-up

question is I like the failure one this time around. So, maybe you can tell us about what your favorite failure is and what you learned from it. Sure.

Um there’s just so many right in life. Um so I I would say that I learn a

tremendous amount from failed grant applications um that I need to submit. So I really

study reviewer comments and I’ve learned that it’s not about me. Sometimes it’s

about the ideas. Sometimes it’s about the framing or the methodology. and that

communicating more clearly is usually what we need to do. So, I’ve I’ve

learned a tremendous amount from from those failures. That’s a good attitude to have about it. I think uh I’ve always been too

intimidated to submit grants, so I I don’t do that. Pod podcasting just seems easier. I don’t know about you, Paul,

but that’s my feeling. Oh, for sure. Yeah. I will say reviewers for like journal articles submitted, I I

will harbor over animosity towards them and hope that I never actually meet them in real life. You’re you’re a better person than I am.

Uh, all right. Well, we we have a big script. So, Leah, let’s get to our first case from Cashlac.

All right. So, our case from Cashlac is Mr. Carter. He’s a 76-year-old man who

you’re seeing in your clinic for an urgent visit with several days of acute and chronic right knee pain, stiffness,

and new swelling. He was carrying several boxes upstairs while cleaning his basement the morning before his

symptoms started. And now he has difficulty going up and down the stairs. The pains relieved somewhat by rest and

worse at the end of the day. And he has stiffness just for a few minutes after getting out of bed. He’s lived alone in

his two-story home since his wife passed away 5 years ago. And at baseline, he’s fully independent in his ADLs and IDLs.

Ambulates without an assisted device. He’s not had any falls in the last year, but he says he has to take it slow

because his right knee gives out sometimes. He’s got a history of hypertension, CKD, stage 3 A, and AIB

complicated by remote embolic CVA when those residual deficits. So, um, pretty

typical case in primary care. Um, Una, could you tell us your general approach

to joint pain in older adults? Absolutely. Um, this sounds like one of

my classic cases as well, even as a rheatologist. So, I would say that the key is really

to to listen carefully to the patient’s history. You know, is this acute or chronic? It sounds like this is subacute

on chronic. Um, is the onset gradual or abrupt onset with symptoms that come on

episodically. Um, episodic aspect might make me think about a crystal arthritis. gradual onset

may be osteoarthritis. Um, when I hear about acute onset, this

can be related to trauma or sometimes overuse like this gentleman going up and

downstairs. And if you don’t hear the history, ask about it, especially about

falls. Um, acute onset can also be infection or septic arthritis. Um, so

really pay attention to the history. The other thing I I pay attention to is the distribution of joint pain um and

associated swelling. So if it’s monoarticular this and there’s warmth

that could be crystal um like gout or pseudo gout um and when you think of

distribution of joints you know some patients will localize to the knees. Is

this unilateral or bilateral? If it’s unilateral, I always ask that they have

a remote trauma um that may result in secondary OA that can cause just one

side to be affected. If they report hand pain, is this mostly in the wrists, the

metacarpal falangial joints and here the proximal interfallangial joints or

isolated to the DIPs. And that all gives me clues. If we have

MCPS and PIPs, I think of RA. If we have DIPs, the distal interfallangial, I

sometimes think of seroriatic arthritis, sometimes erosive osteoarthritis. And I

just want to emphasize, as you know, you know, most will have multi-sight pain

that will include spine, knees, hips, hands. And it’s important to try to tease out the different types of pain

that occur because really how we treat the pain depends on the underlying

diagnosis and also how we educate our patients about the pain. Um and so in

that sense I just want to emphasize one important point that I speak to my my trainees about um and that is you know

understanding how the patients joint pain symptoms impact their daily function.

So we tend to focus quite a bit on the pain intensity, the pain severity. Usually with that question, that

numerical rating scale, you know, tell me about your pain rated zero to 10. And

that’s very subjective of course. So I like to understand how does that number

impact their day-to-day activity? How does it interfere with um hobbies or

things that they love to do? So the key message here is that really high impact pain um that which interferes with daily

life is more likely to result in worse outcomes and disability. So focus on

function and interference over pain severity and intensity.

Can I ask a clarifying question? And when you mentioned multi- joint, were you saying that you what you really if

they say they have multiple joints affected, are you trying to say like is this multiple different things like they

have a rotator cuff and they have neoa or are you trying to figure out if it’s the same process in those multiple

joints? Is that what you were getting at? So all of all of the above. I just think

that the norm that we see in clinic is multi-sight joint pain. So it they there

could be different ideologies of the joint pain. You could have OA, you can have RA. I see a lot of patients with

lupus and comorbid fibromyalgia, right? And so the norm is actually

multiple sites of pain. And I think part of the fun is trying to distinguish,

you know, what what’s going on. I don’t think this will be too much of a detour, but you mentioned fibromyalgia.

Is that is is the thinking there that like if someone’s had chronic pain from

RA, lupus, something like that, that eventually they get like central sensitization and and they have comorbid

fibromyalgia. Is that the idea or is it is are people still fighting out whether

what what is actually going on there? I think we’re still fighting out and trying to determine what’s happening.

You know, there are different pain mechanisms. No sisceptive is osteoarthritis and RA. Noiplastic is

fibromyalgia. Do patients who tend to have longstanding RA also develop

fibromyalgia? Sometimes, but not always. And so I I I don’t think it’s

necessarily an issue of duration of another type of pain that increases the

risk of fibromyalgia. It’s a separate entity. Okay. Yeah. So, all right. Not too much of a detour,

