#493 Joint Pain in Older Adults with Dr. Una Makris

July 28, 2025 | By Leah Witt

Audio

Video

Transcript available via YouTube

An age-friendly approach to arthralgias 

Attack arthralgias with ease! Learn how to evaluate and manage common joint complaints in older adults. We’re joined by Dr Una Makris, @unamakris.bsky.social (UT Southwestern).

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Show Segments

• Intro
• Case 1 from Kashlak
• General approach to joint pain in older adults
• Diagnosing osteoarthritis
• Management of osteoarthritis in older adults
  • Non-pharmacological interventions
  • Pharmacological interventions: topicals, orals, injectables
  • When to refer for joint replacement
• Case 2 from Kashlak
• Diagnosis of Late onset rheumatoid arthritis (LORA)
  • Differential Diagnosis and Distinguishing features
  • Lab work/Imaging
  • When to refer to rheumatology
• Approach to managing LORA
  • The 5Ms framework
  • Initial treatment with glucocorticoids
  • Ageism as a driver of undertreatment in older adults
  • Treating to target

• Key takeaways 
• Outro 

Credits

• Producers, Writers and Show Notes: Joseph (Lee) Young, MD, Leah Witt, MD, Rachel Miller, MD
• Cover Art and Infographic: Leah Witt, MD
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Reviewer: Emi Okamoto, MD
• Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
• Technical Production: PodPaste
• Guest: Dr. Una Makris

Disclosures

Dr. Makris reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Joint Pain in Older Adults Pearls

1. Joint pain (arthralgia) in older adults is caused by many types of acute or chronic diseases of the joints (arthritis). Osteoarthritis and rheumatoid arthritis are two of the most common types of arthritis, but there are many others (not discussed in depth in this episode!).
2. Osteoarthritis is a clinical diagnosis, so focus on taking a thorough history and physical and don’t rely on unnecessary imaging. 
3. When managing OA in older adults, focus on establishing functional goals and develop a multi-modal “menu of options” that includes behavioral interventions like physical activity, nutritional counseling and weight loss. When choosing  pharmacological interventions, be mindful of the risk profiles of different medications in older adults.  
4. The diagnosis of late-onset rheumatoid arthritis (LORA) is often delayed, as is initiation of appropriate treatment with DMARDs. Know when to suspect it and when to refer.  
5. Prednisone is not disease-modifying in LORA and carries significant risk of adverse effects, especially in older adults. Traditional DMARDs and biologics are both safe and effective in older adults. 
6. Try incorporating the 5Ms framework to develop treatment strategies that align with patient priorities.

Ageism can influence assumptions about patient goals, priorities and expectations, which can in turn shape clinical decision making. 

Joint Pain in Older Adults

General Approach to Joint Pain in Older Adults

History is key

• symptom duration (acute vs subacute vs chronic vs acute on chronic)
• onset (abrupt vs episodic vs gradual)
• inciting events (history of trauma—recent or remote—or overuse)
• number (mono-, oligo- or poly-) and distribution of joints involved (symmetric vs asymmetric; small, medium, large joints). Specific patterns of involvement point to different etiologies (e.g. metacarpalphalangeal [MCPs] and proximal interphalangeal [PIPs] should make you think rheumatoid arthritis [RA], whereas distal interphalangeal [DIPs] should raise suspicion for psoriatic arthritis or erosive osteoarthritis[OA]).

For most patients, and especially older adults, multiple sites and types of pain is the norm. Remember that multiple processes can be happening at the same time, e.g. concurrent OA and RA, or systemic lupus erythematosus (SLE) and fibromyalgia. Teasing out the different underlying etiologies is essential to determining best approaches to treatment, as is understanding that there are distinct pain mechanisms in different disease processes (e.g. nociceptive pain in OA and RA vs nociplastic pain in fibromyalgia).

Assessing pain interference is more important than solely quantifying pain severity

When trying to understand symptom burden, Dr. Makris focuses on understanding functional impairment, such as difficulty performing activities of daily living (ADLs) or hobbies (rather than asking patients to rate their pain severity from 1-10). Pain that interferes with daily function is more likely to result in negative outcomes and disability, also termed high impact chronic pain (Dahlhamer 2018, Pain Management Collaboratory). Emphasizing function also provides a frame for establishing treatment goals and expectations, as discussed later.

Diagnosing Osteoarthritis

OA is a clinical diagnosis!

