Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing

Louisiana State Health Sciences Center in New Orleans, Louisiana

The terminology of aging has changed over the past decade or so, and we’re now using phrases such as young old (aged 60 to 69 years), middle old (aged 70 to 79 years), and the very old (aged 80+). According to the Census Bureau, 5.7 million people in the United States are aged 80-84 and 5.5 million are aged 85 and older. People are now living longer than ever before. In fact, the Hallmark Cards Company sells 85,000 “Happy 100th Birthday!” cards each year.

 is an evolving challenge. The numbers are growing, and with increasing age, come increasing medical problems. It’s not uncommon for an older patient to have heart disease, diabetes, arthritis, and other medical disorders in addition to cancer. These patients are likely to be taking multiple drugs, which may interact with cancer treatment and/or require close monitoring during treatment. The decision to treat—or not treat&mdash;an older patient may be difficult; aging is highly individualized so treatment decisions cannot be made on the basis of age alone. And because the elderly are under-represented in clinical trials, information about how to best treat an older population is limited.

Treatment decisions need to be based on potential benefits and how the patient may be affected by adverse effects. This decision-making can be an ethical dilemma; however, the starting point is considering the patient’s wishes after providing accurate information about risks and benefits of treatment.

Recommending no treatment and offering only symptomatic/palliative care is difficult for many clinicians and may not be an option the patient wants to consider. In reviewing hundreds of medical records over the years, I’ve yet to see a documented discussion of recommending no treatment. Instead, some type of treatment, including giving a “sprinkling of chemotherapy,” has been recommended. It appears it is just too difficult to suggest no treatment. The hesitation may be that no treatment is equated to “doing nothing,” which is not the case. When clinicians are fully informed about and comfortable with the principles of palliative care, there is much that can be done in the absence of cancer treatment.

To assist in decision making about the treatment of cancer in the elderly, we need to carefully examine the likelihood of response to chemotherapy and survival benefit. We also need to consider the physiological changes that accompany aging, such as diminished organ function, which will affect how chemotherapy is metabolized. Impaired heart, lung, kidney, liver, or bone marrow reserve are particularly problematic when giving chemotherapy or radiotherapy. However, when older patients are carefully screened and monitored throughout treatment, adverse effects can be minimized or quickly addressed.

An 11-question survey can be used to assist in determining which older patients can benefit from chemotherapy and which ones are unlikely to tolerate treatment. A tool for assessing chemotherapy tolerance in older patients was developed by Arti Hurria, MD, and the City of Hope Comprehensive Cancer Center. It looks at such risk factors as the patient’s age (72 years or older), hearing, creatinine clearance, hemoglobin levels, number of falls in the last 6 months, and level of social activity.1 A score of 0 to 5 indicates that the patient has a low risk of experiencing severe toxicity from chemotherapy, 6 to 9 indicates about a 50% risk and 10 to 19 indicates a high risk of developing a severe or even fatal reaction to chemotherapy.

The longer Comprehensive Geriatric Assessment (CGA) also is a valuable tool in the assessment of older patients but may be cumbersome to implement for daily clinical use. Regardless of the tool used, care of elderly patients with cancer can be improved by identifying the patients who are best suited for treatment.

Hurria A, Towgawa K, Mohile SG, et al. Predicting Chemotherapy Toxicity in Older Adults with Cancer: A Prospective Multicenter Study; 

Articles

Nurse's Notes

The terminology of aging has changed over the past decade or so, and we're now using phrases such as young old (aged 60 to 69 years), middle old (aged 70 to 79 years), and the very old (aged 80+).

Treating Elderly Patients: How Old Is Too Old?

Cancer treatment can render the most capable 30-somethings unable to care for themselves, but it can take a far greater toll on older patients.

Chemotherapy can hasten physical and cognitive decline. Surgery can leave patients permanently weak. Even milder treatments that range from endocrine therapy to simple antihistamines can produce serious side effects.

Independent oncology practices cannot afford to address these challenges the way academic hospitals have, by hiring neurologists, dietitians, physical therapists, and other specialists. Nevertheless, nurses who work at smaller facilities can provide older patients with many of the same benefits.

“Even the largest of the specialty programs are executing a relatively simple idea: older patients undergo special assessments, and the results help to guide their treatment,” said Arti Hurria, MD, director of the Cancer and Aging Research Program at City of Hope in Duarte, California.

“Those big programs obviously have great resources at their disposal, but a few standardized assessments that are free online, combined with some operational flexibility and a willingness to refer patients to outside help, can often produce similar benefits.”

A patient’s chronological age matters less in “geriatric” oncology than the specialty’s name implies. Age does determine which patients undergo which assessments, but its importance fades thereafter. Calendar age correlates so imperfectly with individual decline that assessments are more informative than birth certificates.

