dear editor, Psoriasis management in the rapidly expanding geriatric population can be complex owing to frailty, comorbidities, comedication and limited available data on treating older patients with psoriasis. 1 Previous studies reported comparable disease severity in patients aged ≥ 65 years and patients aged < 65 years, 2 , 3 , 4 although prescribed antipsoriatic therapies differed between age groups. 2 , 3 , 5 This might be due to comorbidities and comedication, and/or disease perception or patient preferences. 3 , 5 Unfortunately, little is known regarding these topics in older patients with psoriasis. Moreover, it has been suggested that currently available quality‐of‐life (QoL) assessment tools do not always appropriately reflect true QoL impairment in older adults. 6
To improve personalized psoriasis management in older adults, this study evaluated the unmet needs in geriatric patients with psoriasis using a nationwide self‐administered survey, distributed among all members of the Dutch Psoriasis Association (n = 3310). The methodology of this study was described in a previous publication. 4 The Dermatology Life Quality Index (DLQI), 5‐point Likert scales and open‐ended questions were used to study disease burden, QoL impact, treatment goals, preferences and satisfaction. To adjust for ‘not relevant’ responses (NRRs), the DLQI‐Relevant (DLQI‐R) score was calculated, with a maximum of three NRRs per patient. 7 Patients were categorized into respondents aged ≥ 65 years and those aged < 65 years. A Mann–Whitney U‐test was used to compare continuous variables between the age groups and χ2‐test or Fisher’s exact test were used for categorical variables. Missing values were not included in the analyses. The Research Ethics Committee of the Radboud University Medical Centre passed a positive judgement on the study before execution of the study had started.
Among the responses suitable for analysis (n = 950; 28·7%), 414 (43·6%) patients were aged ≥ 65 years (mean age 72·4 ± 5·9 years). Disease severity was comparable between the groups. 4 Patients aged ≥ 65 years and those aged < 65 years reported pruritus as the most bothersome aspect of psoriasis [127 (35·0%) vs. 200 (39·8%), P = 0·146], followed by flaking [72 (19·8%) vs. 122 (24·3%), P = 0·120] and visibility [58 (16·0%) vs. 107 (21·3%), P = 0·049]. Although the original DLQI was significantly lower in patients aged ≥ 65 years vs. patients aged < 65 years (mean 2·98 ± 3·5 vs. 3·89 ± 4·55, P = 0·006), the DLQI‐R was not significantly different between the groups (mean 3·42 ± 4·00 vs. 4·13 ± 4·76, P = 0·076). At least one NRR was reported by 238 (60·7%) patients aged ≥ 65 years vs. 161 (31·3%) patients aged < 65 years (P < 0·001). The least applicable items according to patients aged ≥ 65 years were item 7 [work, n = 191 (49·2%)] and item 6 [sports, n = 117 (30·3%)].
The most important relevant treatment goals in both age groups were to be free of pruritus [overall mean 4·56, NRR in 39 (4·1%) patients], scaling [overall mean 4·37, NRR in six (0·6%) patients] and visible lesions [overall mean 4·15, NRR in nine (0·9%) patients]. Freedom from pain and sleep disturbances were not relevant for 181 (19·1%) and 371 (39·1%) patients, respectively; however, these treatment goals were highly valued by those for whom they were applicable (Table 1). Minimalization of adverse events associated with antipsoriatic therapies was valued as the most important patient preference in both age groups (overall mean 4·63). Patient preferences regarding the reduction of several treatment modalities were valued as significantly more important by patients aged ≥ 65 years vs. those aged < 65 years. These included minimizing the use of topical treatment (mean 4·13 vs. 3·94, P = 0·004), injections (mean 4·13 vs. 3·74, P < 0·001) and pills or capsules (mean 3·84 vs. 3·40, P < 0·001)]. Moreover, minimalization of hospital visits and the absence of laboratory assessments were valued as significantly more important by patients aged ≥ 65 years (Table 1). After Bonferroni correction for multiple comparisons, the main outcomes showed comparable results.
Table 1.
An overview of treatment goals, treatment satisfaction and patient preferences in patients with psoriasis aged ≥ 65 years compared with patients aged < 65 years
| < 65 years | ≥ 65 years | NRR | P‐valuesa | ||
|---|---|---|---|---|---|
| Treatment goals | |||||
| To be free of pruritus | 4·52 ± 0·7 | 4·61 ± 0·6 | 39 (4·1) | 0·059 | |
| To be free of pain | 4·41 ± 0·7 | 4·47 ± 0·7 | 181 (19·1) | 0·517 | |
| To be free of scaling | 4·32 ± 0·7 | 4·43 ± 0·8 | 6 (0·6) | 0·003 | |
| To be free of sleep disturbances | 4·31 ± 0·9 | 4·39 ± 0·8 | 371 (39·1) | 0·374 | |
| To be free of negative impact on daily activities | 4·28 ± 0·8 | 4·23 ± 0·9 | 192 (20·2) | 0·713 | |
| To be free of visible lesions | 4·09 ± 1·0 | 4·23 ± 0·9 | 9 (0·9) | 0·050 | |
| Complete clearance of psoriasis lesions | 4·00 ± 1·0 | 4·16 ± 0·9 | 2 (0·2) | 0·009 | |
| To be free of redness | 3·94 ± 0·9 | 4·11 ± 0·9 | 19 (2·0) | 0·006 | |
| Patient preferences | |||||
| Minimize the adverse effects of therapy | 4·64 ± 0·5 | 4·61 ± 0·7 | – | 0·875 | |
| To have confidence in therapy | 4·64 ± 0·5 | 4·57 ± 0·6 | – | 0·170 | |
| To apply/use therapy without help from others | 4·56 ± 0·7 | 4·56 ± 0·7 | – | 0·891 | |
| Minimize the use of topical treatment | 3·94 ± 1·1 | 4·13 ± 1·0 | – | 0·004 | |
| No usage of injections/syringes/intravenous treatment | 3·74 ± 1·4 | 4·13 ± 1·2 | – | < 0·001 | |
| Minimize the amount of hospital visits | 3·77 ± 1·2 | 4·04 ± 1·1 | – | < 0·001 | |
| No usage of pills/capsules | 3·40 ± 1·4 | 3·84 ± 1·3 | – | < 0·001 | |
