An update on a systematic review of the use of geriatric assessment for older adults in oncology.

BACKGROUND: Our previous systematic review of geriatric assessment (GA) in oncology included a literature search up to November 2010. However, the quickly evolving field warranted an update. Aims of this review: (i) provide an overview of all GA instruments developed and/or in use in the oncology setting; (ii) evaluate effectiveness of GA in predicting/modifying outcomes (e.g. treatment decision impact, treatment toxicity, mortality, use of care). MATERIALS AND METHODS: Systematic review of literature published between November 2010 and 10 August 2012. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of GA instruments were included. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL and Cochrane Library. Two researchers independently reviewed abstracts, abstracted data and assessed the quality using standardized forms. A meta-analysis method of combining proportions was used for the outcome impact of GA on treatment modification with studies included in this update combined with those included in our previous systematic review on the use of GA. RESULTS: Thirty-five manuscripts reporting 34 studies were identified. Quality of most studies was moderate to good. Eighteen studies were prospective, 11 cross-sectional and 5 retrospective. Three studies examined treatment decision-making impact and found decisions changed for fewer than half of assessed patients (weighted percent modification is 23.2% with 95% confidence interval (20.3% to 26.1%). Seven studies reported conflicting findings regarding predictive ability of GA for treatment toxicity/complications. Eleven studies examined GA predictions of mortality, and reported that instrumental activities of daily living, poor performance status and more numerous GA deficits were associated with increased mortality risk. Other outcomes could not be meta-analyzed. CONCLUSION: Consistent with our previous review, several domains of GA are associated with adverse outcomes. However, further research examining effectiveness of GA on treatment decisions and oncologic outcomes is needed.

Factors influencing adherence to cancer treatment in older adults with cancer: a systematic review.

BACKGROUND: Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer. PATIENTS AND METHODS: Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011. RESULTS: Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies. CONCLUSION: Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.

Use of geriatric assessment for older adults in the oncology setting: a systematic review.

BACKGROUND: Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult's medical, psychological, social, and functional capacity. No systematic review of the use of geriatric assessment in oncology has been conducted. The goals of this systematic review were: 1) to provide an overview of all geriatric assessment instruments used in the oncology setting; 2) to examine the feasibility and psychometric properties of those instruments; and 3) to systematically evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes (including the impact on treatment decision making, toxicity of treatment, and mortality). METHODS: We searched Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library for articles published in English, French, Dutch, or German between January 1, 1996, and November 16, 2010, reporting on cross-sectional, longitudinal, interventional, or observational studies that assessed the feasibility or effectiveness of geriatric assessment instruments. The quality of articles was evaluated using relevant quality assessment frameworks. RESULTS: We identified 83 articles that reported on 73 studies. The quality of most studies was poor to moderate. Eleven studies examined psychometric properties or diagnostic accuracy of the geriatric assessment instruments used. The assessment generally took 10-45 min. Geriatric assessment was most often completed to describe a patient's health and functional status. Specific domains of geriatric assessment were associated with treatment toxicity in 6 of 9 studies and with mortality in 8 of 16 studies. Of the four studies that examined the impact of geriatric assessment on the cancer treatment decision, two found that geriatric assessment impacted 40%-50% of treatment decisions. CONCLUSION: Geriatric assessment in the oncology setting is feasible, and some domains are associated with adverse outcomes. However, there is limited evidence that geriatric assessment impacted treatment decision making. Further research examining the effectiveness of geriatric assessment on treatment decisions and outcomes is needed.

A systematic review of unmet needs of newly diagnosed older cancer patients undergoing active cancer treatment.