Paul. I’m a pro. I knew it. I’m proud of you. That’s strong work. Okay. So, we’re we’re asking the person

uh is it acute? Is it chronic, subacute, was the onset gradual or abrupt? Um and

then we’re sort of getting a sense of the dis the distribution of which joints are involved. Um you gave us some clues

as to what that makes you think, but importantly, we’re asking them about the impact on function. Okay. And you’ve

given us a pretty good differential there. So Leah, do you want to go to the next part of the case and then we can

keep going? Yeah, sure. So on exam, he’s aphibbrrial and hematonymically stable. The right

knee appears mildly swollen, but it’s not warm or amitus. He has crerepidus

and pain throughout the full range of active and passive flexion and extension. He has reduced muscle ma mass

in his legs and he uses his arms to rise from his chair. His gate is antelic, but he appears steady on his feet. So what

do you think of that physical exam? Does it change your approach or your differential? And do we need anything

else to make the diagnosis? Are you thinking about labs or imaging? Sure. I would say that osteoarthritis is

still highest on my differential here. You know, for for various reasons. Um,

age is certainly a risk factor. The fact that there is minimal stiffness that it

gets worse throughout the day on exam. His his exam is pretty consistent with

osteoarthritis. I’m always looking for bony hypertrophy. I actually like to look for vary deformity and

bow-leggedness. And I think of it like the mechanical forces that sit through the hips kind of wear down the medial

aspect of the knees. I’m looking for swelling and feeling for warmth. Is there crepitus with range of motion? Is

there joint space tenderness to palpation? That’s probably the most common sign I see. Um, and I’m always

looking for quadricep atrophy. So really, it’s a clinical diagnosis based on history and exam. I don’t need labs

and actually I don’t need imaging to confirm the diagnosis. Whenever um I see

a patient in rheumatology, typically they already have multiple sets of plane films and I always ask myself why. And

so when I think about imaging, I ask myself what am I looking for and will it change my management? And I tend to only

image if there’s a change in clinical presentation if I’m worried about a different

diagnosis or progression or if I’m referring to orthopedics and they

require the imaging. Can I ask from an exam standpoint? I feel like I’ve asked this in a different context. if I remember like the

evidence-based stuff like the bony hypertrophy and the various deformity or like the really big sort of likelihood ratio changes I feel like comes up all

the time but I and I feel like I just never know how excited to get about it and that there’s a difference between course and fine grapice and what to do

with it like because my I make the joke when I’m examining patients that the hearing test is that they can hear my knees pop when I stand up after checking

their legs so and I my knees feel fine I I probably have some arthritis but I guess to the to the question the

crepitus in particular um I I never quite know what to do with that information so I’d love to hear how you think about it as a rheatologist just

if it’s not present, they can still have arthritis, right? If it is present, it’s just kind of a neat exam finding um that

is likely related to their osteoarthritis, but in its absence, it

it it doesn’t mean they, you know, they don’t have the arthritis. Also pertinent to the physical exam, you

mentioned once or twice this atrophy of the quadricep. Can you talk about that a

little bit? Sure. Um I really talk about it you know

in the context of management but I don’t know where in this cycle this occurs.

It’s probably underuse right if someone has knee pain they may be less physically active which then may uh

yield less you know use of their joints ligaments muscles and that can lead to

atrophy. Um, and so that’s kind of a sign that they may be less physically

active than we want them to be. Okay. Thank you. Yeah, that’s something I’ll have to start. I I feel like people

come in, they want you to examine their knees and they’re wearing like tight jeans that you like can’t pull up over their knees. It’s it’s it’s always an

issue and then you have to make the decision. Is it is it worth making them change it to the gown or if you have a

clinic that has shorts? Paul, do you deal with this, too, or am I just the only lazy one that’s like I I can pull

the jeans up? Uh, I I I’m gonna say my our staff are actually excellent at my particular

small division of cash lock and making sure someone’s gowned up if I need to look at stuff. So, it’s it’s I’m in a good place right now. But, yes, historically, it’s it’s always

the skinny jeans when someone has a knee complaint. So, I feel your pain. Yeah. Okay. It’s going to get worse with our

generation. Our generation grew up on skinny jeans, you know. Yeah. And they’re going to have tattoos covering their whole leg. you would be

able to see the knee anyway. Ruffy. Okay. Are we ready to talk about treatment or is it too soon?

You know what? Can I make one more point that I forgot to mention about imaging? Oh, yeah, please.

So, this is especially important for older adults. Um, that radiographic

findings do not always correlate with what we see clinically. And so, I just want to highlight that, you know, I can

see severe joint space narrowing. I can see sclerotic margins and osteophittes and really severe radiographic OA and

yet the patient is telling me that they’re walking 2 to three miles a day. And so I just want the audience to kind

of recognize that and you’ll see that time and time again in your clinics. And so don’t make all decisions based on the

X-ray. Listen to your patients and what they’re telling you. Yeah, great point.

Thanks. That’s a great tip. So what is your approach to OA treatment? Where do you like to start?

So I typically start by emphasizing kind of behavioral and non a medication

approaches and I think that most of the clinical practice guidelines support that whether it’s American College of

Physicians or the CDC for chronic pain because we’re talking about osteoarthritis I want to kind of

reference the American College of Rheumatology clinical practice guidelines from 2019 which really

highlight a lot of these non-farm behavioral psychosocial approaches as

well as um pharmarmacologic management. So I usually start with emphasizing um

education like we don’t maybe spend enough time educating our patients about what’s going on and what they can do for

self-management or the importance of various non medication modalities. So I

end up spending a lot of time on weight management and nutrition potentially. Um

especially since we know obesity is a risk factor for osteoarthritis.

Um we also know certain mindbody movements like taichi and yoga have been

very useful and can be modified for older adults. Um my research specifically focuses on

how do we enhance physical activity among older adults to improve pain. So I

spend a lot of time trying to counsel patients how they can integrate movement

into their routine. And it really boils down to access safety and comfort. And I

usually kind of try to to explain how physical activity and exercise are not

all about fancy equipment and sports gear and looking good in the gym, but it

could just be walking around the block safely, you know. Can I ask is actually just I I meant to

ask this a little bit earlier. I think it ties into the educational component, I guess. How do you when you’re talking about osteoarthritis in particular with

patients, how do you talk to them about it? Because I think it’s easy to for it to sound as if you’re saying, “Well, you’re disordered and this is what’s

going to happen.” Like I I I think sometimes that’s what’s heard. So when you’re talking about the disease process and you’re sort of doing your general counseling, how do you how do you

explain the disease or even do you like I guess how much time do you even spend covering that ground?

