The ElderDerm: Episode 1, Geriatric Dermatology

Listen to the first ElderDerm Podcast, where co-hosts Dr Adam Friedman and Jaya Manjunath discuss what is geriatric dermatology, why there is a need for this area in training and announce the inaugural ElderDerm Conference, to be hosted at George Washington University in DC on June 6th, 2024. 

Adam Friedman, MD, FAAD, is the Chair of Dermatology at GW School of Medicine and Health Sciences.

Jaya Manjunath, is a 3^rd  year medical student at GW, is the founder of the 501(c)(3) nonprofit organization, Seniors with Skills, an international nonprofit with a mission to end social isolation amongst senior citizens.

Transcript:

Dr Friedman: Welcome everyone to a new podcast at The Dermatologist entitled ElderDerm, where we focus on all things geriatric dermatology. I'm Dr Adam Friedman, professor and chair of dermatology at GW School of Medicine and Health Sciences. I am joined by my amazing co-host, Jaya Manjunath, a 3^rd  year medical student at GW, who is very quickly making a name for herself as a result of a tremendous passion for working with the elderly population founder of the 501(c)(3) nonprofit organization, Seniors with Skills, an international nonprofit with a mission to end social isolation amongst senior citizens. Jaya has focused her interest towards dermatology, helping usher in a new and fled subspecialty geriatric dermatology, and we're gonna be talking all about that today. Welcome, Jaya.

Manjunath: Thank you so much for that introduction, Dr Friedman. I'm so happy to be here.

Dr Friedman: Yeah. So we're, we're gonna have a lot of fun over the next, I guess, several podcasts leading up to even some more educational, fun and, and resources and programming. But I think a great place to start is to give the audience maybe in a million mile high view of what exactly is geriatric dermatology.

Manjunath: So geriatric dermatology is an emerging subspecialty in dermatology, which really emphasizes that the practice of dermatology can benefit from including unique provisions for older adult patients. So essentially, this approach integrates important geriatric principles into dermatology care. So let me give you some examples. First, life expectancy. For example, in a healthy 70-year-old patient, they may have a life expectancy over 10 years, making treatment of a low risk basal cell carcinoma appropriate. However, a frail 90-year-old patient with a large number of comorbidities may not live long enough to benefit. So shared decision making is really important in this population. Additionally, considering polypharmacy and medication adverse effects is really important. So, for instance, a patient with itch who is prescribed a sedating antihistamine and has this long medication list may experience dizziness and falls due to this medication, which is very scary in older adult patients. Also, cognition is important to consider.

So, a patient with dementia may not fully understand why they are having a biopsy procedure performed, and this procedure can induce a lot of fear and anxiety. Additionally, when thinking about geriatric patients, it's important to sort of complete a functional assessment and see, for example, if a patient has poor mobility, they may be at increased risk of pressure ulcers. And the last topic I'll mention is with these geriatric patients, it's really important to involve caregivers in social support system to ensure that their overall wellbeing and needs are addressed comprehensively at each visit. So essentially, geriatric dermatology is the specialized approach to provide effective and empathetic care accounting for the unique needs and challenges faced by elderly patients.

Dr Friedman: Well, I think you highlighted the big why. Like, why is there a need for specific considerations for this? I would say rapidly growing population. I mean the size of this cohort certainly is increasing. Our patients are living longer which is fantastic, but that's also more opportunities for things to go wrong with the largest organ being the skin. Now given even the few considerations you brought up which I think many of us don't necessarily automatically think about when we're walking into our clinics is there training to assist with kind of shifting gears and kind of putting on the, I am working with someone who has unique needs you know, in my clinic. Is there a training already to kind of address some of these things you brought up?

Manjunath: That's, that's a great question. So I would say in terms of training, there's been a lot of initiatives on the research front, but not as, not as much attention from the clinical training front. So in terms of clinical training, outside of what is really taught in dermatology residency, there is no formal fellowship or additional clinical training that I'm aware of. So if these cover, if these topics are covered during a resident intern year or during residency, then they may be covered. But if not, I'm not aware of other training that they may experience. And one of the projects I'm really interested in completing is really understanding what is the level of geriatric dermatology education provided at residency programs, because I feel like it could be a very valuable education model for them, because there's these topics like recognizing cutaneous signs of elder abuse, adverse drug reactions in older adults, understanding medication, Medicare coverage of derm services, that could be very useful.

And even having topics such as, how do you, or what do you do when a patient comes in with a very long medication list? How do you manage a patient with dementia when you only have such a limited clinic time? So I'm interested in completing this project to understand if there are gaps in our training and actually creating a model to address these gaps. But there actually is quite a lot of grant opportunities and research training opportunities that I can talk about now. So, the Geriatric Derm Expert Resource Group is a group that I'm co-leading with Dr Daniel Butler from Arizona, and Eleni Linos from Stanford. And the website, geriderm.org, is currently the best place to find more opportunities about training options and grant opportunities related to Geriatric Derm. So, for example, for medical students, there's this MSTAR and medical students in aging research funded by the NIH program tailored to aging research. And for PIs who are early in their career, there's these grant opportunities such as Clin-STAR and GEMSSTAR that exist.

