Our patients’ skin biology undergoes several changes with advanced age, including thinning of the epidermis, reduced cell turnover, and vascular flow, which leads to more fragile skin vulnerable to trauma and poor wound healing. Age should not deter from offering gold-standard treatments.
William Osler said:“The good physician treats the disease; the great physician treats the patient who has the disease.” These words are are still topical today as they were when the Canadian professor first said them more than 100 years ago.
Most healthcare physicians won’t appreciate the gravity of his words until they care for elderly patients. There have been tremendous advancements in medicine and technology, leading to a population that is living longer. Particularly in dermatology, our armamentarium of treatments has massively expanded allowing us to cure or manage a lot more conditions.1 Therefore, it has never been easier to be ‘the good physician’ treating a plethora of diseases we weren’t able to before. However, this has made becoming a great physician even more challenging. We have a rising elderly patient population who are extremely diverse and with various levels of complexity, not just clinically but also on a social, psychological and ethico-legal level.
According to the dictionary, the definition of old is ‘having lived for a long time.’2 Medical treatment of the ‘elderly’ starts from the age of 65 years, which nowadays, does not truly reflect the physiological age of most 65-year-olds.3 Clinicians have different views of who should be classified as elderly and even more debate arises regarding their treatment. Should their age matter? Undoubtedly, the skin of elderly patients is both functionally and structurally different from that of younger age groups.1
We are moving towards the personalised medicine era, urging the patient-doctor relationship to acquire a shared decision-making approach. How can this apply to our elderly patients, in particular those with dementia and those with fluctuating mental capacity? Acting in their best interests often raises ethical dilemmas of what is the ‘right’ thing to do. Appreciating their narrative is vital in enabling us as clinicians to address these ethico-legal challenges and provide a truly holistic approach to their care. There is the fear of under-treating and the concern about ageism, but what about the risk of over-treating?
There has been a rise in the ageing population. One in five Europeans is over 60 years, thus our dermatology cases will predominantly consist of elderly patients.1 Our patients’ skin biology undergoes several changes with advanced age, including thinning of the epidermis, reduced cell turnover, and vascular flow, which lead to more fragile skin vulnerable to trauma and poor wound healing. They are prone to several chronic dermatological conditions such as nummular and xerotic eczema, recurrent ulcerations and chronic venous in-sufficiency.1
They also suffer from age-related immunosuppression, which increases their risk of infections and cancer. The use of immunosuppressive agents in this context gives rise to greater anxiety and concern.4 Often elderly patients have multiple comorbidities including renal/hepatic or cardiac impairment which further exacerbates a clinician’s concerns regarding systemic treatments. The balance of risks versus benefits has to be constantly addressed. It is crucial to consider all alternative treatments and to stay up to date with new and emerging evidence.
An example of this is the results of the BLISTER study, which has provided an alternative treatment for Bullous Pemphigoid with doxycycline instead of prednisolone.5
Bullous Pempighoid is very common amongst elderly patients and doxycycline provides a treatment option with a milder side-effect profile compared to that of systemic steroids. Unfortunately, the majority of clinical trials do not include elderly patients and therefore it is harder to predict treatment outcomes.
When formulating treatment plans for our elderly patients, it is important to evaluate their social and psychological considerations. Certain treatments such as phototherapy may seem innocuous but do require multiple appointments and the ability to stand for long periods of time. Certain elderly patients may not have the physical ability to complete this type of treatment; they may be socially isolated with no help and struggle to attend multiple outpatient appointments. We have a duty to treat the patient as a whole, and tailor our treatment options to be pragmatic and appropriate in each particular case. This often requires us to exercise our clinical judgment and which may potentially involve acting outside of guidelines and protocols.
Age has been used as a criterion for rationing scarce healthcare resources. It has been justified on the basis of the greater good versus the individual: that older people have a shorter length of benefit and they have had a ‘fair innings’.6 In an era where the average life expectancy is 75-80 years old, this mentality is no longer acceptable. We witness daily in clinical practice patients over 75 years with active and fulfilling lives. There is evidence that older people are less likely to receive indicated treatments compared to younger people.7 The NICE guidelines on Social Value Judgement, even supported decision-making based on age: ‘where age is an indicator of benefit or risk, age discrimination is appropriate.’8 There have been reports of over-generalisation of evidence from clinical trials to older patients at risk in other specialties.7 It is important that healthcare’s mentality modifies and address these patients’ care on a case-by-case basis.
A solid understanding of medical ethics enables us to guide our patient through their treatment options. In patients with capacity this can be achieved through supporting their autonomy, the right to exert one’s own will.9 This can be achieved through providing them with all the information, assessing their ability to evaluate the situation and facilitating them to make a decision. This task becomes more challenging in those patients who have irreversible loss of mental capacity. The notions of beneficence (our duty to do good) and non-maleficence (our duty to do no harm) can become more ambivalent. Clinicians may all have different tactics in managing these situations. At times, clinicians need to become a patient’s advocate in obtaining treatments for their elderly patient; this can often be seen in a multi-disciplinary context where their age is just number on a piece of paper.
In our urge to fight against ageism, we risk giving treatments to our elderly patients ‘just because we can’. A study led by University of San Francisco found that most non-melanoma skin cancers were typically treated surgically, regardless of the patient’s life expectancy or whether the tumour was likely to recur or harm them. One in five patients in this study reported a complication from their treatment, and approximately half the patients with limited life expectancy died of other causes within five years.10
The line between beneficence and maleficence becomes blurred again. There have been occasions when patients with advanced dementia have required sedation just to attend their two-week wait appointment. Is it appropriate to sedate these patients to have a biopsy for their slow growing basal cell carcinoma (BCC)? All treatments will have side-effects/complications, but which one will they tolerate the best and cause them least harm? This type of dilemma is raised on a daily basis. Once I was advised, it is just easier to “excise the BCC, don’t overthink it!” But we have a duty in our busy outpatient clinics to think what is best for that particular patient. A narrative ethics approach enables us to take on board our patient’s story, who they are, those involved in their story such as their next of kin and the wishes they may have had if they were able to express them.11 This can seem time consuming in a pressured environment, but allows us to guarantee that we are truly acting to our patient’s best interest. This approach best thrives in a multi-disciplinary clinic setting where these patients can be reviewed individually.
Our elderly dermatology patients are a rising population. They face not only clinical complexities, but also social, psychological and ethico-legal issues. The concept of ‘right treatment, right time, right patient’12 resonates the loudest when managing these patients. Their age should not deter us from offering gold-standard treatments, but a thorough assessment of their comorbidities, performance status and wishes should be our guide instead. An appreciation of their narrative and a balanced measure of risks versus benefits should always be applied when managing this very diverse cohort of patients.
Dr Leila Asfour, Dermatology Specialist Trainee, Salford Royal Hospital
Prize winner, British Society of Geriatric Dermatology Kligman Essay Competition
Conflict of interest: none declared
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2. Definition: old. en.oxforddictionaries.com/definition/old Accessed 12/04/18
3. Jackson SA. The epidemiology of aging. In: Hazzard WR, Blass JP, Ettinger WH Jr, Halter JB, Ouslander JG, eds. Principles of Geriatric Medicine and Gerontology, 4th ed. New York: McGraw-Hill; 1999: 203-25
5. Chalmers JR, Wojnarows F, Kirtschig G, et al. ‘A randomized controlled trial to compare the safety and effectiveness of doxycycline with oral prednisolone for initial treatment of bullous pemphigoid: a protocol for the Bullous Pemphigoid Steroids and Tetracyclines (BLISTER) Trial. Br J Dermatol 2015; 173(1): 227–34