The American Thoracic Society has released an evidence-based clinical practice guideline for the treatment of patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD), as published in the American Journal of Respiratory and Critical Care Medicine.
Notably, the recommendations do not provide a hierarchy of which treatment to use. “[T]he committee felt that a prescriptive decision tree would not be appropriate for this patient population with the evidence that was available,” said the guideline authors. They therefore assessed the medications independently. They also encouraged clinicians to use their recommendations “in conjunction with shared decision-making with patients,” incorporating patient preferences and concerns with respect to side effects, route of administration, and/or cost.
“This guideline aims to serve as a starting point to highlight gaps in evidence to encourage future research into topics and comparisons that can then provide more prescriptive guidance,” stated the guideline authors, an international committee that included pulmonologists with ILD expertise, rheumatologists with SSc expertise, a general pulmonologist, a pulmonologist/rheumatologist with expertise in SSc and ILD, an information scientist, and 2 patients with SSc-ILD.
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The guideline strongly recommends treating patients with SSc-ILD with mycophenolate and conditionally recommends treatment with cyclophosphamide, nintedanib, rituximab, tocilizumab, and the combination of nintedanib plus mycophenolate.
The current recommendations are intended for a heterogenous population of patients with SSc-ILD, regardless of their disease status, said guideline authors. From the outset, the authors aimed to provide guidelines based on disease status for 3 patient subgroups: patients initially manifesting of SSc-ILD; patients with stable SSc-ILD; and patients with progressive SSc-ILD. Ultimately, this was not done because information on treatments effects according to disease status was not available.
The committee based its recommendations on a literature search in MEDLINE, EMBASE, the Cochrane Registry of Controlled Trials, Health Technology Assessment, and the Database of Abstracts of Reviews of Affects for relevant articles published through October 2022. The quality of evidence was based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.
Key Clinical Questions Addressed
The SSc-ILD guideline recommendations address 8 key clinical questions related to 6 individual therapies and 2 combination therapies.
Cyclophosphamide
Question 1 addresses whether patients with SSc-ILD should be treated with cyclophosphamide, a cytotoxic agent that has shown efficacy in some types of inflammation-associated ILD, including SSc-ILD. Cyclophosphamide is also associated with serious side effects, including bone marrow suppression and infections. Overall, the quality of evidence was rated as low, and the guideline committee issued a conditional recommendation for use of cyclophosphamide to treat patients with SSc-ILD. The committee noted that mycophenolate is used more frequently than cyclophosphamide owing to a more favorable side effect profile for mycophenolate, and most of the benefits of cyclophosphamide waned 1 year after cessation of treatment.
Mycophenolate
Question 2 concerns whether patients with SSc-ILD should be treated with mycophenolate, which is currently used as a standard-of-care treatment for patients with SSc. In 1 study, the mean forced vital capacity (FVC) percent predicted significantly improved from baseline to 12 and 24 months for mycophenolate compared with placebo. Significant differences in breathlessness, including at 24 months, also were observed in favor of mycophenolate vs placebo. Because of the reported significant decrease in disease progression and improvement in quality-of-life measures with minimal adverse events, the committee provided a strong recommendation for using mycophenolate to treat patients with SSc-ILD, although the evidence was of very low quality.
Rituximab
Question 3 asked whether patients with SSc-ILD should be treated with rituximab. A meta-analysis found that rituximab attenuated FVC percent predicted decline compared with placebo at 24 to 48 weeks. Rituximab also reduced the decline in diffusing capacity of the lung for carbon monoxide (DLCO) in 2 studies, and increased DLCO in 1 study. The committee issued a conditional recommendation for using rituximab to treat patients with SSc-ILD (very low-quality evidence).
Tocilizumab
Question 4 addressed whether patients with SSc-ILD should be treated with tocilizumab, for which a conditional recommendation was given (very low-quality evidence). The committee noted that tocilizumab was associated with significant reduction in disease progression; research found tocilizumab treatment vs placebo was associated with a favorable mean absolute change in FVC from baseline at 48 and 96 weeks.
Nintedanib
Question 5 asked whether patients with SSc-ILD should be treated with nintedanib, an oral intracellular tyrosine kinase inhibitor, for which the guideline committee issued a conditional recommendation (very low-quality evidence). The committee cited research showing a significant decrease in disease progression against gastrointestinal adverse events, which can be managed with medication discontinuation, though there are a limited number of randomized studies and the evidence was primarily from post hoc data analysis. The recommendation is for all patients with SSc-ILD, regardless of whether their disease is progressive or stable.