Yeah. So my approach is to kind of explain that this is kind of a wear and

repair and repair of the cartilage. Um I think the language that we use is so

important. So, thanks for bringing this up. I think we tend to say, “Oh, it’s bone on bone. It’s uh it’s it’s wear and

tear. You got nothing left there.” And, “Oh, by the way, go walk and exercise.” And then they and then they think, “Oh,

I’m going to do more damage. It’s just going to be worse for me.” And so, it’s not the right it it’s not a message that

encourages engagement in the physical activity that we need and want them to do. And so I usually say, you know, it’s

a breakdown of cartilage over time. This is a chronic condition. This is not

something that’s going to go away, but I can help you in various ways kind of

support the knee all in an attempt to kind of improve your function. You know, everyone’s talking about their pain, but

I tend to reframe the conversation around function. And that’s where the quad strengthening comes in. And that’s

where if they have quad atrophy, it’s a really nice visual to point to it and

say, “I would love for you to engage in physical therapy and strengthen this quad muscle right here.” And you point

to it and you say, “This can help buffer and strengthen and kind of support um

the knee and and and help with the knee osteoarthritis.” Yeah. I love that. Reframing reframing

things. Yeah. And and people anecdotally, it it seems like people

tell me like let’s say someone has a terrible lifestyle. They’re not moving. They’re eating terribly. I’ve had

multiple patients like tell me that they feel just in general all their joints feel a little bit better when they when

they stop doing that. is I don’t know if there’s evidence for that or if that’s something people say to you as well, but

it just I’ve had multiple patients tell me more that I think it’s not just a coincidence or maybe it’s maybe they

just feel better about themselves and their all their pain gets better. I don’t know when when they

when they’re just sort of like if that let’s say their lifestyle is like they’re doing all the wrong things. It’s

like high processed food diet, lots of time on the couch and not barely moving

and then all of a sudden they start doing some of these things and then they say, “Oh, my joints feel better.” I I’ve

had multiple people tell me that that’s the case. Yeah, I don’t think it’s a coincidence.

I think that movement um is medicine. We’ve heard that many times before, but

I do think if you don’t use it, you lose it. Um, and we really need to encourage

movement and physical activity. And you know, this might be a little bit of a tangent, but a lot of our patients might

feel like they’re in a catch 22 situation where they have severe knee

osteoarthritis and pain and they can’t get moving and then their sleep is impaired. And so I I think this is a

very common cycle people get into. And so I actually draw the cycle with them in the middle and I talk about how can

we um tackle this and just jump into the cycle somewhere. And um you know often

times it starts with a little bit of weight loss with eating better and a

little bit of physical activity and then they get into a cycle and a feedback loop where they see they feel better

with improved activity, nutrition, better sleep. Are you prescriptive about

the type of home exercises they can do? Because what I’ve seen is like people will improve after PT and then they’ll

stop doing their exercises and kind of slide back. Do you have handouts or how do you counsel them for their home

exercises? That’s a great question and I’ve thought a lot about these prescriptions for

physical activity and exercise. So I kind of look at PT a little differently.

So they’ll go to PT, they’ll do the strengthening exercises. the stretches,

range of motion, and then they’ll get a home exercise program that I do encourage everyone to ask their patients

about because once they’re done with PT, the question is really, are you doing the home exercises? And if not, why not?

They can do the home exercises that might involve bands. That’s wonderful. But more than anything, I like them to

choose a physical activity that they can integrate into their life. park a little

further in the parking lot and walk into that mall or the church or the Walmart,

you know. And so we talk about how to increase steps in various ways in their day-to-day life. For a lot of my

patients, walking may not be the right modality. If they have access to a pool,

aquatic therapy has been very useful. Um, cycling has been incredibly helpful

for a lot of my patients. Um, and so we kind of talk about what they have access

to and what they feel safe doing. Fantastic. What where where are you at

on topicals like dicloanac gel? I know the in some of the guidelines the

topicals are sort of recommended for knee knee and hand oa maybe maybe it’s

harder to think how they’re how well they’re going to work on the hips, but can you talk about that? Absolutely. I’m a huge fan of topicals.

Everyone gets topical dloopac. So I will say I usually start with um the options

of mental camphour or capsain either the cold or the hot and then we move pretty

quickly on to topical dicloanac. And I love this because of the limited systemic absorption. Um and so if you

have coorbidities like kidney disease, if you’re anti-coagulated, it may be safer. So usually I really push them,

you know, have you tried the topical dicloanac? Oh, I tried it once, once a week. Well, let’s try it four times a

day. It’s kind of like your full-time job now to apply it to that area. If you are on um couadin, if you’re on if

you’re on um warin or if you have chronic kidney disease, I usually tell them to take it twice a day. We don’t

have a lot of literature on those folks because they tend to be excluded from randomized control trials. As I try to

encourage my patients to be more physically active, sometimes I tell them, why don’t you try applying it 30

minutes before you go out um for your bike ride, for your walk, that type of thing. And then I also um I really like

hot and cold modalities. So that’s kind of trial and error, what works for most folks, but most people really like ice

packs. What about like a knee brace? I think a lot of people’s normal approach is to go

to the pharmacy and just buy anything that they see that could be helpful. Do you recommend against? What do you think

about those sorts sorts of things? So, I usually ask the question if they feel unstable um and if they feel like

their their knee feels rather unstable, um I might uh recommend a knee brace.

Sometimes they’re very bulky and they’re hinged. Sometimes it’s the neoprene brace that just provides enough support.

Um and oftentimes my physical therapist colleagues will recommend um a specific

brace given what they see. Yeah, people people love their knee braces. Uh if if they love them, they

love them. So Paul, you seem like a knee brace guy. It’s I’m I’m agnostic. If they feel like

it helps, then great. Go with God. You know, I I think we’ve Oh, yeah. Sure. I just wear them just

prophylactically just in case my knees start hurting. You wear them over your khakis, right? Yeah, of course.

