EBMT NAP Meeting - 18th November 2011 Professor Margot Gosney University of Reading and The Royal...
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Transcript of EBMT NAP Meeting - 18th November 2011 Professor Margot Gosney University of Reading and The Royal...
EBMT NAP Meeting - 18th November 2011
Professor Margot Gosney
University of Reading and
The Royal Berkshire NHS Foundation Trust, UK
Care of the older HSCT recipient – physical and
psychological perspective
EBMT NAP Meeting - 18th November 2011
May be older and physically robust
May be younger and physically frail
Will have underlying physical and psychological needs
Will not be the workload of the majority of Haematology units
The Patient
EBMT NAP Meeting - 18th November 2011
An endangered species
To wrap in cotton wool and keep out of public view
or allow to roam freely in the hope of natural
selection allowing their survival?
The Geriatrician
EBMT NAP Meeting - 18th November 2011
What is a Geriatrician?
1909 Nascher invented the work “Geriatrics”
1947 Founding of the British
Geriatrics Society
1948 Geriatric Medicine became a speciality in the United Kingdom
EBMT NAP Meeting - 18th November 2011
Why do we need them?
Care of dependent, aged and chronic sick was
the responsibility of the state for four centuries
Much care was carried out in Workhouse
Infirmaries (warehouses for bedfast patients
who were undiagnosed and untreated)
Marjory Warren, Medical Officer at the West
Middlesex Hospital, inaugurated rehabilitation
EBMT NAP Meeting - 18th November 2011
Four aspects of Marjory Warren’s message
Geriatrics is an important subject for the teaching of medical students
Care of the chronic sick should comprise an essential part of training student nurses
For the proper care of the chronic sick full facilities of a general hospital are necessary both to establish the diagnosis and for treatment
It is important to encourage research work on diseases of old age
EBMT NAP Meeting - 18th November 2011
Are Geriatricians involved in the care of older people with cancer?
In UK 76% of cancer deaths are in people over 64 years
In UK 47% of cancer deaths are in people over 74 years
Increasing old age
Increasing diagnostic certainty
Increasing survival
Increase in number of older patients with co-morbidity
EBMT NAP Meeting - 18th November 2011
Remember it is often difficult to separate symptoms of cancer from
symptoms of “old age”
Constipation
Weight loss
Malaise
Fatigue
Breathlessness
EBMT NAP Meeting - 18th November 2011
Physical problems of elderly people
Poor eyesight therefore more problems with colostomy
Decreased mobility; colostomy etc
Manual dexterity; prostheses etc
Increased incidence of confusion
Constipation more likely
Incontinence may be precipitated or worsen
Pressure area instability
EBMT NAP Meeting - 18th November 2011
Psychological problemsin elderly people
Body integrity; co-morbidity, new impairment
Constraints; physical, mobility, ADL
Dependency; financial, social,
transport
Comfort; lonely, emotional
equilibrium
Loss; status, role
Future; uncertain survival, impending treatment
EBMT NAP Meeting - 18th November 2011
Remember Most performance measures in Oncology are
alien to those used by Geriatricians
What is more important: PS on the day of the Haematology opinion or that 2 months earlier ….. are we measuring pre-morbidity or cancer
morbidity?
If you see no patients with cognitive decline you are not seeing a typical population
EBMT NAP Meeting - 18th November 2011
Remember Should we be treating the patient or the scans….
if the patient, then why do we continue to waste money on investigations that do not alter management?
What is quality of life?
Loss of status when we finish
reproducing or retire!
Lots of cancer specific QoL and Elderly specific but little validated in elderly people with cancer e.g. HAD
Is an MDT an MDT if it lacks a Geriatrician?
EBMT NAP Meeting - 18th November 2011
Areas often forgotten bycancer specialists
Remember that you can persuade most elderly people to do what you want them to do
Many symptoms that you are trying to palliate may not be from the cancer e.g. OA
Hospitalisation alone can cause delirium
Is the disease worse than the treatment?
Must not allow relatives to make all decisions for elderly patients
EBMT NAP Meeting - 18th November 2011
Decreased cardiac index
Decreased glomerular filtration
Decreased vital capacity
Decreased renal blood flow
Altered pharmacokinetics
Altered pharmacodynamics
The Normal Elderly
EBMT NAP Meeting - 18th November 2011
In 1985 19,945 papers on cancer management
Only 11 were specifically about the elderly
In 1995 32,421 papers on cancer management
Only 26 were specifically about the elderly
In 2005 67,500 on cancer management
18,600 specifically about the elderly
Treatment of Elderly Patients
EBMT NAP Meeting - 18th November 2011
The truth
Equal access
Choice of therapy
Multidisciplinary input
Decision-making on clinical grounds not by age
What do patients want?
EBMT NAP Meeting - 18th November 2011
Before treatment
During treatment
After treatment
Old age specific or oncology specific?
Is there a gold standard?
AssessmentWhy do we need it?
EBMT NAP Meeting - 18th November 2011
No such thing as a typical 80 year old
Effect of pre-morbid state
Physical, social and psychological
Effect of gender, age, marital status,
Country and wealth
Why do we need assessment?
