geriatric assessment and interventions · mrsa–geriatric assessment • functional status:...

Geriatric Assessment and

Interventions

Siri Rostoft, MD, PhD

Department of Geriatric Medicine

Oslo University Hospital

Norway

Disclosure

No conflicts of interest to declare

Mrs A, aged 94

• Admitted to the acute geriatric ward

because of fatigue and dizziness

• Work up revealed severe iron-deficiency

anemia (she was bleeding)

• Colonoscopy revealed right sided large

colon cancer, narrow passage

• Surgery?

Decrease in capacity - heterogeneity

Muravchik, Anesthesia 5th ed, 2000

What factors to consider?

• Discuss for 2-3 minutes with the person next

to you

Geriatric assessment (GA)1

- Functional status

- Comorbidity

- Polypharmacy

- Cognitive function/

dementia

- Nutritional status

- Depression

- Social support

Remaining life expectancy

Detection of unidentified problems

Optimization before treatment

Prediction of adverse outcomes

Treatment planning

Baseline information

Shared decision-making

FRAILTY

1Wildiers et al, JCO, 2014

Siri Rostoft 2017

Studies included in review

• CGA and ability to detect health problems: n=29

• CGA and prediction of outcomes: n=17

• CGA and tailored interventions: n=3

Results

• All CGA types identified

- large numbers of geriatric problems

- multiple comorbidities likely to interfere with

cancer treatment and to compete with cancer as a

cause of death

• Some CGA domains may influence treatment decisions

– functional status and nutritional status may have the strongest effect

Results cont.

• Each CGA domain was associated with chemotoxicity and survival in at least one study

• The domains most often predicting mortality and chemotoxicity:

– functional impairment

– malnutrition

– comorbidities

Siri Rostoft 2017

Methods and results

• 10 studies included in the review

• Change in oncologic treatment:

– the initial treatment plan modified in 39% of patients

after geriatric evaluation

– two thirds resulted in less intensive treatment

• Implementation of non-oncologic interventions

– interventions were suggested for more than 70% of patients

– most frequently social interventions and pharmacological interventions

Conclusion

• A geriatric evaluation has significant impact on

oncologic and non-oncologic treatment

decisions in older cancer patients

Journal of Surgical Research 193 (2015) 265-272

Siri Rostoft 2017

Results

• Elective surgery only

• 10 publications from 6 studies

• GA domains predicting overall and major complications

– dependency in ADLs and IADLs (functional status)

– higher ASA score

– decreased mini-mental state examination score

– worse geriatric depression score

– worse frailty scores

– fatigue

Journal of Surgical Research 193 (2015) 265-272

Results cont.

• Age was not an independent predictor of morbidity

in any studies

• No GA domains predicted postoperative mortality

(low mortality rates in elective surgery)

• Frailty predicted readmissions

• Functional status and frailty predicted discharge to

a nursing home

Journal of Surgical Research 193 (2015) 265-272

Categorization

Geriatric assessment

Geriatric assessment

FitFit IntermediateIntermediate FrailFrail

Geriatric assessment

• Overall assessment

• Multidisciplinary

• Areas where older patients often have

problems

• CGA – assessment with interventions

• Implementing GA in older hospitalized adults

increases likelihood of being alive and living in

their own home1

1Ellis Cochrane Rev 2011

GA in oncology

• Delphi study1:

• All cancer patients > 70 years

• Younger with age-related issues

• Most important domains:

– Functional status

– Comorbidities

– Cognitive function

1O´Donovan et al 2015

Mrs A – Geriatric Assessment

• Functional status: Dependence in IADL. Needed help shopping. Problems walking, uses a cane. TUG > 20 sec

• Comorbidity: Heart failure – but is the diagnosis correct? She can walk one flight of stairs without being out of breath. Stroke in 2008, no apparent sequela. Reduced vision and reduced hearing.

• Polypharmacy: beta blocker and diuretics

• Nutritional status: No appetite last month (due to tumour), weight loss, at risk of malnutrition

• Cognitive function: MMSE 27/30, she appeared adequate in conversation, she could discuss treatment options

• Emotional status: No symptoms of depression

Recommendation

• She had some frailty indicators, risk of post-

operative complications high

• Complications from tumour at present

(anemia, weight loss)

• Risk in emergency surgery much higher than

elective surgery

• Operated electively, had some complications,

survived, discharged home

A FEW WORDS ABOUT FUNCTIONAL

STATUS

Case – man with rectal cancer

• 69 years old, home dwelling

• Locally advanced rectal cancer

• Admitted for preoperative chemoradiotherapyaccording to guidelines

• After a week non-cooperative, pulled out i.v.lines, completely bed-ridden, aggressive

• What do we call this? Any risk factors?