Nintedanib Plus Mycophenolate
Question 6 addressed whether patients with SSc-ILD should be treated with nintedanib plus mycophenolate. It is currently unknown whether a combination of treatments with different mechanisms of action may be preferable to individual agents; moreover, if dual therapy is preferred, it is unknown what the most effective combination would be. Research has shown a lower annual rate of decline in FVC and FVC percent predicted for combination therapy with nintedanib plus mycophenolate compared with placebo. Combination therapy also was associated with an increased risk for decreased appetite, as well as an increased risk for diarrhea, nausea, vomiting, and/or fatigue compared with placebo. The guideline committee provided a conditional recommendation for using the combination of nintedanib plus mycophenolate to treat patients with SSc-ILD (very low-quality evidence).
Question 7 asked whether patients with SSc-ILD should be treated with pirfenidone, an antifibrotic agent that has been recommended for use in idiopathic pulmonary fibrosis and has been evaluated in guidelines for progressive pulmonary fibrosis. Critical outcomes included disease progression and mortality. A systematic review identified 1 RCT on pirfenidone in SSc-ILD, but it was underpowered for the proposed outcomes. The committee recommended further research regarding the safety and efficacy of pirfenidone for patients with SSc-ILD, and the quality of evidence for critical and important outcomes was very low.
Pirfenidone Plus Mycophenolate
Question 8 addressed whether patients with SSc-ILD should be treated with pirfenidone plus mycophenolate. In 1 study, the combination of pirfenidone plus mycophenolate was associated with improvement in the Transition Dyspnea Index score at 16 weeks compared with mycophenolate alone, but no significant difference occurred in Health Assessment Questionnaire-Disability Index scores. The committee recommended further research regarding the safety and efficacy of pirfenidone plus mycophenolate combination therapy for treating patients with SSc-ILD, and the quality of evidence was very low.
Corticosteroids and Renal Crisis
The guideline committee also noted that renal crisis in patients with SSc is associated with systemic corticosteroid therapy in some cases, especially among patients who have early diffuse cutaneous SSc. Thus, the committee provided a best clinical practice statement, urging that caution should be taken in using systemic corticosteroids in patients with SSc with or without SSc-ILD, and the daily dose should not exceed the equivalent of 15 mg prednisone when possible.
Directions for Future Research
Further research is needed “to determine treatment efficacy, safety, and impact on patient QoL by disease status,” the guideline authors stressed. In particular, the question of whether there is a “differential treatment effect going from initial diagnosis of SSc-ILD to development of progressive SSc-ILD” has yet to be addressed. “Furthermore, additional studies looking at combination therapy and the sequence of initiating each therapy would be of clinical benefit,” the guideline authors noted.
Disclosure: Committee members disclosed all potential conflicts of interest according to the ATS policies. Please see the original reference for a complete statement on disclosures.
Patients with pulmonary fibrosis (PF) have limited treatment options. But with all the research currently being done around PF, “there remains a lot of enthusiasm and hope in this disease space,” according to Joyce Lee, MD, senior medical advisor of research and health care quality at the Pulmonary Fibrosis Foundation.
September is Pulmonary Fibrosis Awareness Month. This interstitial lung disease —which is characterized by progressive irreversible lung scarring, breathing difficulty, and persistent coughing — currently affects approximately 250,000 Americans, with an estimated 50,000 new cases diagnosed annually.1 Given the lack of curative therapies and treatment options for this patient population, Pulmonary Fibrosis Awareness Month aims to raise the visibility of this difficult disease, as well as to highlight promising PF research developments and increase knowledge of the disease state.2
At present, ongoing and planned studies in PF “span the breadth of administration, from inhaled to oral therapies, as well as novel mechanisms of action and genotype-driven patient identification,” Dr Lee noted.
“Efforts like these will move us closer to the goal of personalized medicine for patients living with PF,” said Dr Lee, who is also director of the Interstitial Lung Disease Program at the University of Colorado School of Medicine in Aurora.
