Issues Concerning the Elderly

From Current Topics in Geriatrics, sponsored by the Johns Hopkins University School of Medicine, Baltimore, MD

Educational Objectives

The goal of this program is to improve the management of dermatologic conditions and to address caregiving and driving concerns with older patients. After hearing and assimilating this program, the clinician will be better able to:

Select appropriate treatment for actinic keratoses and pruritus.

Determine causes of drug eruptions, based on clinical findings and drug history.

List challenges and rewards associated with caregiving.

Distinguish active problem-solving approaches from passive approaches.

Identify red flags and counsel older patients about driving safety.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of inter­est. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a pro­prietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Drs. Beacham, Ankrom, and Weiss spoke in Towson, MD, at the Edmund G. Beacham 36th Annual Current Topics in Geri­atrics, presented February 12-14, 2009, by the Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the produc­tion of this program.

Most Common Questions About Geriatric Skin Problems

Bruce E. Beacham, MD, Clinical Associate Professor of Dermatology, University of Maryland School of Med­icine, Baltimore

Actinic keratoses (patient asks, “how can I get rid of all these spots?”): single hypertrophic actinic keratosis can be excised and sent to pathology laboratory to rule out squamous cell carcinoma, or frozen and checked in 6 mo; actinic keratoses around scalp and forehead can range from actinic dermatitis to squamous cell carcinoma; cascade of tumor progression and field cancerization occurs at different stages at multiple sites on sun-exposed skin; risk of developing invasive squamous cell carcinoma higher with greater number of precancerous lesions; unable to pre­dict which lesions will progress to invasive squamous cell carcinoma (all actinic keratoses should be treated)

Treatment options: efficacious; safe; choice of agent depends on comfort level, practice style, and patient variables; flu­orouracil (5-FU; eg, Carac), diclofenac (eg, Solaraze gel), and imiquimod result in 50% complete clearance rate; cryosurgery  —  useful for patients with few lesions; best response (80% complete response rate) seen when lesion frozen for 10 to 15 sec; longer freeze time increases risk for permanent hypopigmentation at treatment site; not use­ful for treatment of cancerization fields (ie, multiple lesions) or lesions not yet visible; new approaches  —  changes in regimen; combinations of therapies (eg, 5-FU and photodynamic therapy [PDT]); newer drugs

Short-contact PDT: emerging treatment for field cancerization; aminolevulinic acid (ALA) applied to field for »1 hr, then field exposed to blue light for 10 to 14 min; resulted in »75% clearance in »90% of patients studied, with 20% recurrence rate at 12 mo; may need to be coupled with cryosurgery to treat larger hypertrophic actinic keratoses; in­effective for squamous cell or basal cell carcinomas

Imiquimod: 5% cream; immune-response facilitator; antineoplastic and antiviral effects  —  enhanced innate and ac­quired local immunity; promotion of cytokine release; promotion of antigen recognition and Langerhans cell mi­gration to regional nodes; recruitment of activated T lymphocytes; promotion of apoptosis; applied 3 times per week for 4 to 8 wk (if inflammation brisk, reduce to twice weekly; if inflammation severe, take rest period of 1-4 wk); data show 80% to 100% lesion clearance, with 5% to 10% recurrence rate at 1 yr; conclusions  —results in high sustained clearance rate for actinic keratoses; created immunologic memory for long-term response; may re­duce risk for squamous cell carcinoma; cosmetically improves skin quality; useful for field cancerization, actinic keratoses, squamous cell in situ and superficial basal cell carcinoma; good adjunctive treatment to cryosurgery; ef­fective prophylactic or maintenance treatment for patients with high sun exposure and many actinic keratoses and squamous cell carcinomas

Aging skin (patient asks, “what can I do to improve my looks?”): innate aging  —  fine wrinkling; atrophy of der­mis; reduced subcutaneous tissue; actinic damage  —  coarse wrinkling and furrowing; pigmentation; thickening of skin; elastotic changes; tretinoin (eg, Retin-A)  —  gold standard in topical rejuvenation agents; normalizes epidermal atypia; increases dermal collagen and new blood vessel formation; improves fine wrinkling and normalizes pig­mentation; gives richer tone to skin; topical ascorbic acid  —  “pretty good” antioxidant; best for lightening pigmen­tation; glycolic and lactic acids  —  a-hydroxy and fruit acids; induce exfoliation of photodamaged skin; increase mucopolysaccharides and collagen synthesis; b-hydroxy acids  —  eg, salicylic acid; good for smoothing skin, but does not affect collagen; sunscreen  —  broad-spectrum protection (ie, against UVA and UVB) important; may im­pair vitamin D synthesis; Anthelios SX effective at blocking UVA