EBMT NAP Meeting - 18th November 2011
Barthel’s Index of activities of daily living (BAI)1. Bowel Status 0 points – Incontinent (or needs to be given enema)
1 point – Occasional accident (once a week)
2 points – Fully Continent
2. Bladder Status 0 points – Incontinent or catheterized and unable to manage
1 point – Occasional accident (max once per 24 hours)
2 points – Continent (for more than seven days)
3. Grooming 0 points – Needs help with personal care: face/hair/teeth/shaving
1 point – independent (implements provided)
4. Toilet Use 0 points – Dependent
1 point – Needs some help but can do something alone
2 points – Independent (on and off/wiping/dressing)
5. Feeding 0 points – Unable
1 point – Needs help in cutting/spreading butter/ etc
2 points – Independent (food provided within reach)
6. Transfer 0 points – Unable (as no sitting balance)
1 point – Major help (physical/one or two people)
2 points – Can sit minor help (verbal or physical)
3 points – Independent
7. Mobility 0 points – Immobile
1 point – Wheelchair-independent (including corners etc)
2 points – Walks with help of one person (verbal or physical)
3 points – Independent
8. Dressing 0 points – Dependent
1 point – Needs help but can do about half unaided
2 points – Independent (including buttons/zips/laces etc)
9. Stairs 0 points – Unable
1 point – Needs help (verbal/physical/carrying aid)
2 points – Independent up and down
10. Bathing 0 points – Dependent
1 point – Independent bathing or showering
Barthel Score (max 20):___________
EBMT NAP Meeting - 18th November 2011
Incontinence-faecal and urinary
Instability and falls
Impaired hearing and vision
Intellectual decline-dementia and delirium
The Giants of Geriatric Medicine
EBMT NAP Meeting - 18th November 2011
Associated with poor mobility and impaired
cognition
Effect on pressure area integrity
Associated with depression and socialwithdrawal
May be caused or worsened by cancer therapy
e.g. post hemicolectomy, TURP or drugs
Incontinence
EBMT NAP Meeting - 18th November 2011
Impaired homeostasis with ageing
Predisposed to by polypharmacy
Often scares off surgeons, oncologists and haematologists
Coincidental osteoporosis and muscular frailty
may be worsened by steroids or other drugs e.g. vincristine etc
Instability and Falls
EBMT NAP Meeting - 18th November 2011
Delirium common post operatively and
associated with infection, under nutrition and
electrolyte disturbances
Dementia associated with paraneoplastic
phenomena
Should mild cognitive impairment prohibit
palliative treatment?
Intellectual Decline
EBMT NAP Meeting - 18th November 2011
Problems with colostomy
Problems with temperature checking
Problems with access to buildings for treatment
and follow up
Sensory deprivation increases likelihood of
delirium
How can you effectively consent somebody
who hears only 50% of the conversation?
Impaired Vision and Hearing
EBMT NAP Meeting - 18th November 2011
In post operative patients:
Low preoperative MMSE
Cognitive impairment (x12 – x17 )
Age > 80 (x 2 )
What are the risk factors for developing delirium?
EBMT NAP Meeting - 18th November 2011
Who and When?
Most common in those > 70 years
Prevalence may be as high as 24%
in A&E
Hospitalised 14 – 56%
Post operative 0 – 74% - (36.8%)
Community studies 10-25%
# NoF 25% - 65%
EBMT NAP Meeting - 18th November 2011
Why does it matter?
Patients have high mortality rates and longer lengths of stay
Often not recognised
Can be poorly managed
Can be prevented in 1/3 of patients
How many of you are Geriatricians or nurses with a special interest in elderly care
medicine?
How many of you have been trained in Geriatric Medicine?
How would you feel if someone with no formal training in your specialty started to profess an expertise?
How many of you do a formal AMTS when you meet an older patient for the first time?
Questions
EBMT NAP Meeting - 18th November 2011
Can you diagnose depression, dementia and pseudo-dementia?
What proportion of 70 year olds fall each year? What is the commonest treatable cause of falls? What proportion of this group of fallers have cancer?
A test of your Geriatric Medicine skills
EBMT NAP Meeting - 18th November 2011
Act as patients advocate Screening/early detection Treatment decisions Support of patient and carers Palliative care/End of life care Management of multiple pathology Education re ageing Liaison with other specialties
What is the role of the Geriatrician?
EBMT NAP Meeting - 18th November 2011
More likely to be wives than husbands Wives provide twice the hours of care that husbands provide Female patients have more outside care than
males In 82% of cases caregivers were spouses of
patients
Carers
EBMT NAP Meeting - 18th November 2011
What is quality of life? Questionnaires specific to cancer Questionnaires specific to specific site Questionnaires specific to older people Development of new questionnaires
Quality of life
EBMT NAP Meeting - 18th November 2011
When Casanova was 68, a correspondent called him a ‘vulnerable old man’ to which he replied ‘ I have not yet reached that wretched age at which one can no longer make any claim to life.’
What is old or elderly?
EBMT NAP Meeting - 18th November 2011
Tolstoy learnt to ride a bicycle when he was 67,he played tennis and bathed in the ice cold river. Aged over 70 his health began to fail and a fit of malaria obliged him to take to his bed. He reconciled himself with the idea of dying but recovered and went to the Crimea for a rest. He had episodes of pneumonia and of typhoid. But he did not give up the struggle.
Are all older people the same?
EBMT NAP Meeting - 18th November 2011
Increase working between haematologists and geriatricians
Sharing of expertise within the MDT Increased awareness of extension of intensive
therapies for older people Validation of different assessment methodologies Increased research funding and joint working
For the future
EBMT NAP Meeting - 18th November 2011
EBMT NAP Meeting - 18th November 2011