Treviso Geriatric Oncology Advanced Course · Fried LP et al, Cardiovascular Health Study . A...
Transcript of Treviso Geriatric Oncology Advanced Course · Fried LP et al, Cardiovascular Health Study . A...
Treviso Geriatric Oncology Advanced Course
The management of cancer in the older
person
G.Colloca MD PhD
Università Cattolica del Sacro Cuore Roma
4
Changing Patients, Changing needs
HEALTH PROFESSIONALS NO GERIATRIC
TRAINING
PATIENTS OVER 80: OVER THE PAST 10 YEARS
The management of cancer in the older person
• GERIATRIC ASSESSMENT
The management of cancer in the older person
• GERIATRIC ASSESSMENT
DOES NOT EXIST…..
The management of cancer in the older person
• GERIATRIC ASSESSMENT is:
Methodology
Experience
Management
Involvement
The management of cancer in the older person
• GERIATRIC ASSESSMENT is:
DIFFERENT POINT OF VIEW
Think different
The management of cancer in the older person
• GERIATRIC ASSESSMENT
chronological age vs biological age
The management of cancer in the older person
• GERIATRIC ASSESSMENT
• LIFE EXPECTANCY (LONGEVITY)
All older cancer patients
Community Hospital Long Term Care
Facility Hospice
SCREENING (oncologist or geriatrician)
ONCOLOGIST
Interdisciplinary Team:
Oncologist, Geriatrician, Physical therapist,
Professional Nurse, Psycho-oncologist, Social Worker……….
Modified approach
FRAIL
PRE-FRAIL/FRAIL FIT
Usual Care
GERIATRICIAN (CGA)
Geriatric palliative care
Palliative Oncology
Balducci L, Colloca G et all. Surg Oncol. 2010 Sep;19(3):117-23
FRAILTY….
The management of cancer in the older person
Does it REALLY EXIST?
The management of cancer in the older person
82 yrs Women Ovarian Cancer
VES 13: 2 Fried criteria: >3 FRAIL ADL:4/6 IADL:5/8 SPPB:5/12 GDS: 6/15 MMSE: 28/30
NO FRAIL
Brown M, and coll. J Gerontol A Biol Sci Med Sci 2000;55:M350-
M355[17]
Physical frailty is due to a number of factors, including declines in strength,
loss in range of motion, slowness of movement, paucity of movement, poor
balance, and reduced muscular and cardiovascular endurance.
Carriere I, and coll. J Clin Epidemiol 2005;58:1180-1187[20] Frailty is a physiological precursor of disability. Frail subjects are those
who are at risk of becoming disabled (despite of the apparent good health),
and to whom can be recommended physical training programs designed to
postpone dependence
Chin A Paw MJ, and coll. J Clin Epidemiol 999;52:1015021[21] Frailty is a physical condition representing a large threat to older people’s
functioning and quality of life. It is different from functional dependence and
can be found in non-institutionalized subjects
Fried LP, and coll. J Gerontol. 2001;56A:M146-M156[9] Biological syndrome of decreased reserve and resistance to stressor,
resulting from cumulative declines across multiple physicologic systems,
and causing adverse outcomes. This concept distinguishes frailty from
disability.
Minitski A, and coll. J Am Geriatr Soc 2005;53:2184-2189[14]
Rockwood K, and coll. J Gerontol A Biol Sci Med Sci 2007;62:722
727[15]
Rockwood K, and coll. CMAJ 2005;173:489-495[16]
Frailty is a multifactorial and dynamic process determined by the
accumulation od deficits (symptoms, signs, functional impairments, and
laboratory analyses)
Rockwood K, and coll. CMAJ 2005;173:489-495[16] Frailty is a multidimensional syndrome characterized by loss of reserves
(energy, physical ability, cognition, health) and rising vulnerability
Powell C. J R Soc Med 1997;90:23-26[19] Frailty is identified by decreased reserves in multiple organ systems. It
may be initiated by disease, lack of activity, inadequate nutritional intake,
stress, and/or the physiologic changes of aging. Frailty develops slowly in
a stepwise process, with increments of decline precipitated by acute
events. Frail older persons present “homeostenosis”, a state of decreased
ability in the body physiologic response to maintain homeostasis in times
of acute stress. Frailty is a product of excess demand imposed upon
reduced capacity.
Puts MTE, and coll. J Am Geriatr Soc 2005;53:40-47[18] Frailty in older persons is an unstable condition due to a dynamic reduction
of physiological reserves, physical abilities, comorbidity, and multisystem
decline. It causes an increased risk for adverse outcomes, such as falls,
disability, institutionalization, and death. Frailty can be seen as a position
on a continuum from healthy through very frail.
Cesari M, Colloca G, Pahor M, Sarcopenia and Frailty in older woman.