A thorough history and physical exam are all you need to diagnose OA. In our case from Kashlak, the presentation of acute on chronic pain in a commonly affected joint following an inciting event in a patient with at least one risk factor immediately raises suspicion for OA (Katz et al, JAMA. 2021).

Most commonly affected joints:  

–    Large weight bearing: knees, hips and spine (lower and upper)

–    Fingers (PIP and DIP), hands—esp. base of the thumb—and wrists

–    Sites of prior joint injury (post-traumatic OA)

Important risk factors:

–    older age

–    female sex

–    obesity

–    inactivity/sedentary lifestyle

–    occupations involving repetitive joint loading 

–    history of injury/trauma

Supporting aspects of history:

–    pain that worsens throughout the day and with use, improves with rest

–    joint stiffness lasting less than 30 minutes

–    absence of accompanying symptoms

Key physical exam findings:

–    joint line tenderness

–    bony hypertrophy

–    for knee OA, varus (bow-legged) deformity and quadriceps atrophy

–    crepitus may be present but has less diagnostic utility

Joint swelling/effusion and warmth, particularly during acute exacerbations, can be present, but marked warmth and erythema should raise suspicion for other diagnoses including crystalline (i.e. gout or CPPD) or septic arthritis, especially in patients with micromotion tenderness and/or constitutional symptoms like fever.   

Imaging and Labs?

Imaging is not required to diagnose OA. In fact, radiographic findings often do not correlate with clinical disease. Imaging may be indicated when clinical changes or features introduce diagnostic uncertainty, or for purposes of surgical planning. Similarly, diagnosing OA does not require lab work, though it may be indicated when other etiologies are on the differential.

Managing OA in Older Adults

Start with non-pharmacological interventions

In concurrence with the American College of Physicians and CDC Clinical Practice Guidelines for managing chronic pain, Dr. Makris focuses initial management on behavioral and psychosocial interventions. Evidence-based, non-pharmacological strategies include physical therapy, exercise programs, mind-body practices (like tai chi and yoga), and nutritional counseling to promote weight loss in patients with obesity.

Patient education is essential to setting and achieving treatment goals but is often underemphasized. Dr. Makris avoids phrasing like “bone on bone” or “wear and tear” as these can inadvertently deter patients from engaging in physical activity, thereby worsening the cycle of functional impairment and symptom burden. Instead, she describes a chronic “wear and repair” process and reframes the conversation around achieving functional goals rather than focusing solely on pain management. Setting personal functional goals also helps tailor exercise programs to individual patients. This involves finding activities that are safe, accessible and readily integrated into routines.     

Pharmacological Interventions

Topical treatments are first-line. Dr. Makris likes to start with menthol-camphor or capsaicin and quickly move to topical diclofenac as a next step. Topical diclofenac has a better safety profile than oral NSAIDs due to lower systemic absorption. This is especially important in older adults who are more likely to have contraindications to systemic NSAIDs (e.g. kidney and/or cardiovascular disease, history of GI bleed; drug-drug interactions).

Dr. Makris does not typically recommend naturopathic/supplements such as turmeric, chondroitin or glucosamine given the absence of quality evidence supporting these and a lack of regulation (Vasiliadis et al 2017, Onakpoya 2017). For patients already taking these, she asks whether they perceive any benefits, whether they can easily afford to continue taking them, and whether they are experiencing any adverse effects.    

When oral pain medications are needed, Dr. Makris prefers acetaminophen in her older adult patients, recognizing that evidence suggests that it is not as effective as NSAIDs for treating OA-related pain (Leopoldino et al 2019) . For the aforementioned reasons, she avoids oral NSAIDs, however, recognizes that many older adults are safely taking these medications for either short-term treatment or as needed relief. Similarly, opioids should not be prescribed for OA, though many older patients with OA will have been prescribed NSAIDs and/or opioids which can be a source of tension when managing these patients.  The key to managing patients on potentially harmful medications for OA (NSAIDs and opioids)is to ask at each visit about functional improvements or status (sometimes maintaining status quo is ok), any adverse events, and try to maintain the lowest effective/ safe dose.

Intraarticular corticosteroid injections have mixed evidence but can offer short-term relief for many patients who often don’t have other options. There is some evidence suggesting potential adverse outcomes in patients who undergo corticosteroid injections more frequently (> 3 every months) and for longer duration (McAlindon 2017, Sharma 2021, Wang et al 2022), so Dr. Makris tries to emphasize strategies for prolonging the interval between injections. There is no evidence that hyaluronic acid injections are clinically more effective than placebo and they can lead to a very painful reactive effusion (Pereira et al 2022).  