PURPOSE: The aim of this study is to systematically review evidence with regard to answering the following questions: (1) What are the unmet care needs of older persons diagnosed with cancer who are undergoing active cancer treatment? (2) What are the predictors of unmet needs of older persons while undergoing active cancer treatment? METHODS: A systematic review of the literature published between January 1996 and December 2010 was completed. Manuscripts could be published in English, French, Dutch, or German searching the Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library databases. The literature search was performed by two researchers with the assistance of a university librarian. Abstracts were reviewed by two reviewers for inclusion. RESULTS: Thirty studies were included. A significant proportion of newly-diagnosed patients undergoing cancer treatment had unmet needs, ranging from 15 to 93%. The most common needs varied by study but included psychological needs, information needs, and needs in the physical domain. Most studies showed that the level of unmet needs was highest after diagnosis and start of treatment and decreased over time. Predictors of unmet needs included: younger age, female gender, depression, physical symptoms, marital status, treatment type, income, and education. CONCLUSIONS: The level of unmet needs in newly diagnosed older cancer patients after the start of treatment is high, and the most common needs are psychological and information needs. More research is needed which would focus on the needs of older adults with comorbid conditions, and how these comorbid conditions influence the level of unmet needs.

Quality of life during the course of cancer treatment in older newly diagnosed patients. Results of a prospective pilot study.

BACKGROUND: The aim of this prospective study was to report the quality of life (QoL) of older cancer patients during the first year after diagnosis and factors influencing QoL. PATIENTS AND METHODS: Newly diagnosed patients aged ≥65 years were recruited for a pilot prospective cohort study at the Jewish General Hospital, Montreal, Canada. Participants were interviewed at baseline, and at 1.5, 3, 4.5, 6, and 12 months. QoL was assessed at each interview using the European Organization for the Research and Treatment of Cancer Quality of Life Core Questionnaire with 30 items. Logistic regression was conducted to determine which sociodemographic, health, and functional status characteristics were associated with decline in global health status/QoL between baseline and 12-month follow-up. RESULTS: There were 112 participants at baseline (response rate 72%), median age of 74.1, and 70% were women. Between baseline and 12-month follow-up (n=78), 18 participants (23.1%) declined ≥10 points in global health status/QoL, while 34 participants (43.6%) remained stable and 23 participants (33.3%) improved ≥10 points. None of the sociodemographic, health, and functional status variables were associated with decline in logistic regression analyses. CONCLUSION: Almost 25% of older adults experienced clinically relevant decline in their QoL. Further research is needed on which factors influence decline in QoL in older adults.

Potential drug interactions in elderly cancer patients.

INTRODUCTION: Drug interaction constitutes a major challenge in elderly cancer patients. This study investigated the number and types of medications patients and potential drug interactions in these patients. METHODS: Treatments received by 105 cancer outpatients aged ≥70 years were analyzed using the French Thesaurus to identify drug-drug interactions according to four levels: contraindication, concomitant use not recommended, concomitant medications requiring precautions and concomitant medications to be taken into account. RESULTS: The mean number of medications per patient was 4.7 (range: 0-14). Among 97 patients taking ≥2 drugs, 45 potential interactions were identified, occurring in 32 patients. No contraindication, 2 cases of concomitant use not recommended, 9 cases requiring precautions (20%) and 34 cases of concomitant medications to be taken into account were identified. Drug interactions caused respiratory distress and increased bleeding risk. CONCLUSION: Drug interactions are common in the elderly, but almost half of interactions were moderate.

Does frailty predict hospitalization, emergency department visits, and visits to the general practitioner in older newly-diagnosed cancer patients? Results of a prospective pilot study.

Research on the use of health care by older newly-diagnosed cancer patients is sparse. We investigated whether frailty predicts hospitalization, emergency department (ED) and general practitioner (GP) visits in older cancer patients in a prospective pilot study. Newly-diagnosed cancer patients aged 65 years and over were recruited in the Segal Cancer Centre, Jewish General Hospital, Montreal, Canada. One hundred ten patients participated, mean age 74.1, 70% women. During 1 year follow-up, 52 patients (47.3%) had cancer-related hospitalizations, 23 patients (20.9%) had ED visit and 17 patients (15.5%) had GP visit. No frailty marker predicted hospitalization or visits to the GP. Cognitive impairment suspicion was the only frailty marker that predicted ED visits (odds ratio 4.97; 95%CI 1.14-21.69). Although health care use was considerable in this sample, most frailty markers were not associated with health care use in this pilot study.