Progress and Setbacks
“With increasing incidence of pulmonary fibrosis, especially idiopathic pulmonary fibrosis (IPF), significant strides have been made in the understanding of the underlying pathobiology of IPF,” said Tejaswini Kulkarni, MD, director of the Interstitial Lung Disease Program at the University of Alabama at Birmingham and Vice-Chair of the Interstitial Lung Disease Section with the American College of Chest Physicians.
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Including more patients in the development of clinical trials is critical, and involvement of patients from the start of the drug discovery process can be very meaningful for those developing potential therapies.
“New knowledge in the disease mechanisms, from inflammation to fibrosis in non-IPF interstitial lung diseases (ILDs), including differences and commonalities with IPF, have recently emerged, leading to the development of promising drugs not only for IPF but also patients with progressive pulmonary fibrosis (PPF).”
PF researchers are continuing to explore novel therapies for PF treatment after disappointing results in several recent trials. As reported in May 2023, for example, the novel autotaxin inhibitor ziritaxestat failed to demonstrate efficacy as a treatment for IPF in 2 identically designed phase 3 trials (ISABELA 1 and ISABELA 2; ClinicalTrials.gov Identifiers: NCT03711162 and NCT03733444).7
Additionally, in findings announced in June and August 2023, respectively, the humanized monoclonal antibody pamrevlumab failed to reduce the rate of decline in forced vital capacity (FVC) in the phase 3 ZEPHYRUS-1 trial (ClinicalTrials.gov Identifier: NCT03955146), and the novel galectin-3 inhibitor GB0139 failed to reduce the rate of decline in FVC in IPF in the phase 2b GALACTIC-1 trial (ClinicalTrials.gov Identifier: NCT03832946).8,9
“Despite these recent failures, we have learned important lessons to consider when designing PF clinical trials,” Dr Kulkarni noted. “Aside from several drugs in early-phase clinical trials, at least 3 drug candidates are being evaluated in phase 3 studies of patients with IPF and PPF,” including inhaled Treprostinil (ClinicalTrials.gov Identifier: NCT04708782), BI 1015550 (ClinicalTrials.gov Identifier: NCT05321069), and BMS 986278 (ClinicalTrials.gov Identifier: NCT04308681).10
Other Recent Research
The PRECISIONS trial (ClinicalTrials.gov Identifier: NCT04300920), which is currently underway, is investigating use of N-acetylcysteine (NAC), “an inexpensive and well-tolerated agent for treatment of lung and other organ diseases, as a potential treatment for IPF, said Dr Lee.5 The study is the first pharmacogenomic study in IPF patients to be sponsored by the NIH, Dr Lee noted, with additional support from the Pulmonary Fibrosis Foundation (PFF) and the Three Lakes Foundation.
An initial paper on the study was published in December 2022 by the PRECISIONS team and the PFF, said Dr Lee, who further explained that “The study is investigating whether NAC provides clinical benefit in the quarter of patients with IPF that carry a specific genetic variant, the TOLLIP rs3750920 TT genotype.”
Other notable research from the past year explored associations between disease outcomes in ILD and exposure to particulate matter 2.5 μm or less in diameter (PM2.5).6 The study, by Goobie et al, analyzed satellite-based pollution data and as well as medical data from 3 patient cohorts with 6388 patients, including 1870 patients from the PFF Registry.
Results showed that increased PM2.5 exposure was linked to worse baseline lung function and higher transplant and mortality rates only in the cohort with the highest exposure to sulfate, ammonium, and black carbon, which are PM2.5 constituents associated with industrial and traffic-related emissions. Increased PM2.5 exposure was also associated with worse baseline lung function and higher transplant and mortality rates in a meta-analysis by Goobie et al combining all 3 cohorts.6
Such findings underscore the need for more stringent regulation and reduction of human-derived emissions, the study authors wrote.
Expanding Trial Participation
Efforts are being made to expand the pool of patients participating in PFF clinical trials, which has been an ongoing challenge, said Dr. Lee.
“Including more patients in the development of clinical trials is critical, and involvement of patients from the start of the drug discovery process can be very meaningful for those developing potential therapies,” Dr Lee noted.
“We are working to increase marketing efforts to recruit from a wider pool of geographic locations and conducting outreach through community organizations and foundations to engage more patients in clinical trials,” Dr Lee said. The PFF Clinical Trial Finder provides a comprehensive list of trials that patients can search to identify “relevant and feasible” opportunities to participate in PF studies.
