Geriatric Syndromes and Assessment in Older Cancer Patients

ABSTRACT: Older individuals are at risk for adverse events in all settings where cancer is treated. Common geriatric syndromes can complicate cancer therapy, and thus, increase patient morbidity and the costs of care. Furthermore, cancer treatment can worsen geriatric syndromes. It is often difficult to determine whether declining health is a result of cancer treatment or the patient’s underlying disease. Baseline assessment of multiple factors may facilitate detection of a decline in the patient’s health status, which may be remediable. Geriatric syndromes may substantially affect quality of life and are also important in the prognosis and outcome of cancer therapy. This article reviews the assessment of cognitive syndromes (dementia and delirium), vision and hearing impairment, gait and balance difficulties, malnutrition, incontinence, depression, osteoporosis, sleep disorders, environmental and social issues, and functional decline. Although there are many geriatric domains and many focused assessment tools, assessment does not need to be time-consuming. Streamlined assessment tools have been developed; they are brief, inexpensive, and easily administered, and they may be valuable to the oncologist. Staff such as nurses, social workers, or office personnel could perform these assessments and minimize the impact on the physician’s time. [ONCOLOGY 15:1567-1591, 2001]

Despite recent advances in geriatric care, the elderly remain at risk for adverse events in all settings where cancer is treated. Common geriatric syndromes such as delirium, gait imbalance, malnutrition, and incontinence can complicate cancer therapy, and thus, increase patient morbidity and the costs of care. Furthermore, cancer treatment can worsen geriatric syndromes. Chemotherapy can affect cognition, function balance, vision, hearing, continence, and mood. It is often difficult to determine whether declining health status is a result of cancer treatment or the patient’s underlying disease. Baseline assessment of multiple factors may facilitate detection of a decline in health status, which may be remediable.[1]

The role of the oncologist may also include the provision of primary care. Many cancer patients see their oncologist for primary care issues. As the population of older Americans dramatically increases, the oncologist will likely need to assume some of the responsibilities of a primary-care physician or geriatrician. Because geriatric syndromes may substantially affect quality of life, oncologists will need to be comfortable with assessing and addressing geriatric syndromes. Many of these syndromes (eg, cognition and function decline) are also important in determining prognosis and outcome in cancer therapy.

This article will review the assessment of cognitive syndromes (dementia and delirium), vision and hearing impairment, gait and balance difficulties, malnutrition, incontinence, depression, osteoporosis, sleep disorders, environmental and social issues, and functional decline. The goal of this review is to recognize the importance and relevance of these geriatric syndromes in the care of elderly cancer patients and to understand the assessment instruments available to screen for these syndromes.

Cognitive Syndromes

In older patients, the two most important cognitive problems are dementia and delirium.

Dementia

Dementia is defined as a significant decline in two or more areas of cognitive functioning. Most people with dementia (60% to 70%) have Alzheimer’s disease (which affects 4 million Americans). Vascular dementia (15% to 25%) and mixed dementia (10% to 15%) are the next most common types of the disease. Other types include dementia with Lewy bodies, frontal-temporal dementia, dementia associated with Parkinson’s disease, and pseudodementia, a dementia-like syndrome that occurs in conditions (eg, depression) with no pathologic features of dementia.[2]

The most important risk factors for Alzheimer’s disease are age and family history. Other factors include head trauma, depression, and Down syndrome. Recently, a variation in the apolipoprotein E gene has been identified as a risk factor. Of the three alleles (APOE 2, 3, and 4), the APOE 4 allele increases risk, whereas the APOE 2 allele is thought to be protective.[3]

Delirium

Delirium is defined as a disturbance of consciousness with decreased ability to focus that develops over a short period of time and fluctuates. It is often associated with changes in cognition and perceptual-classically, visual-disturbances.

The prevalence of delirium among patients over the age of 65 years presenting to the emergency room ranges from 10% to 24%. Among hospitalized older patients, prevalence ranges from 25% to 60% and is a predictor of poor prognosis, with the risk of short-term mortality increased 2- to 20-fold.[4,5] However, when controlling for age and severity of disease (both of which are risk factors for delirium), delirium is not an independent risk factor in long-term mortality.

