Systemic Lupus Erythematosus in Elderly Populations

  • Ana M. Bertoli
  • Guillermo J. Pons-Estel
  • Paula I. Burgos
  • Graciela S. AlarcónEmail author


Systemic lupus erythematosus (SLE) is increasingly being recognized among the elderly. The so-called late-onset lupus seems to conform a quite defined patient subgroup with a frequency that ranges from 4–18% in different studies. According to several authors, late-onset lupus patients tend to have less of a female predominance. More insidious and less defined disease manifestations among this patient population may turn the diagnosis into a clinical challenge; therefore, many other diagnoses need to be excluded. It has been suggested that late-onset patients have a more benign disease course as they usually have less major organ system involvement, fewer clinical relapses, and lower degrees of disease activity. Mucocutaneous, renal, and neurological involvement has been reported to be less frequent among these patients. Treatment modalities have not been specifically studied in this patient subgroup; pharmacological interventions need to be tailored not only to the clinical manifestations of the disease, but also to the presence of other comorbidities and the drugs’ safety profiles. Despite this apparent benign course, patients whose disease begins later in life may not have such a good prognosis in terms of survival. It is possible that these patients’ poor long-term outcomes result from the impact SLE, along with other comorbidities, has in this older patient population.


Systemic lupus erythematosus Late-onset lupus Elderly Disease activity Damage Mortality 



The work of Drs. Guillermo Pons-Estel and Paula Burgos was supported by a Supporting Training Efforts in Lupus for Latin American Rheumatologists (STELLAR) award funded by Rheuminations, Inc.


  1. 1.
    Arias E. United States life tables, 2004. Natl Vital Stat Rep. 2007;56(9):1–39.PubMedGoogle Scholar
  2. 2.
    Keating N, Fox WT. Editorial: longevity health and well-being. Issues in aging in North America. J Nutr Health Aging. 2008;12(2):99–100.PubMedCrossRefGoogle Scholar
  3. 3.
    Taylor K, Chung S, Graham R, Ortmann W, Lee A, Langefeld C et al. Genetic risk score for systemic lupus erythematosus is associated with age of onset and autoantibody production [abstract/program 1873]. Presented at the 59th Annual Meeting of The American Society of Human Genetics, Honolulu, Hawaii. 2009.
  4. 4.
    Catoggio LJ, Skinner RP, Smith G, Maddison PJ. Systemic lupus erythematosus in the elderly: clinical and serological characteristics. J Rheumatol. 1984;11(2):175–81.PubMedGoogle Scholar
  5. 5.
    Mak SK, Lam EK, Wong AK. Clinical profile of patients with late-onset SLE: not a benign subgroup. Lupus. 1998;7(1):23–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Font J, Pallares L, Cervera R, Lopez-Soto A, Navarro M, Bosch X, et al. Systemic lupus erythematosus in the elderly: clinical and immunological characteristics. Ann Rheum Dis. 1991;50:702–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Voulgari PV, Katsimbri P, Alamanos Y, Drosos AA. Gender and age differences in systemic lupus erythematosus. A study of 489 Greek patients with a review of the literature. Lupus. 2002;11(11):722–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Rovensky J, Tuchynova A. Systemic lupus erythematosus in the elderly. Autoimmun Rev. 2008;7(3):235–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Ward MM, Polisson RP. A meta-analysis of the clinical manifestations of older-onset systemic lupus erythematosus. Arthritis Rheum. 1989;32(10):1226–32.PubMedCrossRefGoogle Scholar
  10. 10.
    Boddaert J, Huong DL, Amoura Z, Wechsler B, Godeau P, Piette JC. Late-onset systemic lupus erythematosus: a personal series of 47 patients and pooled analysis of 714 cases in the literature. Medicine (Baltimore). 2004;83(6):348–59.CrossRefGoogle Scholar
  11. 11.
    Maddison P, Farewell V, Isenberg D, Aranow C, Bae S, Barr S, et al. The rate and pattern of organ damage in late onset systemic lupus erythematosus. J Rheumatol. 2002;29(5):913–7.PubMedGoogle Scholar
  12. 12.
