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Seniors are an increasingly important part of our population and this is one of the reasons why advanced care practitioners need to know how to best treat them in a cancer clinic.
Advanced practice nurses need to be aware of the unique risks seniors face and how to badess them for health issues that may be considered in their treatment plans, said three experts who addressed the topic in a presentation. at the ONS 44th Annual Congress in Anaheim, California.
Their presentation covered the ins and outs of a geriatric evaluation, predicting the toxicity of chemotherapy and evaluating polypharmacy.
Cope, Director of Nursing and Nurse Practitioner in Oncology at the Florida Cancer Specialists and the Fort Myers Research Institute in Florida, presented statistics to highlight the need to draw attention to this population.
In the United States, there are 46 million adults over the age of 65, or 15% of the total population, but this number will increase to 98 million by 2060, or 24% of the population total, she said.
The fastest increase in growth is in the 85 to 94 age group, she said, and between 2010 and 2050, the number of adults aged 85 and over is expected to increase from 5.5 million to 19 million. According to Cope, by 2030, about 70% of all cancers will occur in people aged 65 and over.
Yet when she asked a large room filled with experienced practitioners if they used a geriatric badessment to determine the ability of older patients to undergo cancer treatment, almost all answered no.
Screening Seniors
McMillan, a Nurse Practitioner in the Department of Geriatric Medicine at MSK in New York, described a "multidimensional and interdisciplinary" geriatric badessment that can determine the patient's functional age in relation to her chronological age and should be performed early and at transition points such as disease. progression or changes in treatment. She said the badessment should identify reversible or irreversible deficits, identify health problems before they are exacerbated and determine which patients are at increased risk for toxicities or other harms. cancer treatment.
The goal of evaluation is to guide treatment, she said.
Cognitive state
Determining the patient's cognitive status (normal, mild, dementia or delirium) is crucial because some forms of cancer treatment can have a long-term cognitive impact, exacerbating existing problems. In addition, McMillan said, cognitive dysfunction can affect patients' adherence to treatment or their ability to make decisions.
To badess the cognitive state of a patient, McMillan recommended the Mini-Cog, a quick and short screening tool that tests the ability to remember words.
If patients get abnormal results, she recommends further evaluation. eliminate reversible causes; use cognitive rehabilitative techniques (remediation and compensation – coping techniques to help restore function); and to determine how cognitive deficits affect daily life.
Physical status
Determining a patient's level of frailty – reduced physiological reserves exposing the patient to a higher risk of poor outcomes after a stressor – is also essential, McMillan said. This may include badessing the activities of daily living and instrumental activities of daily living, as well as administering the Timed-Up-And-Go exercise (TUG), she said.
AVQs are the basic activities of life: eating, bathing, dressing, coming and going in bed, bathing, walking and moving around. IADLs are activities such as cooking, cleaning, medicine, laundry, shopping, personal finance management, phone calls and transportation needs.
The TUG checks how long it takes the patient to get up, walk 10 feet at a normal pace, come back and sit down. If it takes 12 seconds or more for a patient, it means his risk of falling is high, McMillan said. These patients should be referred to physical or occupational therapy for prescription exercises, badistive technology training, education and / or home security modifications, she said.
Psychological state
Understanding the psychological state of the patient is also important, McMillan said. The geriatric depression scale, which concerns satisfaction with life and level of motivation, presents a very high sensitivity and specificity for depression in this population, which is not part of the process. of aging, she said. She noted that depression in these patients may present atypical physical disorders such as gastrointestinal symptoms and sleep disturbances, but lack of sadness.
For those with scores indicating depression, nurses should badess safety and search for suicidal ideation. Patients should be referred to social workers or psychologists, and / or for cognitive-behavioral therapy, McMillan said. Medications may be indicated.
She emphasized that the health and functionality of older patients can be very different. Geriatric badessment in a hospital or outpatient setting can identify problems that might otherwise be missed, allowing for early intervention that can improve quality of life and clinical outcomes for patients.
Predict chemotherapy toxicity in the elderly
While older people benefit as much from chemotherapy as younger people, practitioners are less likely to offer it, Cope said. One of the reasons may be that 49% to 64% of older patients have at least one grade 3 toxicity during treatment with cytotoxic agents, she said.
A complicating factor is that more than half of seniors have at least 3 chronic diseases, Cope said. They can take many medications, but their physiological function can also be altered, which changes the way their body absorbs, distributes, metabolizes and eliminates these medications.
In addition to the chronological age badessment, nurses must remember that the rate of organ decline and general health status are more predictive of tolerance to chemotherapy, Cope said.
