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Deep Dive into Navigating Tough Medical Choices for an Older Patient with Multiple Myeloma
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Jun 17, 2025
When you are faced with cancer, but you also suffer from some degree of memory impairment, you can be in a challenging position. On one hand, you need treatment for your cancer. On the other hand, cancer treatment might be brutal if you have difficulty remembering to take your medications properly, or cancer treatment may make your cognition worse. In this real case, we will deep dive into the challenges that patients may face.
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0:05
okay let's dive into something um
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complex but really really important
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today you know what happens when
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someone's already dealing with well the
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challenges that come with getting older
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maybe some memory things moving a bit
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slower maybe a whole list of medications
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right and then on top of all that a
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serious new diagnosis lands like cancer
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it's a scenario a lot of families face
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unfortunately and navigating it
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requires well a really careful balancing
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act it really does and our source
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material today gives us a fantastic
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window into exactly this challenge we're
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looking at a specific case study yeah a
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really detailed one we're going to deep
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dive into the story of an 82year-old
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gentleman let's call him Mr b like in
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the source who's facing a new active
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cancer diagnosis multiple myyoma right
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which had been sort of quiet before but
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now needs treatment exactly and he's
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dealing with this right alongside
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several other health issues those sort
1:00
of typical age related conditions
1:02
pediatric syndromes yeah so we'll untack
1:05
the uh the medical thinking the human
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side of it and really what it takes to
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figure out a path forward when things
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are this complicated think of it as
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getting the key insights into geriatric
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oncology without needing the medical
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degree it's about seeing the whole
1:19
picture absolutely looking at the whole
1:22
person not just the you know the latest
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diagnosis and the source does a great
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job it takes us right inside the
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geriatric oncology consultation for Mr b
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you see that comprehensive approach in
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action okay so let's paint the picture
1:35
mr b 82 years old he has multiple myyoma
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it was smoldering before kind of lurking
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present but not causing major problems
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yeah but now it's progressed it's active
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needs treatment and the oncology team is
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thinking about a pretty significant
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regimen looks like uh Lundel Demide
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dexamethasone and derodma heavy hitters
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right and the fact that they even
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requested a geriatric oncology consult
2:01
that tells you something straight away
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that it's not straightforward exactly it
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signals they need help assessing his
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overall fitness for that kind of
2:08
treatment because like you said he's got
2:09
these other geriatric syndromes going on
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things that can really affect how
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someone tolerates tough treatments
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precisely resilience response to the
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stress of therapy it all gets
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complicated and something that jumps out
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immediately in the source material Mr b
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didn't go to this important consultation
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alone no he had his daughter and son
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with him both described as highly
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involved that's huge isn't it that
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family support invaluable absolutely
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critical in these complex situations and
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their perspective their worries were
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clearly a big part of this consultation
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so what were their main concerns
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according to the source well at top of
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the list honestly his thinking his
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cognition they were seeing memory
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problems especially short-term stuff you
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know forgetting appointments needing
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things repeated over and over and this
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wasn't just a vague feeling right he
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actually has a diagnosis yeah a formal
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Alzheimer's diagnosis from 2021 and that
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the family shared this really um
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striking example the one about his
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brother that's the one he failed to
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recognize his own brother by name until
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he physically saw him wow that really
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hits home doesn't it it does and
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interestingly his son mentioned that a
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particular medication Martazipene seemed
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to help his engagement and maybe his
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cognition a bit in the past something
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they'd observed okay so cognition was
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number one what else mood was another
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big one he apparently has a long history
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of chronic depression dysmimeia they
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call it like a persistent lowgrade
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depression exactly going way back to his
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youth the family felt the Alzheimer's
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was making it worse and he was still
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feeling pretty down despite being on an
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anti-depressant bopropian and they
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mentioned mortazzipene again here yeah
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they felt that it it helped his mood
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before along with sleep and appetite so
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that was on their minds and then just