“She Was Probably Able to Ambulate,

but I’m Not Sure”

• Failure to assess functional status in hospitalized patients is the norm

• Basic: ADL-function, mobility, and cognition

• 1/3 of patients 70+ encounter hospitalization-associated disability (even when acute illness is effectively treated)

Covinsky JAMA 2011

How to measure functional status

ADL = activities of daily living

- survive (eat, go to the toilet)

IADL = instrumental ADL

- live independently (manage money, shop,

medication use)

Performance measures: Gait speed, TUG (timed

up and og test), grip strength

Ask about falls

Walter et al, JAMA, 2001Siri Rostoft 2017

Stanaway, BMJ, 2011

Grim reaper´s maximum speed: 1.36 m/s

“HAVE YOU FALLEN?”

Jones et al, JAMA Surgery, 2013

COMORBIDITY

Siri Rostoft 2017

Why is comorbidity relevant?

• Discuss with the person next to you for a few

minutes

• How do you assess comorbidity in your clinical

practice?

Siri Rostoft 2017

Barnett et al, Lancet 2012

Chronic disorders by age-group

Siri Rostoft 2017

Comorbidity scales

• Charlson´s comorbidity index

• Weighted comorbidity index

• Predicted survival in cancer patients

• 19 selected conditions

Siri Rostoft 2017

CIRS – cumulative illness rating scale

• Developed in 1968

• Revised in 1992

• Revised scoring manual in 2008

• Scores 14 organ systems – disease severity

possible to score

• Too cumbersome for clinical practice

Siri Rostoft 2017

Optimization of comorbidities

• Geriatrician?

• Internal medicine specialist?

• Subspecialist, i.e. cardiologist?

• Core activity in the acute geriatric ward

• Competing risks

Siri Rostoft 2017

Polypharmacy

• Definitions vary

– More than 5 drugs in daily use

– The use of inappropriate medications

• Interactions

• Adverse events

• Polypharmacy is a risk factor for

undertreatment

Siri Rostoft 2017

Polypharmacy

• Goal: Dynamic approach

• What about drugs with a preventive effect?

• Discontinuation trials

Siri Rostoft 2017

Siri Rostoft 2017

Patients and methods• Multicenter, parallel-group, unblinded, pragmatic

clinical trial

• Estimated life expectancy 1 month - 1 year

• Statin therapy for 3 months or more for primary or sec. prevention of cardiovascular disease

• Recent deterioration in functional status

• No recent active cardiovascular disease

• Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year

Conclusions

• Stopping statin medication therapy is

- safe

- may be associated with benefits including

improved quality of life

- use of fewer non-statin medications

Cognitive function

• Mild cognitive impairment

• Dementia

• Screening instruments, MMSE, MOCA, Mini-Cog

• Why improtant?

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Why important?

• Consent

• Prognosis

• Treatment planning

• Baseline - chemobrain

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NUTRITIONAL STATUS

Malnutrition

• Differs between countries – in Norway

malnutrition is the dominant problem

• Home dwelling: 6%, hospitals 40%, nursing

homes 14%

• Tool: mini nutritional assessment (MNA)

• Definite risk factor – but do interventions

help?

• How to intervene?

Siri Rostoft 2017

EMOTIONAL STATUS

Siri Rostoft 2017

Emotional function

• Depression, anxiety and distress

• Common among older people

• Common among cancer patients

• Risk factors are pain and physical distress

• Fear of impeding mortality

• Protective: Attachment security, self-esteem, sense of meaning and purpose

• Treatment options?

Siri Rostoft 2017

Study (depression)1

• Older cancer patients (>70) receiving

chemotherapy (n=344)

• 45% depressed

• Risk factor: malnutrition at baseline

1Duc et al. Psychooncology, 2016Siri Rostoft 2017

SOCIAL SUPPORT

Siri Rostoft 2017

Social support

• Fundamental for treatment planning

• Population level – sociodemographic factors

strong predictors for receiving treatment and

survival

Siri Rostoft 2017

GA COMPLETED – WHAT NOW?

Siri Rostoft 2017

Geriatric assessment (GA)1

Remaining life expectancy

Detection of unidentified problems

Optimization before treatment

Prediction of adverse outcomes

Treatment planning

Baseline information

Shared decision-making

1Wildiers et al, JCO, 2014

TOO TIME-CONSUMING???

Siri Rostoft 2017

SUMMARY

• The heterogeneity increases with increasing

age

• We need to assess frailty rather than looking

at chronological age alone when deciding

treatment

• Geriatric assessment provides a practical

approach to older patients

• GA is necessary in many older cancer patients

for a number of reasons

THANK YOU FOR YOUR ATTENTION

QUESTIONS?