NcXHF

TREATING OLDER ADULTS WITH CANCER
TABLE 1. Characteristics Associated with Chemotherapy Toxicity among Older Adults with Cancer
Study (No. of Patients) Physical Limitations Sensory Impairment Cognitive Impairment Depressive Symptoms Nutrition Polypharmacy
Hurria et al 20
(500, mixed sample)
Extermann et al 17
N/A
(510, mixed sample)
Aparicio et al 16 (123, colon) N/A N/A
Freyer et al 18 (83, ovarian) N/A
Hamaker et al 19 (73, breast) N/A
Abbreviations: N/A, not assessed.
acteristics that are independently associated with toxicity and
show that the cumulative burden of impairments is prognostic
(Table 1). Most importantly, a GA can identify areas of
vulnerability and can be utilized to guide interventions. The
domains of a GA are reviewed below, with a focus on specifıc
pertinence to the care of older adults with cancer.
KEY POINTS
Functional Status
A functional status assessment focuses on the need for assistance
with daily activities to maintain independence in the
home (Activities of Daily Living [ADL]) and in the community
(Instrumental Activities of Daily Living [IADL]). Activities
of Daily Living include basic self-care skills such as
bathing, dressing, toileting, transferring, and maintaining
continence. IADL are activities needed to maintain independence
in the community such as shopping, taking
transportation, preparing meals, doing housework, taking
medications, and managing personal fınances. Among the
geriatric population, the need for assistance with these activities
is predictive of overall life expectancy and resource requirement
(such as nursing home placement). 21 For the older
patient with cancer, understanding the need for assistance
with these activities is critical for treatment planning. For example,
an integral part of cancer treatment is the use of supportive
care medications that are taken at home to minimize
treatment side effects. A key part of a geriatric assessment is
to evaluate whether the patient can take their medication at
the right doses and at the right time. If not, then interventions
can be implemented such as engaging family or a visiting
nurse to assist. In addition, before prescribing chemotherapy,
a transportation plan needs to be discussed. Some chemotherapy
side effects, such as fever and neutropenia, can be
life-threatening and require immediate attention. Key questions
include whether the patient has transportation to clinic
visits and whether they have a caregiver to provide transportation
if they are not feeling well.
A part of functional assessment is to evaluate for the risk for
falls. Falls in older adults account for many hospital admissions
and, even without apparent injury, are a warning sign
for impending functional decline. Falls can result in immobilization
and disablement even if the patient does not sustain
a fracture. These risks are even greater in older adults
with cancer, especially if there is metastatic disease to bone or
use of cancer treatments that accelerate bone loss. Furthermore,
cancer or cancer treatments can be associated with
platelet disorders and thrombocytopenia. Older adults with
cardiovascular disease may already be on anticoagulants,
further compounding risk. A fall can cause disastrous intracranial
bleeding. Falls are predictable by any of the
short directly observed tests of gait and balance that typically
take less than 2 minutes and can be built into the
patient check-in procedure. 22
Oncologists need to be familiar with practical strategies to
assess physiologic and functional capacity in older patients
to inform optimal management.
Geriatric assessment can predict treatment outcomes.
Incorporation of geriatric assessment strategies and
geriatric medicine consultation can help individualize initial
treatment decisions and inform management strategies
during the course of treatment and survivorship.
Dose modification for vulnerable older adults reviewing
palliative therapy is common and may optimize therapeutic
benefit for some patients.
Consideration of patient-centered outcomes inclusive of
functional independence, health care utilization, and
psychosocial health are critical for clinical trial design and
to inform management of older adults receiving
chemotherapy.
Comorbidity
An assessment of comorbidity is an integral part of cancer
treatment planning. It is particularly important for older
adults, due to the increased prevalence of multiple chronic
conditions with age and the variability of comorbidity burden
among similarly aged older adults. First, it can be utilized
to assess overall life expectancy and to weigh competing
causes of morbidity and mortality. 23 Second, it can be utilized
to tailor cancer treatment. Key questions include whether the
patient’s other medical problems affect the ability to tolerate
cancer treatments. For example, in a patient with diabetes,
supportive care medications, such as steroids, may exacerbate
diabetes. If steroids will be used, education and blood
sugar management need to be considered. Furthermore, the
choice of chemotherapy may be influenced by diabetic com-
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