https://orcid.org/0000-0001-9874-4670
Abstract
Background
Evidence-based guidance in older adults (≥65 years) with psoriasis is sparse and undertreatment might be present.
Objectives
To assess prescribing patterns, comfort levels, barriers and needs of dermatologists when treating older adults with systemic antipsoriatic therapy.
Methods
A mixed-methods design was used including a survey among all Dutch dermatologists and residents, followed by semi-structured interviews.
Results
Most of the survey respondents applied systemic treatment to the same extent in older versus younger patients (n = 49; 67.1%) and weren’t reluctant prescribing systemic therapy (n = 50; 68.5%) in older adults. However, 26% (n = 19) of the respondents treated older adults less often with systemic therapy compared to younger patients and 68.1% (n = 49) performed additional actions in older adults, e.g. intensified monitoring or dose reduction. Based on the survey and interviews (n = 10), the main reasons for these age-based treatment differences were comorbidity, comedication, and fear of adverse events. More evidence-based guidance, education, and time to assess older adults were identified as most important needs, especially regarding frailty screening.
Conclusions
Age-based treatment differences in and reluctance to treating older adults with systemic antipsoriatic therapy were common. There is a need for more evidence-based guidance, education, and consultation time, to improve treatment in this growing population.
Introduction
Psoriasis is prevalent in older adults (≥65 years) and dermatologists will be increasingly confronted with this patient group due to an aging world population (Citation1–4). Selecting the most appropriate treatment might vary between age groups and depends on various factors such as patient preferences, quality of life, disease severity, comorbidity and comedication (Citation5–7).
Literature regarding this specific population is sparse, since older adults are repeatedly excluded from clinical trials (Citation8,Citation9). Although a comparable disease severity between older adults and younger patients has been reported, older adults tend to receive less systemic therapy than younger patients (Citation10–13). Several possible explanations can be assumed for the apparent differences in treatment choices between age groups, such as a higher rate of comorbidities, comedication use, frailty, and differences in treatment goals (Citation6,Citation13,Citation14). Furthermore, a (disproportional) reluctance amongst physicians to prescribe systemic antipsoriatic therapy in older adults is suggested as a probable explanation, possibly caused by limited experience and sparse evidence-based guidance (Citation15).
The objective of this study was to gain insights in the prescribing patterns, comfort levels, possible barriers, and needs of dermatologists when applying systemic therapies in older adults with psoriasis. These insights are expected to contribute to the optimization of care in this population.
Methods
Study design and recruitment of participants
A mixed-methods study was conducted, consisting of two consecutive sub studies. First, a nationwide survey was sent by email to all dermatologists and dermatology residents in the Netherlands through the Dutch Society for Dermatology and Venereology (n = 714). A hyperlink to an online survey (Qualtrics, Provo, UT, USA) was provided and after five weeks a reminder was sent. Secondly, in-depth semi-structured interviews were performed with a subgroup of respondents. For the interviews, we attempted to include an equal number of participants who were (1) reluctant to prescribe systemic antipsoriatic therapy in older adults, (2) not reluctant, or (3) unknown (based on the individuals’ response from the survey). This study is reported following the Standards for Reporting Qualitative Research (SRQR) and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (Citation16,Citation17). The committee on Research Involving Human Subjects of the Radboud University Medical Center reviewed the study proposal and waived further formal study approval (reference number: 2021-8107). All participants provided written informed consent for participation.
