Older adults represent a rapidly growing proportion of our population, and that’s one reason advanced care practitioners need to know how best to treat them in the cancer clinic.
Advanced practice nurses must be aware of the unique risks faced by seniors and how to assess them for health issues that might factor into their treatment plans, said three experts who addressed the topic in a presentation at the ONS 44
Their talk covered the ins and outs of a geriatric assessment, predicting chemotherapy toxicity, and evaluating polypharmacy.
Giving the talk were Sincere McMillan M.S., ANP-BC, RN
, of Memorial Sloan Kettering Cancer Center (MSK); Diane Cope Ph.D., ARNP-BC, AOCNP,
of Florida Cancer Specialists; and Rowena (Moe) Schwartz, Pharm.D., BCOP
, of the University of Cincinnati.
Cope, director of nursing and an oncology nurse practitioner at Florida Cancer Specialists and Research Institute in Fort Myers, Florida, offered statistics to explain the need for attention to this population.
While there are 46 million adults over age 65 in the U.S. today, totaling 15% of the population, that number will grow to 98 million by 2060, totaling 24% of the population, she said.
The fastest rise in growth is occurring in the group aged 85 to 94, she said, and between 2010 and 2050, it’s expected that the number of adults aged 85 and older will grow from 5.5 million to 19 million. By 2030, an estimated 70% of all cancers will occur in people aged 65 or older, Cope said.
Yet, when she asked a large room full of advanced practitioners if they use a geriatric assessment to determine the fitness of older patients for cancer treatment, nearly all indicated they do not.
McMillan, a nurse practitioner in the department of geriatric medicine at MSK, in New York City, described a “multidimensional, interdisciplinary” geriatric evaluation that can determine a patient’s functional versus chronological age and should be done at baseline and at transition points such as disease progression or treatment changes. She said the evaluation should identify reversible or irreversible deficits, pinpoint health issues before they are exacerbated, and determine which patients face an increased risk of toxicities or other harms from cancer treatment.
The goal of the evaluation is to guide treatment, she said.
Determining the patient’s cognitive status—normal, mild impairment, dementia or delirium—is crucial, because some forms of cancer therapy can have long-term cognitive impact, compounding existing issues. In addition, McMillan said, cognitive dysfunction may affect patients’ adherence to treatments or ability to make decisions.
To assess a patient’s cognitive state, McMillan recommended the Mini-Cog, a quick, brief screening tool that tests the ability to remember words.
If patients score abnormally, she recommended further assessment; ruling out reversible causes; using cognitive rehabilitation techniques (remediation and compensation—adaptive techniques to help restore function); and determining how cognitive deficits are affecting daily life.
Determining a patient’s level of frailty—reduced physiologic reserves that put the patient at higher risk of poor outcomes after a stressor—is also key, McMillan said. Testing this can include assessing activities of daily living (ADL) performance and instrumental activities of daily living (IADLs), as well as administering the Timed-Up-And-Go (TUG) exercise, she said.
ADLs are the basic activities of living: eating, bathing, dressing, transferring in and out of bed, toileting, walking, and moving around. IADLs are activities including cooking, cleaning the house, taking medication, doing laundry, going shopping, handling personal finances, making phone calls, and taking care of transportation needs.
The TUG tests how long it takes a patient to stand up, walk 10 feet at a normal pace, return and sit down again. If this takes a patient 12 seconds or more, it means he or she faces a high risk of falling, McMillan said. These patients should be referred to physical or occupational therapy for prescribed exercise, assistive device training, education, and/or home safety modifications, she said.
Understanding a patient’s psychological status is also important, McMillan said. The Geriatric Depression scale, which asks about satisfaction with life and level of motivation, has very high sensitivity and specificity for depression in this population, which is not a normal part of aging, she said. She noted that depression in these patients may present atypically with physical complaints such as gastrointestinal symptoms and sleep disturbance, but a lack of sadness.
For those whose scores indicate depression, nurses should assess safety and look for suicidal ideation. Patients should be referred to social workers or psychologists, and/or for cognitive behavior therapy, McMillan said. Medications may be indicated.
She emphasized that older patients can differ widely in their health and functionality. Inpatient or outpatient geriatric assessment can pick up problems that might otherwise be missed, allowing for prompt intervention that can improve quality of life and clinical outcomes for patients.
Predicting Chemotherapy Toxicity in Older Adults
While older adults get as much benefit from chemotherapy as younger people, practitioners are less likely to offer it to them, Cope said. One reason may be that 49% to 64% of older patients experience at least one grade 3 toxicity during treatment with cytotoxic agents, she said.
A complicating factor is that more than half of older adults have 3 or more chronic diseases, Cope said. They may be taking numerous medications, but also could have decreased physiological function that changes the way their bodies absorb, distribute, metabolize, and eliminate those drugs.
