Clinical Rheumatology

, Volume 38, Issue 12, pp 3351–3360 | Cite as

Validity of adopting a Health Assessment Questionnaire Disability Index less than 0.5 as a target in elderly rheumatoid arthritis patients

  • Ichiro YoshiiEmail author
  • Tatsumi Chijiwa
  • Naoya Sawada
Original Article



The effect of age on the Health Assessment Questionnaire Disability Index (HAQ-DI) scores of rheumatoid arthritis (RA) patients and the validity of adopting HAQ-DI < 0.5 as the target for functional remission and comprehensive disease control (CDC) under a treat-to-target (T2T) treatment strategy were investigated.


A total of 441 RA patients with > 3-year treatment under T2T were evaluated. The relationships between the HAQ-DI score at follow-up (HAQ) and 28-joint Disease Activity Score with C-reactive protein, Sharp/van der Heijde Score, age at follow-up, and HAQ-DI at baseline were statistically evaluated with best subset regression analysis in groups separated according to age and the EULAR response. CDC status was evaluated with a chi-square test.


The HAQ score significantly correlated with all indices in the group ≥ 65 years old (G-O) and in the group with good or moderate EULAR responses (p < 0.01). No significant correlation was observed in the group < 65 years old (G-Y) or in the group with no EULAR response. The CDC ratio was not significantly different between the age groups, whereas the HAQ failure ratio was significantly greater in G-O than in G-Y (p < 0.01). No significant difference was found between the EULAR response groups.


The HAQ score is influenced by age in patients > 65 years. T2T is appropriate for attaining good disease activity control but does not always lead to functional remission in these patients. The HAQ score < 0.5 is not an appropriate target for functional remission according to the CDC criteria for elderly patients.

Key Points

ADL in elderly RA patient aged ≥ 65 years declines corresponding to his/her aging.

Functional remission for elderly RA patients is not the same as that for young RA patients.

The HAQ score < 0.5 in elderly RA patient is not an appropriate target for CDC.


Activities of daily living Aging Comprehensive health care Rheumatoid arthritis 



The authors would like to thank Kaoru Kuwabara, Sayori Masuoka, and Mariko Osaki for their dedicated data collection.

Compliance with ethical standards

This study was conducted in compliance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects of Japan under the Declaration of Helsinki. The Ethics Committee of the institution approved the protocol and consent forms (approval number: YH-RA-201803). Patients and their families were informed that personal information would be anonymous and used only for analysis before they signed the consent forms.



Supplementary material

10067_2019_4692_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 16 kb)