“Increasingly, geriatricians define frailty as a
biological syndrome of decreased reserve and
resistance to stressors, resulting from
cumulative declines across multiple
physiologic systems, and causing adverse
outcomes. This concept distinguishes frailty
from disability”
Fried LP et al, Cardiovascular Health Study
A syndrome encountered in older persons that has
diverse predisposing, precipitating, enabling and
reinforcing factors. The key feature is a state of
vulnerability to adverse health outcomes. There is a
characteristic clustering of features that can lead to
its recognition. The balance between assets and
deficits will determine the consequences for an
individual. Adaptability, physical environment & social
environment are important determinants of the
impact of frailty.
Canadian Initiative on Frailty and Aging, 2003
The management of cancer in the older person
• GERIATRIC ASSESSMENT
• LIFE EXPECTANCY (LONGEVITY)
• FRAILTY
PHYSICAL
FUNCTIONAL
COGNITIVE
FRAILTY
Multidimensional
Unstable
Heterogeneous
AGING Increased vulnerability to
disease and accidents over time
DISABILITY Functional limitations
resulting from impairments
COMORBIDITY Disease processes
resulting from biology and exposures
Walston J, Ferrucci L,Fried L, J Am Geriatr Soc. 2006 Jun;54(6):991-1001
Molecular and Disease
Oxidative Stress Mitochondrial Deletion Shortened Telomeres DNA Damage Cell Senescence
Gene variation
Inflammatory disease
Inflammation
Neuroendocrine
Dysregulation
Interleukin 6
IGF-1
Dehydroepiandrosterone-
sulfate
Sex steroids
Anorexia
Sarcopenia, osteopenia
•Immune function
•Cognition
•Clotting
•Glucose Metabolism
Impaired Physiological Clinical
Slowness Weakness Weight Loss Low Activity Fatigue
Lang PO, Zekry D Gerontology. 2009;55(5):539-49.
• Frailty is most obvious under “stress”
acute illness
new medications
surgery
pain
change in environment or support
• Surgery and Illness - Frailty Stress Tests
FRAILTY AND STRESS
The management of cancer in the older person
• GERIATRIC ASSESSMENT
• LIFE EXPECTANCY (LONGEVITY)
• FRAILTY
The management of cancer in the older person
• GERIATRIC ASSESSMENT
• LIFE EXPECTANCY (LONGEVITY)
• FRAILTY
• COMORBIDITY/MULTIMORBIDITY
Comorbidity: combination of additional diseases beyond an index disorder.
Multimorbidity:any co-occurrence of two or more chronic or acute diseases and
medical conditions within one person, whether coincidental or not, indicating a
shift of interest from a given index condition to individuals who suffer from
multiple disorders.
Disease based
perspective
Individual based
perspective
A. Marengoni J Am Geriatr Soc 57:225–230, 2009.
Patterns of Chronic Multimorbidity in the Elderly Population
The management of cancer in the older person
• GERIATRIC ASSESSMENT
• LIFE EXPECTANCY (LONGEVITY)
• FRAILTY
• COMORBIDITY/MULTIMORBIDITY
• COMPLIANCE/QUALITY OF LIFE
Quantitative and qualitative model of successful aging
SUCCESSFUL AGING
Optimal overall functioning Well-being
Physical
Functioning
Social
Functioning
Psychocognitive
Functioning
WELL-BEING = SUCCESSFUL AGING
Social Contacts
Physical and Cognitive
Functioning
Adaptation
Margaret Von Faber et al, Arch Internal Med 2001;161:2694-2700
“Health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
WHO
If you do not ask the right questions, you do not get
the right answers.
A question asked in the right way often points to its
own answer. Asking questions is the A-B-C of
diagnosis. Only the inquiring mind solves problems
Edward Hodnett
The “Modern” Patient
Co/multimorbidity
Multiple drugs
Function deficits Cognitive deficit Physical deficit
Incontinence
Malnutrition Anemia
Osteoporosis
FRA
ILTY
Researchers have largely shied away
from the complexity of multiple chronic
conditions — avoidance that
results in expensive, potentially harmful
care of unclear benefit.
Tinetti M. NEJM 2011
Affective problems Social problems
Falls Sarcopenia
Specific Guidelines
RCTs
Observational Studies
Biological Evidences
Evidence Based Medicine (EBM)
52
A Missed Target
Real World
RCTs Multim
orb
idity
Age
60 85
Guidelines for Older Adults
GU
IDEL
INES
Comorbidity: combination of additional diseases beyond an index disorder.
Multimorbidity:any co-occurrence of two or more chronic or acute diseases and
medical conditions within one person, whether coincidental or not, indicating a
shift of interest from a given index condition to individuals who suffer from
multiple disorders.