| To apply/use therapy without laboratory assessment | 2·89 ± 1·4 | 3·34 ± 1·4 | – | < 0·001 | |
| Treatment satisfaction | |||||
| Ease of current treatment | 3·90 ± 1·0 | 3·96 ± 0·9 | – | 0·433 | |
| Overall treatment satisfaction | 3·71 ± 1·0 | 3·75 ± 1·0 | – | 0·763 | |
| Satisfaction regarding treatment frequency | 3·58 ± 1·1 | 3·69 ± 1·0 | – | 0·165 | |
| Burden of side‐effects | 2·51 ± 0·9 | 2·56 ± 0·9 | – | 0·806 | |
NRR, ‘not relevant’ response. Treatment goals and patient preferences were measured using a 5‐point Likert scale (5 indicating highly important, 1 indicating not important at all). Treatment satisfaction was measured using a 5‐point Likert scale (5 indicating highly satisfied, 1 indicating least satisfied). The burden of side‐effects was measured using a 5‐point Likert scale (5 indicating a high burden, 1 indicating no burden at all). aAll results were calculated using a Mann–Whitney U‐test; means were presented to improve comprehensibility of the outcomes. Data are presented as mean ± SD or n (%).
In accordance with previous studies, 6 , 7 these data show that DLQI responses are affected by age and that older patients more frequently select NRRs. This emphasizes the underestimation of the actual QoL impairment, as NRRs are currently scored as ‘0’, which is equivalent to ‘not at all’. Especially in cases where clinical decisions depend on QoL impact (e.g. reimbursement criteria for biological therapies) or studies comparing QoL between age groups, calculation of the DLQI‐R should be considered. A possible limitation of this study was that comparisons were not adjusted for possible confounders. Overall treatment goals, bothersome disease aspects and treatment satisfaction were comparable between the age groups, although the heterogeneity in these outcomes (e.g. the varying number of NRRs regarding treatment goals) accentuates the need for individualized management decisions and specific attention relating to individual patient goals and preferences, reaching further than age alone.
It should be taken into account that overall patient preferences in patients aged ≥ 65 years differed from those of patients aged < 65 years, particularly in relation to the reduction of medication use and hospital visits. Dependency on others could be an explanation for this outcome, 4 as functional impairments in this patient group can cause difficulty in reaching certain areas of the body. Therefore, patients aged ≥ 65 years might experience a higher treatment burden when using topical or subcutaneously administrated therapies. Moreover, comorbidities and comedication could contribute to these patient preferences in those aiming to reduce medication use. 8 Therefore, assessment of individual patient characteristics, QoL impact, treatment goals and preferences could facilitate decision making.
Author Contribution
M.E.C. van Winden: Conceptualization (lead); Data curation (lead); Formal analysis (lead); Investigation (lead); Methodology (lead); Project administration (lead); Writing‐original draft (lead); Writing‐review & editing (lead). E.L.M. ter Haar: Data curation (equal); Project administration (equal); Writing‐original draft (supporting); Writing‐review & editing (supporting). J.M.M. Groenewoud: Formal analysis (equal); Methodology (equal); Writing‐original draft (supporting); Writing‐review & editing (supporting). P.C.M. van de Kerkhof: Conceptualization (supporting); Funding acquisition (equal); Supervision (equal); Writing‐original draft (supporting); Writing‐review & editing (supporting). E.M.G.J. de Jong: Conceptualization (supporting); Funding acquisition (equal); Supervision (equal); Writing‐original draft (supporting); Writing‐review & editing (supporting). S.F.K. Lubeek: Conceptualization (lead); Funding acquisition (lead); Supervision (lead); Writing‐original draft (equal); Writing‐review & editing (equal).
Acknowledgments
We are grateful to all respondents who completed the survey, and to the Dutch Psoriasis Association. We want to thank all focus group members, especially J. van den Reek, M. Kooijmans‐Otero, S. Spillekom‐van Koulil, M. Eilander, M. Teunissen and A. van der Wielen‐Willems. Lastly, we thank M. Poll for his administrative help.
Funding sources: this investigator‐initiated study was conducted with financial support from Almirall. The funding source had no influence on study design, data collection and analysis, or the content of the manuscript.
Conflicts of interest: M.E.C.v.W. has carried out investigator‐initiated research with financial support from Almirall and has conducted clinical trials for AbbVie, Celgene, Janssen, Leo Pharma, Lilly and Novartis. E.L.M.t.H. has carried out investigator‐initiated research with financial support from Almirall and has conducted clinical trials for Novartis. P.C.M.v.d.K. served as the chief medical officer of the International Psoriasis Council 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.d.J. has received research grants for the independent research fund of the Department of Dermatology, Radboud University Medical Centre, Nijmegen from AbbVie, Pfizer, Novartis, Janssen Pharmaceutica and Leo Pharma, 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 including AbbVie, Janssen Pharmaceutica, Novartis, Lily, Celgene, Leo Pharma, UCB and Almirall. All funding is not personal but goes to the independent research fund of the Department of Dermatology at Radboud University Medical Centre Nijmegen, the Netherlands. S.F.K.L. has received research grants for investigator‐initiated research by Almirall.
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