A 75-year-old who runs a successful business clearly needs less cognitive support than a 75- year-old who forgets to get dressed. That said, experts warn, all elderly patients should be formally tested for age-related decline, no matter how functional they seem. People often hide their weaknesses, consciously and unconsciously, during ordinary interactions, but it is hard to fool a good assessment tool.

Such tools, moreover, are freely available online. Researchers have developed and validated a wide range of tests that provide large amounts of actionable information in small amounts of time.

Patients can perform some assessments entirely on their own simply by filling out questionnaires that gauge comorbid conditions, mood, eating habits, and physical abilities. This strategy is particularly efficient when practices let patients take their assessments on tablets or computers that send the answers directly into electronic health records (EHRs) and (in some cases) tabulate results automatically.

Initially, gerontologists worried about the reliability of this self-reported data, but studies have consistently shown that validated questionnaires hold up surprisingly well, even when compared with time-consuming performance evaluations that require third-party administration.

Among the best known of these tools is the 18-question Mini Nutritional Assessment (MNA) and its even briefer sibling, the six-question Mini Nutritional Assessment Short-Form, (MNASF). More than two dozen published studies have evaluated numerous aspects of the MNA in various settings over the past 20 years.

A review of those studies published in 2006 by the Journal of Nutrition, Health & Aging found that the tool had consistently demonstrated itself to be both accurate and easy to use in trials on more than 10,000 patients. Just 3 years later, the same journal printed a widely cited study that used data from more than 2000 patients to reach much the same conclusion about the newest version of the MNA-SF.

Research also has validated other assessments of individual aspects of patient health and functionality, but Hurria and her colleagues in the Cancer & Aging Research Group (CARG) have attempted to simplify matters by combining several validated tools into a single geriatric assessment that is largely self-administered. It is, of course, much longer than the MNA-SF. Indeed, its dozens of questions cover topics as diverse as losing weight, climbing stairs, driving automobiles, attending church, feeling depressed, maintaining relationships, and suffering ailments.

Still, older patients get through it with surprising speed. A 2011 study in the Journal of Clinical Oncology found that 87% of an 85-patient cohort (mean age 72) completed all of the questions, without help, in an average of just 22 minutes.

The many advantages of questionnaires might tempt time-strapped practices to omit objective tests entirely, but Hurria and other experts recommend that they resist the temptation. Indeed, the CARG assessment includes a couple of tests of basic physical and mental ability that caregivers must administer. Other popular options that provide similar information include the Mini Cog and the Timed Up and Go.

Such tests consume a surprisingly small amount of staff time. Timed Up and Go simply measures the number of seconds a person takes to get up from a chair, walk 10 feet, return to the chair, and sit back down. Even the Mini Cog has just 3 steps: (1) Read the patient three unrelated words and ask the patient to repeat them; (2) Ask the patient to draw an analog clock reading 11:10 or 8:20 on a blank circle; (3) Ask the patient to recall the three words.

How much information can such simple tests reveal? Studies show that the first is an accurate predictor of fall risk, whereas the second is an accurate detector of cognitive impairment. All told, at practices that administer questionnaires electronically and use software to score results, it might take an experienced nurse 15 minutes to gather and review the information from all the tests discussed above. And, another 15 minutes of informal observation can provide a wealth of extra insight.

“Assessing the older patient beyond standard oncology management is critical to the clinical picture. Selecting appropriate assessment instruments can help construct a reasonable cancer care strategy,” said Janine Overcash, PhD, GNP-BC, associate professor at Ohio State University College of Nursing.

“Of course, assessing a patient’s condition is the easy part. The harder and more time-consuming part is responding appropriately when those tests reveal problems. You need to decide how you’re going to handle whatever issues you find, and then you need to carry out whatever plan you make.”

For nurses, good response planning starts with a procedure for communicating relevant assessment results to oncologists and other specialists.

Granted, oncologists already have many other tools to help them match individual treatments with individual patients, including patients with age-related morbidities. Still, the data that nurses gather from age-related assessments and personal observations provide a valuable addition that can sometimes change treatment decisions.

Patients with signs of dementia, for example, will not reliably comply with treatment plans that require them to do much more than take a fixed number of pills at a single set time each day. A particularly frail patient, on the other hand, will often fare worse on chemotherapy than hardier ones.

Nurses themselves can do even more with the data they gather. Indeed, the results will often indicate that patients have greater needs than nurses can address on their own.

Oncology nurses can give tips for maximizing calorie intake to patients who struggle to eat enough during chemotherapy. However, when complete diet programs are required for patients who suffer malnutrition at baseline, that’s a job for a dietitian. When meals need to be prepared for patients who lack the strength and energy to make them on their own, social workers and family members can provide support.

