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

## TL;DR

Late-onset rheumatoid arthritis (LORA) in people over 65 has distinct features and requires personalized treatment strategies to manage disease activity and aging-related conditions.

## Contribution

This paper provides a comprehensive overview of LORA's unique clinical features, comorbidities, and tailored therapeutic approaches compared to younger-onset rheumatoid arthritis.

## Key findings

- LORA is characterized by acute onset, higher disease activity, and less autoantibody presence compared to younger-onset RA.
- Elderly LORA patients often have comorbidities and polypharmacy, requiring individualized treatment to prevent geriatric syndromes.
- Aggressive treatment is suitable for non-frail patients, while frail patients need strategies to avoid worsening geriatric conditions.

## Abstract

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.

The main features of late‐onset rheumatoid arthritis (LORA), manifesting after age 65, are acute onset, higher disease activity, systemic involvement, and less presence of autoantibodies. Management requires individualized strategies, balancing aggressive treat‐to‐target therapy in robust patients with frailty‐focused approaches to prevent geriatric syndromes, considering comorbidities and polypharmacy.