  1. 1.
    Sokka T, Hakkinen A, Kautiainen H, Maillefert JF, Toloza S, Hansen TM et al (2008) Physical inactivity in patients with rheumatoid arthritis: data from twenty-one countries in a cross-sectional, international study. Arthritis Rheum 59:42–50. CrossRefPubMedGoogle Scholar
  2. 2.
    Fransen J, Moens HB, Speyer I, van Riel PLCM (2005) Effectiveness of systematic monitoring of rheumatoid arthritis disease activity in daily practice: a multicenter, cluster randomized controlled trial. Ann Rheum Dis 64:1294–1298PubMedPubMedCentralGoogle Scholar
  3. 3.
    Aletaha D, Funovits J, Smolen JS (2008) The importance of reporting disease activity states in rheumatoid arthritis clinical trials. Arthritis Rheum 58:2622–2631PubMedGoogle Scholar
  4. 4.
    Kirwan JR, Reeback JS (1986) Stanford health assessment questionnaire modified to assess disability in British patients with rheumatoid arthritis. J Rheumatol 25:206–209Google Scholar
  5. 5.
    Smolen JS, Aletaha D, Grisar JC, Stamm TA, Sharp JT (2010) Estimation of a numerical value for joint damage-related physical disability in rheumatoid arthritis clinical trials. Ann Rheum Dis 69:1058–1064PubMedGoogle Scholar
  6. 6.
    Schiff MH, Yu EB, Weinblatt ME, Moreland LW, Genovese MC, White B (2006) Long-term experience with etanercept in the treatment of rheumatoid arthritis in elderly and younger patients: patient-reported outcomes from multiple controlled and open-label extension studies. Drugs Aging 23:167–178PubMedGoogle Scholar
  7. 7.
    Krishnan E, Sokka T, Häkkinen A, Hubert H, Hannonen P (2004) Normative values for the Health Assessment Questionnaire Disability Index: benchmarking disability in the general population. Arthritis Rheum 50:953–960PubMedGoogle Scholar
  8. 8.
    Krishnan E, Hakkinen A, Sokka T, Hannonen P (2005) Impact of age and comorbidities on the criteria for remission and response in rheumatoid arthritis. Ann Rheum Dis 64:1350–1352PubMedPubMedCentralGoogle Scholar
  9. 9.
    Fries JF, Spitz P, Kraines RG, Holman HR (1980) Measurement of patient outcome in arthritis. Arthritis Rheum 23:137–145PubMedGoogle Scholar
  10. 10.
    Emely P, Kavanaugh A, Bao T, Ganguli A, Mulani P (2015) Comprehensive disease control (CDC): what does achieving CDC mean for patients with rheumatoid arthritis? Ann Rheum Dis 74:2165–2174Google Scholar
  11. 11.
    Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO III, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JMW, Hobbs K, Huizinga TWJ, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Ménard HA, Moreland LW, Naden RL, Pincus T, Smolen JS, Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovský J, Wolfe F, Hawker G (2010) 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 62:2569–2581Google Scholar
  12. 12.
    Smolen JS, Aletaha D, Bijlsma JWJ, Breedveld FC, Boumpas D, Burmester G, Combe B, Cutolo M, de Wit M, Dougados M, Emery P, Gibofsky A, Gomez-Reino JJ, Haraoui B, Kalden J, Keystone EC, Kvien TK, McInnes I, Martin-Mola E, Montecucco C, Schoels M, van der Heijde D, for the T2T Expert Committee (2010) Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 69:631–637PubMedPubMedCentralGoogle Scholar
  13. 13.
    Smolen JS, Breedveld FC, Burmester GR, Bykerk V, Dougados M, Emery P, Kvien TK, Navarro-Compán MV, Oliver S, Schoels M, Scholte-Voshaar M, Stamm T, Stoffer M, Takeuchi T, Aletaha D, Andreu JL, Aringer M, Bergman M, Betteridge N, Bijlsma H, Burkhardt H, Cardiel M, Combe B, Durez P, Fonseca JE, Gibofsky A, Gomez-Reino JJ, Graninger W, Hannonen P, Haraoui B, Kouloumas M, Landewe R, Martin-Mola E, Nash P, Ostergaard M, Östör A, Richards P, Sokka-Isler T, Thorne C, Tzioufas AG, van Vollenhoven R, de Wit M, van der Heijde D (2016) Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis 75:3–15PubMedGoogle Scholar
  14. 14.
    Aletaha D, Nell-Duxneuner V, Stamm T, Uffmann M, Pflugbeil S, Machold K et al (2005) Acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: validation of a clinical activity score. Arthritis Res Ther 7:796–806Google Scholar