The hinged ones too. I want to talk about like just the no sleeves. Like I like it’s a whole thing. Uniboo, the

whole nine. Speaking of things that that patients love, where where are we with the the naturopathic supplements? Like I

have lots of people who are taking sort of joint health and uh glucosamine and chondroitin. I am not above recommending

turmeric based on some general clubs that we did earlier um in prior episodes, but I guess what what do you

feel okay about? What do you recommend against or sort of how do you counsel patients in general about these sort of other um perhaps less evidence-based

modalities or or I guess a better ways like the naturopathic modalities? So sometimes we don’t have enough

highquality data to guide these decisions. So my approach typically and this is just my style. If they’re asking

you me, let’s say about glucosamine chondroitin, I say, “Have are you taking it?” “Yes,

I’m taking it.” “Is is it effective? Does it help you?” If the answer is no,

I’ll let them know that that’s consistent with what I know of the literature in the area. If the answer is

it helps, I say that’s fantastic. I’m glad it helps. Can you afford it? Right? So if it’s not

effective that you know that that is consistent with the literature for glucosamine condritin um and it it can

save them a few dollars in their in their wallet certainly um I do not typically recommend glucosamine

condritin just based on the literature I also don’t reach for turmeric if someone really wants to take turmeric for

example um that’s fine I I I am fully supportive if it helps I also am not

always clear what they’re ingesting because a lot of this um is not

regulated. And so sometimes I’m concerned about the marketing aspect and

do we know what we’re actually ingesting? Yeah, it’s that’s a tough landscape to

navigate and I find that the people that like to take supplements like to take

supplements and may maybe they would stop if it’s like if if if you kind of point out to them, well, you’re you’re

taking it, it doesn’t seem to be helping you. Is it expensive? That’s the only times I’ve really had people stop it.

But if they if they like the results and they like taking it, they just take it. That’s exactly right. And sometimes if

you can point out adverse effects, that’s another reason to come off. Good point. Yeah.

How about sort of related, I guess, with topicals like CBD cream or even oral

THC, CBD? Do you what do you counsel people about that?

I think it really depends. Um, I mean CBD oils are super common um and are helpful

for many patients. So I don’t dissuade them. I’m in Texas,

you know, and so some of the modalities we we don’t have access to and we don’t recommend and frankly we don’t have

tremendous um robust data in all populations. And I do think about safety

concerns in my older adult populations and kind of CNS and sedation uh

possibilities there. So I will say when it comes to oral pain meds um I still do

trial a menophen. Some of the metaanalyses suggested is not as

effective as NSAIDs but I think in the older adult population it is uh safer

option and can be effective. Um, and then I don’t typically start patients on

opioids or NSAIDs, but I inherit a lot of patients on these medications.

Yeah. So, Mr. Carter has CKD stage 3A. Um, so NSAIDs might be difficult for him

because of the risk for his kidney disease. What would you start the acetaminophen dosing at? What would you

give a patient for treatment with that? So I think he can have up to two grams a

day. That’s fine. And along with topicals. So it’s it’s very common that

I will kind of lay out an approach in a menu of options that includes um

non-farmacologic physical therapy, topicals, acetaminophen

um and then follow up in 3 months. Um sometimes they are actually coming to me

for corticosteroid injection. So, it just depends um you know where they are

um as far as having tried the menu of options. Yeah. Can you talk to us about

injectables like what’s your practice there and how you how do you talk to patients about that like the I guess and

the the evidence you know risks benefits that sort of thing certainly so in our clinic we tend to

inject uh gluccocorticoids triinolone along with bupivocaane so a combination

into the knee joint and and um our patients typically come back every five

six seven eight months. Um and so we have a lot of conversations about once we start that cycle you know have we

tried you know other options and how can we

kind of increase the time in between injections because we do have some data

that you know perhaps you know injecting cortic you know gluccocorticoids into the knee joint every 3 months for 2

years may not be the safest option. Um but it’s really dependent on the patient

in front of me. Sometimes um surgery is not an option and sometimes this

provides just enough relief and functional gains that we all agree this

is the right approach. In our clinic we do not um inject hyuronic acid. We’ve

reviewed the literature and at this time there are quite a few metaanalyses out there that show that hyaluronic acid

preparations are not more effective um than glucocorticoids or placebo. Um

so we do not offer this. Um we have also seen in some instances a kind of a

reactive eusion after injecting the hyaluronic acid. we don’t offer it. Um, and that becomes

kind of a sticky point if they’ve tried it elsewhere and and anecdotally it

works for them. Um, we try to identify a provider who can give that to them.

Yeah, I can’t imagine how many millions of injections of that stuff has been given in in the US over the past however

many decades. But yeah, I’ve seen that acute reaction before and it was it

occurs within a few days of it, right? And it’s like they just you would almost think it was a septic joint if it if the

history wasn’t such a clear time period. That that’s my just like vague. It’s been years since I’ve seen a case, but

is that sort of how it presents? That’s exactly right. So I have Friday clinics and the story usually goes that

they go to the ER by Sunday. Yeah. uh with that type of reaction. It’s that

severe and that painful. Well, at least it’s hard to get through insurance, so that’s good.

Exactly. Do what do you think is going to be as far at your conferences? Are people just

talking are people talking about PRP and stem cells and these sort of things? And do you see any promise or is there any

promising injectable? cuz people seem to like people that get their knees injected just seem to be like they they

get their knees injected and and uh it would be great if we had an injectable that we really knew worked like really

well and have more longlasting effect and was disease modifying. Oh yeah, that’s

we don’t have um disease modifying anti- osteoarthritis meds just yet. I can’t

wait for that day. Um but really in rheumatology conferences we are not

talking too much about PRP or stem cells um I haven’t seen consistently robust

trials that use the same volume that use the same approach um and protocols to feel confident with

what we’re doing there. Yeah. And you know some of the cashlac hospitals uh are now offering this lowd

dose uh radiation which is something I just learned about uh and it seems like

it’s popular in Europe based on observational data but then they did some like sham trials and some our

randomized control trials with like sham treatment in the US or or not necessarily in the US but they’ve done

some randomized control trials of sham treatment and they it looks like it actually is just a lot of placebo

effect. I’m not sure if that’s something that you’re seeing or people are coming in asking you for.

I’m I’m no one is asking about that yet. Interesting. So, it must be

they seem to be happy with my gluccocorticoid. It must be a northeast region thing that people are starting to ask me about it

now. So, I Yeah, I guess maybe like Lyme disease, it will spread from the northeast down to down towards Texas.

Uh, all right. Okay. Okay. Well, Leah, I think I think we’ve done a a great a lot of great discussion on osteoarthritis.