Survey, data collection and analysis
A survey concerning systemic therapy use in older adults with psoriasis was developed, based on a literature search and experiences from previous research (Citation6,Citation13). To assess the comprehensiveness, clarity and relevance of the formulated questions, the survey was pre-tested by ten dermatologists and residents. Mostly multiple-choice questions were used to assess practitioners prescribing patterns, preferences and influential factors when treating older adults with psoriasis. To assess the comfort levels of respondents regarding prescription of systemic antipsoriatic therapy in older adults, a five-point Likert-scale was used with the options: very comfortable (5), comfortable (4), neither comfortable nor uncomfortable (3), uncomfortable (2), very uncomfortable (1). Furthermore, open-ended questions were added to further evaluate relevant items not captured by the multiple-choice questions and these answers were manually categorized for further analysis. The survey also enquired about socio-demographic practitioner information (e.g. age, sex, years of experience). Completing the survey was anonymous, but respondents could leave their contact details voluntary if they were willing to be contacted for any additional questions/interview. Statistical analyses were performed using Statistical Package for Social Sciences (SPPS) version 25.0 (IBM, Armonk, NY) and R (version 3.6.3) (Citation18). To summarize continuous variables and categorical data descriptive statistics were used such as mean (± standard deviation (SD)) or median (range) and frequencies and percentages, respectively. To determine the comfort levels using Likert-scales, the overall mean score per treatment was calculated and differences among treatments were tested using a multilevel model with a random intercept for respondent followed by a correction for multiple testing using Bonferroni. Selection bias due to nonresponse was tested by comparing respondents’ sex and age with the target population using a chi-square test and independent t-test. A p-value <.05 was considered significant.
Interviews, data collection and analysis
A semi-structured interview guide was developed after a literature review, assessing the survey data and discussion in the research group, including an expert on qualitative research (MT). The interviews were conducted in Dutch and audio recorded by EtH from March 2021 to July 2021 until data saturation was reached, defined as when no new concepts emerged. The interview-guide was adjusted throughout the interviewing process, when new subjects or questions emerged. Data were analyzed using inductive thematic analysis. The codes and themes were derived directly from the data using Atlas.ti 8 software (Citation19). The interviews were transcribed verbatim by EtH and the transcripts were read several times resulting in a coding framework. In regular meetings, the codes were discussed with the research team. The coding framework was used to define themes and subthemes which were discussed with SL and MT until consensus was achieved.
Results
Study participants
Between September 2020 and April 2021, a total of 89 responses were collected (response rate 12.5%). Due to an insufficient amount of answered items (e.g. baseline respondent characteristics only) 16 responses were excluded, leaving 73 responses suitable for further analyses. The median respondent age was 46 years (range: 27–64) and 30 respondents (41.1%) were male. Of the respondents, 59 (80.8%) were dermatologists and 14 (19.2%) were residents. A comparison of age and sex between the survey respondents and the target population showed no significant differences, indicating representativeness on age and sex (Supplemental Table 1). In total ten in-depth semi-structured interviews were conducted, resulting in data saturation. Half of the interviews were conducted in person, the other half using an online video connection. The mean duration of the interviews was 36 min (range: 24–49). A full overview of survey respondent characteristics and interview participants is given in .
Table 1. Survey respondent and interview participant characteristics.
Quantitative results: survey
Systemic antipsoriatic therapy in older adults
Most respondents had experience with prescribing methotrexate, dimethyl fumarate, acitretin and adalimumab in older adults with psoriasis. The majority of respondents (n = 49; 67.1%) indicated that they treated older and younger patients to the same extent with regard to systemic therapy. Twenty-six percent of the respondents (n = 19) reported to treat older adults less often with systemic therapy compared to younger patients. Most reported reasons for this were (reporting of multiple reasons was possible): presence of comorbidity (n = 19), comedication use (n = 16), risk of adverse events (n = 14), and treatment choices of the patient (n = 10). Furthermore, most respondents (n = 49; 68.1%) performed additional actions when using systemic antipsoriatic therapy in older adults compared to younger patients. The most frequently reported additional actions were: more intensive monitoring of comorbidity and comedication use (n = 37), more frequent consultations with other specialists and/or general practitioners (n = 24), prescribing a lower dosage compared to standard care (n = 24), and performing laboratory tests more frequently (n = 19). A full overview is given in .
Table 2. Survey respondent experiences when treating psoriasis in older adult patients with systemic therapy.