Delirium in hospitalized patients is also frequently persistent. It only resolves completely by the time of discharge in a small portion (4%) of patients, within 3 months in 21%, and within 6 months in 18%.[6,7] Although most patients improve over time, some older patients retain persistent features of delirium.

Risk factors for delirium include preexisting dementia, severe medical illness, alcohol abuse, diminished functional ability, depression, and hearing or visual impairment.[8] A diagnosis of dementia or psychiatric disorder, such as psychosis, should not be made during delirium.

Dementia vs Delirium

It is often difficult to distinguish dementia from delirium, but there are several important differences. In delirium, symptoms develop over a few hours, whereas in dementia, they develop insidiously. In delirium, impairment of attention is a central feature, but in dementia, attention is relatively preserved until the late stages of the disease. Moreover, in delirium but not in dementia, the patient’s level of consciousness typically fluctuates. In addition, speech is often incoherent in patients with delirium but usually both coherent and ordered in patients with dementia.

Cognitive impairment in cancer patients often goes unrecognized.[9] Cognitive function and capacity are important issues to consider in decision-making with older patients. The prognosis of dementia patients depends on the mental and physical state of both the patient and caregiver.[10] Given the impact of dementia on prognosis and quality of life, oncologists should take into account the level of cognitive function when deciding whether to pursue aggressive cancer therapy in the demented older person.

Older cancer patients must either have the capacity to provide informed consent or must delegate decision-making to a proxy. A diagnosis of dementia per se does not mean an inability to give informed consent. However, a careful assessment of competency may be necessary in a patient with dementia to demonstrate that consent is truly "informed." Nevertheless, most patients with delirium will not be able to give consent. Furthermore, as the patient’s underlying cancer progresses or complications of treatment develop, the older patient may become unable to make health-care decisions. Therefore, issues regarding resuscitation status and potential levels of treatment should be discussed early in the course of cancer care and revisited if the patient’s disease progresses.

Dementia can develop secondary to cancer treatment. Dementia has been reported following radiotherapy of brain tumors when administered either alone or in combination with nitrosurea-based chemotherapy.[11] More often, however, chemotherapy predisposes the patient to delirium. For example, older patients have been shown to have more cognitive deficits after postoperative adjuvant chemotherapy for breast cancer.[12] In addition, many cancer patients undergoing chemotherapy are at risk for infection (with or without neutropenia), dehydration, electrolyte disorders (especially hyponatremia), and malnutrition, either directly from the tumor or as a side effect of the chemotherapy. These patients are at high risk of developing delirium.

Assessing Cognitive Function

TABLE 1

Folstein Mini-Mental Status Examination

A first step in the evaluation of mental function in the elderly may be assessment with the Mini-Mental Status Exam (MMSE). The MMSE is a 30-point scale that evaluates time and place orientation, registration, attention, calculation, naming, repetition, comprehension, reading, writing, and drawing (Table 1).[13] Although performance on this exam may be affected by age and education, a score of 24 or less suggests cognitive dysfunction for most people.[14]

A commonly used screening test for delirium is the Confusion Assessment Method. The criteria and algorithm for this assessment evaluate four features associated with delirium:

1. Acute onset and fluctuating course-Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the past day, ie, tend to come and go or increase and decrease in severity?

2. Inattention-Does the patient have difficulty focusing attention, eg, is she or he easily distractible, or having difficulty keeping track of what is said?

3. Disorganized thinking-Is the patient’s speech disorganized or incoherent, manifesting as rambling or irrelevant conversation, an unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

4. Altered level of consciousness-How would you rate the patient’s level of consciousness? Alert (normal), vigilant (hyperalert), lethargic (drowsy), stuporous (difficult to arouse), or comatose (unarousable)? For this feature, any answer other than alert is abnormal.