Is is there anything else here that you that you think we should go through or do we do we want to make our patients

sicker? You know, as as we do, we definitely should we should definitely come back to him in about a

year. I just before we move on from OA, when should we refer for knee replacement?

Like what’s the threshold for that? It’s a great conversation to have. Um,

so I refer to orthopedics to discuss knee or hip replacement when

conservative management including PT, injections, topicals and so forth have

have failed and also when the function is declining and I think that’s the key and I don’t like to wait too long

because rehabilitation posttop for a replacement is so important. So, we want to give our patients the best chance to

recover from surgery before contraurs might develop. Um, I’m always asking

about the social context. So, is there someone at home who could help them? Um, and I I will say a lot of patients are

nervous about uh surgery. So, they are happy sticking with conservative

management until a certain point. And so, it’s it’s just a it’s a fine line. You don’t want to wait too long.

Okay. Great. All right. Well, let’s come back to Mr. Carter about a year and a half later. He did end up getting a

right knee replacement about twice of conservative management and then unfortunately he had a posttop course

complicated by delirium and an aspiration event. He was in the ICU briefly. Um but luckily he’s recovered

but he’s back to see you because over the last 3 months he’s gotten too sto sore and stiff to do anything. All of a

sudden he has pain from his shoulders down to his hands. His symptoms started suddenly one morning in his shoulders

and spread to the joints of his elbows, wrists, and hands over subsequent days. He does have some improvement in pain

and stiffness throughout the day, but he also has fatigue, chills, and reduced appetite. He tried the dicloanac gel

that you gave him previously, and he occasionally uses that for his knee pain, but it hasn’t provided relief for

the new symptoms that he has. So, what do you think is going on now and how does your initial approach to joint pain

shift with his new symptoms? Absolutely. Um, so we know he has

underlying OA, but this is something else, right? I’m, you know, this presentation sounds uh different. um the

acute onset, the distribution of the joint pain, especially in an older adult

makes me think about late onset rheumatoid arthritis or polymyalgia

rheumatica even PMR crystal arthritis especially um you know if it’s episodic

uh could be on the differential in this case it sounds like it’s been pretty steady although acute onset um for the

last 2 to 3 months so I would say highest on my differential is late onset

RA and PMR and I think it’s really important to think about shoulder involvement of pain

and stiffness. PMR comes to mind um and in PMR polygomatica these patients can

also present with hand joint involvement that make it really hard to distinguish

between RA and PMR. um whenever PMR is on my differential, giant cellaritis has

to come right after. So I think that it’s important to start asking questions about headaches, visual loss,

um jaw claudication, scalp tenderness, and so really late onset RA, um you

know, we we often miss this diagnosis. I’ve had a few cases this year already

because we think of the biodal distribution but we really think this is a condition of younger adults. Um and so

we don’t recognize this late onset RA. Um however up to you know onethird of

rheumatoid arthritis patients have an onset of RA over the age of 60 or 65. So

that would be late onset and these patients um tend to have more acute

onset, more systemic features which you described. Uh they can have more PMR-

like symptoms. They can have large proximal joints. I really see a lot of the shoulder involvement. These folks

can be sergative meaning negative rheumatoid factor or anti-CCCP. They tend to have high ESR and CRP. So,

that’s where I would um I would lean towards Laura, late onset RA.

Yeah, that was a I mean, I knew older adults could could have it, but I didn’t realize that this late onset rheumatoid

arthritis, Laura, was like a a thing that had been described and that that this can be sergative and it has like a

little bit of a different presentation. So, um I’m glad we’re doing this show because I I learned something. I’ve

definitely seen it before. Can you give us any tips in primary care like how maybe we can recognize, you know, this

earlier because or or what about this one kind of jumps out at you that would make us think that this could be

something? Cuz there’s a lot of times where I see people and they’re stiff and they have a lot of joint complaints, but

I examine them and I’m not like if the joints are not overtly red and very swollen, I’m just like, uh, I don’t see

any inflammation. So can you tell us like what do you think people are missing before they get to you?

I think the biggest key is the acuity the acute onset. These these patients

tend to be quite miserable and usually the chronic inflammation when it’s missed for a long period of time it’ll

start accumulating. They may have some weight loss slightly higher u baseline

temperatures. really this unchecked chronic inflammation will take a toll on the patient and and really palpate the

shoulders um palpate very carefully for civitis in the MCPS in the wrists in the

elbows um check the inflammatory markers check for the rheumatoid factor and

anti-CCCP but um shoulder and hip girdle I think

it’s really important um to think immediately of PMR and potentially late

onset RA when you’re palpating the shoulders, what are you feeling for? Like I feel like I can I maybe I can determine

cineitis in the wrist and other joints, but the shoulder exam, you know, is notoriously challenging for a lot of

folks, but so when you’re just sort of feeling around there, what are you feeling for that might suggest that this is more late onset RA picture as opposed to a PMR or does does even help

differentiate in that way? So in a very severe case you’re going to feel warmth and there may be an eusion

kind of anteriorly especially you know as as you know especially in primary care shoulder is always multiffactorial

there’s so much going on in the shoulder um but in this case like you you may actually feel an eusion it may be warm

um but your shoulder exam might look very typical of a rotator

cuff as well but feel for warmth and and take the shirt off looking for an eusion.

Yeah, put them put them in a gown. Right. These are the patients that definitely need a gown. U Okay, so we talked a little bit about

assessments. Are there maneuvers? There’s always all these maneuvers with names that I never remember. Are we Do

we need to remember any maneuver names? Okay, it’s the worst. I don’t think maneuver names. I think

that one of the things as a rheatologist I see often is you know ex you know

examine the patient for the distribution of joint involvement and really document

where the civitis you know civitis is really palpating on the sides and above

and below the joint and then document that in the note because I usually see

uh referrals with a zero muscularkeeletal exam documented and so it’s just really helpful to know what

the distribution is and if there’s civitis present. So we’re not, you know, looking for bony hypertrophy. We’re

really looking for um sponginess in the most technical terms, sponginess, boggginess, red hot swollen where

they’re flinching as you palpate. These aren’t Paul Williams notes because he’s America’s primary care physician

and he he knows what he’s doing. He’s a he everyone know clubbing cinosis edema.