Reluctance with prescribing systemic antipsoriatic therapy
Almost half of the respondents (n = 33; 45.2%) indicated that their colleagues are (more) reluctant to use systemic therapy in older adults. However, when asked whether the respondents themselves were reluctant to prescribe these therapies in older adults, the majority reported that they were not (n = 50; 68.5%). Respondents that reported to be reluctant (n = 20; 27.4%) described several reasons for this, of which most reported reasons were (reporting of multiple reasons was possible): presence of comorbidity (n = 19), use of comedication (n = 17), and risk of adverse events (n = 15). A full overview is provided in .
Table 3. Reluctance amongst survey respondents with systemic antipsoriatic therapy in older adults.
Comfort-levels in systemic antipsoriatic therapy
Respondents indicated they were most comfortable prescribing the following systemic antipsoriatic therapies in older adults (range 1–5; higher scores indicate respondents to be more comfortable): methotrexate (4.26 ± 0.6), acitretin (4.18 ± 0.6), ustekinumab (4.03 ± 0.7), and adalimumab (4.03 ± 0.7). For ciclosporin (2.82 ± 1.1, p < .001) and infliximab (3.12 ± 1.2, p < .001), a significant lower mean score was seen compared to methotrexate, indicating that respondents were most uncomfortable prescribing these therapies ().
Table 4. Comparison of comfort levels of respondents when using systemic antipsoriatic therapy in older adults.
Qualitative results: interviews
The following themes were identified from the interviews: prescribing patterns, challenges and barriers when prescribing systemic antipsoriatic therapy in older adults, needs when treating older adults with psoriasis, and future recommendations for treating older adults with psoriasis. See for an overview of themes/subthemes. For illustrative quotes supporting the themes, see Supplemental Tables S2–S5.
Table 5. Overview of the key themes, subthemes and codes, emerged from the interview analysis regarding systemic antipsoriatic therapy in older adults.
Prescribing patterns
Regardless of a patient’s age, most participants considered several factors when deciding upon a treatment type, e.g. disease severity, patient treatment goals, and (potential) contra-indications. For the treatment of older adult patients, participants mostly tended to follow the current psoriasis guideline recommendations, as they would in younger patients (age-based treatment equality).
Older people are entitled to systemic therapy like all other age categories. It's just a safe and good way of treatment, provided that you do it lege artis (P4)
Often, the concept of shared-decision making is used as a tool for treatment selection.
I always try to apply shared-decision making, so I will never present a patient with only one treatment option (P2)
However, in older adult patients the following factors related to aging receives more attention by participants in daily practice: comedication use, comorbidity, frailty, mobility, cognitive function, and social support system. Participants indicated that these factors can lead to a more cautious treatment approach and are likely to contribute to a reluctance for prescribing systemic therapy and perform additional actions in this population. Examples of the latter are: dose adjustments, more frequent lab controls, consulting other specialists and actively checking patients understanding of treatment use (age-based treatment inequality).
I feel that I am slightly more reluctant with systemic antipsoriatic therapy in older adults than in the younger population (P5)
Challenges and barriers
The factors as described above, were also defined by the participants as barriers and challenges for the use of systemic antipsoriatic therapy in older adults. Especially in frail patients, participants are more cautious and sometimes reluctant to prescribe systemic antipsoriatic therapy. The difficulty of making a good estimate and prevent misjudgment of patients’ vulnerabilities (e.g. cognitive function, patients comprehensibility, mobility, social support system), especially in the short amount of time given at an outpatient clinic was defined as a barrier. Other defined barriers are the often more extensive multimorbidity and comedication use in this population, which can complicate the prescription of certain antipsoriatic therapies.
Especially the comorbidity and multi-drug use, I often find that difficult (P9)
Other possible barriers for the use of systemic antipsoriatic therapy in older adults were: fear of adverse events, inexperience with the prescription of specific treatment options, the presence of patient-related treatment reluctancy, patients’ dependency in activities of daily living (i.e. proper use of prescribed therapy), suboptimal compliance, and patient’s outspokenness (i.e. will the patient ask for help when needed or will the patient indicate whether treatment regimens are unclear).