Dr Kulkarni urged pulmonologists in various clinical settings to remain aware of PF trials and discuss the possibility of clinical trial participation with every patient with PF.
Yet even patients who are eager to participate in PF clinical trials may face significant barriers to participation, Dr Kulkarni acknowledged.
Travel difficulties represents a major factor affecting patient enrollment in clinical trials, said Dr. Lee. Such difficulties include challenges with coordinating oxygen during travel and the need to drive long distances to participate in trials conducted at academic centers.
PF trial criteria for inclusion and exclusion may also preclude some interested patients from participating in trials. “Although these criteria have evolved over time and are now broader, very few trials will allow inclusion of patients with advanced disease,” noted Dr Kulkarni. “Thus, careful consideration of these factors by industry and investigators when designing clinical trials may improve trial efficiency.”
“Patient and caregiver empowerment and incorporation of patient-centric endpoints may overcome some of these barriers to clinical trial enrollment in PF,” Dr Kulkarni added.
PFF Community Registry
Continuing growth in the PFF Community Registry – which now has more than 2,000 participants3 – will help to expand to the pool of research participants, and is an advance to be celebrated, said Dr Lee.3
“This unique and decentralized registry study relies on self-reported information from patients and lung transplant recipients who have been diagnosed with PF or ILD, as well as their caregivers and biological family members,” said Dr Lee.
“The Community Registry complements the PFF Patient Registry, which began in 2016 and includes patient data provided by clinicians.”4 The combined data from these registries provide a comprehensive and multifaceted resource for PF research, said Dr Lee.
An Emerging Research Priority
One emerging priority in PF research is the identification of early PF and related treatment implications, noted Dr Lee. “Work has been done that identifies ‘high-risk’ individuals, which not only includes those with a family history of PF, but also those with underlying conditions, such as rheumatoid arthritis,” she stated. “Many investigators are interested in these early forms of PF, and future work will focus on determining if early identification and subsequent intervention has an impact on long-term disease outcomes,” said Dr Lee.
Interstitial lung disease (ILD) affects an estimated 400,000 people in the US.1 Because of this, the odds of a primary care physicians encountering a patient with ILD is rare, and symptoms are easily overlooked by clinicians and patients alike. This results in delays — in diagnosis, specialist referrals, and access to treatment.1,2
A 2021 study found the time to ILD diagnosis was greater than 1 year in 40% of cases,3 and diagnostic delays exceeding 5 years have also been demonstrated in this patient population.2 For patients, such delays can be catastrophic: although there is no cure for ILD, which causes lung inflammation and permanent scars, treatments can slow progression and lessen symptom severity, allowing patients to live longer and with a higher quality of life.
In some instances, time lost can mean lung lost2,4: In idiopathic pulmonary fibrosis (IPF), for example, which accounts for 17% to 37% of all ILD diagnoses,5 a delayed diagnosis can lead to irreversible loss of lung function and may eliminate certain treatment options, such as lung transplantation.2
To improve early diagnosis, a clinician toolkit and other resources were recently developed by a collaboration involving pulmonologists and primary care physicians (PCPs) from across the US.4 These experts comprise the steering committee for Bridging Specialties™: Timely Diagnosis for ILD, a joint initiative between the American College of Chest Physicians (CHEST) and the Three Lakes Foundation,1 a nonprofit organization founded by a family tragically affected by lack of awareness and treatment options in ILD/IPF.
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Unless the disease is on the forefront of a busy clinician’s radar, it will frequently be missed. In addition, many clinicians are unfamiliar with algorithms and resources to further manage a suspected ILD.
The clinician toolkit includes:
an ILD-specific patient questionnaire;
e-learning modules and a video gallery to increase provider knowledge of symptoms and radiologic features of ILD; and
an interactive decision-making module to guide the examination, diagnosis, and treatment or referral of patients who may have ILD.
Additional resources available from the Bridging Specialties initiative include a white paper on factors influencing diagnostic delays in these patients and a podcast on overcoming barriers to ILD diagnosis.
To learn more about issues related to the timely diagnosis and treatment of ILD, we interviewed 2 members of the Bridging Specialties steering committee: William Lago, MD, family medicine physician at the Cleveland Clinic Wooster Family Health Center in Ohio; and Mary Beth Scholand, MD, FCCP, director of the Interstitial Lung Disease Clinic at the University of Utah in Salt Lake City.
