Rheumatoid Arthritis and the Aging Process

Aging is simply the process of growing older. Old age is not a disease. It is living at an older age. Unfortunately, too many people -- physicians included -- think of aging as a disease and, therefore, do not focus adequately on true disease - the things that you can do something about.

Thus, although no one can stop you from growing older, doctors can effectively treat rheumatoid arthritis, as well as diseases that are more common as we age, such as osteoarthritis, osteoporosis, and problems of thethyroid and nervous system.

So do not slough off your problems as "old age," and do not put up with a doctor who does so. That's doing yourself a great disservice.

Nonetheless, some diseases do occur with a greater frequency in older people. And there may be synergistic problems when you already have RA. So the real questions to address here are how does aging affect RA, how does RA and its treatment affect aging, and what can be done about it?

Rheumatoid arthritis is an inflammatory disease. Inflammation characteristically produces heat, pain, redness, and swelling. It involves certain kinds of cells in the body and is distinct from non-inflammatory diseases. As a direct result of the inflammation, RA destroys cartilage and bone. Besides affecting peripheral joints in the arms and legs, it can affect the neck, but the rest of the spine is not involved. Unfortunately, RA also can increase your risk of osteoporosis because destruction around the joints washes calcium out of the bone. In this discussion, it should be kept in mind that while an inflammatory disease must be treated with anti-inflammatory measures, other disorders common in aging that do not involve inflammation should not be treated with anti-inflammatory measures.

Osteoarthritis (OA) is not an inflammatory disease. Although some people may get pain, swelling and redness only at the outset of osteoarthritis arthritis, in general, the joints are usually not hot. They may swell somewhat, but they tend to get knotty more than anything else. There is destruction of cartilage but, except in the advanced stages, usually no bone destruction. By age 60, everyone has osteoarthritis, although it may not cause them any problems. Why do some people get it earlier than others? Any kind of joint problem that has already damaged the joint can accelerate the OA process. So people who have RA have joints that have been set up for OA. Further, OA may affect the entire spine.

Spinal stenosis may occur due to cartilage destruction. This may cause pressure on the spinal cord and nerve roots. The resulting pain and weakness may lead to problems with movement anywhere below the area of damage. So people may have pain in their legs and feet when walking or even when resting in bed, which can be very disabling. Although spinal stenosis primarily develops due to OA, the neck involvement of RA may also cause it.

Osteoporosis is a thinning of bone that can lead to fractures. In addition to the impact of RA in increasing osteoporosis, people with RA have the same osteoporosis risks as the rest of the population as we age. Women are at special risk due to a decline in estrogen after menopause. Decreased weight bearing due to inadequate exercise also contributes to osteoporosis. So if you cannot bear weight and are not walking enough due to RA, you have a further accelerated osteoporosis risk. In addition, some drugs used to treat RA can accelerate osteoporosis; in particular, steroids (prednisone) are one of the most potent agents leading to osteoporotic fractures - one of the reasons why we use them as little as possible.

Muscle strength often declines with aging, and factors related to RA, OA, and osteoporosis can make it worse. For example, if RA impairs your ability to be active, your muscles will get weaker and smaller. If you develop a fracture due to osteoporosis, again, your inactivity causes muscles to atrophy. Certain medications used for RA, again including steroids but also pain medications (opiates such as codeine) can cause muscle weakness and atrophy.

When muscle atrophy occurs, exercise focusing on very small muscle groups can have a tremendous impact on stabilizing your ability to walk. Particularly important are the quadriceps muscles in the front of the thigh. They are the main muscles that stabilize the knee, but they can atrophy quickly. If you sit around for even a few weeks, you may have trouble with standing, walking, balance, and pain. This common problem in both RA and OA cannot be solved just by walking. You have to do exercise focused on the quadriceps. For example, when seated, raise your calf until the leg is straight in front of you, holdfor a count of five, and slowly lower. It's simple but effective. Other muscles also have to be strengthened individually. So physical therapy as a means of dealing with both RA and OA can be very valuable.

Thyroid disease also occurs more commonly in older people, contributing to osteoporosis and muscle weakness. Hypothyroidism (low thyroid) is a particular problem as we age. It causes low energy, anemia, and depression. Hyperthyroidism (high thyroid levels) also can occur, causing you to be jittery, lose weight, and become osteoporotic. But thyroid disease is easily treatable today.

Medications can present special problems as we age because our kidneys and livers become a less adept at clearing many things from our bodies. So older people may need lower than standard doses of many medications. Some medications should be used rarely, if ever, by older people. Often misused are non-steroidal anti-inflammatory drugs (NSAIDs such as Advil and Motrin) that pose a greater risk of ulcers as you age and have other health problems. Even the new COX-2s (Celebrex and Vioxx), although they are less likely to produce ulcers, still cause just as much kidney problems, fluid retention, abdominal pain and nausea. The only time to use NSAIDs is when you do not have an alternative. So, for example, you should not treat knee pain due to quadriceps weakness with NSAIDs; you should treat it by building muscle strength.