Dr Friedman: That's fantastic. Well, thank you for sharing those resources in, in terms of, you know, educational opportunities. And I know you know, you, and I—and I'd love for you to speak a little bit about this—you and I performed a survey study not too long ago trying to get a, a very baseline assessment of exposure to training in kind of some of these areas with respect to specific considerations for geriatric dermatology. And no surprise the response was there wasn't really dedicated education in training or, you know, at the CME level, for example. So, I'd sort of love to have you touch on that, but from an educational perspective. Is there anything upcoming that could be not just of use, but maybe help already start to fill some of those gaps that we identified?

Manjunath: Yes. So, Dr Friedman, I would love to share that you and I have been starting this initiative, the ElderDerm 2024 conference, which will really be the first geriatric dermatology conference. And we plan to host this on June 6th, 2024 at the George Washington University School of Medicine in Washington DC. And we will be covering a large number of topics, including pruritus in older adults, geriatric teledermatology skincare, and old skin cancer in older adults and wound care in older adults. And this will be an excellent platform to connect researchers all over the world who are in this space and to collaborate form new research projects, connect and integrate medical students and residents into the subspecialty. And as you can tell, I am really excited to be starting this conference with you.

Dr Friedman: Yeah, I feel like I set that up, like we're on the home shopping network. So, tell them about the great deal that's coming. You know, I'm excited as well. I think that there's a really unmet need here and this conference which will be an in-person conference, bringing in experts from around the country to lecture on a wide array of topics. Even simple things like considerations for systemic therapies in the elderly. Something that may you know not, I don't wanna say scare some folks off, but certainly raise some concerns given a lot of the amazing advanced therapies we have in the phase three programs, the cohort of subjects in terms of age ranges, usually very small cohorts when it comes to those 70 plus. So certainly getting some expert guidance and advice from mostly experience and anecdote is gonna be very helpful when considering using these therapies among the many other topics that, that you brought up. I was wondering if you could talk a little bit about some of the research you've done to date in this area. I kind of alluded to some of the gaps that you identified, but what, what are some of the highlights you could mention?

Manjunath: Yeah, so I would like to talk about 2 projects. So 1 of the projects that we did together was a really meaningful project for me, and we did a survey study, essentially aiming to assess provider perceptions and attitudes regarding the unique needs of older adults in dermatology clinics. And we identified several barriers to care and treatment, including limited social support systems, difficulty and comprehension of treatment plans, financial barriers, hearing problems, telehealth, transportation barriers. And these are a lot of the topics that I've been talking about during the podcast that are really important. And this is honestly one of the most meaningful research products that I've done because it really establishes the need for more attention to older adult care. And a lot of my future projects, including the conference, really stems from establishing that original need and then building from that.

And I'll touch on another project that was meaningful for me which was a project I did with Dr Silverberg at George Washington. And that was looking at the association of sleep disturbances with geriatric age and atopic dermatitis patients. And it was published in the JAAD. So essentially, we found that geriatric atopic dermatitis patients had more profound sleep disturbance, particularly staying asleep and having fatigue. And the reason this project was meaningful for me is doing this clinical project made me really question, are there differences in the presentations and pathogenesis of germ conditions in older adults? So, for example, is immunosenescence at play. And that really motivated me to then go and do translational research here to sort of understand differences in proteins, biomarkers, cytokines, and looking at differences in older adult dermatology patients. And also, just studying derm disease that predominantly affect older adults such as CPUO or chronic pruritus of unknown origin.

Dr Friedman: Well, we will certainly wait with bated breath to receive some of that translational data to your point, really be able to define the kind of hetero ethnicity of disease in that, you know, the same disease can be very unique and different in different demographics. Here we're talking about different age ranges and sort of that can help maybe guide therapeutic selection and, and more appropriate personalized approaches, especially this patient population. Well, we're gonna keep it short and sweet for our inaugural podcast. I'm gonna leave with just 1 question to you. What is your hope for this area? What is, you know, if, if all things being equal, everything, all the stars align, what do you hope will happen? With the field of geriatric dermatology

Manjunath: Overall, I genuinely just hope to expand the field, and I want more researchers to be talking about this because there are a lot of researchers doing geriatric derm research. They don't know that this group exists, that we are trying to collaborate, that we're starting this conference. So I think all in all, I want geriatric dermatology to grow naturally as a specialty by just integrating more researchers and collaborations. And I would say the 2nd hope that I have for this area is another topic I'm very passionate about, which is expanding geriatric teledermatology as there is a large population of older adults who are unable to travel to dermatology outpatient appointments for a large number of reasons, including staying at nursing homes with limited transportation access, complex medical conditions, inadequate family support, etc. And I think that's really an interesting space that I'd like geriatric dermatology to move towards to best serve this population.

Dr Friedman: No, that's such a great point because, you know, when we think about access to care that word access has so many different meanings. And, and to that point, there's so many different types of barriers depending on your patient population that can limit their ability to access the care that they need, especially to manage chronic disease states that given, you know, the life expectancy and, you know, extension of life these days can, can really impact one's golden years. Well, Jaya, thank you so much for really taking the lead on this one and, and kind of giving our audience an overview of what is geriatric dermatology, why should everybody care about geriatric dermatology, but also what's already going on? There's already a very robust pipeline of educational and research initiatives that will ultimately make it easy for all of us to take care of this growing population.

So, all those that tuned in, certainly you know, look out in the near future for several more specific topic specific podcasts that we'll be bringing to you probably with some special guests that will be invited to the podcast to share their expertise in these different areas. And you know, as Jaya mentioned, this is an important topic that we should all get behind and certainly become knowledgeable on in order to take care of all of our patients equitably and effectively. Thanks so much for tuning in.