Geriatric Assessment and Interventions - Geriatric Geriatric Assessment and Interventions Siri Rostoft,

  • View
    9

  • Download
    0

Embed Size (px)

Text of Geriatric Assessment and Interventions - Geriatric Geriatric Assessment and Interventions Siri...

  • 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

  • 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

    FRAILTY

    1Wildiers et al, JCO, 2014

  • 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

  • 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

  • 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 diganosis 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 chemoradiotherapy according to guidelines

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

    • What do we call this? Any risk factors?

  • What about functional status?

    • The majority of people aged 80 years have a good functional status and live independent

    lives (75% in a Swedish study) despite having

    chronic diseases

    • Frequently large changes in health status around ages 80-85

  • “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

  • Walter et al, JAMA, 2001

  • Stanaway, BMJ, 2011

    Grim reaper´s maximum speed: 1.36 m/s

  • COMORBIDITY

  • Barnett et al, Lancet 2012

    Chronic disorders by age-group

  • Comorbidity scales

    • Charlson´s comorbidity index

    • Weighted comorbidity index

    • Predicted survival in cancer patients

    • 19 selected conditions

  • 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

  • Optimization of comorbidities

    • Call your geriatrician

    • Or internal medicine specialist

    • Core activity in the acute geriatric ward

    • Competing risks

  • 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

  • Polypharmacy

    • Goal: Dynamic approach

    • What about drugs with a preventive effect?

    • Discontinuation trials

  • 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, clock- drawing test

  • Why important?

    • Consent

    • Prognosis

    • Treatment planning

    • Baseline - chemobrain

  • Patients and methods

    • 1622 patients >70 years

    • Assesses for cognitive impairment, dementia excluded

    • Follow-up 6 years

    • Cognitive impairment: 60% increased mortality (HR 1.62, CI 1.13-2.33)

  • Conclusions

    • Cogni