Clinical experience of cancer specialists and geriatricians involved in cancer care of older patients: A qualitative study.

INTRODUCTION: Cancer is an important health problem in older persons. The aim of this study was to explore how cancer specialists and geriatricians manage the treatment of older patients with cancer. METHODS: Interviews using semi-structured open-ended questions. SAMPLE: physicians working in oncology and geriatric medicine at McGill affiliated hospitals. ANALYSIS: Grounded-theory approach. RESULTS: 24 cancer specialists and 17 geriatricians participated. There was considerable variability with regard to assessment, treatment plan, and follow-up care and little collaboration between both specialists. The cancer specialists have more older cancer patients in their practice and collaborate with geriatricians mostly to deal with complications of cancer treatment. However, both groups of specialists expressed a desire to collaborate more and had similar research priorities. CONCLUSIONS: There was considerable variability in the management of older patients with cancer. Care for older patients with cancer might be improved by more collaboration between cancer specialists and geriatricians.

Changes in the prevalence of chronic disease and the association with disability in the older Dutch population between 1987 and 2001.

BACKGROUND: most studies of older populations in developed countries show a decrease in the prevalence of disabilities, and an increase in chronic diseases over the past decades. Data in the Netherlands, however, mostly show an increase in the prevalence of chronic diseases and mixed results with regard to the prevalence of disability. This study aims at comparing changes in the prevalence, as well as the association between chronic diseases and disability between 1987 and 2001 in the older Dutch population using data representative of the general population. Most studies, so far, have only dealt with self-reported diseases, but in this study, we will use both self-reported and GP-registered diseases. STUDY DESIGN: data from the first (1987) and second (2001) Dutch National Survey of General Practice were used. In 1987, 103 general practices, compared to 104 in 2001, participated. Approximately 5% of the listed persons aged 18 years and over was asked to participate in an extensive health interview survey. An all-age random sample was drawn by the researchers from the patients listed in the participating practices (in 1987 n = 2, 708; in 2001 n = 3, 474). Both surveys are community based, with an age range between 55 and 97 years. Data on chronic diseases were based on GP registries and self-report. RESULTS: the prevalence of disability and of asthma/COPD, cardiac disease, stroke, and osteoarthritis decreased between 1987 and 2001, while the prevalence of diabetes increased. Changes were largely similar for GP-registered and self-reported diseases. Cardiac disease, asthma/COPD, and depression led to less disability, whereas low back pain and osteoarthritis led to more disability. CONCLUSIONS: in general, there were reductions in GP-registered chronic diseases as well as in self-reported diseases and disability. Results suggest that the disabling impact of fatal diseases decreased, while the impact of non-fatal diseases increased.

What does quality of life mean to older frail and non-frail community-dwelling adults in the Netherlands?

Quality of life is a commonly used but seldom defined concept and there is no consensus on how to define it. The aim of this study was to explore the meaning of quality of life to older frail and non-frail persons living in the community. Qualitative interviews were conducted with 25 older men and women. The audio-taped interviews were transcribed and coded for content and analyzed using the grounded-theory approach. Five themes emerged: (physical) health, psychological well-being, social contacts, activities, and home and neighborhood. Factors that influenced quality of life were having good medical care, finances and a car. Respondents compared themselves mostly to others whose situation was worse than their own, which resulted in a satisfactory perceived quality of life. However, the priorities of the domains of quality of life were observed to change. Moreover, the health of the frail limited the amount and scope of activities that they performed. This led to a lower quality of life perceived by the frail compared to the non-frail.

[Unhealthy lifestyles during the life course: association with physical decline in late life]. / Ongezonde leefstijl in de loop van het leven: samenhang met lichamelijke achteruitgang op oudere leeftijd.