Drug eruptions (patient asks, “what is causing this rash?”): chronologic factors important; refer to nurse’s notes to determine time of rash onset; 90% of drug eruptions in elderly exanthematous (morbilliform) and urticarial; lichenoid  —similar to lichen planus; flat-topped violaceous papules; most commonly seen with hydrochlorothia­zide, antimalarial agents, nonsteroidal anti-inflammatory drugs (NSAIDs), gold, penicillamine, and captopril; lu­pus-like  —  commonly seen with anticonvulsants, isoniazid, hydralazine, minocycline, procainamide, penicillin, and D-penicillin; subacute lupus erythematosus  —  configurate, red, odd-shaped lesions; commonly seen with tumor ne­crosis factor (TNF)-a inhibitors (eg, etanercept [Enbrel]), azathioprine, glyburide, griseofulvin, terbinafine, hydro­chlorothiazide, penicillin, penicillamine, and piroxicam

Pruritus (patient asks, “can you stop me from itching?”): substances that produce itch include papain, trypsin, se­rotonin, bradykinin, kallidin, kallikrein, substance P, and vasoactive intestinal peptide (VIP); prostaglandins exag­gerate existing itch; opiates have central and peripheral itch-producing action; asteatotic eczema (“winter itch”) and extreme xerosis respond to emollients and low-dose topical steroids; advise patients to use mild cleanser (eg, Dove) and to avoid using antistatic dryer sheets

Conditions that cause pruritus: chronic renal disease  —  10 treatments with narrow-band UV phototherapy effec­tive (treatments may then be reduced to once monthly); cholestasis  —itch due to high level of bile salts; cholestyr­amine rapidly decreases level and causes symptomatic improvement; endocrine diseases  —  thyrotoxicosis often due to increased skin blood flow and release of histamine; in hypothyroidism, pruritus secondary to dry skin of myxedema; postmenopausal pruritus generally localized to anogenital area (associated with pruritus ani); important to correct endocrine problem before trying medications or creams; malignancy  —  Hodgkin’s disease; »50% of pa­tients diagnosed with polycythemia vera have water-induced pruritus (“bath itch”; can precede polycythemia vera by years; itch independent of temperature of water)

Work-up for generalized pruritus: physical examination (including pelvic and rectal examinations); complete blood cell count (CBC); ova and parasites; tape test to check for pinworms; chest x-ray; thyroid, renal, and liver function tests; palpate for lymphadenopathy; drug history; first-line therapy  —disease-specific therapy; patient edu­cation about bathing practices; topical emollients; menthol; phenol; camphor; glycerin; fingernail trimming; topical primacaine; use caution with sedating antihistamines (eg, hydroxyzine, doxepin); consider starting with nonsedat­ing antihistamine (eg, desloratadine [Clarinex], cetirizine [Zyrtec; slightly sedating]); second-line therapy  —  topical steroids combined with menthol or primacaine; UV light for refractory pruritus; narrow-band UVB therapy; nal­trexone; gabapentin, 1 tablet/day (work up to 3 tablets/day; monitor for ataxia, instability of gait, and sedation); third-line therapy  —  topical capsaicin may be effective after 3 to 4 wk

Rosacea (patient asks, “why am I getting pimples now?”): presents as red papules and papulopustules in central region of face against vivid background of telangiectasias; diffuse hyperplasia of connective tissue with enlarged sebaceous glands develops; usually localized to nose, cheeks, chin, and forehead; retroauricular region, V-shaped chest region, neck, and back less commonly affected; flushing and blushing evoked by UV light, heat, cold, chemi­cal irritation, strong emotions, alcohol, hot beverages, and spices; subtypes  —  1) erythematotelangiectatic; redness with telangiectasias; common; difficult to treat; start with topical sulfacetamide (consider adding low-dose oral doxycycline or tetracycline); niacinamide reduces redness; consider intense pulse light therapy or laser treatment; 2) papulopustular; requires combination of oral antibiotics and metronidazole (eg, MetroGel) or azelaic acid (eg, Finacea); start with topical treatment; 3) rhinophyma; nose, earlobes, and chin grossly deformed with sebaceous hyperplasia; treat with laser reshaping of nose; treat inflammatory rhinophyma with isotretinoin (Accutane); 4) oc­ular; causes itchy eyes, conjunctivitis, and inflammation of meibomian glands; treat with eye drops and oral tetra­cycline or doxycycline