What are some of the key barriers to the timely diagnosis of ILD?
Dr Lago: Some of the barriers are the fact that ILD is relatively rare, and its symptoms are often vague and mild at presentation. They can often be confused with other, more common and immediate issues like heart disease or other serious issues. Patients may delay seeking treatment if the symptoms are mild enough as well. There have also been longstanding ideas among patients and even some providers that little can be done to help with the treatment of ILD, which can lead to further delays in seeking diagnosis and treatment.
Dr Scholand: Recognizing an ILD requires an awareness of this possibility when a patient presents with a cough or shortness of breath with activity. Further, specialized studies such as a high-resolution CT scan are required to secure the diagnosis. Finally, access to pulmonologists and ILD specialty centers can be difficult due to geographic and time barriers. In summary, there are many steps required to recognize and then confirm an ILD diagnosis.
What prompted the development of the ILD Clinician Toolkit by the Bridging Specialties steering committee?
Dr Lago: This was a project designed to increase awareness about ILD, aid PCPs in recognizing it earlier, and improve ILD diagnosis and treatment. Any time gained in getting patients diagnosed and beginning treatment can make significant differences in the lives of patients.
Dr Scholand: The toolkit was devised to provide clinicians with accessible, efficient, and useful information to raise awareness of the entity of ILD and to improve confidence in the detection and management of an ILD. Unless the disease is on the forefront of a busy clinician’s radar, it will frequently be missed. In addition, many clinicians are unfamiliar with algorithms and resources to further manage a suspected ILD. The goal of the Bridging Specialties steering committee was to break down these barriers by bringing assistance to the fingertips of providers throughout a variety of specialties.
What are additional ways for clinicians to reduce the time to ILD diagnosis?
Dr Lago: The committee developed educational information to help clinicians improve their recognition of ILD, along with diagnostic tools they can use while seeing patients. We have also created information that physicians can share with patients to help them understand the importance of rapid diagnosis and treatment.
I think the most important thing is to put ILD on the radar of physicians, to include ILD in our differential diagnosis when looking at vague symptoms such as cough, mild shortness of breath, or fatigue. We can also utilize these tools to work with our pulmonary colleagues to help improve patient treatment and quality of life.
Dr Scholand: Perhaps the most important element is recognition. The data support that these patients are left without a definitive answer to their concerns for at least 1-2 years.2 If clinicians can recognize easy clinical clues such as persistent symptoms, crackles at lung bases, or oxygen desaturations, then they can move towards making a diagnosis more quickly.
Bringing together PCPs and pulmonologists, including ILD specialists, to rapidly identify and begin treatment for these patients has so many positive effects for patients, including alleviating the anxiety of an uncertain diagnosis and beginning therapies that can slow progression of the disease, allowing for long-term improvements in quality of life.
What other measures are needed to improve the overall landscape of care for ILD, and what is the potential role of the Bridging Specialties initiative in these endeavors?
Dr Lago: I think having more options and better treatments at our disposal could help patients who are devastated by diseases like pulmonary fibrosis. Any hope we can give these patients will have a huge impact on their health.
With Bridging Specialties, CHEST and Three Lakes Foundation were able to bridge the gap between primary care and specialty care to help frontline providers improve their ability to diagnose and treat patients with rare but significant ILDs like pulmonary fibrosis. By working together, we can make a huge impact on our patients' lives.
Dr Scholand: There are so many more things we need to learn about ILD and pulmonary fibrosis. We have effective therapies that slow progression of fibrosis, but research is needed for better therapies that halt or regress fibrosis. We need to continue to improve our coordination amongst specialties to decrease the health care burden for patients with ILD.
The Bridging Specialties initiative is innovative, as it gets to the very basis of patient care — understanding our patient’s needs and acting on them efficiently and effectively. ILD is an unusual etiology for common symptoms, but there are many patients suffering from this group of diseases. We are hopeful that our program, including the toolkit, will catalyze important changes in the lives of patients with ILD through early detection, better coordination of care, and improved therapies.
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Clinicians should not allow their own preconceptions about aging to prevent them from providing optimal care to their older patients, according to the lead author of a study linking everyday ageism to a higher prevalence of physical and mental health problems.
