Current understanding of the challenges in the diagnosis and management of spondyloarthritis in older adults

Spondyloarthritis (SpA) encompasses a group of immune-mediated, inflammatory diseases, most notably axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA). As the global population ages, so does the population living with these conditions. Age-related immune changes - including chronic low-grade inflammation and the accumulation of senescent T cells - are increasingly recognised as contributors to disease pathophysiology in these individuals. People over the age of 50 often present with a distinct clinical phenotype, including more peripheral arthritis, dactylitis, and psoriasis. A subset may also present with pitting oedema and polymyalgic symptoms, sometimes associated with underlying malignancy. Imaging in older adults can be challenging, as structural and inflammatory changes such as bone marrow oedema and erosions may be seen in asymptomatic individuals without SpA, increasing the risk of misdiagnosis. Age-related comorbidities - including frailty, sarcopenia, falls, fractures, and dementia - occur more frequently in older individuals with SpA, further complicating diagnosis and treatment. Despite this, therapeutic responses appear similar to those in younger populations, particularly with tumour necrosis factor inhibitors (TNFi). Nonetheless, clinicians must be cautious of increased risks of serious infection and heart failure in this age group. Important questions remain about the long-term safety of disease-modifying antirheumatic drugs (DMARDs) in older patients and the efficacy and tolerability of newer biologic or synthetic agents targeting interleukin-17 (IL-17), IL-12/23 and Janus Kinases (JAK) pathways. A better understanding of SpA in older age is critical to delivering effective, individualised care to this growing population.