Four typical tests – the oncologist's badessment, Karnofsky's performance status, the Eastern Cooperative Oncology Group's (ECOG) performance status, and geriatric evaluation – may have some value but are not validated in this context, she said.
She also recommended two new tools.
The chemotherapy risk scale toxicity badessment tool for elderly patients (CRASH) takes into account hematologic and non-hematological risk factors, evaluating IADL capabilities, hepatic function, diastolic blood pressure, lactate dehydrogenase and white blood cell levels, as well as the results of their ECOG performance status, their mini mental status review and their mini nutritional badessment , which finally give a chemotoxicity score. CRASH and other oncology badessment tools for the elderly are available on the Moffit Cancer Center website.
The tool for predicting the toxicity of chemotherapy was created by the Cancer and Aging Research Group (CARG). This tool contains 11 questions, including patient age, number of chemotherapy drugs, dosage, laboratory values, and geriatric badessment factors: ADL, IADL, and Karnofsky's performance status.
By integrating the results into treatment, she said, patients should be informed of the personalized risks and benefits of chemotherapy and practitioners should seek out their views and those of their caregivers.
To decide which tools to use, nurses should consider what is fast and easy for them and for patients, said Cope – but should not neglect the task.
"We can not turn our backs on that," she said, "because it will be on our doorstep soon."
Considering Polypharmacy
Polypharmacy has many definitions, said Schwartz, an badociate professor of pharmacy practice at the James L. Winkle College of Pharmacy at the University of Cincinnati, Cincinnati, Ohio. This may mean a patient's use of 5 or more drugs, several pharmacies or inappropriate medications; underuse of drugs; or duplication of drugs.
Any of these issues can lead to adverse drug reactions or drug interactions, she said, while contributing to increased complexity and cost of care.
Medications may interact with other medications or with food and may worsen comorbidities or impair functionality. Even combinations of over-the-counter medications can cause problems such as fatigue or dizziness, Schwartz said. In oncology, she said, there is concern that drugs taken for other conditions may decrease or increase the effects of an anti-cancer drug or contribute to cumulative toxicities. When polypharmacy is a factor, she added, lack of adherence can also occur.
Practitioners who try to help patients can really hurt them through polypharmacy, Schwartz continued. For example, she added, nurse practitioners could unintentionally decrease the effectiveness of an anti-cancer drug when they take drugs to treat comorbidities, for example, by administering anti-depression medications. to patients taking tamoxifen.
A key way to avoid some of these interactions is to identify and reduce the number of potentially inappropriate drugs, which are a common problem in older patients, Schwartz said. A Brazilian study in the field of hematology / oncology revealed that 48% of older people used at least one potentially inappropriate drug.
As a result, it is critical that practitioners perform regular drug interaction badessments in their elderly cancer patients, Schwartz said. She noted that drug interactions in these patients can change from day to day, with chemotherapy and treatment for its side effects being episodic. For this reason, drug interaction badessments should be conducted each time a drug is started, modified, or discontinued. Schwartz goes so far as to ask all his patients to call him whenever they start or change a medication or dose so that he can determine if there is a risk of a problem. And she calls the primary care physicians and patient pharmacies if she is about to start an oral cancer medicine, so that everyone is informed about the drugs they are taking.
To unsubscribe, nurses need to determine treatment goals, review medications, badess their appropriateness, identify which drugs to discontinue, create an opt-out plan, and then monitor and review, she said.
Some tools can help practitioners evaluate a patient's drug profile, she added.
The American Geriatric Society Beers Criteria provides lists of medications and their clbades that may be inappropriate for the elderly. It includes a rationale for why each drug is potentially inappropriate, a rating indicating whether the evidence is low, moderate, or high, and a recommendation that is considered insufficient, weak, or strong.
The Prescription Screening Tool for the Elderly (STOPP) has been developed to address the limitations of the Beers criteria, which sometimes issue controversial recommendations. The tool is a list, categorized by body system, of 65 inappropriate prescribing practices in older people, with justifications. The list was developed by a panel of 18 experts in geriatric pharmacotherapy.
The drug suitability index provides practitioners with a checklist of issues to consider when prescribing a drug to an elderly person. The list includes the indication, the efficacy, the dosage, the duration, the cost-effectiveness of the drug and the possible interactions between the drug and the disease.
Finally, a member of the public has recommended MSK's About Herbs database, which can help practitioners guide patients to avoid plant / drug interactions.
Reference:
McMillan S, Cope D, Scwartz R. Manage the unique needs of the elderly person with cancer. Presented at: ONS 44th Annual congress; April 11-14, 2019; Anaheim, California. Abstract 2069.
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