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Screening, Geriatric Assessment and Interventions Screening, Geriatric Assessment and Interventions

Screening, Geriatric Assessment and Interventions - PowerPoint Presentation

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Screening, Geriatric Assessment and Interventions - PPT Presentation

Pierre Soubeyran and Siri Rostoft Disclosure Research SupportPI Roche TEVA Employee No relevant conflicts of interest to declare Consultant No relevant conflicts of interest to declare ID: 910524

patients status functional geriatric status patients geriatric functional treatment cancer assessment screening risk abnormal oncol cga score surgery 2011

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Slide1

Screening, Geriatric Assessment and Interventions

Pierre Soubeyran and Siri Rostoft

Slide2

Disclosure

Research Support/P.I.

Roche, TEVA

Employee

No relevant conflicts of interest to declare

ConsultantNo relevant conflicts of interest to declareMajor StockholderNo relevant conflicts of interest to declareSpeakers BureauNo relevant conflicts of interest to declareHonorariaSPECTRUM, Pierre FabreScientific Advisory BoardTEVA, CELGENE

Slide3

Disclosure

No conflicts of interest to declare

Slide4

Mrs

A, aged 94Admitted 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?

Slide5

Decrease in capacity - heterogeneity

Muravchik, Anesthesia 5th

ed

, 2000

Slide6

What factors to consider?

Discuss for 2-3 minutes with the person next to you

Slide7

Screening

tools

Relevance for the management

of cancer patients

Pierre Soubeyran, MD,

PhDInstitut Bergonié, Université Bordeaux

Slide8

What

is the final goal ?

Better

treat

patientsEnsure tumor control, as much as possibleLimit the risk of adverse events which may lead to dependencies or even deathMaintain quality of lifePatient is still leaving at homeStill autonomous with no sequellaeCancer is controlled (cured ?)

Slide9

Available data for screening

Standard evaluation

Performance

status

At

baselineA few months beforeOrgan functionCreatinine clearanceLiver tests…Nutritional statusWeight, albumin…Geriatric assessmentDesigned for the oldestTo be implemented in oncology9

Slide10

How

many Risk Groups ?

Heterogeneous

population

Three

groups (or even more) FitIntermediateFrail

Slide11

How to design screening

tools ?

Various

solutions

Identify

a specific vulnerable profile Vulnerable geriatric profile Questionnaires, Fried criteriaNon feasibility of a specific treatmentOr Identify predictors of unacceptable events Early death, functional decline, toxicity

Slide12

Oncologists

’ approach

Feasibility

of

chemotherapy

>70 and at least one factorPoor performance status (WHO 3-4)Cardiac contra-indication to doxorubicinLow creatinine clearance (<50 ml/mn)Neutropenia or thrombocytopeniaSevere comorbiditiesSoubeyran P, J Ger Oncol 2011;2:36-44

Slide13

Another

approach

Predictors

of

unacceptable

eventsEvents which would have changed your initial decision, would you have known it may occur later…Early deathFunctional declineHospitalization for toxicity

Slide14

P

Soubeyran, J Clin Oncol 2012; 30: 1829-34

MNA and TGUG

add

to

Stage and Sex for prediction of early deathAnother approachPredictors of early death

Slide15

S Hoppe, J Clin

Oncol 2013; 31: 3877-82IADL and GDS15 are the

only

predictors

of early functional declineAnother approachPredictors of functional decline

Slide16

16

Arti Hurria,

J Clin

Oncol

2011;29:3457-65

Martine Extermann, Cancer 2012;118:3377-86IADL, MMS, MNA and MAX2orIADL and physical activitiespredict severe toxicityAnother approachPredictors of toxicity

Slide17

17

Thrombocytopenia and Malnutrition

predict

severe

toxicityOR95% CIP-valueMNA <244.1941.7 - 10.30.0018Platelets3.7631.3 - 10.80.0140Treatment strategy 0.5090.26 - 0.990.0465T Warkus, Proc SIOG 2011Another approachPredictors of hospitalization for toxicity