This study aimed to examine the association between unhealthy lifestyle in young age, midlife and/or old age and physical decline in old age, and to examine the association between chronic exposure to an unhealthy lifestyle throughout life and physical decline in old age. The study sample included 1297 respondents of the Longitudinal Aging Study Amsterdam (LASA). Lifestyle in old age (55-85 y) was assessed at baseline, while lifestyle in young age (around 25 y) and midlife (around 40 y) were assessed retrospectively. Lifestyle factors included physical activity, body mass index (BMI), number of alcohol drinks per week and smoking. Physical decline was calculated as change in physical performance score between baseline and six-year follow-up. Of the lifestyle factors present in old age, a BMI of 25-29 vs. BMI <25 kg/m2 (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.1-2.2) and a BMI of > or =30 vs. BMI <25 kg/m2 (OR 1.8; 95% CI 1.2-2.7) were associated with physical decline in old age. Being physically inactive in old age was not significantly associated with an increased risk of physical decline, however, being physically inactive both in midlife and in old age increased the odds of physical decline in old age to 1.6 (95% CI 1.1-2.4) as compared to respondents who were physically inactive in midlife and physically active in old age. Being overweight in both age periods was associated with an OR of 1.5 (95% CI 1.1-2.2). These data suggest that overweight in old age, and chronic exposure to physical inactivity or overweight throughout life increases the risk of physical decline in old age. Therefore, physical activity and prevention of overweight at all ages should be stimulated to prevent physical decline in old age.

Static and dynamic measures of frailty predicted decline in performance-based and self-reported physical functioning.

OBJECTIVE: To determine the effect of frailty on decline in physical functioning and to examine if chronic diseases modify this effect. METHODS: The study sample was derived from the Longitudinal Aging Study Amsterdam and included respondents with initial ages 65 and over at T(2) (1995/1996), who participated at T(1) (1992/1993) and T(2) and performed physical performance tests (n = 1,152) or reported functional limitations (n = 1,321) at T(2) and T(3) (1998/1999). Nine frailty markers were determined in two ways: low functioning at T(2) (static definition); and decline in functioning between T(1) and T(2) (dynamic definition). Using logistic regression analyses, the effect of frailty was examined on change in physical functioning between T(2) and T(3), adjusting for sex, age, education, and additionally chronic diseases. RESULTS: Static frailty was associated with performance decline only in the middle-old group (OR 2.43; 95%CI 1.23-4.80) and associated with decline in self-reported functioning (OR 2.44; 95%CI 1.77-3.36). Dynamic frailty was associated with decline in performance only in women (OR 1.72; 95%CI 1.11-2.67) and with self-reported functional decline (OR 1.77; 95%CI 1.29-2.43). These associations were independent of chronic diseases. CONCLUSION: Frailty is more strongly associated with self-reported functional decline in older persons than with performance decline.

[The opinion on care of patients with cancer undergoing palliative treatment in day care]. / De opinie over de zorgverlening van patiënten met kanker die op de dagbehandeling een palliatieve behandeling ondergaan.

OBJECTIVE: To study the care utilisation and unmet care needs of patients receiving palliative treatment at the day care clinic of the Netherlands Cancer Institute/Antoni van Leeuwenhoek hospital. DESIGN: Descriptive. METHODS: During the periods 1 April-31 July 2000 and 1 April-31 May 2001 adult cancer patients were interviewed regarding their complaints and symptoms as a result of the disease and the treatment and regarding the problems that they had with the provision of care. RESULTS: There were 155 patients who agreed to participate: 56 men and 99 women, with an average age of 57.5 years. On average, they had 3.2 'severe' complaints. According to the patients, 65% of these 'severe' complaints were known by the specialists, 38% by the general practitioners, 24% by the day care nurses and 83% by the next of kin. Again according to the patients, 17% of the reported severe complaints received insufficient attention. About 25% of patients felt that they had received insufficient information about their disease, treatment, side effects and/or complications. CONCLUSION: The day care centre did not seem to be optimally equipped to meet the needs of patients receiving chemotherapy on an outpatient basis. According to the patients, the specialists were relatively the best informed of all the care providers about their complaints and problems.