That’s my msk example. You’re welcome.

Okay. Uh, Leah, do we have more of the case here? Yeah. Yeah. Okay. So, we do an exam. Um,

so his vitals, his temperature is 99.8 Fahrenheit and he’s otherwise heically

stable. His joints. Okay. So, this you as the primary care doctor did a great

um msk exam. He’s got bogginess over the bilateral MCP and wrist joints with tenderness to palpation, pain on passive

and active range of motion. He’s got most severe pain when he’s trying to make a tight fist. His elbow and

shoulders are warm and tender to palpation with pain, limited range of motion, but no micro motion tenderness

or significant eusion appreciated. He has marked crepitus of his right knee with full active and passive range of

motion. Very mild joint line tenderness, bony enlargement, and no eusion. No

tenderness of hips, pelvic girdle or SI joints. He has no rashes. He’s got some cervical and inguinal lymph nodes. So

what are you thinking with the physical exam and how does that guide your workup? Do we do we get labs this time?

We we we definitely get labs this time, right? We definitely get labs this time. So I think the key here is having this

clinical suspicion for late onset RA and to refer early to rheumatology so we can

solidify the diagnosis and start appropriate treatment. The labs that are helpful to order, we will we can order

them, but it’s always helpful to have them I if you order them in primary care would be a rheumatoid factor

anti-itrolinated protein. I have to add we we really don’t need an ANA

unless there’s an underlying suspicion for lupus or another autoimmune disease. But you know there are some panels and I

think it’s the culture of the institution. Sometimes they just have a I think they a rheumatoid panel that

includes ANA, RF, CCP, ESRC, CRP, just order it all. Um, but I think we want to

discriminate here and just say this looks like an inflammatory arthritis like RA. Let’s get a CCP and RF.

Anti-CCCP is uh very specific, however, can be positive in smokers. So,

keep that in mind. If you’re worried about gout, get the uric acid. All of

our patients have an ESR and or a CRP. And then the other labs I’m looking for

really help guide my management and next steps. Those are chemistries. I’m looking for renal function, AS, ALT.

Later on, when I’m thinking about biologics, you know, I’m thinking about hepatitis B and C, corology is a

quantiferon, and so forth. And then if I if a primary care doctor really wants to

be um comprehensive, you can get X-rays of the affected joints, always get

bilateral films. But we will tend in rheumatology to get baseline uh plain

films of hands and feet mostly to um look for progression over time for um

erosive disease. Okay, great. So let me finish the rest of the case then we have a lot of

questions to ask you once you know all the data. So his labs, he’s got mild neurocyitic anemia, borderline

luccoytosis, that’s neutrfil predominant. His creatinine is at his baseline. Um he’s got CKD stage three.

CRP and ESR are elevated. His rheumatoid factor SSA and SSB are negative, but his

anti-CCCP is um slightly elevated. The HEP C and B corologies are negative.

Iron studies looks like anemia of chronic disease. And then you did get X-rays um of the hands, wrists, elbows,

and shoulders. And he’s got periarticular soft tissue swelling and ja articular osteopenia but no erosions

or joint space narrowing and no large eusions and costroinosis condroel condondroalinosis

um in the left shoulder but not the right. So, okay, we you already said we, you know, probably needed to put the

rheatology referral in with the labs. Um, but let’s talk about your approach to RA treatment. Like, what could the

primary care doctor kick off versus what needs to be left to that rheatology referral?

So, as far as I’m concerned, you’ve you’ve made my job much easier. They arrive to me with all the appropriate

labs, and your physical exam is is incredible. So, um, when they arrive to

me, I have pretty much everything I need. I think the question is in your system,

how quickly can your patient get to the rheatologist? So, I think access varies

across the country. And so, just keep that in mind. If you don’t have access to a rheatologist for three months,

happens six months even, um you could curbside your favorite rheatologist and ask what they would put the patient on.

But typically, these patients um are started on prednazone at some point, but really I

have everything I need. So I think the key message here is um refer as early as

possible so we can initiate disease modifying therapy because predinazone is

not disease modifying. And one one tip I don’t know Paul if you found this too but I I will typically like tell the

patient please make an appointment with a rheatologist and then I will once they have an name I will call that person say

hey this person’s seeing you in three months can I you know and then I will often get some collaboration and like

often they’ll offer to get them in sooner but also I can start something just based on like that conversation. So

uh that tends to work. I don’t know, Una, if if people do that do pull that move on you, but it it it usually works

for me. Yeah, I love that. And that also shows um kind of interdisciplinary

collaboration because we do like to communicate with the primary care doctors once they see us for RA. So,

that’s that’s a really nice um relationship that you have. So, uh let let’s talk about this a

little bit. um when when they’re going to be seeing you. Um how are you going to approach this case?

So this is an older adult and that’s you know a passion of mine managing older

patients with rheumatic disease. So I think this is the perfect opportunity to

talk about the 4 M the 5 M and how we might integrate that approach into the

management of uh late onset RA here. So I’m sure this audience is already aware

the four was proposed by the Institute of Healthcare Improvement. They include

mind, mobility, medications, and what matters most. These are a set of four

evidence-based elements of highquality care in older adults. And then

multicmplexity was added later um to create a consolidated framework known as

the geriatric 5Ms that helps ensure older adults receive the best care possible. Um they’re not harmed by care

and they’re satisfied with the care they receive. So I’m happy to walk through kind of the geriatric 5M’s approach as

it applies to this patient. we can be uh brief but I also want to

um kind of reference um a really nice series on aging. We

were invited to to publish in the Lancet rheumatology a series on aging and one

of the reviews focuses on integrating the five Ms in rheumatology. So that

article covers all of kind of what we’re going to talk about. Yeah, that’s great. And our audience

will remember we we did a COPD show where we talked about the the five Ms.