Surgery

All patients should have an adequate trial of conservative management, but for those who are surgical candidates and are experiencing functional decline, it is important not to wait too long to pursue joint replacement. Patients with lower functional status are at higher risk of poor surgical outcomes. When considering surgery, it is important to learn about social context, including living situation and social support.  

The upshot is that all patients should be offered a “menu of options” of multiple modalities, and then followed-up to assess efficacy, adherence and indications for changes.

Diagnosing Late Onset Rheumatoid Arthritis

Definition

Late-onset rheumatoid arthritis (LORA) is defined as rheumatoid arthritis with disease onset at 60 years or older. As many as 30% of RA cases are LORA, making it an important but often missed diagnosis (Serhal et al. Autoimmunity reviews. 2020, Pavlov-Dolijanovic et al. Medicina. 2023).

Clinical features

There are several features that distinguish LORA from younger-onset disease:

–    tendency for more acute onset

–    predilection for large, proximal joint involvement including shoulders, hips and knees, particularly at initial onset

–    more pronounced constitutional symptoms like fever, fatigue, anorexia and weight loss

–    more commonly seronegative (negative RF and anti-CCP)

Differential Diagnosis of LORA

–    Polymyalgia Rheumatica (PMR): LORA frequently presents with a PMR-like syndrome with shoulder and/or pelvic girdle pain and stiffness accompanied by constitutional symptoms. Like LORA, PMR is more common in older adults and can be very difficult to distinguish from LORA on history and physical alone. And remember, up to 20% of patients with PMR will have giant cell arteritis (GCA), so don’t forget to ask about headache, scalp tenderness, jaw claudication and vision changes.  

–    Crystalline Arthropathy: Chronic calcium pyrophosphate deposition disease (CPPD) is also more common in older adults and can present with an RA-like syndrome of inflammatory polyarthritis, but will typically have less symmetric and more sequential joint involvement.

Physical Exam

The most important physical exam finding is evidence of synovitis in a typical distribution (MCPs, wrists, elbows, shoulders), keeping in mind that larger joints can often be involved. This can be appreciated by carefully palpating the periarticular tissues for warmth, bogginess and tenderness. Patients may also have joint effusions.

Initial lab workup

Inflammatory markers: ESR and/or CRP (will be elevated in LORA but do not distinguish LORA from PMR or RA-like CPPD)

RF and anti-CCP: CCP is highly specific, but patients with LORA are more commonly seronegative so a negative result does not rule out the diagnosis

There is no need to order other serologies (ie ANA, SSA-SSB, myositis panels) in patients whose symptoms are consistent with LORA

If crystalline arthropathy is on the differential, joint aspiration can help establish the diagnosis. In patients with prior history of episodic acute arthritis that raises suspicion for gout, uric acid levels can also be helpful.

In anticipation of targeted treatment initiation: Chemistry panels to check kidney and liver function, and hepatitis panels

Imaging

Initial bilateral radiographs are indicated at diagnosis in order to evaluate for erosive disease and track disease progression over time.  

When to refer?

Patients should be referred to rheumatology as soon as there is suspicion of LORA, as timely initiation of targeted therapy with DMARDs provides the best outcomes. There are often significant delays in being seen by a specialist. In these cases, a PCP might curbside a rheumatologist colleague to get guidance on initial management with corticosteroids (more on this below) in the interim.  

Managing LORA

The 5Ms as a general framework

Regular listeners will be familiar with the Geriatric 5Ms framework for providing age-friendly care for older adults by focusing on 5 interrelated domains: Mobility, Medications, Mind/Mood, Multimorbidity/Multicomplexity and Matters Most. Here is how Dr. Makris integrates the 5Ms to manage patients with LORA: (see Buehring et al 2024) 

Multimorbidity: Defined as >=2 chronic medical conditions, multimorbidity is common in older patient populations, and those with RA have more comorbidities than those without RA. Diseases can interact in complex ways to produce pain, functional impairment, and mental health burden. Understanding these interactions rather than treating disease entities in a vacuum can lead to more effective treatment strategies. When addressing multicomplexity, it is essential to address psychosocial factors like social supports and stressors, and comorbid mental health conditions like depression and anxiety. Doing so can encourage safety, better adherence, and improvements in function and quality of life.

