Student Projects

Title: The Underrepresentation of Older Adults in Randomized Clinical Trials for JAK Inhibitors to Treat Atopic Dermatitis: Barriers and Recommendations

Authors
Shreya Sreekantaswamy, BS,1 Linda Edelman, PhD2

Affiliations
1 University of Utah School of Medicine
2 University of Utah College of Nursing

Atopic dermatitis (AD), or eczema, is classically thought of as a disease of childhood. Recent research, however, has revealed that the prevalence of AD can reach as high as 8.7% among adults over the age of 65. Yet, older adults have been found to be severely underrepresented in clinical trials for current standard AD treatments (eg. methotrexate, mycophenolate mofetil). As dermatology is turning to JAK inhibitors (JAKi) to expand the therapeutic horizon for AD, it is therefore important that older adults are adequately represented in JAKi AD clinical trials, for if not, they will be treated with medications whose efficacy and safety profile have not been explicitly evaluated in their age group. For this study, we reviewed clinicaltrials.gov to assess the age range and inclusion and exclusion criteria for Phase II and Phase III clinical trials evaluating the efficacy of JAKi (abrocitinib, baricitinib, upadacitinib, ruxolitinib, and delgocitinib) to treat atopic dermatitis. Of the 35 Phase II and Phase III AD clinical trials for these JAKi, only 14 adult trials have published data. Of these 14 trials, only five report the proportion of older adults in their participant cohort, which ranged from 2.13% - 7.95%, despite none of these trials having an upper age limit. Most trials (62.5%) had vague exclusionary criteria which stated that certain unspecified laboratory abnormalities or medical conditions could exclude participants at the discretion of the investigator, a statement which likely disproportionately excluded older adults. Underrepresentation of older adults in these trials might also be attributable to difficulty in recruiting and retaining geriatric patients in clinical research. Potential methods to increase the recruitment of older adults for studies are provided, such as assisting with transportation, or utilizing services like ResearchMatch to specifically target the older participant demographic. Ultimately, further efforts are needed to actively include and study older adults in clinical trials for JAKi so that dermatologists can make evidence-based therapeutic selections when treating older patients with atopic dermatitis.   

JAKi OA Exclusion 10.5 smallerr


Title: The Importance of a Comprehensive Geriatric Assessment in Older Adults with Cancer

Author: Alec Hansen

Introduction: There are more adults ages 65 and older today in the United States than at any other time in history. This number is expected to grow from 49 million to approximately 72 million by 2030. [1,2] Cancer is common in the geriatric population, with more than 50% of all cancers and more than 70% of cancer-related deaths in the United States occurring in patients ages 65 years and older. [2] It is important to consider more than just a patients chronological age while determining treatment options for older adults with cancer. [3]

Prevalence: According to the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) Program, the median age of a cancer diagnosis is 66 years. [4] The life expectancy in the United States for Females is 81.2 years, and for Males is 76.2 years, suggesting that half of all lifetime cancer diagnoses occur in the last 10-15 years of an individual’s life. [5] Cancer is the leading cause of death in men and women aged 60 to 79 years. [6]

Treatment: The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary, in-depth evaluation that assesses the objective health and well-being of older adults while evaluating multiple domains which may affect cancer prognosis, treatment choices, and tolerance. [7] The CGA can reveal geriatric issues that are not detected by routine oncology care. Areas of evaluation include function, mobility, polypharmacy, comorbidities, social support, cognition, psychologic problems, and nutrition. [7,8,9,10,11,12,13,14,15,16]

Community Resources: The Geriatric Oncology Assessment and Plan (GOAL) clinic through the Huntsman Cancer Institute is a referral based, supportive service lead by an Oncology and Geriatric trained Nurse Practitioner. Focused on evaluating comprehensive geriatric needs and collaborating with the geriatric and oncology teams. Performs comprehensive geriatric assessments, assists with symptom management, provides palliative care, helps connect patients to community resources, and participates in frequent and thorough goals of care conversations.