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the sheer number of medications he was
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taking oh yeah polyfarm pharmacy that
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was definitely a worry for them all
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those pills potential side effects drug
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interactions it's a lot to manage a lot
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and they specifically asked about one
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drug he was taking for urinary
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incontinence Merbetric they wondered if
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it's uh anticolinergic properties might
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be adding to his cognitive fuzziness
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right those anticolinergic drugs can
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sometimes affect thinking especially in
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older adults exactly and they also
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remembered that the mazipene while maybe
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helpful for mood had made him dizzy in
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the past so you know trade-offs and
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physically any limitations there yes
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significant ones his mobility was really
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limited because of spinal stenosis
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that's a narrowing in the spine puts
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pressure on nerves right and hip pain
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probably arthritis he could only walk
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about 20 yards 20 yards that's not far
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at all that really impacts daily life
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hugely but let's circle back to that
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positive point you made earlier the
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family support that robust social
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support as the source calls it his son
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and daughter sound incredibly switched
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on engaged asking questions trying to
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figure out the best way forward they're
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clearly a massive asset here absolutely
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and knowing about that support helps
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frame the kind of the underlying goal of
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the care plan right which is well it
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seems to be treat the myyoma get it
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under control if possible but do it in a
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way that carefully manages and minimizes
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the risks from all these other health
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issues finding that balance exactly
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balancing fighting the cancer with
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protecting his quality of life his
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ability to function dayto-day makes
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sense the source lists the key meds they
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discussed too right let's see the Exalon
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patch and meantine those are for the
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Alzheimer's bubbropion for depression
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mortazzipene which he'd taken before for
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mood sleep appetite and meabron that's
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mubetric for the bladder issues and some
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he'd stop like flock and oxybutin right
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and if you look at his whole medical
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history together Alzheimer's the myyoma
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that's now active the chronic depression
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spinal stenosis osteoarthritis hip pain
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anemia probably from the myyoma some
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kidney function worries the urinary
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incontinence it really paints a picture
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of the total health burden he's carrying
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it absolutely does a complex picture
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okay so that's the background the
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family's view his history now what did
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the doctor do find the objective stuff
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in the geriatric assessment well a lot
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of it confirmed and kind of quantified
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what the family reported functionally
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yes that limited mobility 20 yards was
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noted right and the assessment was that
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he likely needs help with what we call
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instrumental activities of daily living
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so not just basic washing and dressing
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but things like managing money managing
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his medications correctly remembering
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appointments maybe complex cooking
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things that require more executive
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function and that's mostly due to the
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cognitive issues largely yes the
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assessment confirmed Alzheimer's
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diagnosis noted significant short-term
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memory problems the need for repetition
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did they notice his distress about it
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they did the source mentions he was
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distressed by his own deficits and it
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noted those fluctuations in clarity and
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brought up that powerful example again
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about not recognizing his brother it
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clearly made an impression clinically
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too and his mood confirmed the chronic
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dysmimeia and yes he was showing
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depressive symptoms even on the
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bopropion and the chart noted the
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family's report about mortazzipene
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potentially helping in the past okay and
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the medication situation the poly
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pharmacy clearly flagged he was on at
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least five psychoactive or
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neurologically active medications plus
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others and just as the family suspected
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Merbetric with its anticolinergic side
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effects was specifically noted as a
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potential contributor to cognitive
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issues so the family's instincts were
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spot on there seems like it the rest of
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his medical history as we listed
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Alzheimer's myoma depression spine
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joints kidneys bladder it just
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reinforces the overall health burden did