A positive test for delirium requires an abnormal rating for questions 1 and 2, and either 3 or 4.[15]

Vision Impairment

The prevalence of visual impairment, defined as a visual acuity of 20/40 or worse, is 4% to 5% among persons over age 65 years and 10% to 21% among those over age 75.[16] In 36% of older persons with visual impairment, the cause is cataracts; in 14%, macular degeneration; in 7%, diabetic retinopathy; and in 5%, glaucoma.[17] The leading cause of blindness among African-Americans is cataracts, whereas for Caucasians, it is macular degeneration.

Cancer treatment of an older patient with visual impairment poses additional risks beyond the normal complications of chemotherapy. First, many chemotherapy regimens and underlying malignancies can cause symptoms of fatigue, dizziness, and peripheral neuropathy, which, combined with visual impairment, can greatly increase the risk of falling. Furthermore, the morbidity (eg, hip fractures) and mortality associated with falling may be greater among patients with low platelet counts, bleeding disorders, or bony metastasis.[18] Compliance with dosing schedules may also be hindered if the patient lives alone and cannot see well enough to read labels.[19]

Testing Visual Acuity

Screening for visual impairment can be performed by using a Snellen chart or instruments such as the Activities of Daily Vision Scale (ADVS). Visual disability may not be captured by routine visual testing, but the ADVS has proven to be a reliable and valid measure of such impairment.[20] The ADVS focuses on five subscales: distance vision, near vision, glare disability, night driving, and daytime driving. Far vision tasks that are evaluated with the ADVS include reading signs, use of transportation, and walking up steps. Near vision tasks include items such as watching television, reading medication bottles, writing checks, and using threads and needles or rulers and screwdrivers.

Hearing Impairment

In the community, the prevalence of hearing impairment among persons over age 65 is approximately 25% to 40% and among those over age 75, 70% to 80%. The prevalence in the nursing home setting is even higher-approximately 80% to 85%.

Hearing impairment is relevant to cancer care because of the ototoxicity of chemotherapeutic agents and the effect of such a disability on treatment. Several chemotherapeutic agents and other medications that are used commonly in oncologic practice have substantial ototoxicity.[21] Cisplatin (Platinol), a widely used anticancer drug, is cochleotoxic. Some studies suggest that some level of hearing impairment occurs in 65% to 70% of people exposed to a total dose of cisplatin greater than 200 mg/m².[22] Complete deafness has also been reported to occur.

Furthermore, the ototoxicity of cisplatin is synergistic with gentamicin. Other cancer agents reported to be ototoxic include carboplatin (Paraplatin), dichloromethotrexate, and vincristine.[23] Also, medications such as furosemide, vancomycin, and metronidazole are toxic in some instances, especially when used in conjunction with gentamicin.

Sensory deficits such as loss of hearing also affect the ability to give adequate informed consent in oncology. The ability to comprehend speech frequently diminishes with age, due to impaired hearing and central auditory processing disorders.[24] This becomes a substantial problem in the setting of a busy and noisy cancer clinic. Consonant sounds tend to be the most difficult to perceive because much of the sound is concentrated in higher frequencies, where hearing loss due to presbyacusis most commonly occurs.

Assessing Hearing Deficits

One way to formally test a patient’s hearing is with a handheld audioscope. However, most specialty clinics are not equipped with this instrument. Therefore, other simple assessment tools may be useful. The Whispered Voice test is preferred by many geriatricians because it requires no equipment and can be performed quickly. The tester stands 2 feet behind the patient and whispers three numbers while covering one of the patient’s ears. Failure to repeat 50% or more of the numbers on two trials is considered a failure and suggests a 30-dB or greater hearing loss. This test has been shown to have a sensitivity of 100% and specificity of 84%.[25]

TABLE 2

Clinical Scale to Detect Hearing Loss

The Brief Scale to Detect Hearing Loss Screener is based on the National Health and Nutritional Examination Survey (NHANES). It consists of seven questions on an 8-point scale (Table 2). A score of 3 or more is considered positive.[26]

Gait and Balance Impairment

Older patients are more likely to have gait and balance impairments, which increases their risk of falling.[27] There is a high rate of injury among older persons without cancer resulting from falls, and it is likely that older patients with cancer are at even greater risk of serious injury due to several factors. First, cancer patients frequently have fatigue, dizziness, dehydration, or other symptoms that increase the likelihood of a fall. In addition, cancer patients with bony metastases to the hip, wrist, or vertebral body are at greater risk of fracture due to the structural weakness of their bones. Also, the risk of serious morbidity and mortality is greater among patients with low platelet counts.