Conclusions: The prevalence of cancer in older adults will continue to increase as the population ages. Treating cancer effectively in older adults requires a comprehensive geriatric assessment. Resources such as the GOAL clinic through Huntsman Cancer Institute can help ensure that the geriatric oncology population is properly cared for. 

CGA in Elderly Patients with Cancer Poster 1

Citations:
[1] https://www.nia.nih.gov/about/aging-strategic-directions-research.
[2] Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27(17):2758-2765. doi:10.1200/JCO.2008.20.8983
[3] Mohile SG, Dale W, Somerfield MR, et al. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol. 2018;36(22):2326-2347. doi:10.1200/JCO.2018.78.8687
[4] https://www.cancer.gov/about-cancer/causes-prevention/risk/age
[5] www.cdc.gov/nchs/products/databriefs/db355.htm
[6] Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021 [published correction appears in CA Cancer J Clin. 2021 Jul;71(4):359]. CA Cancer J Clin. 2021;71(1):7-33. doi:10.3322/caac.21654
[7] https://jnccn.org/view/journals/jnccn/19/9/article-p1006.xml
[8] Pal SK, Katheria V, Hurria A. Evaluating the older patient with cancer: understanding frailty and the geriatric assessment. CA Cancer J Clin. 2010;60(2):120-132. doi:10.3322/caac.20059
[9] Katz, Sidney, et al. "Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function." jama 185.12 (1963): 914-919.
[10] Pal SK, Hurria A. Impact of age, sex, and comorbidity on cancer therapy and disease progression. J Clin Oncol. 2010;28(26):4086-4093. doi:10.1200/JCO.2009.27.0579
[11] Tomaka J, Thompson S, Palacios R. The relation of social isolation, loneliness, and social support to disease outcomes among the elderly. J Aging Health. 2006;18(3):359-384. doi:10.1177/0898264305280993
[12] Chew ML, Mulsant BH, Pollock BG, et al. Anticholinergic activity of 107 medications commonly used by older adults. J Am Geriatr Soc. 2008;56(7):1333-1341. doi:10.1111/j.1532-5415.2008.01737.x
[13] Vega JN, Dumas J, Newhouse PA. Cognitive Effects of Chemotherapy and Cancer-Related Treatments in Older Adults. Am J Geriatr Psychiatry. 2017;25(12):1415-1426. doi:10.1016/j.jagp.2017.04.001
[14] Canoui-Poitrine F, Reinald N, Laurent M, et al. Geriatric assessment findings independently associated with clinical depression in 1092 older patients with cancer: the ELCAPA Cohort Study. Psychooncology. 2016;25(1):104-111. doi:10.1002/pon.3886
[15] Hurria A, Li D, Hansen K, et al. Distress in older patients with cancer. J Clin Oncol. 2009;27(26):4346-4351. doi:10.1200/JCO.2008.19.9463
[16] Pressoir M, Desné S, Berchery D, et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010;102(6):966-971. doi:10.1038/sj.bjc.6605578


U of U Geriatric Poster Abstract

Title: The Geriatric Emergency Department: An Examination of Current Trends, Benefits, Barriers, and Implementation

Author: Aaron Perez, MS IV1

Affiliations: 1University of North Texas HSC at Fort Worth—Texas College of Osteopathic Medicine

Older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the Emergency Department (ED), they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge which drives up the cost of health care. [3,4] Adults 65 and older in the US are expected to grow from 49 million today to approximately 72 million by 2030 and 84 million by 2050. [1,2] With that, the expected number of ED visits by older adults is expected to increase significantly. As it stands, current ED models may not be well-equipped to address the complex care needs of older adults. [3] Developing a Geriatric Emergency Department (GED) can promote improved, cost-effective care with better outcomes for this growing population of patients. [5] According to the 2018 National Emergency Department Inventory by the Emergency Medicine Network, there are 5,533 EDs in the US. Of these, only 276 have received accreditation through the Geriatric Emergency Department Accreditation (GEDA) program with the majority being in urban areas and achieving only a Level 3 distinction. [7] Potential benefits to promoting geriatric-specific care protocols in the ED include lowering costs by reducing unnecessary procedures, hospital-acquired infections, and allocating appropriate resources to patients. Patients and families will also be able to make more informed decisions when seeking care. Potential barriers include the recruitment of key players due to insufficient evidence of the financial benefits of implementing a GED. Securing the appropriate number and type of well-trained staff as well as applying protocols amidst common ED problems (overcrowding, boarding, nursing shortages) are other barriers. There are a wide array of available resources to learn more about the importance of GED as well as specific interventions to make any ED more equipped to care for older adults. As more emergency departments work to achieve GED accreditation and promote care for this specific population, costs will be decreased, and outcomes improved for this growing group of patients.