Similar logic applies in many areas. Nurses should try to help patients who get a little blue during chemotherapy; psychiatrists should try to help patients who suffer from clinical depression. Nurses should encourage fundamentally fit patients to keep (somewhat) active during treatment; physical therapists should try to improve functionality in frail patients. Nurses should advise people with borderline blood pressure to walk a little more and ease up on the salt; internists should treat the sort of severe hypertension that can hinder cancer treatment and trigger strokes.

Proper assessment of older patients will reveal that many need all sorts of specialty help. Some will need social workers to keep their houses in order or provide guidance on finances. Some patients will need medical alert systems, regular visiting nurses and, in some cases, a place at an assisted living facility.

Specialty help not only improves overall patient welfare, but also improves oncology outcomes. Depressed, malnourished patients lack the physical and mental strength to recover properly from cancer treatment. Each practice should compile a list of well-regarded providers of services senior patients might require when assessments demonstrate a particular need.

Of course, many patients will never make any appointments because their problems prevent them from exerting the necessary effort, even when they start off with contact information. A better policy, therefore, might be to actually set up appointments for patients who consent to such help.

This policy has obvious benefits for patients, but experts say it can also benefit oncology practices. If, for example, you try to make appointments with providers who use the same EHR you use, then you will have easy access to records that can help your treatment decisions (assuming your patients allow it). Even if sharing isn’t always seamless, standing relationships facilitate communication and promote success.

Better still, when patients get all the supplementary help they need, they often need much less special attention from oncology nurses. Physical therapy increases strength and improves balance. Better nutrition increases both patients’ energy levels and their ability to concentrate.

Age-related impairment slows both mind and body, so nurses (and schedulers) need to allot more time for every aspect of every visit: a walk down the hall, a change of clothes, a trip to the bathroom, and a simple discussion. They also need to modify their normal techniques for communicating complex information.

Older patients, even those who suffer no cognitive impairment, tend to process information relatively slowly and forget it relatively easily. Nurses should counter this by speaking at a more deliberate pace, cutting information into small nuggets, writing those nuggets out for later study and suggesting websites that provide reliable supplemental information. (The idea that seniors struggle online is outdated, gerontologists say. Today’s seniors were middle-aged when the Internet became popular, and they often spend more time online than younger patients.) The key to minimizing the extra time requirements is thinking things out in advance.

“Little things like giving people who walk slowly the examining rooms nearest the waiting room, advising unsteady patients about which footwear minimizes fall risk, or positioning the people who will need the bathroom most in the chair that’s next to the bathroom—they all add up,” said Lorraine K. McEvoy, DNP, MSN a nurse leader in the geriatrics program at Memorial Sloan Kettering Cancer Center.

McEvoy believes practices should work particularly hard to minimize walking distances for geriatric patients who undergo chemotherapy. Such efforts do more than save time. They increase patient safety.

“One significant challenge of geriatric oncology is awareness of how the necessary premedication drugs should be dosed to adequately prepare the older adult for a particular regimen of chemotherapy,” she said. “Seniors tend to experience adverse reactions to many of the medications that are typically used, but there’s usually no way to omit those medications altogether and still give the chemotherapy. The challenge, therefore, is to determine what dose of each medication provides the optimal balance of effect and side effect.

“Even when you find the right dose,” she continued, “side effects can occur, so you need to watch senior patients far more carefully. For example, an older adult should never get up from a chemo chair without help from someone. You just need to commit yourself to the extra effort, or eventually you’re going to be dealing with falls and broken bones and hospitalizations.” As geriatric patients move through their course of treatment, nurses need to keep a particular eye out for signs of decline.

Here, again, the initial assessments prove beneficial, in this case because they provide an objective basis for measurement. Without baseline tests, nurses might not recognize if a particular patient’s gait is deteriorating. Having a clear understanding of where the patient was prior to the start of treatment enables the clinician to recognize subtle alterations in the patient’s status.

This is important for at least two reasons. First, cancer treatments (especially chemotherapy) are often far more toxic in older patients than younger ones and can do substantial permanent damage if problems are not caught early. Tests that demonstrate a patient’s gait has gotten worse are important because they signal a need to check whether it is the neurotoxicity of the treatments that has caused the problem.

Second, declines that put geriatric patients at risk of falling are particularly dangerous and demand countermeasures. Falls produce broken bones, which can lead to hospitalizations and (in a surprising number of cases) permanent decline.

Geriatric care would benefit patients with cancer significantly if it did nothing more than prevent a fair number of those debilitating missteps, and even basic geriatric care can improve outcomes. Yet, the one thing it doesn’t improve is the bottom line.

“There’s almost no way for an oncology practice to bill for any extra service they provide to geriatric patients, so all their pains generally won’t produce an extra nickel of revenue,” said Hyman B. Muss, MD, a professor at the UNC-Chapel Hill School of Medicine who helped build the geriatric oncology program at the university’s Lineberger Cancer Center.