So why are NSAIDs so widely used to treat OA? Because they work to reduce pain and swelling. Particularly in the early phase of OA when swelling may occur, they may work better than simple painkillers such as acetaminophen (Tylenol). But, in a recent study, two groups of patients with OA of the hip were followed: half took acetaminophen, physical therapy, and a daily walking regimen; the other half took NSAIDS. When they were compared to discern who was more likely to eventually need hip replacement surgery due to pain and disability, those who did the exercise did as well or better than those who took NSAIDs.

This emphasizes an earlier point: a non-inflammatory process should not be treated with anti-inflammatory drugs. If you are treating RA inflammation, then you need something more potent than NSAIDs - something like methotrexate or Enbrel. But if the inflammation has quieted and you simply have a knee troubled by OA, then other options should be considered. As quick fixes, NSAIDs are okay. But as chronic long-term therapy, they should be questioned because they produce too many side effects, especially in older people.

Balance problems are another common issue as we age. When they cause falls, recuperation can decrease muscle strength and increase osteoporosis risk. But declining muscle strength alone - due to arthritis or drugs taken for it - also may impair balance. In addition, balance difficulty may be due to problems with one or more of our senses.

• Vision difficulty, due to cataracts or macular degeneration, can lead to a vicious cycle. If you do not go out and walk because of vision problems, muscles atrophy. When you finally get your eyes fixed, then you cannot walk because of muscle atrophy and major rehabilitation is needed. So maintaining sight as best you can is important for fall prevention and mobility.
• Hearing is an important way we keep in touch with our environment and has a major impact on balance and walking. People who do not hear do not get cues about things that may be coming at them and that they would normally, at a subconscious level, avoid.
• Touch is vital for normal ambulation. For example, we feel the floor beneath our feet as we step down. So if you have problems with diabetes, spinal stenosis, or other conditions that cause numbness, you may miss that aspect of touch.
• Position sense (technically called proprioception) is the way we unconsciously know where our bodies are in space, for example, whether your foot is down or up, whether your finger is bent or curved. Again, diabetes, spinal stenosis, or medications may impair that sense.
• Pain medications, while dulling pain, can also dull the same senses we need for balance.

When problems with these senses impair balance, people walk with their legs apart in a broad-based gait. When you have sensation problems, which increase your risk of falls, that's the safest way to walk.

Sleep disturbance is also more common as we get older. Although some people need less sleep as they age, do not assume that impaired sleep is acceptable. Difficulty falling asleep, waking early, or awaking frequently during the night - whether due to bladder problems, pain, depression, or other causes - should be evaluated and their underlying cause treated. (Please remember that depression is a treatable organic illness that should be treated as seriously as RA.)

Sleeping pills alone are not enough. In fact, the combination of pain medications and the benzodiazepine class of sleep medications (Valium, Restoril and Xanax) are notorious for increasing the risk of falling. They should be used as little as possible. But, again, sleep problems may be intertwined with RA. For example, if you are not exposed to light during the day because you stay indoors due to RA disability, you do not get enough light and can develop sleep problems. And even healthy people whose sleep is disturbed develop diffuse pain similar to fibromyalgia.

Weight can play a critical role in well-being as you age, as well as to arthritis. The less weight you are carrying, the easier it is for your skeleton and muscles to hold you up and the less the stress on inflamed joints. Overweight can play a role in the development of OA, as well as heart disease and diabetes. Yet all three can be intimately interwoven. For example, if arthritis impairs your ability to get out and walk, you decondition and do not metabolize cholesterol well, upping your heart disease risk. Anti-inflammatory drugs also may increase cholesterol. So when we decrease joint destruction due to RA, we can cut your risk of heart disease by multiple mechanisms.

Social and Environmental Issues refer to problems you may have taking care of yourself, having access to food, medications, and your physician. These may occur due to limited incomes after retirement or the absence of an extended family as we age, when our social networks tend to fall apart. Some of these issues may be more difficult to solve than medical problems, but they can be addressed.

The bottom line is, yes, RA and its treatment can affect the common illnesses of aging, and vice versa. But all of these problems can and should be treated. Years ago, it was assumed that when you got old you would either be in bed or a wheelchair. Today, except in unusual circumstances, we know how to assure that you can walk and be relatively pain free. Your aging will be a very different experience from your grandparents - as long as you and your physician recognize all of the issues and deal with them effectively.

And if you're looking for a common thread, notice the emphasis on getting out and walking every day. If you cannot do that, all sorts of problems may arise. So if you cannot get out and walk, talk with your doctor.

About the Living with RA Workshop at HSS