    Bertoli AM, Alarcon GS, Calvo-Alen J, Fernandez M, Vila LM, Reveille JD. Systemic lupus erythematosus in a multiethnic US cohort. XXXIII. Clinical [corrected] features, course, and outcome in patients with late-onset disease. Arthritis Rheum. 2006;54(5):1580–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Baker SB, Rovira JR, Campion EW, Mills JA. Late onset systemic lupus erythematosus. Am J Med. 1979;66:727–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Costallat LT, Coimbra AMV. Systemic lupus erythematosus: clinical and laboratory aspects related to age at disease onset. Clin Exp Rheumatol. 1994;12(6):603–7.PubMedGoogle Scholar
  15. 15.
    Formiga F, Moga I, Pac M, Mitjavila F, Rivera A, Pujol R. Mild presentation of systemic lupus erythematosus in elderly patients assessed by SLEDAI. SLE Disease Activity Index. Lupus. 1999;8(6):462–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Shaikh SK, Wang F. Late-onset systemic lupus erythematosus: clinical and immunological characteristics. Med J Malaysia. 1995;50(1):25–31.PubMedGoogle Scholar
  17. 17.
    Mok CC, Mak A, Chu WP, To CH, Wong SN. Long-term survival of Southern Chinese patients with systemic lupus erythematosus: a prospective study of all age-groups. Medicine (Baltimore). 2005;84(4):218–24.CrossRefGoogle Scholar
  18. 18.
    Lalani S, Pope J, de Leon F, Peschken C. Clinical features and prognosis of late-onset systemic lupus erythematosus: results from the 1,000 faces of lupus study. J Rheumatol. 2010;37(1):38–44.PubMedCrossRefGoogle Scholar
  19. 19.
    Dimant J, Ginzler EM, Schlesinger M, Diamond HS, Kaplan D. Systemic lupus erythematosus in the older age group: computer analysis. J Am Geriatr Soc. 1979;27(2):58–61.PubMedGoogle Scholar
  20. 20.
    Appenzeller S, Pereira DA, Costallat LTL. Greater accrual damage in late-onset systemic lupus erythematosus: a long-term follow-up study. Lupus. 2008;17(11):1023–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Pu SJ, Luo SF, Wu YJ, Cheng HS, Ho HH. The clinical features and prognosis of lupus with disease onset at age 65 and older. Lupus. 2000;9(2):96–100.PubMedCrossRefGoogle Scholar
  22. 22.
    Ho CT, Mok CC, Lau CS, Wong RW. Late onset systemic lupus erythematosus in Southern Chinese. Ann Rheum Dis. 1998;57(7):437–40.PubMedCrossRefGoogle Scholar
  23. 23.
    Mak A, Mok CC, Chu WP, To CH, Wong SN, Au TC. Renal damage in systemic lupus erythematosus: a comparative analysis of different age groups. Lupus. 2007;16(1):28–34.PubMedCrossRefGoogle Scholar
  24. 24.
    Sayarlioglu M, Cefle A, Kamali S, Gul A, Inanc M, Ocal L, et al. Characteristics of patients with late onset systemic lupus erythematosus in Turkey. Int J Clin Pract. 2005;59(2):183–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Borchers AT, Keen CL, Gershwin ME. Drug-induced lupus. Ann N Y Acad Sci. 2007;1108:166–82.PubMedCrossRefGoogle Scholar
  26. 26.
    Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1982;25:1271–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40:1725.PubMedCrossRefGoogle Scholar
  28. 28.
    Ballou SP, Khan MA, Kushner I. Clinical features of systemic lupus erythematosus. Difference related to race and age of onset. Arthritis Rheum. 1982;25:55–60.PubMedCrossRefGoogle Scholar
  29. 29.
    Koh ET, Boey ML. Late onset lupus: a clinical and immunological study in a predominantly Chinese population. J Rheumatol. 1994;21(8):1463–7.PubMedGoogle Scholar
  30. 30.
    Wilson HA, Hamilton ME, Spyker DA, Brunner CM, O’Brien WM, Davis JS, et al. Age influences the clinical and serologic expression of systemic lupus erythematosus. Arthritis Rheum. 1981;24(10):1230–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Hochberg MC, Boyd RE, Ahearn JM, Arnett FC, Bias WB, Provost TT, et al. Systemic lupus erythematosus: a review of clinico-laboratory features and immunogenetic markers in 150 patients, with emphasis on demographic subsets. Medicine. 1985;64:285–95.PubMedCrossRefGoogle Scholar
  32. 32.
