Insights Into Late-Onset Rheumatoid Arthritis (LORA): Characteristics (Clinical and Imaging), Comorbidities, and Therapeutic Targets

Late-onset rheumatoid arthritis (LORA) is defined as rheumatoid arthritis (RA) manifesting after the age of 65 years, although the terminology remains somewhat ambiguous. With the advent of a super-aging society and extended life expectancies, a significant increase in the incidence of LORA is anticipated. In comparison to young-onset RA (YORA), LORA is predominantly characterized by a higher incidence of acute onset, augmented disease activity and constitutional symptoms, a propensity for systemic manifestations, increased erythrocyte sedimentation rate at disease onset, reduced seropositivity, a predilection for involvement of large and proximal joints with symptoms resembling polymyalgia rheumatica, a higher frequency of erosive disease, and a more evenly distributed gender ratio. Elderly individuals, particularly those with multimorbidity and on multiple medications (polypharmacy), are at an elevated risk of developing geriatric syndromes, including sarcopenia and frailty. The response to TNF inhibitors in elderly individuals with RA is generally comparable to that in younger patients, though it may be slightly diminished. The duration of the disease appears to have a more pronounced impact on outcomes than the patient's age. For the management of LORA, it is critical to adopt a patient-specific approach. Non-frail LORA patients who are otherwise aging healthily should receive aggressive treat-to-target management. Conversely, in pre-frail and frail patients, the therapeutic focus should be on averting the progression of irreversible geriatric conditions. The confluence of multimorbidity, polypharmacy, and geriatric syndromes in this patient population necessitates a tailored therapeutic approach to maintain patient autonomy and functional status.