Caregiver Concerns

Michael Ankrom, MD, MHS, Chief of Geriatrics, Baltimore Washington Medical Center, Baltimore

Informal caregivers: family; not paid to provide care; examples  —  adult child caring for parent; spouse providing care for elderly husband or wife; middle-aged parent providing care for disabled adult child; adult caring for friend or neighbor; minor children caring for disabled parent or grandparent

Changing roles: mother and daughter  —  mother provides care to daughter, but eventually daughter provides care to mother; if mother becomes disabled or ill, roles and interactions change (transition may be difficult); husband and wife  —  husband provides finances, house and yard maintenance, and management of legal affairs; if husband be­comes ill, he can only provide some yard maintenance; function of caregiver changes

Challenges between caregiver and care recipient: spousal relationship  —  intimacy; changes in sexual function or drive can create conflict; family and friends  —  common for caregiver and care recipient to become socially isolated; regular functions and activities (eg, physician visits) become more difficult; changes in interaction (with, eg, family member who develops Alzheimer’s disease [AD]); care needs of care recipient and caregiver must be negotiated; diagnosis of disease  — in dementia or dementia-like syndromes, communication between care recipient and care­giver needed; interaction with family and environment (eg, understanding diagnosis and working with care recipi­ent) important; communication  —changes in communication ability of care recipient; communication between caregiver and care recipient; personal care  —identify limits (eg, “what are you uncomfortable doing?”) and bridge gaps; member of extended family or hired caregiver may feel more acceptable; home safety  —  address wandering, cooking safety, and fire safety; driving  —  discuss comfort level of patient and family members; physician visits  —  involve family members to help clarify information; family visits and holidays  —  may be difficult for care recipient to leave house; holidays may cause overstimulation; AD and dementia  —patients require more assistance as disease progresses

Risks associated with caregiving: depression; mental and physical health complications; anxiety; long-term medical problems (eg, heart disease, cancer, diabetes, arthritis); burden  —feelings of frustration, anger, or guilt; loneliness; fatigue; physical, emotional, or financial exhaustion; stress  —  can weaken immune system; caregivers report more days sick (with, eg, common cold) than noncaregivers; associated with weaker response to influenza vaccine, slower wound healing, and higher levels of obesity; stressed elderly who care for disabled spouses 63% more likely to die within 4 yr, compared to nonstressed caregivers; female caregivers less likely to seek medical care for self, fill prescriptions (due to cost), undergo mammography, get adequate sleep, and cook healthy meals

Rewards of caregiving: feelings of giving back to loved one; feeling needed; stronger relationship with person re­ceiving care; 50% report greater appreciation for life; 50% report feeling good about themselves; caregivers who spent ³14 hr/wk giving care lived longer, with risk for death reduced by 50%; study found high-intensity caregiving (providing 24 hr/wk of care) reduced mortality and decreased rate of mobility decline (eg, walking speed, physical function)

Active problem-solving: may reduce feelings of stress

Patient with dementia says, “I want to go home” when at home: passive approach  —  “you are home”; active prob­lem-solving  —  address feeling or emotion (eg, “I feel uncomfortable too”); distract patient (eg, “I’m hungry; are you hungry?”)

Restlessness and pacing: common in inpatient settings and in patients who suffered stroke; passive approach  —  “sit down”; “be still”; active-problem solving  —  consider patient may need to walk or exercise; be aware patients with dementia may not be able to tell what problem is (eg, arthritis flare, constipation); distraction techniques may be useful

Patient with dementia asks, “where is my mother?”: common; passive approach  —  “your mother is dead”; active problem-solving  —  consider patient feels lost (eg, “I’m here; how can I help you?”)

