Caring for older patients during COVID-19? What you need to know.

DW Weekly talks to Daniel Butler, MD, co-founder and co-chair of the Academy’s Geriatric Dermatology Expert Resource Group about caring for older patients during the COVID-19 pandemic.

DW Weekly: Can you provide a little background on the Academy’s Geriatric Dermatology Expert Resource Group (ERG)?

Dr. Butler: We started the Geriatric Dermatology Expert Resource Group with the backing of the Academy in 2018 and had our first meeting at the AAD Annual Meeting in 2019. We have been slowly growing our membership with experts from around the country and around the world. Our mission from the beginning has always been to find out what the challenges are when managing older patients in dermatology and acknowledging that their problems are understood as unique — not just because of their age but in the context of someone’s entire wellbeing and their entire health.

DW Weekly: Why did the Academy’s Geriatric Dermatology ERG create a task force on caring for older patients during the COVID-19 pandemic?

Dr. Butler: When COVID-19 hit, it really struck a lot of different chords in what we are trying to address with the Geriatric Dermatology Expert Resource Group. It became very clear very quickly that this is an at-risk patient population and dermatologists, as vital contributors to the health of older adults, would be challenged in dealing with this new risk. About three or four weeks ago, we sent out a message to all our ERG membership asking for ideas on successful practices or challenges they encountered in managing older patients during the pandemic. We then convened a task force to discuss best practices and challenges. We ultimately came up with recommendations for our group, who specialize in seeing older adults, on how to navigate these issues. The hope is that we can provide better care, nationally and internationally, for these patients, while also providing a resource for our colleagues who may have similar questions and challenges.

DW Weekly: Why is this particular patient population an important group to focus on right now?

Dr. Butler: The higher COVID-19 risks facing this older population don’t just affect these patients. Everyone has someone they love who is older and we as physicians all have older patients who we love. The risk and subsequent anxiety is not theirs alone. The anxiety about the care for these patients spreads among physicians, patients, and their families. We didn’t have a template for how to manage these patients during this pandemic, and the only way to do it was to discuss it and see what’s working and what’s not working.

DW Weekly: The group identified three buckets of considerations for physicians when caring for older patients during the pandemic (see chart below). The first highlights best practices for the delivery of care. What does that entail and what were the group’s overall recommendations?

Dr. Butler: Our recommendations were very similar to what we’re using for other people, but the unique element when treating older patients is to really understand the risk of providing care for individual patients, without generalizing by age. When you look at risk profiles, you will see that patients over 65 are deemed higher risk. Our task force was adamant that this is an unacceptable way to triage patients. You need to have a greater depth of understanding of someone’s risk to appropriately triage them and help guide them to what the next best steps are in their care. What we want people to do is triage patients and decide how to deliver care based on true risk factors rather than just looking at an age, which is often sometimes the default way of deciding whether someone is “old” or not. There are so many more nuances in this population that dictate what their true risk is. You need to ask about their functionality and other diseases that they may have, all in the context that these may put them at higher risk. That is the best way to understand the right steps when delivering care.

DW Weekly: How is the adage “age is just a number” applicable here in approaches to care delivery?

Dr. Butler: Age 65 is not the same as age 95. You’re seeing a lot of population data out there saying that patients over 65 are at higher risk, and that probably oversimplifies the risk profile. There’s new risk data indicating that people over 85 have an accentuated risk over those who are 65. Just calling someone old when they get to 65 is really oversimplifying it and does not necessarily mean much unless we really dig into what puts them at risk, which is comorbidities, functionality, ability to take care of themselves, etc. As physicians, we must be more analytical and understanding of risk than just looking at a number.

DW Weekly: When it comes to therapeutic decisions, what guidelines does the group recommend in determining appropriate approaches for treatment for various patients?

Dr. Butler: The way that I start all geriatric cases is that treatments are very individualistic for the patient. To oversimply these discussions into the “right and wrong decision” is not the right way to care for patients. These discussions — in a changing risk environment with so many patient differences —must be individualistic.

You do this by making decisions through shared decision making. You discuss with the patient all the things that you know, as well as all the things that you don’t know. You also need to find out the things that are important to them and the things that are not important to them. Using that honesty and building that understanding of what is important to the patient and what the goals are for care, then everyone can decide what the next step is.

Shared decision making is an important concept that is really propagated in the geriatric literature, but it has not been popularized in dermatology, although practiced individually. However, it is more important now than ever for dermatologists to be practicing shared decision making. We need to prioritize the knowledge that we have and acknowledge what we do not have and then communicate that to the patient in the thread of what is so important to them.

DW Weekly: What role is teledermatology playing with older patients during the COVID-19 pandemic?

