# Epistemic Injustice in Rheumatoid Arthritis Care: A Narrative Review of Invisible Suffering, Ageism, and Treatment Delay

## TL;DR

This paper explores how ageism and social biases in healthcare lead to delayed treatment for older rheumatoid arthritis patients.

## Contribution

It reframes treatment delay in rheumatoid arthritis as an epistemic injustice issue, highlighting testimonial and hermeneutical injustice in clinical settings.

## Key findings

- Patient reports of pain and fatigue are often discounted when objective markers are normal, reflecting testimonial injustice.
- Older and socially isolated patients lack frameworks to interpret symptoms as pathological, leading to hermeneutical injustice.
- Epistemic injustice contributes to treatment delays before and after diagnosis, beyond structural or biomedical factors.

## Abstract

Despite advances in disease-modifying therapies and treat-to-target strategies, many patients with rheumatoid arthritis (RA) continue to experience persistent pain, fatigue, and functional impairment. These symptoms are particularly common among older adults and are frequently under-recognized in clinical practice. This study examines RA care through the lens of epistemic injustice to explore how patients’ experiential knowledge is interpreted, valued, or discounted, and how these processes contribute to treatment delay in aging societies. We conducted a narrative review of peer-reviewed literature addressing patient experiences, diagnostic and treatment delays, aging-related factors, and epistemic concepts relevant to RA care. Publications were identified through targeted database searches and citation tracking across rheumatology, social medicine, and medical ethics. Studies were examined conceptually to identify patterns of testimonial and hermeneutical injustice operating across the RA care continuum. Across the included literature, patients’ reports of pain, fatigue, and functional decline were frequently afforded reduced credibility when objective inflammatory markers appeared controlled, reflecting testimonial injustice. Hermeneutical injustice was evident when patients, particularly older and socially isolated individuals, lacked interpretive frameworks to recognize symptoms as pathological rather than age-related. These intersecting epistemic failures operated both before and after diagnosis, contributing to delayed help-seeking, delayed referral, and delayed treatment adjustment despite ongoing suffering. Treatment delay in RA cannot be fully explained by structural or biomedical factors alone. Epistemic injustice plays a critical role in shaping symptom interpretation and clinical decision-making, particularly in older adults. Addressing these epistemic dimensions by integrating patient testimony and patient-reported outcomes more meaningfully into care may promote timelier, more equitable, and more responsive RA management in aging populations. This review uniquely reframes treatment delay in RA as an epistemic problem, demonstrating how ageism and social isolation systematically distort symptom interpretation beyond structural or biomedical explanations.