Chemotherapy may also contribute to gait and balance instability in an older patient. Side effects of commonly used oncology agents include cerebellar toxicity, peripheral neuropathy, dizziness, dehydration, and fatigue, and as a result, the increased risk of instability and falls.[28] Fluorouracil (5-FU) and high-dose cytarabine are known to cause cerebellar toxicity.[29] Cisplatin at higher doses can cause delayed peripheral neuropathy, sensory impairment, and loss of proprioception. Paclitaxel (Taxol) is also known to cause peripheral neuropathy, and in conjunction with cisplatin, can potentiate neuropathy.[30] For these reasons, the older cancer patient should be assessed for gait and balance instability prior to and during the course of chemotherapy.

Screening Tools

Screening for gait instability is commonly accomplished with either the Timed Up and Go (TUG) test or the Performance-Oriented Mobility Assessment.

TABLE 3

Performance-Oriented Mobility Assessment

The TUG is typically used to evaluate basic mobility skills in older adults. The measure is simple, can be performed in any setting by nonprofessional staff, and takes only about 5 minutes to complete. The test measures the time it takes to stand up from a chair, walk 3 meters at a comfortable and safe pace, turn around, walk back to the chair, and sit down. The subject performs one practice trial and two test trials that are averaged to obtain a score measured in seconds. In one study, the mean performance on the TUG was 11 seconds when completed without a walking aid, 13 seconds with a cane, 18 seconds with a rolling walker, and 42 seconds with a standard walker.[31]

The Performance-Oriented Mobility Assessment (Table 3) is a 28-point instrument that measures two dimensions: balance and gait.[32] The patient is asked to stand up from a chair, walk 3 meters at a comfortable and safe pace, turn around, walk back to the chair, and sit down. During the standing phase, balance is tested by asking the patient to close his/her eyes and by nudging him/her. A total score below 22 is associated with an increased risk of falling.

Malnutrition

The proportion of hospitalized elderly patients who are malnourished varies between 6.5% and 85%, depending on the criteria used for diagnosis. Weight loss is common among older persons. As normal individuals age, they decrease their food intake to counterbalance the decrease in physical activity associated with aging. This physiologic anorexia of aging increases the propensity to develop pathologic anorexia and weight loss when an older person becomes either medically or psychologically ill.[33]

There are many causes of unintentional weight loss, including acute infections, depression, drugs (eg, chemotherapeutic agents, laxatives, thyroid medications, and amphetamines), conditions that prevent food consumption (eg, painful mouth sores, newly applied orthodontic appliances, loss of teeth), loss of appetite, malignancy, smoking, and AIDS. It is important to differentiate weight loss due to malignancy from weight loss due to malnutrition.

Because malnutrition is a marker of mortality, identifying nutritional status has long been a criterion for selecting therapy in oncology. In older cancer patients, decreased appetite from the underlying tumor may account for the weight loss. However, in attempting to optimize patient outcomes, reversible factors that affect nutritional status should be addressed. These factors include depression, smoking and alcohol use, dysphagia, mucositis, changes in taste and smell, difficulty chewing, the inability to shop or cook, and the side effects of medication.

One study showed that two-thirds of patients with advanced cancer who are over age 65 have had some degree of weight loss, and that more than half are underweight, have loss of appetite, or complain of a decrease in food intake.[34] In many instances, there may be the need to place a temporary percutaneous gastrostomy tube or provide total parenteral nutrition in order to maintain nutrition during the course of chemotherapy.[35] However, the benefit of gastronomy tube placement for palliation in a terminal cancer patient or frail elderly patient has not been proven.[36]

Further Evaluation

Involuntary weight loss greater than 5% in 1 month, 7% in 3 months, or 10% in 6 months should signal the need for further evaluation. The laboratory work-up should begin with a few basic tests. Serum albumin and total cholesterol levels are both good but nonspecific markers of nutritional status and mortality. There is a graded inverse relationship between albumin levels below 4 g/L and cholesterol levels below 160 mg/dL in the elderly frail patient. Prealbumin has a very short half-life (about 2 days) and may be more useful in monitoring the success of nutritional interventions. A complete blood count may be useful in determining whether nutritionally related anemia is present. A total lymphocyte count or anergy testing has less clinical value in evaluating nutritional status.

