The comprehensive geriatric assessment provides an avenue for oncologists to discuss advance directives and the role of palliative care measures early in an ambulatory setting.— Amy MacKenzie, MD
End-of-life care in any patient with cancer is challenging for the patient, family, and physician. Issues faced at the end of life include pain, depression, loss of dignity, and hopelessness. In the geriatric patient, additional complexities are present in the form of comorbid conditions, polypharmacy, and geriatric syndromes. The geriatric assessment can provide a roadmap to addressing these issues in the geriatric oncology patient. Using these tools may offer objective data that allow for patient-centered conversations and decision-making for end-of-life care.
Oncologists frequently use the Eastern Cooperative Oncology Group (ECOG) performance status to characterize the functional condition of their patients. However, this tool is not sensitive enough to identify functional limitations in the older patient.1 Treatment-related complications and risk of mortality increase with comorbidities and functional impairment related to age. Without a more thorough means of evaluating the multifaceted components of the geriatric patient, decisions regarding treatment become more challenging. Neither the Karnofsky nor the ECOG performance status encompasses the effects of comorbid conditions and geriatric syndromes, which ultimately determine functional status in the elderly.
Activities of daily living, instrumental activities of daily living, the Geriatric Depression Scale, Mini-Mental State Examination, nutrition assessment, polypharmacy evaluation, and screening for comorbid conditions all provide valuable information regarding how a geriatric patient will tolerate a treatment regimen. Incorporating these characteristics of geriatric cancer patients into one tool—the comprehensive geriatric assessment—enables clinicians to enhance decision-making in clinical practice.2 With the comprehensive geriatric assessment, clinicians can establish objective criteria to identify interventions that could provide a more individualized treatment plan. It can also identify a decline in functional status, which can assist in end-of-life discussions.
Stuart M. Lichtman, MD
In the United States, end-of-life decision-making is often not addressed until a patient has been hospitalized and is no longer able to communicate his or her wishes regarding care. The comprehensive geriatric assessment provides an avenue for oncologists to discuss advance directives and the role of palliative care measures early in an ambulatory setting. Discussing these preferences early in the course of treatment is typically less emotionally burdensome and gives the patient and caregiver a greater sense of control.
Earlier Intervention and Advance Care Planning
In 1995, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) was conducted to improve end-of-life decision-making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying. This was a 2-year prospective observational study with 4,301 patients (phase I) followed by a 2-year controlled clinical trial with 4,804 patients and their physicians (phase II) at 5 teaching hospitals in the United States. The intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation, and functional disability at 2 months. Specially trained nurses provided communication with the patient, family, physician, and hospital staff to elicit preferences, facilitate advance care planning, and patient-physician communication.
The phase I observation of SUPPORT confirmed considerable shortcomings in the care of seriously ill hospitalized patients. The phase II intervention did not succeed in improving care or patient outcomes. This study demonstrated that simply enhancing opportunities for more patient-physician communication might not be an adequate intervention to improve patient outcomes. SUPPORT indicates that more creative and proactive efforts may be required to improve the care of patients with life-threatening conditions. It is possible that earlier interventions in different settings would provide greater benefit. While SUPPORT aimed to elicit patient preferences through improved communication with nurses, the study indicated that the medical community has a long way to go in the mission to improve palliative care integration into routine cancer care.
In 2014, the Institutes of Medicine (IOM) published Dying in America, which reviewed the literature on end-of-life care and the role of palliative care. The conclusions of this review imply that earlier involvement in palliative care can increase survival and decrease pain, anxiety, and caregiver exhaustion. Furthermore, the IOM report suggested that advance care planning conversations enable patients to receive medical treatment that coincides with their goals and values.
However, many older patients reach the end of their lives without having these conversations. Some are too fragile or may be too cognitively impaired to make their own medical decisions. This can lead to treatment decisions that contradict individual preferences as well as a disturbing decline in quality of life. Elderly patients can be particularly vulnerable to this issue because of cognitive impairment but also because of a reticence to discuss end-of-life issues.
In 2016, The Journal of the American Medical Association (JAMA) developed a series of articles dedicated to end-of-life care to inform clinicians, health-care systems, and society about the challenges of medical care for patients suffering from life-threatening conditions. The 2016 JAMA International Consortium for End-of-Life Research (ICELR) found that although fewer patients in the United States die in the hospital compared to Belgium, Canada, Norway, Germany, and England, intensive care unit admissions in the United States are more than two times as common as in other countries. In fact, the United States has the highest rate of intensive care unit admission and chemotherapy administration in the last 180 days of life.3
Benefits of Comprehensive Geriatric Assessment
The comprehensive geriatric assessment provides a structure to address the individualized domains that better reflect functional age, life expectancy, tolerance to cancer treatment, and unique geriatric features. Chemotherapy, surgery, and radiation may produce more benefit than harm when a patient has several comorbid conditions, impaired cognition, depression, and limited reserve in multiple organ systems.