Caregiver support groups: caregivers who favor passive approach may benefit by learning and trying active prob­lem-solving techniques

Community services for caregivers: consider “rainy day ideas” (eg, ask about arrangements in case caregiver be­comes ill); resources  —  county or state department on aging may assess needs of patient and family and provide in­formation about available programs

Assessing Older Drivers

Carlos O. Weiss, MD, MHS, Assistant Professor, Division of Geriatric Medicine and Gerontology, Johns Hop­kins University School of Medicine, Baltimore

Driving and function: driving ability can fluctuate; decline can be gradual; driving ability contextual; assess physi­cal ability, choice to drive, and driving environment; loss of driving ability should trigger comprehensive geriatric assessment; driving relates to patient’s sense of self; patients can feel threatened by driving assessment

Discussing driving assessment: affirm primary responsibility to patient; respect patient’s goals; clarify goal to pro­vide accurate information about patient’s driving ability and safety; identify and treat medical conditions; openly acknowledge shared responsibility to prevent accidents; no evidence suggests older adults should be screened for driving safety; watch for red flags

Red flags: observer (eg, relative) expresses concern; history of accident or near accident; syncope; seizure; recent stroke; use of medications or substances known to impair vision, cognition, or motor skills; if patient has ³1 red flags, consider driving assessment

Physical examination: vision  —  visual acuity test; 20/70 commonly accepted threshold; check for abnormality in vi­sual fields; cognition  —  Trail-Making Test, part B (matching scattered numbers and letters on paper) most strongly associated with driving ability; clock-drawing test; check motor function; use clinical judgment; driving ability dif­ficult to predict; some patients may need to be referred for on-the-road driving test; discuss safe alternatives to driv­ing

On-the-road driving test: patients who fail may consider consulting driving rehabilitation specialists; annual evalu­ation for patients who pass; may be costly ($300-$400)

Counseling: advise patients to drive on familiar routes at appropriate speeds, and to avoid driving at night, on ex­pressways, and during rush hour

Liability: inform patients about medications that impair driving ability and document conversation; terms  —  vary across states; reporting liability (ie, “are you at risk if you fail to report risky driver who caused damages?”); immu­nity (protection of physician for damages caused by patient) and breach of confidentiality; in Maryland, drivers re­quired to notify Motor Vehicle Administration (MVA) after diagnosis of certain conditions (eg, dementia, stroke); American Medical Association Physician’s Guide to Assessing and Counseling Older Drivers available free online (www.ama-assn.org/ama/pub/physician-resources/public-health)

Suggested Reading

Arbesman M et al: Evidence-based perspective on the effect of automobile-related modifications on the driving ability, performance, and safety of older adults. Am J Occup Ther 62:173, 2008; Braithwaite V: Between stressors and outcomes: can we simplify caregiv­ing process variables? Gerontologist 36:42, 1996; Fenske NA et al: Cosmetic modalities for aging skin: what to tell patients. Geriat­rics 45:59, 1990; Fisher AA: Drug-induced skin eruptions: typical treatments for topical problems. Geriatrics 34:45, 1979; Fitzpatrick JE: Common inflammatory skin diseases of the elderly. Geriatrics 44:40, 1989; Fredman L et al: Caregiving, mortal­ity, and mobility decline: the Health, Aging, and Body Composition (Health ABC) Study. Arch Intern Med 168:2154, 2008; Gaugler JE et al: The family caregiving career: implications for community-based long-term care practice and policy. J Aging Soc Policy 18:141, 2006; Hirth VA et al: Cognitive performance and neural correlates of detecting driving hazards in healthy older adults. De­ment Geriatr Cogn Disord 24:335, 2007; Epub 2007 Sep 19. Litt JZ: Rosacea: how to recognize and treat an age-related skin dis­ease. Geriatrics 52:39, 1997; Miller EA et al: Commentary: navigating the labyrinth of long-term care: shoring up informal caregiving in a home- and community-based world. J Aging Soc Policy 21:1, 2009; Oswanski MF et al: Evaluation of two assess­ment tools in predicting driving ability of senior drivers. Am J Phys Med Rehabil 86:190, 2007; Richey ML et al: Aging-related skin changes: development and clinical meaning. Geriatrics 43:49, 1988; Rull G et al: The physician's role in assessing and counseling aging drivers: a training session for undergraduate medical students. Gerontol Geriatr Educ 29:38, 2008; Samuel M et al: Interven­tions for photodamaged skin. Cochrane Database Syst Rev:CD001782, 2005; Shaffelburg M: Treatment of actinic keratoses with sequential use of photodynamic therapy; and imiquimod 5% cream. J Drugs Dermatol 8:35, 2009; Silverstein NM: When life ex­ceeds safe driving expectancy: implications for gerontology and geriatrics education. Gerontol Geriatr Educ 29:305, 2008; Soskolne V et al: The context of caregiving, kinship tie and health: a comparative study of caregivers and non-caregivers. Women Health 45:75, 2007.