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Golden Years
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Golden Rules for the Golden Years

According to the U.S. Census, there were 47.8 million people over the age of 65 in the United States in 2015, and it’s expected that this figure will grow to 98.2 million by 2060. Many dermatologists are familiar with this Baby Boomer generation, as the 2017 Burden of Skin Disease Report indicates that 50% of Americans over the age of 65 have skin disease with an average of 2.2 skin diseases per person (J Am Acad Dermatol. 2017; May 76(5):958-72).

However, while dermatologists are uniquely qualified and well-versed in treating skin conditions and diseases among this particular patient population, Justin Endo, MD, MHPE, assistant professor at the University of Wisconsin’s dermatology department, contends that caring for elderly patients spans beyond dermatologists’ robust clinical acumen. “As dermatologists we play a big role
in terms of improving the quality of life for this entire patient population and recognizing issues that other physicians might not think of.”

Dermatology World talks with experts about the following issues that dermatologists may encounter when caring for elderly patients:

  • Treatment Adherence
  • Elder abuse and neglect
  • Legal and ethical considerations

Treatment adherence

According to some estimates, up to 50% of patients with chronic conditions do not take their prescribed medications (Dtsch Med Wochenschr. 2011 Aug;136(31- 32):1616-21). Moreover, “Across the United States, up to 21% of adverse drug events in ambulatory care was associated with nonadherence. It is estimated that $1 billion per year is wasted when patients are not taking their medications the right way,” said Dr. Endo. “That’s not specific to older adults or dermatology, but treatment non-adherence is a huge problem.” Although medication adherence is a challenge for patients of all ages, there are a number of factors that physicians may want to consider if treatment adherence is a challenge with their older patients.

Communication

For Dr. Endo, communication with patients plays
a major role in treatment adherence. “When we’re talking to older patients, we might not be using the best practices for communication.” Potential hearing loss and/or vision deterioration can interfere with communications about medicines. “Speaking in a lower tone can help patients with a hearing impairment,” Dr. Endo said. “Also, using a minimum of a 12-point font and 1.5 line spacing as well as high contrasts like black print on white paper [for printouts] can really improve people’s ability to understand,” Dr. Endo said.

Anne Lynn Chang, MD, associate professor of dermatology at Stanford University School of Medicine, tries to make her medication instructions as clear as possible, both for the older patients and their caregivers. “I will use a body map diagram and write in large font what medicine is applied where on the body. Same with prescription labels, I write down where on the body to apply a topical medication. I’m not just saying ‘Apply to the affected area,’ but ‘apply to arms’ or ‘apply to scalp.’” If adherence is a problem, Dr. Chang will also give patients a large-font printed diary with instructions to record their dates of use. “I ask them to bring their medication tubes and their diary to their next appointment so I can get an idea of how much of the medication they’re using and the frequency. Often drugs are ‘not working,’ according to the patient, but the lack of therapeutic effect is because they are not using their medication regularly and at appropriate amounts.”

Care coordination

In addition to patient communication, Dr. Endo contends that communication with other physicians is a critical component for ensuring treatment adherence, particularly with older patients who may be seeing multiple specialists in a number of care settings. “The more doctors or nurses that you have involved in transitions of care, the more opportunities there might be for medication reconciliation error. We need to make sure that we’re communicating to other providers — not just the patient and their families.”

This pearl applies to pharmacists as well where automatic refills are concerned. “While automatic refill reminders can be good for patients, we actually found at our institution that sometimes it can cause confusion. When a medicine is supposed to be stopped or adjusted, the pharmacy still has it in their system that there are more refills of the old prescription.” Dr. Endo says there are e orts afoot to improve communications with pharmacists so that when a physician discontinues a medication in their electronic medical records, it sends a ‘stop medication’ notification to the pharmacy. Until that happens, he said, physicians and pharmacists should be communicating about medication changes to avoid any confusion.

Comorbidities

In addition to potential hearing loss or vision deterioration, other comorbidities can impede treatment adherence in older patients. “If you have really bad arthritis it might be hard for you to open up a really tiny tube with a little twist top,” Dr. Endo said. “Sometimes it takes some creativity and working with the pharmacist, or asking the patient to work with the pharmacist, to see if they can get their medications in easier-to-open containers.”

Similarly, patients with mobility issues may struggle with topical medications. Dr. Endo encourages physicians to get creative. “There are back-lotion applicators that you can find online that are helpful for all patients. Using assistive devices can make a huge difference.”