Incontinence

Incontinence is often mistakenly assumed to be a part of normal aging, and its impact on a patient’s quality of life is underappreciated. The prevalence of incontinence in the elderly varies considerably. In the community, the incidence of incontinence ranges from 15% to 30%, but in the nursing home setting, as many as 50% to 60% of patients are incontinent.[37]

Metastatic disease to the brain or spinal cord can interfere with nerve pathways needed for normal micturition and cause incontinence.[38,39] Furthermore, incontinence is sometimes an early indication of an underlying urinary tract infection, which may lead to sepsis in older cancer patients. The treatment of cancer may also precipitate or worsen incontinence. Fluids and diuretics are often administered in conjunction with chemotherapy and can exacerbate the symptoms of incontinence, making mild symptoms moderate or severe, and thereby, adversely affecting quality of life.[40]

The history and physical examination are essential in distinguishing transient from chronic causes of incontinence. Transient causes of incontinence include delirium, urinary tract infections, atrophic vaginitis, use of certain medications (eg, benzodiazepines, alcohol, diuretics, anticholinergic agents), psychological disorders, endocrine disorders, restricted mobility, and stool impaction.[41] The postvoidal residual (PVR) test measures residual urine after the patient voids via catheterization or ultrasound. Typically a PVR > 200 mL suggests detrusor weakness or bladder outlet obstruction; even a PVR > 50 mL can be sufficient to exacerbate stress or urge incontinence.

Screening for Incontinence

A simple screening test for incontinence has been validated and consists of the following two questions: (1) In the past year, have you ever lost your urine and gotten wet? and (2) If yes, have you ever lost your urine on at least 6 separate days? A "yes" response to both questions is considered a positive screen, and there is an 83% correlation between patient response and formal urologic assessment.[42]

Depression

In community-dwelling elderly patients, the prevalence of depressive symptoms and major depressive disorders is 15% and 1% to 3%, respectively.[43] Factors associated with depression in the elderly include female gender, alcohol and substance abuse, polypharmacy, family history, and medical conditions such as stroke, Alzheimer’s disease, cancer, and heart disease.[43] Because older patients often deny that they are depressed, present with somatic complaints, or have comorbid anxiety or cognitive impairment, it is difficult to recognize depression in an older patient.

TABLE 4

Geriatric Depression Scale (Short Form)

Many of the symptoms of depression, such as appetite change, weight loss, and loss of energy, are similar to cancer symptoms.[44] Depressed patients with cancer may be at higher risk of suicide. Specific risk factors for suicide include prior psychiatric diagnosis, family history of suicide, delirium, disfiguring disease or surgery, poorly controlled pain, increasing age, poor social support, advanced disease, and substance abuse.

Depressive symptoms are an important component of health-related quality of life. Furthermore, depressed patients are less likely to adhere to treatment regimens. Finally, the diagnosis and treatment of cancer can contribute to depression in family caregivers, possibly limiting their ability to provide support for the cancer patient.

Screening for Depression

One tool used to assess for depression in older individuals is the Geriatric Depression Scale (GDS).[45] The short version consists of 15 yes/no questions (Table 4).[45] Scoring more than five answers indicative of depressive symptoms is considered a positive screen.[46] The characteristics of a two-question case-finding instrument that asks about depressed mood and anhedonia has been shown to be as effective a screening instrument as some longer instruments.[47]

Osteoporosis

Osteoporosis is a common problem among elderly women. More than one-third of women over age 65 years have had at least one vertebral fracture as a result of osteoporosis. The current lifetime risk of vertebral and hip fractures among women in the United States is 35% and 15%, respectively. The functional morbidity and increased risk of mortality of older patients with hip fractures is substantial. The excess mortality due to hip fractures occurs in persons with reduced mental status, reduced somatic health, and low physical ability.[48]