We did a a weight loss show where we talked about it and we did a dementia show where we talked about it. So they

they should know those. And I think it is a great way to to approach just the the older adults and especially if

there’s something complicated going on and and like this this patient that we’re presenting to you is an older

adult. He has multicmplexity. though I think it’s a good th this framework

makes a lot of sense in this case. Super. I’m happy to kind of just think through it briefly. Um I you you know I

usually start with multicmplexity. Um you know multimorbidity is defined as

two or more concurrent conditions and then multicmplexity layers on the kind

of complicated biocschosocial needs. And so really understanding our patients

rheumatoid arthritis in the context of other comorbid conditions is important

and I you know we recognize from the literature that patients with RA tend to have more comorbidities than patients

without RA and that increases with age. So in our case um this patient has

cardiac disease, chronic kidney disease, osteoarthritis and now RA and these all

can interact with each other and impact you know pain, mobility, potential mood,

social functioning. And so how you know how do you think through this? How do you break it down? And one approach is

to really ask about the pain and function. You know the patient has different types of pain. They have RA um

and OA. So asking about how this impacts and interferes with daily life. We

already touched on that earlier in in this um conversation. Are they able to

do their activities of daily living? Are they able to ambulate safely? Um I

really love the concept of life space mobility and individuals kind of multi-dimensional engagement with their

environment over time. So I like to understand where do they get around in the community and how I also ask about

psychosocial coorbidities. And I think as clinicians it’s incredibly important.

You know we all have our lane. You know I’m taking care of the RA

today. I’m taking care of the gout. But it’s so important to ask about depressive symptoms about anxiety about

PTSD about social isolation. Who lives with you? who lives around you. Um, I

tend to engage caregivers and family and friends. And this is all important because it helps with safety. Um, it

helps with medication adherence. It helps with mobility and ADLs. So, um, I

think that medic multicmplexity is a great place to start. And then after we

understand the chronic conditions, then I kind of ask, you know, what matters

most. That’s the second M I like to talk about with patients. Um, and I I think

about this um in the sense that the clinician brings medical expertise and

the patient brings expertise in themselves and what’s important to them. And so what I love most about what I do

is I get to merge that and I get to over time get to know what matters most to

them and what are their priorities and how that shifts over time and how I might modify my management approach to

align with their priorities. So if if the audience is interested, we have a a a really nice section on what matters

most in that Lancet rheumatology article. I don’t have to go into great detail how to elicit what matters most.

Um there really isn’t just one way to do that. Um but I would say ask the patient. Don’t make assumptions.

If possible, engage the caregivers, engage the family. I really like that framing of like

you’re the expert in the disease, they’re the expert in themselves. That’s a really nice framing. Yeah. And I think it’s important to

remember that because sometimes we come to the table like memorizing our clinical practice guidelines and forget

that it has to fit into the context of uh you know the the social situation um

the medical situation of the patient we have in front of us. So it’s really working together on that.

What do what do you go for after? So you do multicmplexity, what matters most and how do you think through the rest of the

M’s? I usually think about medications because it goes along with multicomplexity. People tend to

accumulate meds as they accumulate multiple chronic conditions and so understanding polyarm pharmacy. Polyfarm

pharmacy defined as I think five or more medications and we do know that our patients in with

RA tend to have more polyfarm pharmacy. Um so I believe the prevalence of

polyfarm pharmacy among patients with RA over the age of 65 is 50%. Um, and so I do suggest looking at

beer’s criteria. Beer’s criteria is very useful to highlight some potentially

inappropriate medications in older adults and kind of highlights drug disease, drug drug interactions. And I

will say that in rheumats with rheumatoid arthritis, most of them have been on NSAIDs, opioids,

glucocorticoids, um, anti-dopressants. And so there’s a lot of potential harm here. And so I

think it’s it’s important to acknowledge that as we start new treatments. But I think it’s also critical to be mindful

not to undertreat older adults. And I think that’s happening more and more.

One of my colleagues, Dr. Gi. Hali at University of Michigan is an expert on

optimizing medication use in older adults and she um some of her work

highlights that up to 70% of patients with late onset RA have not

been initiated on appropriate treatment after the first 12 months and that’s astounding.

Yeah. Why do you think that is? Do you think it’s agism or well I guess you know uncreat you know and I I don’t

think we fully understand and I think that a lot of um my colleagues and certainly we don’t want to do harm but I

wonder if we’re making assumptions about our older patients maybe they we have a gestalt we feel they’re frail and we

feel the biologics will cause more harm but we actually know that biologics are very safe and very effective and so I

think we’re trying to um you know uncover the reasons for this. Um, but I think it’s important to just be aware,

do we have biases when it comes to managing older adults and are we undertreating them?

So, the the next M that I usually think about is the mind. Um, and here I think

again about depressive symptoms. I think of delirium, cognitive impairment, and

dementia. And again, I just want to refer the audience to another review in the Lancet rheumatology series focused

on cognition. And here we discuss some of the modifiable risk factors as well

as you know currently unknown risk factors with cognition but we do know that um there appears to be a higher

risk of all cause dementia in RA versus nonr even after adjusting for age sex

education cardiovascular disease risk factors and events. So I think it’s

important to ask ourselves, you know, how does chronic inflammation impact the

might? Wow. I didn’t know about that association. That’s really interesting. Is this the inflammaging that we’ve

heard of this? Is that what what that term is? Absolutely. I think it contributes here. I think it contributes. And I uh think

that the the more aggressive those safely we manage the inflammation the

better our patients do in all aspects. Um so as a rheumatologist I usually get a lot of push back. You know I don’t

want to manage the cognition but I think it’s really important to just ask about it and to rule out mimics of cog of

dementia and then refer as appropriate. Can I just ask Paul what do you think about the term inflammaging Paul? I mean

it’s it’s fine. I I was just it’s I I’m thinking there was a lecture in medical

school and I I will never forget the line where I think I think even a pathologist but they said that life is basically a chronic progressive

inflammatory process that ends in death which I always appreciated. Not grim at all. Thank you.

It is what it is. Sorry not mean to interrupt that nonse. is a fine term to answer your question, man. But we’re trying to reverse it and now

we have many targets and we we can we can at least attack the inflammatory

part of inflammaging. Well, let’s so let’s talk about uh because I know we’re running towards the

end of our time. Let’s talk a little bit about what the treatment approach would be like. So, you mentioned a lot of

people are going to throw predinazone at somebody that has a rheumatoid arthritis flare. So if they if we were sending

them to you, we might start what is it 15 of predinazone or what what dose

might we start and then send them to you and what might you start that’s a disease modifying drug.