Slide18

Too

many patients

to

evaluate

Need

for Screening toolsCGA is time-consumingMost CGA tools are useful

Slide19

G8 questionnaire

Eight

questions

Performed

by a nurse

5 to 10 minAppetite, weight loss, BMIMobilityMood and cognitionNumber of medicationsSelf-related healthAgeAbnormal if ≤14Preliminary analysisSe: 89.6% ; Sp: 60.4%Carine Bellera, Ann Oncol 2012;23:2066-72

Slide20

The ONCODAGE

study

20

Setting:

Patients >70

with cancerImpaired MGA if ≥ one abnormal questionnaireCIRS-G : at least one grade  3ADL : score ≤ 5IADL : score ≤ 7Timed Get up and Go : > 20 sMNA : score ≤ 23,5MMSE : score ≤ 23GDS-15 : score  6Gold standard: Impaired Multidimensional Geriatric Assessment (MGA)Pierre Soubeyran, Proc ASCO 2011

Slide21

What

does G8

detect

?

Detection

ofAbnormal 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%

Slide22

What

does G8

detect

?

False

negative characteristics53,1% with only one abnormal quest. median : 118,4% for true positives median : 3136 patients with grade 3-4 comorbiditiesVascular 49,3% Cardiac 15,4% Respiratory 14% Metabolic 11,8%

Slide23

Confirmation

Kenis

C et al. J Clin

Oncol

2014, 32: 19-26

937 patientsAt least two abnormal tests among:Live alone, ADL, IADL, MMS, GDS15, MNA, CCI

Slide24

Confirmation

Kenis

C et al. J Clin

Oncol

2013 In

Press

Slide25

What

to do when the screening tool

is

positive ?

Slide26

26

Consultation

Screening G8

Pretreatment

work-upGeriatric evaluationGeriatric synthesisTreatment feasibilityAdaptation of non specific treatmentAdverse events to avoidMultidisciplinary Oncology meetingTreatment planAfter Screening

Slide27

Geriatric

assessment

(GA)

1

Functional status

ComorbidityPolypharmacyCognitive function/ dementiaNutritional statusDepressionSocial supportRemaining life expectancyDetection of unidentified problemsOptimization before treatmentPrediction of adverse outcomesTreatment planningBaseline informationShared decision-makingFRAILTY1Wildiers et al, JCO, 2014

Slide28

Slide29

Studies

included in review

CGA and ability to detect health problems: n=29

CGA and prediction of outcomes: n=17

CGA and tailored interventions: n=3

Slide30

Results

All CGA types identified - large numbers of geriatric problems

- multiple comorbidities likely to interfere with

cancer treatment and to compete with cancer as a

cause of death

Some CGA domains may influence treatment decisionsfunctional status and nutritional status may have the strongest effect

Slide31

Results cont.

Each CGA domain was associated with chemotoxicity and survival in at least one study

The domains most often predicting mortality and

chemotoxicity

:

functional impairmentmalnutritioncomorbidities

Slide32

Slide33

Methods and results

10 studies included in the reviewChange in oncologic treatment:

the initial treatment plan modified in

39% of patients

after geriatric evaluation

two thirds resulted in less intensive treatmentImplementation of non-oncologic interventionsinterventions were suggested for more than 70% of patientsmost frequently social interventions and pharmacological interventions

Slide34

Conclusion

A geriatric evaluation has significant impact on oncologic and non-oncologic treatment decisions in older cancer patients

Slide35

Journal of Surgical Research 193 (2015) 265-272

Slide36

Results

Elective surgery only10 publications from 6 studiesGA 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 scoreworse frailty scoresfatigueJournal of Surgical Research 193 (2015) 265-272

Slide37

Results cont.