Many chemotherapeutic regimens used in the treatment of cancer carry the risk of causing or worsening osteoporosis.[49] The issue of osteoporosis is most relevant in breast cancer patients. Women with breast cancer are at high risk of developing osteoporosis. Chemotherapy can have a negative effect on bone mineral density.[50]

Assessment for Osteoporosis

Postmenopausal women with a history of breast cancer should undergo bone mineral density analysis unless they have other risk factors that obviate the need for testing (eg, age greater than 70 years, previous fracture, fracture in a first-degree relative, weight less than 127 lb, or alcoholism). If results are normal and there are no other risk factors, calcium and vitamin D supplementation may be adequate. If osteopenia or other risk factors are present, preventive therapy with other drugs should be considered.

Other options include bisphosphonates, such as alendronate (Fosamax), risedronate (Actonel), or pamidronate (Aredia), and selective estrogen-receptor modulators (SERMs) such as raloxifene (Evista). Intravenously administered bisphosphonates have been shown to decrease pain related to bony metastases and may, in fact, prevent bony metastases in cancer patients.[51] In randomized clinical trials in postmenopausal women with osteoporosis, raloxifene reduced the risk of newly diagnosed estrogen receptor-positive invasive breast cancer by 76% during a median of 40 months of treatment.[52] The SERM tamoxifen (Nolvadex) exhibits both estrogenic and antiestrogenic characteristics, depending on the tissue. In the human breast, it acts as an antiestrogen, whereas estrogenic effects have been reported on endometrium and bone.[53]

Screening for osteoporosis involves bone mineral density measurement, which is most commonly performed using dual-energy x-ray absorptiometry. This technique has the advantages of being inexpensive and painless. Moreover, the test uses little radiation while providing good precision, accuracy, and resolution.[54] The results of dual-energy x-ray absorptiometry are often reported as a T score (ie, density compared to premenopausal controls), with a score 2.5 deviations below the mean meeting the World Health Organization (WHO) definition for osteoporosis.

Sleep Disorders

Sleep disturbance is a common problem among both elderly individuals and cancer patients. Approximately 50% of all older persons report sleep complaints, 30% of which are chronic. Studies of insomnia in cancer patients have shown that 30% to 50% of newly diagnosed or recently treated patients have sleep difficulties, with many reporting insomnia that persists for several years posttherapy.[55]

The consequences of insomnia include a worsening of cancer-related fatigue and functional impairment, comprising both cognitive and psychomotor disabilities.[56] Unfortunately, unlike other aspects of cancer such as depression, nausea, and pain, sleep receives little attention from oncologists. The misperception is that sleep difficulties are always due to depression or anxiety. Although psychiatric disorders are commonly associated with sleep disturbance, cancer is often a precipitating factor for insomnia because both the diagnosis and treatment entail a series of stressful events.

Several cancer therapies increase the risk of developing insomnia. For example, patients with postchemotherapy nausea and vomiting report a high rate of insomnia, which may be secondary to the effects of certain antiemetic medications known to cause insomnia, such as dexamethasone, prochlorperazine, metoclopramide, and granisetron (Kytril).[57,58] In breast cancer patients, drugs such as tamoxifen can cause side effects that interfere with sleep-for example, hot flashes, a symptom shared by prostate cancer patients who are receiving androgen deprivation therapy.[59] Cancer pain is also a common cause of insomnia, with one study showing that 37% of cancer patients with pain report difficulty initiating sleep.[60] Lastly, delirium in older cancer patients is associated with sleep disturbances.

