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

2. No conflict of interests
Disclosure
No conflict of interests

4. 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?

5. 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

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

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

8. 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 ?)

9. 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

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

11. 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

12. 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

13. 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

14. 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:

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

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

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

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

19. 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:

20. 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

21. 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%

22. 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%

23. 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

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

25. What to do when the screening tool is positive ?

26. 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

27. 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

28. 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

29. 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.

30. Journal of Surgical Research 193 (2015) 265-272

31. 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)

32. 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)

33. Geriatric assessment
Fit
Intermediate
Frail
Categorization

34. 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

35. 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

36. 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

37. 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

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

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

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

41. “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

42. 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

43. Walter et al, JAMA, 2001

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

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

46. COMORBIDITY

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

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

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

50. Polypharmacy
Specific talk

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

53. Clock-drawing test

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

55. NUTRITIONAL STATUS

56. 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?

57. EMOTIONAL STATUS

58. 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?

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

60. SOCIAL SUPPORT

61. 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

62. GA COMPLETED – WHAT NOW?

63. 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

64. 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

65. THANK YOU FOR YOUR ATTENTION QUESTIONS?