Screening, Geriatric Assessment and Interventions Texte courant Pierre Soubeyran and Siri Rostoft

No conflict of interests Disclosure No conflict of interests

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 Nedgang i fysiologiske kapasitet, men stor variasjon. Økende alder måles ved tid, men aldring styres av biologiske hendelser Muravchik, Anesthesia 5th ed, 2000

What factors to consider? Discuss for 2-3 minutes with the person next to you

Screening tools Relevance for the management of cancer patients Pierre Soubeyran, MD, PhD Institut Bergonié, Université Bordeaux

What is the final goal ? Better treat patients Ensure tumor control, as much as possible Limit the risk of adverse events which may lead to dependencies or even death Maintain quality of life Patient is still leaving at home Still autonomous with no sequellae Cancer is controlled (cured ?)

Available data for screening Standard evaluation Performance status At baseline A few months before Organ function Creatinine clearance Liver tests… Nutritional status Weight, albumin… Geriatric assessment Designed for the oldest To be implemented in oncology

How many Risk Groups ? Heterogeneous population Three groups (or even more) Fit Intermediate Frail

How to design screening tools ? Various solutions Identify a specific vulnerable profile Vulnerable geriatric profile Questionnaires, Fried criteria Non feasibility of a specific treatment Or Identify predictors of unacceptable events Early death, functional decline, toxicity

Oncologists’ approach Feasibility of chemotherapy >70 and at least one factor Poor performance status (WHO 3-4) Cardiac contra-indication to doxorubicin Low creatinine clearance (<50 ml/mn) Neutropenia or thrombocytopenia Severe comorbidities Soubeyran P, J Ger Oncol 2011;2:36-44

Another approach Predictors of unacceptable events Events which would have changed your initial decision, would you have known it may occur later… Early death Functional decline Hospitalization for toxicity

Another approach Predictors of early death MNA and TGUG add to Stage and Sex for prediction of early death P Soubeyran, J Clin Oncol 2012; 30: 1829-34

Another approach Predictors of functional decline IADL and GDS15 are the only predictors of early functional decline S Hoppe, J Clin Oncol 2013; 31: 3877-82

Another approach Predictors of toxicity IADL, MMS, MNA and MAX2 or IADL and physical activities predict severe toxicity Martine Extermann, Cancer 2012;118:3377-86 Arti Hurria, J Clin Oncol 2011;29:3457-65

Another approach Predictors of hospitalization for toxicity P-value MNA <24 4.194 1.7 - 10.3 0.0018 Platelets 3.763 1.3 - 10.8 0.0140 Treatment strategy 0.509 0.26 - 0.99 0.0465 Thrombocytopenia and Malnutrition predict severe toxicity T Warkus, Proc SIOG 2011

Too many patients to evaluate Most CGA tools are useful CGA is time-consuming Need for Screening tools

G8 questionnaire Eight questions Performed by a nurse 5 to 10 min Appetite, weight loss, BMI Mobility Mood and cognition Number of medications Self-related health Age Abnormal if ≤14 Preliminary analysis Se: 89.6% ; Sp: 60.4% Carine Bellera, Ann Oncol 2012;23:2066-72

The ONCODAGE study Setting: Patients >70 with cancer Gold standard: Impaired Multidimensional Geriatric Assessment (MGA) Impaired MGA if ≥ one abnormal questionnaire CIRS-G : at least one grade  3 ADL : score ≤ 5 IADL : score ≤ 7 Timed Get up and Go : > 20 s MNA : score ≤ 23,5 MMSE : score ≤ 23 GDS-15 : score  6 Setting: Patients >70 with cancer Pierre Soubeyran, Proc ASCO 2011

What does G8 detect ? Detection of Abnormal MNA 94,4% Abnormal ADL 93,6% Abnormal TGUG 91,3% Abnormal GDS15 84,8% Abnormal IADL 84,5% Abnormal MMS 80,5% CIRS-G grade 3 – 4 77,4%

What does G8 detect ? False negative characteristics 53,1% with only one abnormal quest. median : 1 18,4% for true positives median : 3 136 patients with grade 3-4 comorbidities Vascular 49,3% Cardiac 15,4% Respiratory 14% Metabolic 11,8%

Confirmation 937 patients At least two abnormal tests among: Live alone, ADL, IADL, MMS, GDS15, MNA, CCI Kenis C et al. J Clin Oncol 2014, 32: 19-26

Confirmation Kenis C et al. J Clin Oncol 2013 In Press

What to do when the screening tool is positive ?

After Screening Consultation Pretreatment work-up Screening G8 Geriatric evaluation Geriatric synthesis Treatment feasibility Adaptation of non specific treatment Adverse events to avoid Multidisciplinary Oncology meeting Treatment plan

Geriatric assessment (GA)1 Functional status Mobility/falls Comorbidity Polypharmacy Cognitive function/ dementia Nutritional status Emotional status 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

GA leads to non-oncological treatment to improve patient’s health 19 studies on GA in older cancer patients: Median 72% of patients (range 26%-100%) were given treatments or recommendations based on the GA Hamaker ME. Journal of Geriatric Oncology 2018

GA leads to changes in oncological treatment Systematic review of 11 studies: 28% of patients had their oncological treatment-plan changed after the GA Of these, the majority had treatment changed to a less intensive regime Hamaker ME. Journal of Geriatric Oncology 2018.

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

Geriatric assessment Fit Intermediate Frail Categorization

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

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

Self-assessment What are the major components of a GA? Why is a GA useful in the cancer setting?

A FEW WORDS ABOUT FUNCTIONAL STATUS Multimorbiditet og polyfarmasi dekkes godt i kurset videre A FEW WORDS ABOUT FUNCTIONAL STATUS

Question for the audience How do we measure functional status? What influences on your functional status? Mention examples from clinic

“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) Definert som at det taper 1 ADL-funksjon 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, 2001

Grim reaper´s maximum speed: 1.36 m/s Stanaway, BMJ, 2011

“HAVE YOU FALLEN?” Jones et al, JAMA Surgery, 2013

COMORBIDITY

Why is comorbidity relevant? Discuss with the person next to you for a few minutes How do you assess comorbidity in your clinical practice?

Chronic disorders by age-group Barnett et al, Lancet 2012

Optimization of comorbidities Geriatrician? Internal medicine specialist? Subspecialist, i.e. cardiologist? Core activity in the acute geriatric ward Competing risks

Polypharmacy Specific talk

Cognitive function Mild cognitive impairment Dementia Screening instruments, MMSE, MOCA, Mini-Cog Why important?

Clock-drawing test

Why important? Consent, discussing preferences Prognosis Treatment planning, delirium Baseline - chemobrain

NUTRITIONAL STATUS

Malnutrition Differs between countries – in Norway malnutrition is the dominant problem Tool: mini nutritional assessment (MNA) among others Definite risk factor – but do interventions help? How to intervene?

EMOTIONAL STATUS

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?

Study (depression)1 Older cancer patients (>70) receiving chemotherapy (n=344) 45% depressed Risk factor: malnutrition at baseline 1Duc et al. Psychooncology, 2016

SOCIAL SUPPORT

Social support Fundamental for treatment planning Population level – sociodemographic factors strong predictors for receiving treatment and survival Caregivers may be frail Patient may be main caregiver – influences motivation for treatment

GA COMPLETED – WHAT NOW?

Geriatric assessment (GA)1 Shared decision-making Remaining life expectancy Detection of unidentified problems Prediction of adverse outcomes Treatment planning Baseline information Optimization before/during treatment Ongoing assessments necessary 1Wildiers et al, JCO, 2014

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?