Exactly. Good questions and it all depends also on their size. You know what their BMI is, do they have existing

osteoporosis? What are their other coorbidities as far as um diabetes? Um, so that’s those are

those those all come into play when I think about the dose of prennazone. Sometimes patients can get by with 10

milligrams. Other times they need 20 milligrams. I hope not 20 milligs for a long period of time. When they come to

me, if we confirm the diagnosis, if they have normal renal function, I

would say that my first line is typically methtoresate. With this patient’s renal function, I

would avoid methtoresate. And you know we it it really depends on their comfort level. For example um and

this is a conversation we talk about demar’s methtoate plaquinol

sulfocalazine leaflunomide and we talk about that approach where we often use triple therapy or we can talk about

biologics and it what boils down to typically is their comfort level with subcutaneous injections or infusions. We

do have some other molecules including Jack inhibitors. That’s our only oral agent right now, but we we definitely

need to uh take a look at other coorbidities um in that individual patient.

Yeah. So probably in primary care I don’t know that I would feel I mean hydroxychloricquin sure I’ve started

methtoresate on people. Lefthlamite I’m not as familiar with, but th those are I

wouldn’t expect the primary care is going to even be able to get approved any of the biologics or or Jack um Jack

the oral what did you say is it Jack 2 inhibitor or jack inhibitor jack inhibitor yeah we have various

jacks send them to us that’s we we we love these patients and we love having these

conversations and we will be following them closely you know every 3 months until we get their disease under

control. So, um, this is the so-called treat to target that that they talk about in the when

you’re reading the literature, they keep mentioning treat to target. That’s exactly right. We like to have a kind of aggressive initiation, treat to

target. And we’re really focused on disease activity measures. My emphasis

in older adults is not just the swollen, tender, joint count, and the ESRCP, but

I actually treat to function, too. So, I think that’s another take-home message.

We really want to be focusing on what matters most to the patients and are we

achieving the functional goals that they they want to achieve.

I I do I want to make sure I didn’t miss something because sometimes I I’m not good at multitasking, but I did we touch

on mobility? I think I would like to hear more about that if if we’ve not covered if we’ve not covered it already.

Absolutely. So mobility I would say is one of the most important of the Ms. And

here I think about falls or fracture risk and fall prevention. Um in this

category I also think about frailty. I want the audience to think about um body

composition factors including obesity, sarcopenia and osteoporosis.

And I think one of the key messages is to ask about falls. And so I usually use

the CDC questions. Have you fallen in the past year? or do you feel unsteady

when standing or walking? Are you worried about falling? And then really focusing on education, strength,

balance, training, and physical activity. And that kind of ties into earlier on in our conversation.

Great. Yeah, I love the 5M approach. I feel like you can apply it to so many chronic diseases. Um, should we are we

ready to wrap up on Mr. Carter and get our takeaway points? Okay, so Mr. Carter

presented to rheatology. He got in a few months later. He was on prennazone 20 milligrams. He said that um he seemed it

seemed to his doctors that he was good enough on the prennazone. Um and they

they didn’t mention anything more aggressive or any additional treatments beyond prennazone. So the rheatologist

adds on subq weekly biologic injections with tannercept. And in three months he reports he’s virtually symptom free and

weaned off of predinazone. and then his three-month follow-up visit. He’s thrilled to tell you he’s leaving at the

end of his week, end of the week for his annual fishing trip with his daughter and granddaughter. So, what do you think

of that case? Sounds pretty typical based on what you said. Um, yeah. No, this is success. This is

beautiful. So, the patient has started on um one of our TNF inhibitors and the inflammation melts away. Typically, we

see improvement by 3 months or so. Um if not we can cycle and try other

medications. But I think the key message here is not to assume that their

function, their pain, their swelling is good enough just based on their age and to really ask them. And I think that

goes towards your your previous question about agism. And I think that’s where as a field, as a whole professional like

kind of society in rheumatology, primary care and so forth, we really want to

check our biases. We don’t think of agism like we do the other isms. I think it’s under recognized and I think

sometimes we truly undertreat our older adults and we just don’t want to assume

that their current function is good enough. we should ask them. And I I would love if you could link to some of

our recent agism articles where we talk about the health care professionals perspective, but we also have one

article that weaves in the patient voice about um what agism looks like from his

perspective. Great. And before we get to take-home points, we should mention that Paul was this guy’s PCP. So, he made sure he was all

vaccinated before he got his uh his biologic agent. and he also is

aggressively managing cardiac risk factors and all the other good primary care stuff. We’ve talked about that on

prior uh episodes where we talked about RA as well. So Paul, you’re just the best.

Yeah, thanks Matt. I agree. Absolutely. Uh Una, can you give the audience some

take take-home points from what we discussed tonight that you really want them to remember?

Sure. So we first talked about osteoarthritis. So really focus on a detailed history

and physical maybe less reliance on the um imaging or the x-rays. I would say

that we’re seeing increased numbers of older adults with rheumatic disease especially RA. Keep that on your radar

even in older age and uh consider using the geriatric 5M as an approach to

improve age friendly care in the context of RA. when it comes to um what matters

most um I think a key message is don’t make assumptions you know really check

out your own biases and I think it’s important um to um identify

collaborators and interdisciplinary team members that can help us address the

multicmplexity in our older adults. So I think those are the main points.

We can’t thank you enough for all your time. I I got some really great tips from this tonight. I know definitely

some things that will change my practice. So, thank you so much. My pleasure. Thanks for inviting me.

[Music] This has been another episode of the curbsiders, bringing you a little knowledge food for your brain hole.

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I wanted to give a special thanks to our writer and producers for this episode,

Leah Wit, MD, and Lee Young, MD, and to our whole curbsiders team. Our technical

production is done by the team at Podpace. Elizabeth Proto does our social media. Jen Wad runs our Patreon. Chris

the Chu Manchu moderates our Discord. Steuart Bighgam composed our theme music. And with all that, until next time, I’ve been Dr. Matthew Frank Wad.

And I’ve been Dr. Leoit. And as always, our main Dr. Paul Nelson Williams. Thank you and goodbye.

[Music] [Applause]

Hey,