I think there's that fear, that you're doing more harm than the condition you're treating (P4)
You can be well trained in systemic therapy, however, if you don’t prescribe it often in clinical practice, you might become more reluctant to prescribe it (P4)
Patients’ understanding of the antipsoriatic therapy, especially when older patients live alone, is the treatment going well? Patients ability to recognize adverse events and ask for help (P2)
Unmet needs and future recommendations
Participants were asked whether they have unmet needs regarding the prescription of systemic antipsoriatic therapy in older adults. Most participants wished for more evidence-based guidance concerning older adults, such as a compact overview of safe treatments for older adults including dosing regimens, specific contra-indications, and especially treatment-related adverse events.
I think that relatively few patients of this age are included in clinical trials due to contraindications and exclusion criteria. So I think it makes sense to specifically collect data from this patient population, to obtain more real life data (P9)
Some others opted for more education regarding older adults with psoriasis during their residency but also for dermatologists. Also, specific measures were described such as; more consultation time and specific information leaflets for older adults.
I think it is important to have more consultation time and to involve the social support system of the patient, this should be more standard in clinical practice (P8)
Furthermore, some additional future recommendations were suggested: (1) more focus on personalized medicine in dermatology practice (e.g. assessment of frailty and acting accordingly), (2) specific safety measures (e.g. more support at the outpatient clinic by nurse practitioners), and (3) easier and more frequent contact with other caregivers (e.g. homecare facilities).
It is desirable to have a nurse practitioner at the outpatient clinic who knows everything about our systemic antipsoriatic medication. Who can relieve the workload in terms of the time needed explaining the antipsoriatic treatments to patients and can also give patients much more insight into the medication they are about to get (P5)
Discussion
In this mixed-methods study the prescribing patterns, possible barriers, and needs of dermatologists and residents regarding systemic antipsoriatic therapy in older adults were explored. The most important findings were that most survey respondents applied systemic therapy to the same extent in older adults compared to younger patients (67.1%) and were not reluctant to prescribe systemic therapy in this population (68.5%). However, age-based treatment differences and systemic treatment reluctance in this population were also seen. A quarter of the respondents reported to treat older adults less often with systemic therapy compared to younger patients, and respondents often indicated that their colleagues are (more) reluctant to use systemic therapy in this population (45.2%). Furthermore, most respondents (68.1%) performed additional actions when treating older adults with systemic therapy, in particular more intensive monitoring of comorbidity and comedication, more frequent consultations with other specialist, and prescribing a lower dose of systemic antipsoriatic therapy than standard practice.
The main reasons for these age-based treatment differences and reluctance, as indicated by the survey respondents and the additional in-depth interviews, were the presence of comorbidity, comedication use, and the fear of adverse events in older adults. In addition, interviewees mentioned the sparse evidence-based guidance regarding efficacy and safety of these treatments in a geriatric population as another important reason for treatment reluctance. Fortunately, there seems to be more attention for this specific population in all medical fields nowadays. Recent studies regarding older adults with psoriasis report an acceptable safety profile in older adults and that age alone should not be a restrictive factor when treating psoriasis (Citation14,Citation20–22).
Reluctance to prescribe certain medications in older adults is common amongst healthcare providers in other medical specialties and the mentioned reasons to be reluctant in the current study are generally in line with previous research regarding prescription of systemic antipsoriatic therapy in older adults with psoriasis (Citation23–26). A reluctance to use systemic antipsoriatic therapy might be rational and necessary, for instance when possible (relative) contra-indications are present. However, sometimes this reluctance might also be disproportional and potentially leads to undertreatment. This could for instance be due to a lack of knowledge or experience to treat older adults or the conceptions of ageist stereotypes and age-based assumptions without paying proper attention to the heterogeneity of the older adult population in terms of frailty and resilience.
Frailty is a factor physicians find especially hard to assess in older adults. Even though frailty screening tools are available and seem suitable for dermatology practice, there are no studies on this topic for older psoriasis patients (Citation27). These frailty tools might be useful for the management of older adult patients with psoriasis, future studies on frailty screening, and the consequences of frailty in this population would be beneficial to enhance further risk-stratification and optimize personalized medicine in the heterogenous population of older adults with psoriasis. Furthermore, the interviewees in the current study expressed the need for more education and time to assess older patients during their clinical visits. Since it is expected this will aid in assessing frailty and, as a result, may decrease reluctance to prescribe systemic antipsoriatic therapy.