“Take the time to get to know older patients as individuals and ask questions about their needs and preferences, rather than make assumptions based on age,” said Julie Ober Allen, PhD, MPH, of the University of Oklahoma in Norman. “Clinicians who are more aware of their assumptions and stereotypes about aging and older adults, which we have all been socialized to have, are better able to monitor their behavior to make sure they don't act on ageist beliefs.”
Dr Allen recommends that clinicians discuss aging-related cognitive and physical change as a part of human development across the life course rather than inherently representing decline, loss, or something to mourn. While older adults often are resilient, they also may be less likely to adapt successfully or ask for support from others if they believe these efforts will not make a difference. “There's other research indicating that negative beliefs about aging may serve as a self-fulfilling prophecy,” Dr Allen said.
She and her colleagues surveyed 2035 individuals aged 50 to 80 years from the National Poll on Healthy Aging. The higher a person’s score on a scale of everyday ageism experiences, the more likely they were to be in poor physical or mental health, to have more chronic health conditions, or to show signs of depression. In this cross-sectional study, which was published online in JAMA Network Open, everyday ageism was found to be highly prevalent and associated with multiple indicators of poor physical and mental health.
While the study does not show cause and effect, the investigators noted that the linkages between ageism and health need to be explored further and taken into account when designing programs to encourage good health and well-being among older adults.
The researchers used the Everyday Ageism Scale, which calculates a score based on an individual’s answers to 10 questions about their own experiences and beliefs regarding aging. In the current study, 93.4% of the older adults surveyed said they regularly experienced at least one of the 10 forms of ageism. Approximately 80% agreed with the statement that “having health problems is part of getting older,” even though 83% described their own health as good or very good. This kind of internalized ageism also included agreeing with the statements that feeling lonely, depressed, or sad is part of aging.
In this study, 65% of the older adults said they regularly see, hear, or read jokes about older people, or messages that older adults are unattractive or undesirable. Interpersonal ageism was reported as a regular occurrence by 45% of the respondents. Interpersonal ageism was defined as older persons believing that others assume they have problems using technology, seeing, hearing, understanding, remembering, or acting independently, or they do not contribute anything of value.
“Everyday ageism is often subtle and may or may not be intentionally discriminatory,” the investigators wrote. They added that the “microaggressions” that that define everyday ageism “may communicate that older adults are not fully accepted and respected, appreciated for their individuality, or deserving of the rights and privileges afforded other members of society.”
Geriatrician John Morley, MD, of Saint Louis University School of Medicine in Missouri, said physicians need to treat older persons the same as other adults and avoid ageism in patient care. “Be careful not to use ageist language,” Dr Morley said. “Be respectful. Technology has a great future for geriatric care as the average physician has poor understanding of geriatric syndromes. Health care professionals need to know the computer literacy of their older patients. When it’s poor, they need to work with a family member if the patient agrees.”
While portals can greatly enhance care, physician interaction with patients remains central to ensuring communication barriers are address. Dr Morley said office staff should have protocols to address older patients’ communication capabilities and prevent ageism in patient care. “In persons with poor digital skills, the physician and his staff need to work directly with the patient,” he said. “The digital testing can be done in the office by an office staff. We are in a large digital divide and health care professionals need to assess how the patient wishes to interact.”
Dr Allen agrees. Having options and asking patients how they prefer to communicate is an important, perhaps under-recognized, aspect of healthcare provision, she said. Addressing the issue of digital skills could also benefit other groups who are affected by the digital divide, such as low-income individuals, rural patients, and those who are simply less tech savvy, she said.
Wanda Jirau-Rosaly, MD, a geriatrician at the Medical College of Georgia at Augusta University, said there is a great deal of societal misinformation and preconceived notions about aging. “Without conscious knowledge, physicians may be the ones giving older adults ageist messages and having ageist assumptions about our patients,” Dr Jirau-Rosaly said. “We must remember, older adults have lived life [and] have lots of living knowledge and experiences that they can even teach us about.”
Although younger individuals have grown up with technology, Dr Jirau-Rosaly said many of her older adults spend hours on the internet browsing instead of watching TV. “To me, more than technology causing a divide due to age is the fact that we do not communicate as well. We write a couple of sentences through a portal,” Dr Jirau-Rosaly said. “Technology feels impersonal and that is what may create the age divide. Some of my patients show me how to use different applications on my phone. Assuming that technology is an aging issue is ageist in itself. Asking the patient how they prefer to communicate is best practice.”