 

Polypharmacy

In addition to communication discrepancies and challenging comorbidities, another reason that older patients may not be adhering to their treatment plan is that they may be taking several medicines. “In general, older adults take more medicines compared to younger adults and children,” said Dr. Endo. According to Dr. Endo, taking multiple medications, also known as polypharmacy, can increase a patient’s likelihood of treatment non-adherence. “They have to keep track of more medications. It creates more opportunities for human error as regimens get more complicated.” Additionally, says Dr. Endo, older patients may see more specialists in various locations, and as such may have multiple care transitions. “There are all of these additional potential opportunities for medication confusion to occur.”

Recognizing these challenges, Dr. Chang will try not to give her patients too many medications if she can. “It’s easy to feel like we are addressing the patient’s problem when we give out more types of medications, but people get confused or simply don’t have the time to adhere to multiple topical medications. Multiple medications can also get expensive.” Additionally, Dr. Chang will follow up with the patient shortly after the initial appointment to check in on adherence. “Instead of seeing them in six months I’ll see them in maybe a month after the first visit. I need to see them to and out if the drug is working for them. That gives them a concrete endpoint and will hopefully motivate them to give a treatment a decent trial for efficacy. If they know it is efficacious, they may be more likely to stick to a treatment regimen long term,” said Dr. Chang.

Finances

The cost of drugs remains a critical hurdle for some patients with regard to adherence, says Dr. Endo. “The vast majority of people who are older are living on fixed incomes. Many of them are relying on government insurance.” However, the cost of health care in

general may be keeping patients from not only taking medications, but following up with their physician. “The copays for people to visit their doctors can be really expensive, especially for the younger older people who may still be working and don’t have government assistance,” Dr. Endo said.

Dr. Chang agrees. “The cost of medications is definitely a concern. When patients mention that, I try to give them different options. There are some online pharmacies that people can ask a caregiver or family member to help them navigate online. Or they can call around different pharmacies before going to a particular pharmacy. They may find that prices can vary a lot. Then of course, I try to use generics but some generics can be pricey too now,” Dr. Chang said.

While prescription adherence is a key factor
in caring for elderly patients, Dr. Chang adds that physicians should also be encouraging their patients to adhere to basic self-care practices. Dr. Chang will ask her

patients to make their skin care regimen an extension of their other hygiene-related routines. “If they brush their teeth, they should put on their sunblock or moisturizer right afterwards. I also go over non-medical issues like keeping your shower short or not using very hot water while bathing,” Dr. Chang said. “Some of the treatment adherence isn’t just medicine, but also healthy skin habits such as dry skin care.”

Elder abuse and neglect

According to the National Council on Aging, one in 10 Americans older than 60 have experienced some form of elder abuse. Additionally, about five million elders are abused each year. For Dr. Chang, there is a unique role dermatologists can play in identifying elder abuse as many indications of mistreatment are cutaneous. “We look on the skin and do comprehensive skin checks so we often see things that other doctors don’t,” Dr. Chang said.

Monitoring

Elder abuse — from physical and sexual abuse to neglect — can manifest on the skin through bruising, lacerations, burns, genital trauma, and malnutrition. When it comes to bruising and lacerations, Dr. Chang says that asymmetry may be a sign of abuse, as well as if the injury resembles an object such as a belt buckle. Similarly, burns that resemble an object, such as a cigarette, or have a stocking- or glove-type pattern indicating immersion could be red flags (J Am Acad Dermatol. 2015: Aug;73(2):285-93). “Certainly, the things that are typical to a rape victim with the area

of penetration are quite similar here, such as skin breakdown and ulcers that are infected or getting worse,” said Julie Schoen, JD, deputy director of the National Center on Elder Abuse. Additionally, poor hygiene and photo-sensitive dermatitis, for example, could be suggestive of pellagra from a vitamin B3 deficiency (J Am Acad Dermatol. 2015: Aug;73(2):285- 93).

If the physician notices any of these issues, Schoen recommends talking with the patient. “Often the caregiver will come in with the patient, but you’ll want that time alone with the patient to talk with them. Ask them — just like you would with any other patient — how is everything going?” While the patient is talking, keep an eye out for signs of fear and anxiety, or if they seem nervous in the presence of the caregiver, says Schoen. “The key is: What’s unusual? We all hit our shins on the coffee table but if you see something in the middle of the back or hidden from sight that can be a red ag.”

Documenting

If something looks unusual, Dr. Chang recommends documenting those suspicions carefully. “I would get their permission to document with photographs. If you see them once, it may be a one-time event where they fell by accident. However, if it’s a pattern and serious, then that may be something that you want to investigate further and potentially report if the story behind the injuries does not make sense.”

In addition to photos, Schoen says the more details a physician can add about their encounter with the patient, the better. For example, “‘Patient was able to tell me what day it was and knew who I was and seemed alert and oriented.’” However, physicians should be careful about what they include in the records about the patient that can be used against the patient if a case were to go to prosecution, she warns. “Physicians should be cautious about how they write about the patient in their charts. Making judgment calls or loose statements about capacity, you have to be careful with that.”