    Gossat DM, Walls RS. Systemic lupus erythematosus in later life. Med J Aust. 1982;1(7):297–9.PubMedGoogle Scholar
  33. 33.
    McDonald K, Hutchinson M, Bresnihan B. The frequent occurrence of neurological disease in patients with late-onset systemic lupus erythematosus. Br J Rheumatol. 1984;23(3):186–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Takayasu V, Bonfa E, Levy NM, Kumeda C, Daud RM, Cossermelli W. Systemic lupus erythematosus in the aged: clinical and laboratory characteristics. Rev Hosp Clin Fac Med Sao Paulo. 1992;47(1):6–9.PubMedGoogle Scholar
  35. 35.
    Padovan M, Govoni M, Castellino G, Rizzo N, Fotinidi M, Trotta F. Late onset systemic lupus erythematosus: no substantial differences using different cut-off ages. Rheumatol Int. 2007;27(8):735–41.PubMedCrossRefGoogle Scholar
  36. 36.
    Maddison PJ. Systemic lupus erythematosus in the elderly. J Rheumatol. 1987;14 Suppl 13:182–7.Google Scholar
  37. 37.
    Cervera R, Khamashta MA, Font J, Sebastiani GD, Gil A, Lavilla P, et al. Systemic lupus erythematosus: clinical and immunologic patterns of disease expression in a cohort of 1,000 patients. The European Working Party on Systemic Lupus Erythematosus. Medicine (Baltimore). 1993;72:113–24.Google Scholar
  38. 38.
    Domenech I, Aydintug O, Cervera R, Khamashta M, Jedryka-Goral A, Vianna JL, et al. Systemic lupus erythematosus in 50 year olds. Postgrad Med J. 1992;68(800):440–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Garcia-Carrasco M, Ramos-Casals M, Rosas J, Pallares L, Calvo-Alen J, Cervera R, et al. Primary Sjogren syndrome: clinical and immunologic disease patterns in a cohort of 400 patients. Medicine (Baltimore). 2002;81(4):270–80.CrossRefGoogle Scholar
  40. 40.
    Manoussakis MN, Georgopoulou C, Zintzaras E, Spyropoulou M, Stavropoulou A, Skopouli FN, et al. Sjogren’s syndrome associated with systemic lupus erythematosus: clinical and laboratory profiles and comparison with primary Sjogren’s syndrome. Arthritis Rheum. 2004;50(3):882–91.PubMedCrossRefGoogle Scholar
  41. 41.
    Maddison PJ. Is it SLE? Best Pract Res Clin Rheumatol. 2002;16(2):167–80.PubMedCrossRefGoogle Scholar
  42. 42.
    Finks SW, Finks AL, Self TH. Hydralazine-induced lupus: maintaining vigilance with increased use in patients with heart failure. South Med J. 2006;99(1):18–22.PubMedCrossRefGoogle Scholar
  43. 43.
    Carter JD, Valeriano-Marcet J, Kanik KS, Vasey FB. Antinuclear antibody-negative, drug-induced lupus caused by lisinopril. South Med J. 2001;94(11):1122–3.PubMedCrossRefGoogle Scholar
  44. 44.
    Morrow JD, Schroeder HA, Perry Jr HM. Studies on the control of hypertension by hyphex. II. Toxic reactions and side effects. Circulation. 1953;8(6):829–39.PubMedGoogle Scholar
  45. 45.
    Rubin RL. Etiology and mechanisms of drug-induced lupus. Curr Opin Rheumatol. 1999;11(5):357–63.PubMedCrossRefGoogle Scholar
  46. 46.
    Atzeni F, Marrazza MG, Sarzi-Puttini P, Carrabba M. Drug-induced lupus erythematosus. Reumatismo. 2003;55(3):147–54.PubMedGoogle Scholar
  47. 47.
    McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA. 2006;296(13):1633–44.PubMedCrossRefGoogle Scholar
  48. 48.
    Langford RM. Pain management today – what have we learned? Clin Rheumatol. 2006;25 Suppl 1:S2–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Gooch K, Culleton BF, Manns BJ, Zhang J, Alfonso H, Tonelli M, et al. NSAID use and progression of chronic kidney disease. Am J Med. 2007;120(3):280–7.PubMedCrossRefGoogle Scholar
  50. 50.
    American College of Rheumatology Ad Hoc Committee on glucocorticoid-induced osteoporosis. Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. 2001 Update. Arthritis Rheum. 2001;44:1496–503.CrossRefGoogle Scholar
  51. 51.