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they look at nutrition they did noted
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his appetite seemed better on
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mortazzipene previously but there was
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some prior weight loss during the
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pandemic so it's something to keep an
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eye on and the social support rated as
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excellent a definite strength a real
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positive in his corner so pulling all
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that together the clinical findings the
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history what was the overall assessment
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of Mr be's condition his sort of general
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state he was assessed as being prefrail
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to frail prefrail to frail what does
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that mean in practical terms it means
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his physiological reserve is diminished
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he's more vulnerable to stressors like
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illness or in this case intensive cancer
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treatment than a robust older adult
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would be he doesn't have the same
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capacity to bounce back okay which leads
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us right back to the core dilemma
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doesn't it exactly the million-dollar
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question is this 82year-old man with
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Alzheimer's depression frailty mobility
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issues polyfarm
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pharmacy is he actually a candidate for
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this pretty aggressive myyoma treatment
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and this is where the nuance comes in
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and why geriatric oncology is so
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important the answer from the
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specialists was yes yes yes he is a
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candidate because his myoma has
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progressed and warrants treatment by UT
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and this is the crucial part here comes
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the butt a very significant butt he is
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considered to be at very high risk for
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treatment related side effects toxicity
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we call it and also for functional
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decline losing ground physically or
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cognitively and that high risk is
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directly because of all those
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vulnerabilities we just talked about
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precisely the Alzheimer's the mood
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issues the polyarm pharmacy the frailty
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they all stack up to make him much more
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susceptible to the negative effects of
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the cancer drugs okay that makes sense
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he can get the treatment but it's like
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walking a tight rope because the risks
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are so much higher for him that's a good
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way to put it so let's break that down
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how exactly does each vulnerability
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increase the risk let's start with the
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big one the cognitive impairment the
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Alzheimer's okay well think about it his
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Alzheimer's fundamentally impact his
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ability to participate safely in his own
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care one of the myoma drugs lenolyamide
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is an oral pill rev limit yeah taking
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that correctly on the right days not
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missing doses not double dosing when you
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have significant short-term memory loss
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that's incredibly challenging if not
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impossible without help so adherence is
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a huge issue huge it also affects his
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ability to notice and accurately report
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side effects is he feeling more tired
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more confused having new pain he might
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not be able to articulate that clearly
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which means treatment really hinges on
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the family almost entirely they become
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responsible for managing the meds
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watching him like a hawk for any changes
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and you absolutely have to educate them
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about potential cognitive side effects
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from the treatment itself especially the
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steroids especially dexamethasone it's
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notorious for causing confusion
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agitation even delirium in vulnerable
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older adults caregivers need to know
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what to look for okay and his depression
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how does that play into the risk well
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dexamethasone can also worsen mood
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sometimes dramatically so his existing
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chronic depression is a risk factor for
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that making it potentially much worse
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potentially and if his depression isn't
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well controlled it affects everything
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his motivation to stick with the
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treatment plan his overall quality of
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life and again his ability to report
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symptoms accurately is he fatigued from
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the chemo or from the depression it gets
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blurry so managing the mood is critical
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for the cancer treatment to even work
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well it really is continuing his
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bupropion monitoring him super closely
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especially when he gets those steroid
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pulses and keeping mortazzipen in mind
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maybe tweaking the dose if it seems like
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the benefits for mood sleep and appetite
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could outweigh the dizziness risk now
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okay polyfarm pharmacy adding potent
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cancer drugs to an already long list
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sounds tricky it's a minefield a major
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major challenge adding the myyoma drugs
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especially dexamethasone which has tons