Focusing on specific types of systemic antipsoriatic therapy, the results of the survey showed that respondents had most experience with prescribing conventional systemic antipsoriatic therapy (mainly methotrexate, dimethyl fumarate, and acitretin) in older adults with psoriasis. Respondents had less experience with prescribing biologics in this specific population, which is also seen in literature (Citation12,Citation13). In addition, respondents were asked to indicate their level of comfortability with the different types of systemic antipsoriatic therapies. Methotrexate, acitretin, ustekinumab and adalimumab were rated as most comfortable to prescribe in older adults. Ciclosporin was rated as being most uncomfortable with when prescribing in older adults, which was correspondingly also the least prescribed conventional systemic antipsoriatic therapy for older adults in this study, which is in line with literature (Citation13). Obviously, it is not surprising to find this correlation between prescription behavior and the level of comfortability with the different types of systemic antipsoriatic therapies. Also, existing data on efficacy and safety seem to reflect these findings (e.g. the risk for adverse events of ciclosporin in older adults probably reflecting in a low comfortability-score) (Citation14). However, as mentioned before, a lack of knowledge or experience with specific treatment options might also result in a reluctance to prescribe these options in general or in this specific population, potentially leading to undertreatment. This highlights the mentioned needs for more evidence-based guidance and education.
This mixed-method design is subjected to factors as recall bias and the possibility of misinterpretation. To mitigate these, the survey was pretested by several dermatologists and residents and the interview guide was reviewed by the research team. In regular meetings the interview codes and themes were discussed until consensus was reached. The results we found might not be generalizable to all dermatologists/residents due to the possibility of selection bias and limited number of respondents. However, a non-response analysis was conducted to check for selection bias and in the selection for interview participants we aimed to include balanced groups regarding sex and type of medical center.
In conclusion, this study highlights that age-based treatment differences and reluctance to treat older adults with systemic antipsoriatic therapy are common. Comorbidity, comedication, and fear for adverse events were mentioned as the most important reasons for this. More evidence-based guidance, education, consultation time, and the use of frailty screening were the most important needs, to improve treatment and prevent undertreatment in this growing population.
Supplemental Material
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The authors are grateful to all respondents and interview participants who participated in this study.
Disclosure statement
E.L.M. ter Haar has carried out investigator-initiated research with financial support from Almirall and has carried out clinical trials for Novartis. P.C.M. van de Kerkhof serves as the chief medical officer of the International Psoriasis Council, editor of the Journal of dermatological treatment and received fees for lectures and consultancies from Bristol Mayer Squib, UCB, Leo Pharma, Eli Lilly and Company, Dermavant, Almirall, Celgene Novartis, Janssen, and AbbVie. E.M.G.J. de Jong has received research grants for the independent research fund of the department of dermatology of the Radboud university medical center Nijmegen, the Netherlands from AbbVie, BMS, Janssen Pharmaceutica, Leo Pharma, Novartis, and UCB for research on psoriasis, has acted as consultant and/or paid speaker for and/or participated in research sponsored by companies that manufacture drugs used for the treatment of psoriasis or eczema including AbbVie, Amgen, Almirall, Celgene, Galapagos, Janssen Pharmaceutica, Lilly, Novartis, Leo Pharma, Sanofi and UCB. All funding is not personal but goes to the independent research fund of the department of dermatology of Radboud University medical center Nijmegen, the Netherlands.S.F.K. Lubeek has received research grants for investigator-initiated research by Almirall, and has acted as consultant and/or paid speaker for Janssen, LEO Pharma, Almirall, Sanofi Genzyme and Sunpharma. All funding is not personal but goes to the independent research fund of the department of dermatology of Radboud university medical center Nijmegen, the Netherlands. No other potential conflicts of interest were reported.
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