GED Poster Presentation UofU medium

[1] Shadyab AH, Castillo EM, Chan TC, Tolia VM. Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits. J Emerg Med. 2021 Aug;61(2):131-139. doi: 10.1016/j.jemermed.2021.02.036. Epub 2021 May 15. PMID: 34006420.
[2] https://www.nia.nih.gov/about/aging-strategic-directions-research.
[3] Kahn JH, Magauran BG Jr, Olshaker JS, Shankar KN. Current Trends in Geriatric Emergency Medicine. Emerg Med Clin North Am. 2016 Aug;34(3):435-52. doi: 10.1016/j.emc.2016.04.014. PMID: 27475008.
[4] Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002 Mar;39(3):238-47. doi: 10.1067/mem.2002.121523. PMID: 11867975.
[5] American College of Emergency Physicians. "American Geriatrics Society, Emergency Nurses Association, Society for Academic Emergency Medicine, Geriatric Emergency Department Guidelines Task Force. Geriatric emergency department guidelines." Ann Emerg Med 63.5 (2014): e7-25.
[6]ACEP Geriatric Emergency Department Accreditation. Criteria for Levels 1, 2 & 3. American College of Emergency Physicians. Accessed October 26, 2020. https://www.acep.org/globalassets/sites/geda/ documnets/GEDA-criteria.pdf
[7] “GEDA Accreditation List.” American College of Emergency Physicians. acep.org/geda. Accessed November 17, 2021.
[8] Hwang U, Dresden SM, Vargas-Torres C, et. al.; Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) Investigators. Association of a Geriatric Emergency Department Innovation Program With Cost Outcomes Among Medicare Beneficiaries. JAMA Netw Open. 2021 Mar 1;4(3):e2037334. doi: 10.1001/jamanetworkopen.2020.37334. Erratum in: JAMA Netw Open. 2021.PMID: 33646311; PMCID: PMC7921898.
[9] Kennedy M, Lesser A, Israni J, Liu SW, Santangelo I, Tidwell N, Southerland LT, Carpenter CR, Biese K, Ahmad S, Hwang U. Reach and Adoption of a Geriatric Emergency Department Accreditation Program in the United States. Ann Emerg Med. 2021 Aug 10:S0196-0644(21)00513-8. doi: 10.1016/j.annemergmed.2021.06.013. Epub ahead of print. PMID: 34389196.
[10] Rosenberg M, Rosenberg L. The Geriatric Emergency Department. Emerg Med Clin North Am. 2016 Aug;34(3):629-48. doi: 10.1016/j.emc.2016.04.011. PMID: 27475018.
[11] “Accreditation Process Faqs.” ACEP.org, ACEP Geriatric Emergency Department Accreditation, https://www.acep.org/geda/faqs/
[12] https://geri-em.com
[13] https://gedcollaborative.com


Title: Social Determinants of Health Create Disparities in Stroke Outcomes

 

Author: Courtney Reid, OMS IV

Affiliations: A.T. Still University - School of Osteopathic Medicine in Arizona

Geriatrics Poster Presentation UofU


Projects from 2020:

4/22/2020- 
Unique Needs of the LGBTQ+ Population of Older Adults presented by Sky Dean, Fourth Year Medical Student at the University of Utah School of Medicine


3/31/20- "Art with Elders as viewed through the experience of older adult artists" - MS Gerontology Project presented by Lauren Chamberlain, past Graduate Assistant of the UGEC