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of interactions and side effects itself
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dramatically increases the risk of drug
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drug interactions and just the
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cumulative burden of side effects from
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everything combined like that morbetric
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for the bladder that's a perfect example
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its antiolineric effect could worsen
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cognition adding dexamethasone which
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also can affect cognition plus
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potentially other drugs you you see the
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problem dex up fast very fast it means
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the team has to do a really careful
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thorough review of every single
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medication he's taking they need to ask
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is this drug absolutely essential is the
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benefit worth the risk in this context
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now that he's starting chemo could
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Mirbetric for instance be stopped or
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switched to something less likely to
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affect his brain that's wherecribing
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comes in right taking things away
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exactly actively looking for
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opportunities to stop medications that
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are no longer needed or where the risks
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now outweigh the benefits for this
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specific patient at this specific time
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and his physical limitations the frailty
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the walking difficulty that's another
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key vulnerability myeloma treatments
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often cause fatigue some can cause
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peripheral neuropathy nerve damage in
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the hands and feet causing pain numbness
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weakness which could make his walking
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even worse easily much worse so it's
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vital to get a really clear baseline
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picture of what he can do physically
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before starting treatment what's his
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usual level of activity how far can he
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really walk and then you need a very low
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threshold to call in physical therapy if
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you see any decline prevent things from
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spiraling downwards try to yeah maintain
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function as much as possible but that
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strong family support we talked about
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that acts as a buffer against some of
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these risks it's more than a buffer it's
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an essential component of the management
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plan it's because he has that support
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that managing this complex treatment at
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home is even feasible they are the ones
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doing the day-to-day monitoring and
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medication management they are the front
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line giving the pills correctly watching
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for side effects providing emotional and
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practical support without them this
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whole plan would look very different or
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might not even be possible outside of a
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facility so the overall assessment holds
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he can be treated but it's definitely
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not straightforward care not at all it
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demands extreme caution it requires
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really intensive co-management the
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cancer doctors and the geriatric
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specialists working handin glove
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constantly weighing things up constantly
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is the potential benefit of shrinking
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the myyoma worth the very real risk of
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the treatment causing harm tanking his
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quality of life or making him physically
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weaker it's an ongoing calculation which
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underscores why that shared
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decision-making piece is so critical
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involving him involving the family it's
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paramount you have to understand their
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goals what matters most to Mr b and his
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family at this stage of his life is it
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longevity at all costs or is it
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maintaining independence or cognitive
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function or comfort those priorities
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have to guide the treatment choices okay
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so given this incredibly complex
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situation all the risks identified what
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was the actual plan the blueprint for
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moving forward that came out of this
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consultation all right the plan
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essentially said yes proceed with the
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planned cancer treatment the lenolite
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dexamethasone dart or tumamob right but
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and here's the key with very close
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oversight and active co-management from
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the geriatric team alongside oncology so
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not just a one-off consult but ongoing
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involvement exactly geriatric
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co-management was the core strategy to
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try and head off those risks we just
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discussed what concrete actions did that
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involve what tools did they use one
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really practical vital tool they gave
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the family was a daily monitoring log
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log okay like a diary sort of but more
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structured it prompted them to
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specifically track key things linked to
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his vulnerabilities every day his
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cognition Mhm mood down anxious sleep
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appetite urinary symptoms pain levels
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and any new or worsening problems so the
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doctors get real-time data from home