In addition, the comprehensive geriatric assessment provides a platform to address treatable conditions such as malnutrition, depression secondary to medical illness, and geriatric syndromes.4 Limited functional reserve of organ systems, polypharmacy, cognitive impairment, and physical disability can be better characterized.
The comprehensive geriatric assessment also provides a standardized language among clinicians to inform treatment decisions and end-of-life care priorities. By gathering information on comorbidities and geriatric syndromes coexisting in an elderly patient with cancer, an integrated intervention plan can be developed.
Nutritional status has been shown to be an influential prognostic factor in patients receiving chemotherapy. Unintentional weight loss during the 6 months prior to initiation of chemotherapy was associated with poorer survival, lower chemotherapy response rates, and decreased performance status in an ECOG chemotherapy trial.5
Nutrition must be thoroughly assessed in all elderly cancer patients. In addition, physicians should attempt to elicit patient attitudes toward eating. Many geriatric patients do not have an appetite and find eating to be distressing because of pain, nausea, or fear of disappointing other family members by not eating. Decrease in appetite can be caused by treatment, but also by the cancer itself. It can also be a sign that the body no longer requires or desires the fuel to continue functioning. Identifying this for the patient and the family is important, as it can help prevent both physical and emotional discomfort.
A highly relevant nutrition issue in the elderly patient is feeding tube preferences. Use of a feeding tube at the end of life has not been shown to improve outcomes. In fact, a feeding tube can make end-of-life decisions more complicated. Oncologists should address this with patients and caregivers early on to help manage expectations about nutrition at the end of life.
Cognition is most commonly assessed by the Mini-Mental State Examination, which evaluates several dimensions of cognitive function through a 30-item interviewer-administered questionnaire. Validated screening tools that require less time include recall of 3 items at 1 minute, the clock-drawing test, and the serial 7s test (serial subtraction of 7 beginning with the number 100). However, these tools do not take into consideration education level, the native language of the patient, and cultural contributions.
A geriatric assessment has the potential to identify problems that may improve with intervention. It also has the potential to provide objective information as a platform for discussion of care choices throughout treatment and at the end of life.— Amy MacKenzie, MD
Another means of addressing cognition is the Blessed Orientation-Memory-Concentration test. This instrument consists of six questions to screen for cognitive impairment. The Blessed Orientation-Memory-Concentration test is a strong screening tool, which correlates highly with dementia severity ratings by clinicians and predicts results from longer questionnaires. The results can discriminate among patients with mild, moderate, and severe cognitive deficits.6
Geriatric oncology patients with cognitive impairment or a diagnosis of dementia have a shorter predicted life expectancy and a greater likelihood of frailty. Using objective findings in the comprehensive geriatric assessment to identify patients with cognitive impairment or those at risk for cognitive impairment, the oncologist can help prepare patients and caregivers for the cognitive decline and risk of developing delirium as they near the end of life. An underlying diagnosis of dementia increases the risk of delirium, which can be unsettling for both patients and family. Oncologists should be prepared to inform patients about the risk of delirium at the end of life.
There are three levels of functional status: basic activities of daily living, instrumental or intermediate activities of daily living, and advanced activities of daily living. Basic activities of daily living include activities such as bathing, dressing, toileting, continence, feeding, and transferring—all crucial for self-care. Intermediate activities of daily living encompass independent household duties such as grocery shopping, meal preparation, managing finances, driving, housework, laundry, and taking medications. Advanced activities of daily living include broader self-fulfillment tasks such as recreational or occupational activities and societal or family roles. The three domains of functional status can be incorporated into a previsit questionnaire, with broad questioning by the health-care provider about how the geriatric patient spends his or her day.
Even among patients with a good ECOG performance status, nearly 10% of elderly cancer patients assessed by Repetto and colleagues in 2002 were found to have limitations in activities of daily living, and one-third had limitations in intermediate activities of daily living.2 Functional impairment, defined as dependency in one or more activities of daily living, has been a factor that influences a decrease in cancer treatment and increase in palliative care. Thus, a decline in the patient’s ability to perform activities of daily living, and more specifically intermediate activities of daily living, may be more informative than performance status for making prognoses about a patient’s cancer outcome.
An increase in frailty, as demonstrated by an increase in dependence on others for intermediate activities of daily living, portends a more rapid decline. Having an open discussion about frailty and how it will impact a patient’s treatment course and life expectancy will help to prepare patients and caregivers for making treatment decisions.