Insomnia Assessment

Assessment of insomnia centers on ascertaining the nature and intensity of the insomnia, then reviewing sleep habits and exacerbating factors. If a specific sleep pathology is suspected (such as sleep apnea or periodic limb movements), then a nocturnal polysomnography should be performed.[61]

Environmental Hazards

The physical environment can play a major role in the day-to-day functioning and health of older patients. Mismatches between a patient’s capabilities and environmental demands can result in disability. There is a high prevalence of environmental hazards in the homes of older persons. One population-based study showed that there were loose throw rugs and obstructed pathways, respectively, in nearly 80% and 50% of the homes of older persons with physical disabilities.[62] Some studies suggest that between 35% to 45% of falls are attributed to home hazards, such as poor lighting, inadequate bathroom grab rails and stairway banisters, exposed electrical cords, clutter on the floors, and throw rugs.[63]

Home Assessment

TABLE 5

Home Safety Checklist

It can be helpful to have a visiting physician, nurse, or social worker perform a home assessment using a home safety checklist (Table 5) provided by the National Safety Council.[64] Home assessment can also provide other valuable information on nutritional adequacy, sanitary conditions, medication use and misuse, social interactions, and elder abuse and neglect.

Social Support

Social support is another important yet often neglected topic in the health care of the elderly. Potential sources of support include family, friends, caregivers, neighbors, other patients, and volunteers from agencies. Involving families through education and counseling can help support the elderly cancer patient and prevent or slow functional deterioration.[65] Often, one caregiver assumes most of the responsibilities for the older cancer patient. Community-based services aimed at reducing this burden may help maintain social support over a longer period of time.

Religious Factors

Older adults commonly turn to spirituality and religion when they encounter difficult life-changing events and experience personal losses. Several studies of spirituality and health have been conducted. One study found that religiosity is positively associated with health-enhancing attitudes and behaviors, and inversely associated with health-compromising behaviors and adverse health-related outcomes.[66] Oncologists need to be aware that religion may assume more importance as a person ages, and that formal instruments to assess its importance are being developed.

Functional Impairment

TABLE 6

Karnofsky Index

Functional impairment involves the inability of an older person to perform daily life activities normally. A recent survey indicated that 10% to 13% of older persons between the age of 65 and 69 have difficulty getting out of bed, and 6% to 10% need help with routine care. As older people age, this need increases, with 24% to 29% of those over age 80 requiring help to get out of bed, and 29% to 42% requiring help with routine care.[67]

Functional impairment can also affect cancer care. For example, having to depend on someone for transportation may contribute to difficulty in keeping appointments. In older patients with functional impairments, one must also consider the impact of the patient’s disease and treatment on caregiver burden. Appropriate referral to social workers or community-based services may help reduce stress on the caregiver and enable continued care over a longer period of time.

Functional Assessment

TABLE 7

ECOG Permormance Status

Functional assessment instruments, such as the Karnofsky Performance Scale or Index (Table 6) and Eastern Cooperative Oncology Group (ECOG) Performance Status Scale (Table 7), are widely used to help predict prognosis in cancer patients.[68,69] Studies have shown that these two scales are highly correlated and have predictive validity. Functional status is also used as an outcome measure to gauge response to cancer treatment. For example, ECOG values are followed frequently over the duration of therapy.

The Karnofsky Performance Scale has been evaluated in a geriatric outpatient population and compared to the traditional functional assessment measures, Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs are a measure of six basic functions: bathing, dressing, toileting, continence, transfering, and feeding.[70] IADLs are a measure of eight higher-level functions: using the telephone, traveling, shopping, preparing meals, laundry, doing housework, taking medicine, and managing money.[71] A study in 134 patients showed that the above three measures were highly correlated with one another.[72]

Conclusions

TABLE 8

Geriatric Screening in Primary Care

The recognition of issues specific to the elderly is important in cancer care. Geriatric syndromes can complicate cancer care, and conversely, cancer care can worsen underlying geriatric syndromes. Assessing older patients for geriatric syndromes can help cancer care providers improve function and quality of life. Furthermore, general knowledge of health domains relevant to older patients is essential for oncologists who also serve as a patient’s primary caregiver.

Although there are many geriatric domains and many focused assessment tools, assessment does not need to be time-consuming. Streamlined assessment tools developed for primary care providers are brief, inexpensive, and easily administered. These tools may be valuable for oncologists as well. One screening package that has shown good reliability and validity takes approximately 10 to 15 minutes to complete (Table 8).[73] Nurses, social workers, or other office personnel could perform this assessment and minimize the impact on the physician’s time.

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