    Tsakonas E, Joseph L, Esdaile JM, Choquette D, Senecal JL, Cividino A, et al. A long-term study of hydroxychloroquine withdrawal on exacerbations in systemic lupus erythematosus. The Canadian Hydroxychloroquine Study Group. Lupus. 1998;7(2):80–5.PubMedCrossRefGoogle Scholar
  52. 52.
    Fessler BJ, Alarcon GS, McGwin Jr G, Roseman J, Bastian HM, Friedman AW, et al. Systemic lupus erythematosus in three ethnic groups: XVI. Association of hydroxychloroquine use with reduced risk of damage accrual. Arthritis Rheum. 2005;52(5):1473–80.PubMedCrossRefGoogle Scholar
  53. 53.
    Alarcon GS, McGwin Jr G, Bertoli AM, Fessler BJ, Calvo-Alen J, Bastian HM, et al. Effect of hydroxychloroquine in the survival of patients with systemic lupus erythematosus. Data from LUMINA, a multiethnic us cohort (LUMINA L). Ann Rheum Dis. 2007;66:1168–72.PubMedCrossRefGoogle Scholar
  54. 54.
    van Lankveld W, Franssen M, Stenger A. Gerontorheumatology: the challenge to meet health-care demands for the elderly with musculoskeletal conditions. Rheumatology. 2005;44(4):419–22.PubMedCrossRefGoogle Scholar
  55. 55.
    Strand V, Gladman D, Isenberg D, Petri M, Smolen J, Tugwell P. Endpoints: consensus recommendations from OMERACT IV. Lupus. 2000;9:322–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Strand V. Clinical trial design in systemic lupus erythematosus: lessons learned and future directions. Lupus. 2004;13(5):406–11.PubMedCrossRefGoogle Scholar
  57. 57.
    Liang MH, Socher SA, Larson MG, Schur PH. Reliability and validity of six systems for the clinical assessment of disease activity in systemic lupus erythematosus. Arthritis Rheum. 1989;32:1107–18.PubMedCrossRefGoogle Scholar
  58. 58.
    Bombardier C, Gladman DD, Urowitz MB, Caron D, Chang CH, The Committee on Prognosis Studies in SLE. Derivation of the SLEDAI. A disease activity index for lupus patients. Arthritis Rheum. 1992;35:630–40.PubMedCrossRefGoogle Scholar
  59. 59.
    Hay EM, Bacon PA, Gordon C, Isenberg DA, Maddison P, Snaith ML, et al. The BILAG index: a reliable and valid instrument for measuring clinical disease activity in systemic lupus erythematosus. Q J Med. 1993;86(7):447–58.PubMedGoogle Scholar
  60. 60.
    Gladman DD, Goldsmith CH, Urowitz MB, Bacon P, Fortin P, Ginzler E, et al. The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index for Systemic Lupus Erythematosus International Comparison. J Rheumatol. 2000;27:373–6.PubMedGoogle Scholar
  61. 61.
    Manzi S, Meilahn EN, Rairie JE, Conte CG, Medsger Jr TA, Jansen-McWilliams L, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham study. Am J Epidemiol. 1997;145:408–15.PubMedGoogle Scholar
  62. 62.
    Manger K, Manger B, Repp R, Geisselbrecht M, Geiger A, Pfahlberg A, et al. Definition of risk factors for death, end stage renal disease, and thromboembolic events in a monocentric cohort of 338 patients with systemic lupus erythematosus. Ann Rheum Dis. 2002;61(12):1064–70.CrossRefGoogle Scholar
  63. 63.
    Urowitz MB, Gladman DD, Abu-Shakra M, Farewell VT. Mortality studies in systemic lupus erythematosus. Results from a single center. III. Improved survival over 24 years. J Rheumatol. 1997;24:1061–5.PubMedGoogle Scholar
  64. 64.
    Nived O, Jonsen A, Bengtsson AA, Bengtsson C, Sturfelt G. High predictive value of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index for ­survival in systemic lupus erythematosus. J Rheumatol. 2002;29(7):1398–400.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Ana M. Bertoli
  • Guillermo J. Pons-Estel
  • Paula I. Burgos
  • Graciela S. Alarcón
    • 1
    Email author
  1. 1.UABBirminghamUSA

Personalised recommendations