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precisely it helps catch subtle changes
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early before they become big problems
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hugely important given his communication
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challenges smart and what about managing
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that medication list optimizing things
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that was a major focus for mortazzipian
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they decided to continue it at the 15
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milligram dose he was on nightly they
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talked about maybe increasing it later
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for mood appetite but decided to hold
16:03
off for now see how we did with the
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cancer drugs first okay from the bladder
16:07
drug with the cognitive concerns the
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plan was proactive re-evaluation they
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discussed the antiolinergic risk with
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the family the idea was let's see if he
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really needs it if his cognition worsens
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they'd look hard at stopping it or
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switching to something safer for the
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brain and the dexamethasone the steroid
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how are they managing that beast
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proactive education was key they spent
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time explaining the likely side effects
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to the family specifically mood swings
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insomnia recommended taking it in the
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morning for that exactly morning dosing
16:37
to minimize sleep disruption also warned
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about high blood sugar hypoglycemia
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muscle weakness and increased infection
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risk forewarned is fore armed and the
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general medication lists ongoing
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vigilance the plan included regular
16:51
review of all his meds throughout
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treatment constantly asking is this
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still needed is the risk worth it
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actively looking for chances to
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deprescribe so managing the Alzheimer's
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and depression wasn't separate it was
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integrated right into the cancer plan
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absolutely fully integrated cognitive
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support meant reinforcing caregiver
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strategies for managing the Alzheimer's
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dayto-day making sure the medication
17:13
schedule was foolproof right mood
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management meant continuing the bropion
17:18
watching his mood like a hawk especially
17:20
during steroid went and having a plan B
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like involving psychiatry quickly if
17:25
things went south and addressing the
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physical side his mobility yeah
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encouraging him to stay as active as he
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could tolerate specific advice on
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preventing falls which is a huge risk
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when you're frail and maybe dizzy from
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meds and as we said being ready to jump
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in with physical or occupational therapy
17:42
if his function declined any other
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specific issues tackled in the plan yes
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they noted the need to monitor his
17:49
kidney function closely via the routine
17:51
cancer blood tests and really stressed
17:54
keeping him well hydrated also they
17:57
ordered that MRI of his hip to get to
17:59
the bottom of his pain it really sounds
18:01
like a huge part of this was educating
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and empowering the family fundamental
18:05
they didn't just get a plan they got an
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explanation the source says they had a
18:09
deep dive into how aging myoma and the
18:12
treatment all interact they understood
18:14
why the monitoring log was so important
18:16
why open communication was crucial they
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were given a written blueprint
18:20
summarizing everything so they became
18:22
real partners in the plan that was
18:23
clearly the goal and the follow-up
18:25
reflected that too a formal geriatric
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oncology teleaalth visit was scheduled
18:29
for two months later but crucially the
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family was empowered to reach out much
18:33
sooner if anything changed or worried
18:35
them no waiting for the appointment an
18:38
ongoing close coordination between the
18:41
geriatric team and the main cancer team
18:43
was baked into the process okay let's
18:46
pull back then we've gone deep into this
18:48
specific case what does it all mean for
18:50
you listening to this maybe you're
18:51
facing complex health decisions yourself
18:53
or helping someone who is this case
18:55
really crystallizes some key insights
18:57
from the source material it really does
18:59
i think the first big takeaway is you
19:02
simply cannot treat a serious illness
19:04
like cancer in an older adult in a
19:06
vacuum right it's not just about the
19:08
tumor not at all you have to consider
19:10
and actively manage how it interacts
19:12
with those common issues of aging the
19:14
geriatric syndromes like cognitive
19:16
decline frailty polyarm pharmacy they're
19:19
not side issues they fundamentally
19:20
change the game they impact tolerance
19:22
side effects outcomes everything
19:25
everything second big point you need to
19:28
be proactive about managing potential
19:30
side effects especially with drugs like
19:32
steroids or chemo that have known risks
19:34
exactly knowing the patients
19:36
vulnerabilities allows you to anticipate
19:38
problems you can educate monitor have
19:40
backup plans before a side effect
19:42
becomes a crisis it's preventative
19:44
management third point seems to be about
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the family oh absolutely engaged family
19:49
members like Mr be's son and daughter
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aren't just helpful bystanders they are
19:53
essential invaluable partners in care
19:55
and giving them practical tools makes a
19:57
difference a huge difference that
19:59
monitoring lob wasn't just busy work it
20:01
was a critical safety tool it empowers
20:04
caregivers and gives the clinical team
20:06
vital information they wouldn't
20:08
otherwise have and the fourth key
20:09
insight shared decisionmaking it sounds
20:12
simple but it's profound making choices
20:14
together based on a really clear
20:16
understanding of the risks the potential
20:19
benefits and crucially what matters most
20:21
to the patient their personal goals
20:24
their priorities for quality of life
20:26
that has to be the foundation so the
20:28
medical plan actually serves the person
20:30
not just the disease metrics that's the
20:32
essence of it this case is just such a
20:35
powerful illustration of what that kind
20:36
of comprehensive person centered
20:38
geriatric oncology care looks like in
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the real world it really is and you know
20:43
this whole deep dive it really shows
20:45
that just treating a disease well that's
20:47
only part of the picture isn't it
20:49
especially as we age it kind of leaves
20:51
us with a bigger question maybe
20:53
something for you to think about how can
20:55
we as patients as families as a health
20:58
care system get better at empowering
21:01
people to be true partners in navigating
21:03
these super complex health decisions
21:06
yeah how do we make sure that the plans
21:07
we make don't just focus on the
21:09
diagnosis on the chart but truly honor
21:12
the whole person their story and how
21:14
they want to live their life whatever
21:15
challenges they face that's a goal isn't
21:17
it it really is thanks for exploring
21:19
this complex but vital topic with us
21:21
today on the deep dive
#Alzheimer's Disease
#Cancer
#Depression