Besides assessing chronologic age, nurses must remember that the rate of organ decline and overall health status are more predictive of chemotherapy tolerance, Cope said.
Four typical tests—oncologist’s assessment, Karnofsky performance status, Eastern Cooperative Oncology Group (ECOG) performance status and geriatric assessment—may have some value but are not validated in this setting, she said.
She also recommended two newer tools.
The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) toxicity tool considers hematologic and non-hematologic risk factors, rating patients on their IADL capabilities, liver function, levels of diastolic blood pressure, lactate dehydrogenase and white blood cells, and also on their ECOG performance status, Mini-Mental State Exam and Mini Nutritional Assessment results, finally giving a chemotoxicity score. CRASH and other oncology assessment tools for seniors can be found at the Moffit Cancer Center website
The Prediction Tool for Chemotherapy Toxicity was created by the Cancer and Aging Research Group (CARG). This tool
asks 11 questions, including patient age, number of chemotherapy drugs, dosing, laboratory values, and geriatric assessment factors: ADL, IADL and Karnofsky performance status.
In incorporating the results into treatment, she said, patients should be advised of their personalized risks and benefits of chemotherapy, and practitioners should seek their perspectives and those of their caregivers.
In deciding which tools to use, nurses should consider what is quick and easy for both them and patients, Cope said—but should not overlook the task.
“We can’t turn our backs on this,” she said, “because it’s going to be at our doorstep very soon.”
Polypharmacy has many definitions, said Schwartz, associate professor of pharmacy practice at the University of Cincinnati James L. Winkle College of Pharmacy in Cincinnati, Ohio. It can mean one patient’s use of 5 or more medicines, multiple pharmacies, or inappropriate medicines; the underuse of medication; or drug duplication.
Any of these issues can cause adverse drug reactions or interactions, she said, as well as contributing to increased complexity and cost of care.
Drugs can interact with other drugs or with food and can aggravate comorbidities or affect functionality. Even combinations of over-the-counter drugs can result in issues such as fatigue or dizziness, Schwartz said. In oncology, she said, concerns are that drugs taken for other conditions might decrease or increase the effects of an anticancer medication or contribute to cumulative toxicities. When polypharmacy is a factor, she added, lack of adherence also may arise.
Practitioners trying to help patients can actually harm them via polypharmacy, Schwartz continued. For instance, she said, nurse practitioners might unwittingly dampen the effectiveness of an anticancer drug when they medicate comorbidities—for instance, by giving medication for depression to patients who are taking tamoxifen.
A key way to avoid some of these interactions is to identify and deprescribe potentially inappropriate medications, which are a common problem among older patients, Schwartz said. A Brazilian study in the hematology/oncology setting found that 48 percent of older adults were using at least one potentially inappropriate medication.
As a result, it’s crucial for practitioners to conduct drug interaction evaluations regularly in their older patients with cancer, Schwartz said. She noted that drug interactions in these patients can change from day to day, as chemotherapy and treatments for its side effects may be episodic. That’s why drug interaction evaluations should occur any time a drug is started, changed, or discontinued. Schwartz goes as far as to ask all her patients to call her whenever they start or change a medication or dose, so she can evaluate whether there’s likely to be a problem. And she calls patients’ primary care physicians and pharmacies if they’re about to start oral anticancer drugs, so that everyone involved is aware of the medications being administered.
To deprescribe, nurses need to determine treatment goals, review medications being taken, evaluate medication appropriateness, identify medication that should be discontinued, create a deprescribing plan, and then monitor and review, she said.
There are some tools that can help practitioners evaluate a patient’s drug profile, she added.
The American Geriatric Society Beers Criteria provides lists of drugs and their classes that may be inappropriate for older people. It includes a rationale explaining why each drug is potentially inappropriate, a ranking of whether the evidence is low, moderate or high, and a recommendation ranked as insufficient, weak or strong.
The Screening Tool of Older People’s Prescription (STOPP) was developed to address limitations of the Beers Criteria, which in some instances makes controversial recommendations. The tool is a list, categorized by body system, of 65 prescribing practices that are inappropriate in older people, with rationales. The list was devised by a panel of 18 experts in geriatric pharmacotherapy.
The Medication Appropriateness Index gives practitioners a checklist of issues to consider when prescribing a medication to an older person. The list includes the medicine’s indication, effectiveness, dose, duration, cost effectiveness, and potential drug and disease interactions.
Finally, a member of the audience recommended a database offered by MSK, About Herbs
, which can help practitioners guide patients in avoiding herb/drug interactions.
McMillan S, Cope D, Scwartz R. Managing the unique needs of the older adult with cancer. Presented at: ONS 44th
Annual Congress; April 11-14, 2019; Anaheim, California. Abstract 2069.