  15. 15.
    van Der Heijde DM, van Riel PL, Gribnaub FW, Nuver-Zwart IH, van De Putte LB (1989) Effects of hydroxychloroquine and sulphasalazine on progression of joint damage in rheumatoid arthritis. Lancet 333:1036–1038Google Scholar
  16. 16.
    Van Gestel AM, Prevoo ML, Van't Hof MA, Van Rijswijk MH, Van de Putte LB, van Riel PL (1996) Development and validation of the European League Against Rheumatism response criteria for rheumatoid arthritis: comparison with the preliminary American College of Rheumatology and the World Health Organization/International League Against Rheumatism criteria. Arthritis Rheum 39:34–40PubMedGoogle Scholar
  17. 17.
    Wolfe F, Mitchell DM, Sibley JT, Fries JF, Bloth DA, Williams CA et al (1994) The mortality of rheumatoid arthritis. Arthritis Rheum 37:481–494PubMedGoogle Scholar
  18. 18.
    Gabriel SE, Crowson CS, Kremers HM, Doran MF, Turesson C, O’Fallon WM et al (2003) Survival in rheumatoid arthritis: a population-based analysis of trends over 40 years. Arthritis Rheum 48:54–58PubMedGoogle Scholar
  19. 19.
    Sokka T, Häkkinen A, Krishnan E, Hannonen P (2004) Similar prediction of mortality by the health assessment questionnaire in patients with rheumatoid arthritis and the general population. Ann Rheum Dis 63:494–497PubMedPubMedCentralGoogle Scholar
  20. 20.
    Sokka T, Kautiainen H, Hannonen P, Pincus T (2006) Changes in Health Assessment Questionnaire Disability scores over five years in patients with rheumatoid arthritis compared with the general population. Arthritis Rheum 57:3113–3118Google Scholar
  21. 21.
    Aletaha D, Funovits J, Breedveld FC, Sharp J, Segurado O, Smolen JS (2009) Rheumatoid arthritis joint progression in sustained remission is determined by disease activity levels preceding the period of radiographic assessment. Arthritis Rheum 60:1242–1249PubMedGoogle Scholar
  22. 22.
    Keystone FC, Ferdinand C, Breedveld FC, van der Heijde D, Landewé R, Florentinus S et al (2014) Longterm effect of delaying combination therapy with tumor necrosis factor inhibitor in patients with aggressive early rheumatoid arthritis: 10-year efficacy and safety of adalimumab from the randomized controlled PREMIER trial with open-label extension. J Rheumatol 41:5–14PubMedGoogle Scholar
  23. 23.
    Takeuchi T , Tanaka Y, Kaneko Y, Tanaka E, Hirata S, Kurasawa T, Kubo S, Saito K, Shidara K, Kimura N, Nagasawa H, Kameda H, Amano K, Yamanaka H (2012) Effectiveness and safety of adalimumab in Japanese patients with rheumatoid arthritis: retrospective analyses of data collected during the first year of adalimumab treatment in routine clinical practice (HARMONY study). Mod Rheumatol 22: 327–338.PubMedGoogle Scholar
  24. 24.
    Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K (2012) Validity and reliability of the Edmonton Frail Scale. Age Ageing 35:526–529Google Scholar
  25. 25.
    Seichi A, Hoshino Y, Doi T, Akai M, Tobimatsu Y, Iwaya T (2012) Development of a screening tool for risk of locomotive syndrome in the elderly: the 25-question Geriatric Locomotive Function Scale. J Orthop Science 17:163–172Google Scholar
  26. 26.
    Yoshimura N, Muraki S, Nakamura K, Tanaka S (2017) Epidemiology of the locomotive syndrome: the research on osteoarthritis/osteoporosis against disability study 2005-2015. Mod Rheumatol 27:1–5PubMedGoogle Scholar
  27. 27.
    Imagama S, Hasegawa Y, Ando K, Kobayashi K, Hida T, Ito K, Tsushima M, Nishida Y, Ishiguro N (2017) Staged decrease of physical ability on the locomotive syndrome risk test is related to neuropathic pain, nociceptive pain, shoulder complaints, and quality of life in middle-aged and elderly people – the utility of the locomotive syndrome risk test. Mod Rheumatol 27:1051–1056PubMedGoogle Scholar
  28. 28.
