The application of the principles of geriatrics to the management of the older person with cancer

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Abstract

Is the patient going to die of cancer or with cancer? Is the patient going to suffer pain and disability due to cancer? Is the patient able to tolerate aggressive life-prolonging treatment? This paper tries to reply to the fundamentals of these questions by introducing the multidimensional assessment that evaluates areas where age-related changes are more likely. Chronologic age cannot be used to predict the degree of comorbidity and of functional deterioration of the single individual up to age 85 at least. Assessment of aging includes health, functional status, nutrition, cognition, socio-economic and emotion evaluations. This multidisciplinary assessment is referred to as comprehensive geriatric assessment (CGA). The risk of comorbid conditions increases with age and may result in underdiagnosis: in older patients, new symptoms may not be clearly recognized by the patient and may be dismissed by practitioners as manifestations of preexisting conditions. A meaningful assessment of comorbidity may be obtained with a comorbidity index. The Charlson=s scale and the Chronic Illness Rating Scale — Geriatric (CIRS-G), have enjoyed the widest acceptance. The Instrumental Activities of Daily Living (IADL) and the Activities of Daily Living (ADL) are the most sensitive assessment of function in older individuals. IADLs include shopping, managing finances, housekeeping, laundry, meal preparation, ability to use transportation and telephone and ability to take medications: in simple words, the IADLs are those skills a person needs to live independently. ADLs include feeding, grooming, transferring, toiletting and are the skills necessary for basic living. Though a correlation exists among comorbidity, performance status, ADL and IADL, this correlation is not strong enough to be reflected in a single parameter. The Folstein Mini Mental Status (MMS), is the instrument of most frequent use to screen older individuals for dementia. The main problem with the MMS is lack of sensitivity to early stages of dementia. The Geriatric Depression Scale (GDS), a simple tool that can be completed by most patients at home, doubles the rate of detection of depression. The Mini Nutritional assessment is very sensitive to screen older persons for malnutrition. The risk of polypharmacy increases with age and partly results from the fact that older patients visit different practitioners. A CGA should also include evaluation of the so called Geriatric Syndromes like delirium, incontinence, osteoporosis, all of which represent a hallmark of frailty. The CGA may help the management of older individuals with cancer in at least three areas: detection of frailty, treatment of unsuspected conditions, removal of social barrier to treatment.

Section snippets

What does aging mean?

The casual observer, with no clinical background, won't have any problems in distinguishing young and old in Fig. 1 a and b, that portrays a pair of twins at the time of their first and their ninetieth birthday. At the extremes of life, clear hallmarks establish the transition between infancy and young adulthood and between old adulthood and frailty, the last step of life prior to death (Fig. 2). The intermediate transition, that holds critical clinical implications, the transition between

The comprehensive geriatric assessment (CGA)

Broad agreement exists on the areas that should be tested in a CGA (Table 2), though the format of CGA is not standardized [13]. The following discussion illustrates consensus and controversies pertaining to the CGA. The risk of comorbid conditions increases with age: Fried et al. calculated that the average number of diseases for community dwelling elderly aged 77 was 3.7 [14]. As expected, the prevalence of competitive causes of death increases correspondingly: Ragland and Satariano showed

Application of the CGA to the practice of oncology

The CGA may help the management of older individuals with cancer in at least three areas: detection of frailty, treatment of unsuspected conditions, removal of social barrier to treatment.

The frail person, by definition, is the person who has exhausted any meaningful functional reserve (Table 4). As such the frail person has a negligible capacity to cope with stress and is not a candidate for aggressive life-prolonging treatment. This does not mean however, that the frail person has a

Summary

Aging involves changes in different domains, including health, function, cognition, emotional and social status. These changes, that are highly individualized, influence the treatment of cancer in several ways: limited life-expectancy, decreased tolerance to treatment, inability to obtain treatment due to a number of social barriers. CGA accounts for the diversity of the geriatric population. The CGA allows recognition of frailty, management of unsuspected conditions and removal of some

Reviewers

The reviewers for this article are: Prof. Silvio Monfardini, Division of Medical Oncology, Azienda Ospedaliera di Padova, I-35128 Padova, Italy; Dr Lazzaro Repetto, Istituto per la Ricerca sul Cancro, Oncologia Medica I, Largo Rosanna Benzi 32, I-16132 Genova, Italy; and Dr William B. Ershler, Eastern Virginia Medical School, 825 Fairfax Avenue, Room 201, Norfolk, VA 23507-1914, USA.

Lodovico Balducci, Professor of Medicine and Attending Physician, University of South Florida College of Medicine, Program Leader, Senior Adult Oncology Program, Tampa FL. Editor of two textbooks of geriatric oncology and about 150 publications in the field of cancer and aging.

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    Lodovico Balducci, Professor of Medicine and Attending Physician, University of South Florida College of Medicine, Program Leader, Senior Adult Oncology Program, Tampa FL. Editor of two textbooks of geriatric oncology and about 150 publications in the field of cancer and aging.

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