Matters Most: Dr. Makris reminds us that while clinicians bring medical expertise, “patients bring expertise in themselves.” Aligning management strategies and treatment goals with the patient’s own priorities is essential to successful outcomes. It can also protect against assumptions and biases that can reproduce ageism in clinical practice.

Mobility: Dr. Makris likes the framework of “life space mobility” to assess where and how patients move through their environments, and how their symptoms are impacting their ability to do so (including ADLs, iADLS). Always ask about falls using the CDC fall screening questions—Have you had any falls in the past 12 months? Do you feel unsteady on your feet? Are you worried about falling?—as fall-related injuries are a leading cause of morbidity and mortality in older adults.  

Medications: Older adults are at higher risk of adverse drug effects and polypharmacy (defined as >=5 medications). In patients over 65 with RA, 50% have polypharmacy (Bechman 2019, Lee 2022). There are several clinical tools for identifying potentially inappropriate medications in older adults, including the Beers Criteria. Dr. Makris notes that many of the older adults she sees for RA management have been on high-risk medications including NSAIDs, opioids, glucocorticoids, and antidepressants. At the same time, she warns against undertreatment of older patients, citing evidence that up to 70% of patients with LORA have not been initiated on appropriate therapy at 12 months after diagnosis (Schmajuk et al 2007).

Mind/Mood: Individuals with RA are at higher risk of all-cause dementia than individuals without RA when adjusting for age, sex, and cardiovascular risk factors (Kodishala 2023). They also have higher rates of clinical depression, which is associated with worse clinical outcomes (Kekow et al 2011, Myasoedova 2024). Comorbid cognitive impairment and psychiatric illness should be managed within interdisciplinary teams to improve overall outcomes, including medication adherence. 

Initial treatment: The role of glucocorticoids

Most patients will be started on prednisone by their PCP for symptom management while awaiting initiation of DMARDs, and the starting dose will depend on BMI, symptom severity, and comorbid conditions like DM and osteoporosis. Remember that while prednisone is effective in providing rapid symptomatic relief, it is not disease-modifying and comes with significant adverse effects, especially in older adults. These include higher risk of serious infection, neuropsychiatric symptoms/delirium, osteoporosis and fragility fractures, and steroid-induced hyperglycemia, especially in those with comorbid diabetes, all of which are increased with higher doses and longer duration of therapy. If started on steroids, the goal is to taper as quickly as possible to the lowest effective dose or off once DMARDS or biologics are initiated.

Ageism and Undertreatment

As already noted, studies have shown that patients with LORA are less likely to be initiated on DMARDs in a timely manner and often remain on glucocorticoid monotherapy longer than those with early-onset RA. This is despite evidence supporting the efficacy and safety of DMARDs, including newer biologics, in this population.  Could  ageism be  a potential driver of undertreatment in older patients with RA? Dr. Makris reminds us to check assumptions and biases that may impact clinical judgement when it comes to treating older adults with joint pain (Misra et al 2024).  

DMARDs

Traditional DMARDs include methotrexate, hydroxychloroquine, sulfasalazine and leflunomide which can be combined in a “triple therapy” regimen.

Newer biologics include TNF inhibitors, IL-6 inhibitors, JAK inhibitors and B-cell depleting therapy.

Determining the best regimen for a given patient will depend on comorbidities (e.g. kidney or liver disease), personal preferences (e.g. ability to tolerate injections), and individual risk factors. Targeted treatment and monitoring will almost always be managed by a rheumatologist, while the role of the PCP is to treat and co-manage comorbid conditions and risk factors and coordinate an interdisciplinary team.

Treating to Target

This entails timely and aggressive initiation of DMARDs to achieve remission of disease activity. In her older patients, Dr. Makris emphasizes establishing functional goals in addition to typical indicators of disease activity like inflammatory markers and number of swollen tender joints. This allows her to integrate what matters most to the patient into treatment targets and decision making.

Goal

Listeners will develop an age-friendly approach to joint pain in older adults. 

Learning Objectives

After listening to this episode listeners will…

1. Create a differential diagnosis for common arthritis conditions that cause arthralgias in  older adults.
2. Develop a targeted assessment and work-up for joint paint presentations in older adults.
3. Reflect on how ageism can impact diagnosis and treatment of arthritis.
4. Understand how the Geriatric 5M Framework can impact the approach to arthritis care for older adults.

Citation

Young J, Witt LJ, Miller R, Makris UE, Williams PN, Watto MF. “#493 Joint Pain in Older Adults”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast July 28, 2025.