    Markusse IM, Dirven L, Gerards AH, van Groenendael JHLM, Ronday HK, Kerstens PJSM, Lems WF, Huizinga TWJ, Allaart CF (2015) Disease flares in rheumatoid arthritis are associated with joint damage progression and disability: 10-year results from the BeSt study. Arthritis Res Ther 17:232PubMedPubMedCentralGoogle Scholar
  29. 29.
    Ward MM, Guthrie LC, Alba MI (2015) Clinically important changes in individual and composite measures of rheumatoid arthritis activity: thresholds applicable in clinical trials. Ann Rheum Dis 74:1691–1696Google Scholar
  30. 30.
    Yoshii I (2016) The clinical significance of initial treatment and pain-VAS control for attaining long standing Comprehensive Disease Remission (CDR) in rheumatoid arthritis treatment (in Japanese). Clin Rheumatol 28:121–129Google Scholar
  31. 31.
    Sugihara T, Harigai M (2016) Targeting low disease activity in elderly-onset rheumatoid arthritis: current and future roles of biological disease-modifying antirheumatic drugs. Drugs Aging 33:97–107PubMedPubMedCentralGoogle Scholar
  32. 32.
    Sugihara T, Ishizaki T, Hosoya T, Iga S, Yokoyama W, Hirano F et al (2014) Structural and functional outcomes of a therapeutic strategy targeting low disease activity in patients with elderly-onset rheumatoid arthritis: a prospective cohort study (CRANE). Rheumatol (Oxford) 54:798–807Google Scholar
  33. 33.
    Häkkinen A, Kautiainen H, Hannonen P, Ylinen J, Maekinen H, Sokka T (2006) Muscle strength, pain and disease activity explain individual subdimensions of the Health Assessment Questionnaire Disability Index, especially in women with rheumatoid arthritis. Ann Rheum Dis 65:30–34PubMedGoogle Scholar
  34. 34.
    Sokka T, Krishnan E, Häkkinen A, Hannonen P (2003) Functional disability in rheumatoid arthritis patients compared with a community population in Finland. Arthritis Rheum 48:59–63PubMedGoogle Scholar
  35. 35.
    Vita AJ, Terry RB, Hubert HB, Fries JF (1998) Aging, health risks, and cumulative disability. N Engl J Med 338: 1035–1041. PubMedGoogle Scholar
  36. 36.
    Shiozawa K, Tanaka Y, Imura S, Shiozawa S (1997) Elderly-onset rheumatoid arthritis: ageing as an independent marker for better joint prognosis. Mod Rheumatol 7:103–114Google Scholar
  37. 37.
    Momohara S, Tanaka S, Nakamura H, Mibe J, Iwamoto T, Ikari K, Nishino J, Kadono Y, Yasui T, Takahashi K, Takenouchi K, Hashizume K, Nakahara R, Kubota A, Nakamura T, Nishida K, Suguro T (2011) Recent trends in orthopedic surgery performed in Japan for rheumatoid arthritis. Mod Rheumatol 21:337–342PubMedGoogle Scholar
  38. 38.
    Mochizuki T, Yano K, Ikari K, Kawakami K, Hiroshima R, Momohara S (2018) Relationship between achievement of physical activity goal and characteristics of patients with rheumatoid arthritis. Mod Rheumatol 28:606–610PubMedGoogle Scholar
  39. 39.
    Han GM, Han XF (2016) Comorbid conditions are associated with healthcare utilization, medical charges and mortality of patients with rheumatoid arthritis. Clin Rheumatol 35:1483–1492PubMedGoogle Scholar
  40. 40.
    Fried LP, Tangen CM, Watson J, Newman AB, Hirsch C, Gottdiener J et al (2001) Frailty in older adults: evidence for a phenotype. J Gerontol SeriesA 56:M146–M157Google Scholar
  41. 41.
    Collard RM, Boter H, Schoevers RA, Voshaar RCO (2012) Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatric Soc 60:1487–1492Google Scholar
  42. 42.
    Andrews JS, Trupin L, Yelin EH, Hough CL, Covinski KE, Katz PP (2017) Frailty and reduced physical function go hand in hand in adults with rheumatoid arthritis: a US observational cohort study. Clin Rheum 36:1031–1039Google Scholar

Copyright information

© International League of Associations for Rheumatology (ILAR) 2019

Authors and Affiliations

  1. 1.Department of Rheumatology and Musculoskeletal MedicineYoshii HospitalShimanto CityJapan
  2. 2.Department of RheumatologyKochi Memorial HospitalKochiJapan
  3. 3.Department of RheumatologyDohgo Onsen HospitalMatsuyamaJapan

Personalised recommendations