Reporting

According to Todd Whatley, JD, president of the National Elder Law Foundation, physicians are required to report suspicion of elder abuse in almost every state. However, “statistically most physicians don’t because they are concerned about violations of physician-patient confidentiality and HIPAA-related issues.” Physicians can find out what’s required of them and

how to report suspected elder abuse through their state’s adult protective services department. Additionally, if the physician suspects that the patient is receiving sub-optimal care

at a nursing home, Whatley recommends speaking with the patient’s family and/or going to adult protective services. “I would start with the health care power of attorney and family member that is most involved and let them know that there’s a problem. Most family members can then go back to the nursing home and address that. If the situation is really bad, that’s abuse and the physician should be reporting to adult protective services.”

Overall, when it comes to elder abuse, Schoen encourages physicians to be proactive. “Just know that there are resources available and there are solutions. People think that there’s not much they can do about it, but there is a lot they can do.”

Legal and ethical considerations

In addition to spotting abuse and neglect among elderly patients, physicians should also be aware of potential mental capacity issues, says Whatley. “All of us have the responsibility to meet with the client or patient and talk to them and essentially determine if they are making good decisions.” How do you do that? “I think we can all tell if a person is ‘making sense,’” says Whatley. “Are they making reasonable decisions that a person looking out after their own self-interests would? You can tell if a person is simply not making well-reasoned, self-interest-protecting decisions. I think physicians are well trained in that

and can see that fairly quickly.” Indeed, before a procedure, Dr. Chang will talk to the patient to make sure they understand the risks and benefits. “We try to document their assent and that to the best of the patient’s ability they understand the reason for what we’re doing, what the risks are, and what the possible benefits are.”

Medical authority

If the physician suspects that the patient no longer has the capabilities to make decisions about their health care, Whatley says the physician can then seek out others to help the patient make those decisions. “That’s where we hope that the patient has designated a health care power of attorney. This is a written document that is either witnessed and/ or notarized that designates someone to make health care decisions when that person cannot, or to assist the patient in making those decisions.” According to Whatley, the form is often submitted to the patient’s primary care physician or hospital, so a specialist like a dermatologist will need to connect with them. “Typically, with health care powers of attorney, there is no triggering event. It is effective immediately and it is up to the physician to say, ‘I’m seeking someone else’s advice here because my client is not making good decisions.’”

If there is no health care power of attorney, Whatley says that the physician — usually the primary care — can work with the next of kin to determine next steps. “Typically, what most physicians will do is tell the family that they need to get a guardianship. I am very adamant that we should not do guardianships unless it’s absolutely the last resort because that

is taking away the rights of the older person and allowing a judge to appoint someone.”

Care goals

However, many patients will be of sound mind, says Dr. Endo, and it’s important for physicians not to assume otherwise and base care decisions simply on age. “Avoid ageism. The aging process is so variable. When we’re kids, we go through developmental landmarks at roughly the same
age. As we get older, we have different life experiences and health situations which is why geriatric care is not one-size- fits-all.”

Indeed, with this particular patient population, care priorities and goals will vary and may differ between what the patient wants and what the physician recommends. As a result, Dr. Chang suggests taking the time to come to an understanding about the patient’s care goals. “I try to assess what their most important priority is. I don’t want to just roll them into a blanket treatment plan, because I believe that every patient is different. Many older patients are very high-functioning and doctors shouldn’t assume that age alone precludes them from particular treatments, especially if they have few other medical problems. Taking the time

to understand your patient’s goals might seem like it takes a lot of time, but in the long term it’s worth it as it helps you to guide the patient toward the best choices for the particular patient.”

Dr. Endo finds that often his patients will be candid about their care goals. “Some patients will say, ‘I just want to be around for my grandkids’ birthdays.’ Other people might be more concerned with quality of life. It goes back to patient-centered care and recognizing that there’s a lot of variability among older adults in terms of what they value, depending upon their psycho-social circumstances, their health, etc., and not just based upon their chronological age. What’s challenging but also rewarding about taking care of older adults is once we appreciate the big picture, we can optimize our treatment plans and not just focus on the skin.”

When it comes to treating elderly patients, Dr. Chang encourages all physicians to simply put themselves in the shoes of their patients. “The way I think about it is: How would all of us want to be treated when we’re not fully able to take care of ourselves? Hopefully, one day we’ll all be old enough to be in that situation. We should be doing what we can to help these patients age gracefully.” dw

This article was originally published by the American Academy of Dermatology, July 2018.  https://www.aad.org/dw