Dr. Butler: Teledermatology is playing an important role right now in shared decision making. Even if you’re not evaluating someone for a rash or a lesion, teledermatology is vital as it allows us to have these shared decision making conversations and to check in to see how things are changing with our patients. With teledermatology you can use those shared decision making principles to help guide next steps — whether that’s bringing somebody in for a procedure, or whether that’s going to be continuing to monitor something even if that’s just over the phone to see if there’s any progression over time.

DW Weekly: With this patient population, what challenges exist with teledermatology?

Dr. Butler: Some older adults are remarkably tech savvy. You may ask, “Do you have an iPhone?” and they’ll say, “Well yeah, of course I do.” There are many older patients like that who will be fine doing a video visit. On the other side of the equation, there are patients who have no idea what an iPhone is. Both sides need to be acknowledged. You don’t want to oversimply older adults as unable to use video visits, but you also don’t want to limit someone if they can’t do a video visit. Talking to someone over the phone to make a shared decision about their care can be just as valuable as seeing them on a video.

DW Weekly: The COVID-19 pandemic has required lifestyle alterations for everyone. However, the effects of these lifestyle alterations may impact older adults in unique ways, such as barrier dysfunction from frequent handwashing and the negative impact of social distancing. What should dermatologists do to help older patients manage those effects?

Dr. Butler: Most of this can be done via teledermatology. The first touchpoint is helping patients manage a new lifestyle. That is an easy way to help a patient without seeing them or putting them at risk. We can talk to them about the effects of COVID-19 on their lifestyles. That includes the changes of the skin that happen when your life has changed and routine has changed. We want to make sure that patients are following a normal skin care routine, such as moisturizing and repairing their barriers. We need to stress that good health care routines are very important.

The one aspect that I really want to stress, because I worry a lot about this with my patients, is introducing the concept of asking patients about their activity levels and their ability to care for themselves. As physicians, we need to acknowledge that patients’ health in this crisis goes beyond our specialty. We should be asking them: ‘How are you doing from an isolation perspective? I know that you have to stay inside but are you remaining active?’ With a lot of older patients, when their lives get turned upside down, their routines that keep them thriving are changing. As physicians, we have a strong voice and can recommend basic things to our patients including recommending that patients remain as social as possible, even if that means having to physical distance themselves and calling family and friends. From the physical activity standpoint, you want to recommend that even though we’re quarantined or there are limitations in what they can do, that deconditioning — what happens when you’re inactive — that’s a real risk right now. As physicians, we need to stress this awareness and that they’re trying to combat this by staying active while in house or taking a walk while social distancing.

Even though dermatologists don’t usually have these types of conversations with their patients, it’s important for us to do so. Yes, we’re specialists of the skin, but when you take a step back, we are providing care for older adults. Care is not just the skin. There’s a whole element of healthy aging and we play an important role in that.



References

1. J Am Geriatr Soc. Accepted author manuscript. doi:10.1111/jgs.16482.

2. Medical Dermatology Society. www.meddermsociety.org/content/uploads/2020/03/Examples-of-potentially-urgent-skin-issues-that-may-require-in-person-eval-1.docx.

3. Clin Dermatol. Mar-Apr 2018;36(2):140-151.

4. JAMA. 1998 Aug 5;280(5):428-32.

Daniel Butler, MD, is assistant professor of dermatology at the University of California San Francisco School of Medicine.

Members of the Academy’s Geriatric Dermatology Expert Resource Group task force on caring for older patients during the COVID-19 pandemic include:

• Daniel Butler, MD, Department of Dermatology, University of California San Francisco, San Francisco

• Shreya Sreekantaswamy, BS, University of Utah College of Medicine, Salt Lake City, Utah

• Neha Shukla, MD, Department of Dermatology, University of California San Francisco, San Francisco

• Katrina Abuabara, MD, Department of Dermatology, University of California San Francisco, San Francisco

• Jeffery Callen, MD, Division of Dermatology, University of Louisville School of Medicine, Louisville, Kentucky

• Anne Lynn S. Chang, MD, Department of Dermatology, School of Medicine, Stanford University, Stanford, California

• Aaron M Drucker, MD ScM, Division of Dermatology, Department of Medicine, University of Toronto, Canada; Division of Dermatology, Department of Medicine, and Women’s College Research Institute, Women’s College Hospital, Toronto

• Anne Laumann, MBChB, MRCP, Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago

• Adam Luber, MD, Southwest Skin Specialists, Scottsdale, Arizona

• Suzanne Olbricht, MD, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston

• Jonathan Weiss, MD, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston

• Gil Yosipovitch, MD, Department of Dermatology and Cutaneous Surgery and Miami Itch Center Miller School of Medicine University of Miami, Miami

• Eleni Linos, MD, MPH, DrPH, Department of Dermatology, School of Medicine, Stanford University, Stanford, California

• Justin Endo, MD, MHPE, Department of Dermatology, University of Wisconsin – Madison, Madison, Wisconsin

Are you on the front lines managing COVID-19 patients? Share your story with DWW. Email dweditor@aad.org.