Disease based
perspective
Individual based
perspective
A. Marengoni J Am Geriatr Soc 57:225–230, 2009.
Patterns of Chronic Multimorbidity in the Elderly Population
COMPREHENSIVE GERIATRIC ASSESSMENT
DEFINITION
The CGA is “a multidisciplinary evaluation in which
the multiple problems of older persons are
uncovered, described, and explained, if possible, and
in which the resources and strengths of the person
are catalogued, need for services assessed, and a
coordinated care plan developed to focus
interventions on the person's problems”
Solomon D. J Am Geriatr Soc, 36 (1988), pp. 342–347
Second and third generation assessment instruments: the birth of standardization in geriatric care
The systematic adoption of "second-generation" comprehensive
geriatric assessment instruments, initiated with the Minimum Data Set
(MDS) implementation in U.S. nursing homes, and continued with the
uptake of related MDS instruments internationally, has contributed to
the creation of large patient-level data sets.
We argue that the harmonization by InterRAI of the MDS forms for
different health settings, referred to as "the third generation of
assessment," has produced the first scientific, standardized
methodology in the approach to effective geriatric care
Bernabei et al. J Gerontol A Biol Sci Med Sci 2008
Short Physical Performance Battery
• Delirium
• Falls & Immobility
• Acute Urinary Incontinence
• Dehydration or Acute Nutritional Crisis
• Functional Decompensation
Why might each frail older adult manifest the
same stressor with a unique disease presentation?
ATYPICAL DISEASE PRESENTATIONS
59 Follow up yrs
Pro
bab
ility
of
surv
ival
GAIT SPEED AS VITAL SIGN IN OLD AGE Arch Int Med 2012; 172: 1162-68
60
Short Physical Performance Battery (SPPB)
Guralnik JM J Gerontol. 1994
Is this patient going to die of cancer or with cancer ?
Is this patient going to live long enough to suffer the consequences
of cancer ?
Is my patient able to tolerate the treatment ?
Are some complications of cancer treatment more common in
older individuals?
Is the social network of my patient adequate to support him or her
during the treatment ?
THE GERIATRIC EVALUATION OF ELDERLY PATIENTS
WITH CANCER
Comorbidity Charlson comorbidity index
CIRS CIRS-G
NYHA
No. of comorbid conditions
Simplified comorbidity score
Summary of comorbidities
Hematopoietic cell transplantation comorbidity index
Functional
status ADLs (Katz index)
IADLs (Lawton scale)
PS index
Barthel index (any version)
Visual and/or hearing impairment, regardless of use of glasses or
hearing aids
MOS Physical Health
Mobility problem (requiring help or use of walking aid)
Timed Get Up and Go
Hand grip strength
Short Physical Performance Battery
One-leg standing balance test
ECOG PS
Karnofsky self-reported performance rating scale
Comorbidity: Charlson comorbidity index CIRS CIRS-G NYHA Simplified comorbidity score Hematopoietic cell transplantation comorbidity index Functional status: ADLs (Katz index) IADLs (Lawton scale) PS index Barthel index MOS Physical Health Mobility problem Timed Get Up and Go Hand grip strength Short Physical Performance Battery One-leg standing balance test Walking problems, gait assessment, and gait speed ECOG PS23,25,26 Karnofsky self-reported performance rating scale19–21
Cognition Mini Mental State Examination (any version)
Informant Questionnaire on Cognitive Decline in the
Elderly (any version)
Modified Mini Mental State Examination
Clock-drawing test
Blessed Orientation-Memory-Concentration Test
Depression Geriatric Depression Scale
Center for Epidemiologic Studies Depression Scale
Hospital Anxiety and Depression Scale
Mental health index
Presence of depression (as geriatric syndrome)
Distress thermometer
Nutrition Body-mass index (weight and height)
Weight loss (unintentional loss in 3 or 6 months)
Mini Nutritional Assessment (any version)
Short Nutritional Assessment Questionnaire
Polypharmacy Beers criteria
STOPP and START criteria
Geriatric syndromes Dementia
Delirium
Incontinence (fecal and/or urinary)
Osteoporosis or spontaneous fractures
Neglect or abuse
Failure to thrive
Self-reported No. of falls (within different time frames)
Constipation
Polypharmacy
Pressure ulcers
Sarcopenia
If you do not ask the right questions, you do not get
the right answers. A question asked in the right way
often points to its own answer. Asking questions is the
A-B-C of diagnosis. Only the inquiring mind solves
problems
Edward Hodnett
• Weight loss
• Slow walking speed
• Low levels of physical activity
• Subjective exhaustion
• Weakness (Low grip strength)
• 3-5 is “frail”
• 1-2 is “intermediate”
• 0 is “not frail”
“Frailty Phenotype”
Fried LP, Tangen, Walston et al. J Ger Med Sci 2001