Geriatric syndromes encompass a number of different illnesses that are more common in the elderly and predict for greater morbidity and worse outcomes. These syndromes remain somewhat poorly defined but include sensory impairment, frailty, syncope, falls, urinary incontinence, dementia, and delirium. An understanding of geriatric syndromes can guide conversations regarding goals of care and decision-making. A greater number of geriatric syndromes are correlated with worsening frailty, the potential for decreased tolerance to treatment, and a more rapid rate of decline.
Sensory impairment (eg, hearing loss, vision loss, neuropathy) can be present at baseline and can be made worse with treatment. When focusing on palliative care and making decisions about treatment, quality of life is essential. Loss of sensory input is discouraging to older patients and leads to a decline in quality of life. It is therefore vital to identify preexisting sensory impairment.
Urinary incontinence is a common geriatric syndrome, but it is generally not asked about by the oncologist. Patients with urinary incontinence are at risk for dehydration and may have underlying gait issues that prevent them from getting to the bathroom on time. Incontinence can be related to gait dysfunction, neuropathy, muscle weakness, or a combination of these disorders.
Geriatric patients are also at risk for falls because of limited mobility, gait, and balance impairments. A cancer diagnosis can elevate the severity of these falls, as bony metastases increase the risk of a pathologic fracture and chemotherapy may lower the platelet count, thereby increasing the risk of hemorrhage. Clinicians should ask about the number of falls in the past 6 months to determine whether intervention is required. The Timed Up and Go test can provide a general sense of physical mobility. This test evaluates how many seconds it takes an individual to stand up from a standard armchair, walk approximately 10 feet, walk back to the chair, and sit down again. An abnormal result should prompt a physical therapy evaluation.
As mentioned previously, cognitive impairment has a profound impact on tolerability of treatment, understanding of treatment decisions, and life expectancy.
Oncology patients are at greater risk for depressive symptoms than the general population. Up to one-third of elderly cancer patients suffer from psychological distress. Depression and anxiety are associated with poorer treatment outcomes, reduced ability to make decisions, decreased adherence to lengthy treatment, longer hospital stays, and suicide.
A screening questionnaire should be administered at each visit, asking the following questions: (1) During the past month, have you been bothered by feeling down, depressed, or hopeless? (2) During the past month, have you been bothered by little interest or pleasure in doing things? These questions are sensitive but not specific. A positive screening test should be followed by the Patient Health Questionnaire 9 to better detect and monitor depression symptoms among elderly patients.7
Another instrument for assessing the psychological impact of a cancer diagnosis is the Hospital Anxiety and Depression Scale, which is a self-administered questionnaire specifically tested in populations of cancer patients. Depression and anxiety may present in a unique fashion in medically ill patients, and the Hospital Anxiety and Depression Scale assesses these disorders separately. Discussing end-of-life issues can worsen depression or anxiety, and a knowledge of preexisting psychological issues can be essential to ensure proper therapy and medications, if needed.
Discussion of Patient Preferences
In addition to influencing cancer treatment and modifications, the comprehensive geriatric assessment can help physicians better integrate patient preferences into individualized care plans. The comprehensive geriatric assessment allows for the identification of geriatric factors and reversible comorbidities. The problems detected by the comprehensive geriatric assessment can provide information about the necessity of social support, physiotherapy, and nutritional interventions. This information is useful not only prior to treatment decisions, but also in discussions of whether to continue treatment, given the trajectory of functional decline.
It is important to discuss advance directives with geriatric oncology patients. Beginning these conversations early enables patients and caregivers to spend time thinking about end-of-life treatments and specifying a power of attorney for health care. In older patients, there may be a more passive view of end-of-life care, with patients stating, “I’ll do what I have to.”
Using information about the patient’s functional status and preferences, physicians can guide patients and family members toward end-of-life choices that reflect not only the patient’s goals, but also what to realistically expect and hope for. These conversations regarding patient preferences should happen early and often. Speaking with the patient alone, as well as with family members present, can better elucidate the patient’s values and how these preferences align with his or her broader support system.
A geriatric assessment has the potential to identify problems that may improve with intervention. It also has the potential to provide objective information as a platform for discussion of care choices throughout treatment and at the end of life.
Acknowledgment: Dr. MacKenzie would like to thank Ashley Baronner for her help with this article. ■
Disclosure: Dr. MacKenzie reported no potential conflicts of interest.
Dr. MacKenzie is Assistant Professor, Division of Regional Cancer Care, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University.
2. Repetto A, Fratino L, Audisio RA, et al: Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: An Italian Group for Geriatric Oncology Study. J Clin Oncol 15:494-502, 2002.
3. Bekelman DB, Halpern SD, Blankart CR, et al: Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA 315:272-283, 2016.