In older adults, rheumatological diseases can have atypical and more subtle presentations and a varied clinical course. Clinical manifestations come from a combination of accumulation of damage from both active and chronic rheumatologic disease, long-term side effects of treatment, co-morbid medical conditions, frailty, and age-related physiological changes. The gastrointestinal (GI) manifestations associated with chronic rheumatologic conditions, including xerostomia, dysphagia, malabsorption, diarrhea or constipation can contribute to common geriatric syndromes such as weight loss, incontinence and mobility impairment. This makes evaluation and management of complaints complex, increasing morbidity and frustration for patients and clinicians alike. A systematic “Geriatrics 5M” approach—Matters Most, Multi-complexity, Medication, Mind, and Mobility—can be helpful for integrating patients’ individual care goals with comprehensive management strategies. This framework facilitates careful evaluation of functional, cognitive, and psychosocial dimensions, enabling personalized treatment plans that include pharmacologic considerations for older adults and regular reassessment of therapeutic efficacy and side effects. Ultimately, adopting a holistic, patient-centered model can improve medication adherence, minimize treatment-related complications, and enhance overall health outcomes for older adults with rheumatologic diseases.