“There are those who believe that may change if we move far enough from fee-for-service to fee-for-outcome, because good geriatric care certainly improves outcomes. If that is to happen, though, it will require payers to give practices the same amount of money to treat fewer patients, and it will be hard to make that fly, even if it does improve outcomes.”

“Fortunately, it is possible to do the basics efficiently enough to avoid bankrupting your practice, but you will still be sacrificing some amount of profit to help patients do better. It’s a labor of love.”

Cover Story

Optimizing Geriatric Cancer Care Calls for Careful Assessment, Clinical Awareness

Amy R. Lipson, PhD, is a Research Associate, and Sara L. Douglas, PhD, RN is Associate Professor and Assistant Dean for Research, at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.

A new study funded by the National Institutes of Health (NRO14856), “Factors Influencing Cancer Care Decisions,” is currently underway at the Frances Payne Bolton (FPB) School of Nursing at Case Western Reserve University (CWRU) and the Seidman Cancer Center at Case Medical Center. The study focuses on the complex practice of shared decision-making in advanced cancer patients.

Prior research has focused on the examination of healthcare communication with patients or families, or providing more education to patients or families regarding end-of-life treatment decisions.  Results from those studies have shown very mixed results, however. 

This research team believes aggressiveness of care decisions that are made at end-of-life (EOL) are influenced by many factors, including healthcare providers, patients, and family—and these factors are very complex in the way that they influence aggressiveness of care decisions.   

The team, headed by FPB Associate Professor Sara L. Douglas, PhD, RN, is looking at the dyadic processes between oncologist and patient and the influences of the family caregiver and nurse on decision making. Clinical decisions are most often shared, with oncologists providing information and guidance about options and patients evaluating and choosing among the options. In addition to Douglas, the research team includes Barbara J. Daly, PhD, and Christopher J. Burant, PhD, both of the FPB School of Nursing, and Neal Meropol, MD, from the School of Medicine, Case Western Reserve University.

Many patients are influenced in their decisions by family caregiver, oncologist and/or RN evaluations of the appropriate focus of care. Thus, the phenomenon of “decision” is incompletely examined if only one component of the decision-making process is considered and measured independently of the others. This study is designed to help describe the complex nature of the decision-making process involved in EOL treatment for these vulnerable patients. 

Identifying a model that predicts the utilization of aggressive EOL care is an important purpose of this study. The model will incorporate the focus of care (from the perspective of the oncologist, patient, and the oncologist—patient dyad), as well as clinical triggers, EOL preferences, treatment effectiveness, and evaluation of the focus of care (from the perspectives of the caregiver and the RN). 

The researchers hope that examining dyadic relationships between oncologists and patients over time will enable them to describe key aspects that influence EOL treatment decision making. In addition, by including the influence of caregivers and RNs on EOL decision making, the researchers hope to be able to examine factors external to the patient—oncologist dyad.

The study is using a longitudinal, descriptive, correlational design and is recruiting patients with stage IV gastrointestinal or lung cancers. If the patient has a caregiver, that individual is being recruited to participate as well. Baseline data regarding EOL values, religiosity, and optimism are gathered on patients and their caregivers.

Healthcare providers are asked (at baseline) to answer questions related to their own personal EOL values, their comfort with caring for dying patients, and their sense of religiosity. Every 3 months, patients, caregivers, oncologists, and nurses are asked to evaluate treatment effectiveness, their focus of care, the patient’s health-related quality of life, and for oncologists, their predicted survival for the patient. 

We anticipate a sample size of 300 patients, 60% of whom will have caregivers enrolled in the study. There is growing concern that patterns of overly aggressive interventions in the final weeks and months of life seriously detract from quality of life and may not be consistent with patient preferences and values. We believe that it is essential to apply more comprehensive and sophisticated designs in order to be able to identify and implement interventions or decision support systems that can be tailored in such a way as to account for the complex interaction among factors.

Our analysis is expected to yield information that will help us to develop tailored, meaningful interventions that are more likely to be successful in facilitating communication and decision making for those involved in EOL decision for patients with advanced cancer, and we look forward to sharing our findings with at the conclusion of the study.

Partner Perspectives

A new study funded by the National Institutes of Health (NRO14856), "Factors Influencing Cancer Care Decisions," is currently underway at the Frances Payne Bolton (FPB) School of Nursing at Case Western Reserve University (CWRU) and the Seidman Cancer Center at Case Medical Center. The study focuses on the complex practice of shared decision-making in advanced cancer patients.

March 2015

Treating Elderly Patients: How Old Is Too Old?

Optimizing Geriatric Cancer Care Calls for Careful Assessment, Clinical Awareness

Factors Influencing Care Decisions for Patients With Advanced Cancer