Are Anxiety, Depression Cause or Consequence of Frailty in Elderly with Rheumatoid Arthritis?

Marloes van Onna, MD, PhD

A mixed qualitative-quantitative study to characterize frailty in patients with rheumatoid arthritis finds that psychosocial factors, including anxiety and depression, could be more important determinants for developing frailty than increasing age.

"We indeed found comparable rates of frailty (across age groups) when using the Groningen Frailty Indicator (GFI), a questionnaire that heavily relies on the psychosocial effects of frailty such as anxiety, loneliness and depressive feelings," the study principle investigator Marloes van Onna, MD, PhD, Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands told HCPLive.

"It might be possible that the results for frailty measures that more rely on physical effects, such as muscle strength, reduced walking speed and weight loss, do show an age-related effect.We will look into this during future research projects," she added.

van Onna and colleagues explain that while frailty is often defined as an age-associated decline in physiologic reserve and function across multi-organ systems, it can also be measured on a frailty index such as the GFI, and defined as cumulative deficits identified in a comprehensive geriatric assessment.

The investigators undertook two cross-sectional surveys and qualitative follow-up with 90 patients with rheumatoid arthritis in 3 age groups (55-64, 65-74, and ≥75years of age) who regularly visited an outpatient rheumatology clinic, to determine, in the first, whether the occurrence of frailty, measured by the GFI, increased with age; and in the second, to ascertain which of the measured conditions, such as loneliness, contributed to frailty.

In the comparison of frail to non-frail patients, as measured with the GFI, feelings of emptiness were reported in 63.2% vs 3.8%; missing the presence of people around, 65.8% vs 7.7%; feelings of loneliness, 55.3% vs 0%; depression, 73.7% vs 11.5%; and anxiety, 57.9% vs 15.4%.The percentages were similar across age groups.

With the first survey revealing that the distinction between frail and non-frail patients was "almost exclusively" determined by psychosocial factors, the investigators explored the contribution of particular factors by administering several validated questionnaires to the available sub-group (32 [36%]), as well as conducting semi-structured interviews with 10 of the participants.

More frail patients were found to have signs of an anxiety disorder on the Hospital Anxiety and Depression Scale (HADS); and during the interviews, more frail patients reported gloomy feelings, although none confirmed depression or anxiety.

As the investigators noted that rheumatoid arthritis (RA) "might be an extra complicating factor in the interplay between poor psychosocial health and frailty," HCPLive asked van Onna whether the question could be better ascertained in a population without the condition.

"It is extremely difficult to disentangle the causal conundrum between psychosocial health, multimorbidity and frailty," van Onna responded. "Almost all patients who suffer from frailty also suffer from multimorbidity, including RA.A first step to elucidate the relation between psychosocial factors and frailty might be to investigate psychosocial health in a sample of frail individuals, RA and non-RA, whose frailty was confirmed during a comprehensive geriatric assessment."

To the question of the relative utility of measures focusing on joint pain/function or more comprehensive assessments in managing patients with RA, van Onna responded that the latter is "the gold standard."

"Single-disease oriented care organization is often inefficient in elderly patients with frailty and multicomorbidity, and becomes burdensome for patients when physicians only take one complaint into account," van Onna said. "Elderly patients with rheumatoid arthritis and frailty often have health goals that are not necessarily related to their control of rheumatoid arthritis."

"A more holistic or goal-directed approach might in these cases be preferred," van Onna suggested. "Asking patients about their specific health-related goals, including psychosocial health-related goals, and not only focusing on RA disease control, might ultimately improve the overall outcome of these patients."

The study, "Frailty in Relation to Psycho-social Factors in Elderly Patients with Rheumatoid Arthritis: A Cross-Sectional Mixed Qualitiative-Quantitative Study," was published online in the International Journal of Rheumatic Diseases.