Age was not an independent predictor of morbidity in any studiesNo GA domains predicted postoperative mortality (low mortality rates in elective surgery)Frailty predicted readmissionsFunctional status and frailty predicted discharge to a nursing home

Journal of Surgical Research 193 (2015) 265-272

Slide38

Categorization

Slide39

Geriatric assessment

Overall assessmentMultidisciplinaryAreas where older patients often have problemsCGA – assessment with interventions

Implementing GA in older hospitalized adults increases likelihood of being alive and living in their own home

1

1

Ellis Cochrane Rev 2011

Slide40

GA in oncology

Delphi study1: All cancer patients > 70 years

Younger with age-related issues

Most important domains:

Functional status

ComorbiditiesCognitive function1O´Donovan et al 2015

Slide41

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

Slide42

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

Slide43

Recommendation

She had some frailty indicators, risk of post-operative complications highComplications from tumour

at present

(anemia, weight loss)

Risk in emergency surgery much higher than elective surgery

Operated electively, had some complications, survived, discharged home

Slide44

A FEW WORDS ABOUT FUNCTIONAL STATUS

Slide45

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)

Covinsky JAMA 2011

Slide46

How to

measure functional status

ADL

= a

ctivities

of daily livingsurvive (eat, go to the toilet)IADL = instrumental ADLlive independently (manage money, shop, medication use)Performance measures: Gait speed, TUG (timed up and og test), grip strengthAsk about falls

Slide47

Walter et al, JAMA,

2001

Slide48

Stanaway, BMJ, 2011

Grim reaper´s maximum speed: 1.36 m/s

Slide49

“HAVE YOU FALLEN?”

Jones et al, JAMA Surgery, 2013

Slide50

COMORBIDITY

Slide51

Why is comorbidity

relevant?

Discuss with the person next to you for a few minutes

How do you assess comorbidity in your clinical practice?

Slide52

Barnett et al, Lancet 2012

Chronic disorders by age-group

Slide53

Optimization

of comorbidities

Geriatrician?

Internal medicine specialist?

Subspecialist, i.e. cardiologist?

Core activity in the acute geriatric wardCompeting risks

Slide54

Polypharmacy

Specific talk

Slide55

Cognitive function

Mild cognitive impairmentDementia

Screening instruments, MMSE, MOCA, Mini-Cog

Why important?

Slide56

Slide57

Clock-drawing

test

Slide58

Why important?

ConsentPrognosis

Treatment planning

Baseline -

chemobrain

Slide59

NUTRITIONAL STATUS

Slide60

Malnutrition

Differs between countries – in Norway malnutrition is the dominant problemHome dwelling: 6%, hospitals 40%, nursing homes 14%Tool: mini nutritional assessment (MNA)

Definite risk factor – but do interventions help?

How to intervene?

Slide61

EMOTIONAL STATUS

Slide62

Emotional function

Depression, anxiety and distressCommon among older peopleCommon 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?

Slide63

Study (depression)

1Older cancer patients (>70) receiving chemotherapy (n=344)

45% depressed

Risk factor: malnutrition at baseline

1

Duc et al. Psychooncology, 2016

Slide64

SOCIAL SUPPORT

Slide65

Social support

Fundamental for treatment planningPopulation level – sociodemographic factors strong predictors for receiving treatment and survival

Slide66

GA COMPLETED – WHAT NOW?

Slide67

Geriatric assessment (GA)

1

Remaining life expectancy

Detection of unidentified problems

Optimization before treatment

Prediction of adverse outcomesTreatment planningBaseline informationShared decision-making1Wildiers et al, JCO, 2014

Slide68

SUMMARY

The heterogeneity increases with increasing ageWe need to assess frailty rather than looking at chronological age alone when deciding treatmentGeriatric assessment provides a practical approach to older patients

GA is necessary in many older cancer patients for a number of reasons

Slide69

THANK YOU FOR YOUR ATTENTION

QUESTIONS?