Up next in 10
Many times, older adults with cancer ask their doctors about estimates for their life expectancy, likelihood of surviving surgery, and remaining independent. Then they say, "We know that you don't have crystal balls".
While doctors don't have crystal balls. They do use and can use some risk calculators to assess patient outcomes. There are more than a hundred clacultors available for various health-related situations. Some are sophisticated and difficult for patients to understand, while others are easier to use and comprehend by patients and their families.
In part 1 of this series, we will review Karnofsky Performance Scale, Activities of Daily Living, Charlson Comorbidity Index, and POSSUM.
#cancer #olderpeople #geriatriconcology #arminshahrokni #healthrisk #elderly #karnofsky #ADL #charlson #POSSUM #surgery #lifeexpectancy
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0:00
everyone and welcome back to the channel
0:01
Let me ask you something Have you ever
0:03
been in a situation maybe facing surgery
0:06
dealing with a health condition or just
0:08
thinking about the future and wish you
0:10
had a crystal ball the little peak into
0:12
what might happen Of course real crystal
0:15
balls don't exist But what if I told you
0:17
that doctors do have tools powered by
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data from millions of patients that can
0:22
help predict potential outcomes almost
0:24
like specialized calculators for health
0:26
Sounds a bit like science fiction right
0:28
but is very real and is playing an
0:30
increasingly important role in the
0:32
healthcare today We're talking about
0:34
clinical prediction calculators or risk
0:36
stores So what are these things imagine
0:38
researchers studying thousands even
0:40
millions of patient cases over many
0:42
years They look for patterns Does age
0:45
affect recovery from this surgery how
0:47
much does high blood pressure increase
0:48
the risk of that complication does this
0:51
set of lab results usually lead to a
0:53
longer hospital stay they take all of
0:56
these complex patterns and boil them
0:59
down into a mathematical models
1:01
Essentially these calculators the doctor
1:04
can input specific information about an
1:06
individual patient things like age
1:09
existing health conditions lab results
1:12
the type of procedures planned and the
1:14
calculator uses that data to estimate
1:17
the probability or the risk of certain
1:20
things happening Now a huge disclaimer
1:22
These calculators are not fortune
1:24
tellers They provide probabilities based
1:26
on large group of people not certainties
1:29
for one individual Think about it like a
1:31
weather forecast A 70% chance of rain
1:33
means rain is likely but it doesn't
1:35
guarantee you'll get wets These are
1:37
tools to aid doctors and patients in
1:40
understanding risk and making informed
1:42
decisions together They are part of a
1:44
much bigger picture that includes
1:46
doctor's experience your specific
1:48
situation test results and importantly
1:50
your personal values and preferences So
1:52
next time when you're discussing a
1:54
health decision with your doctor don't
1:56
be surprised if they mention a risk
1:58
score or use one of these calculators
2:00
It's a sign that they are using powerful
2:02
data-driven tools to help personalize
2:05
your care Pretty fascinating how data is
2:07
shaping medicine right it's not about
2:09
replacing the human touch but enhancing
2:11
it with information What do you think
2:13
about these prediction tools have you
2:14
ever encountered one let me introduce
2:16
some of these tools to you We first will
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start with some basic tools These are
2:20
carnovski performance scale bartal index
2:23
for activities of daily living and
2:26
charlson comorbidity index Then we will
2:28
discuss pum which is physiologic and
2:30
operative severity score for the study
2:33
of mortality and morbidity Let's start
2:35
with carnowski performance scale
2:36
Karnovski performance scale is a simple
2:38
way for doctors and nurses to describe
2:41
how well a person with an illness can do
2:43
everyday activities It uses score from 0
2:45
to 100 A higher score like 90 or 100
2:48
means the person is doing pretty well
2:50
and can take care of themselves and even
2:52
work Lower scores mean the person needs
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more help with daily tasks Think of it
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as a snapshot of how the illness is
2:59
affecting someone's life like whether
3:01
they can go to work cook meals or even
3:04
just get out of bed Doctors use a scale
3:06
to understand how someone is doing plan
3:08
their treatment and see if things are
3:10
getting better or worse over time It's a
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straightforward way to communicate about
3:14
a person's overall well-being and
3:16
ability to function Excellent Let's move
3:19
on to Bartell's index for activism of
3:21
daily living For this we're going to use
3:22
a website called mdcalc.com So
3:26
mdc.com and in the search box you'll
3:29
just type vortell and then it shows up
3:31
And as you see it lists variety of
3:34
activities that we do on a daily basis
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such as feeding bathing grooming
3:38
dressing bowel and bladder control
3:41
toilet use transfers from bed to the
3:43
chair and back mobility on level
3:45
surfaces stairs and then for each one
3:48
you can select different options So
3:50
let's say as one person for feeding that
3:53
person needs some help that person is
3:55
unable to do the baiting grooming no
3:58
issue Let's say dressing needs some help
4:00
Bowel control maybe some occasional
4:02
accident Bladder control also some
4:05
occasional accident Toilet use needs
4:07
some help Transfers from bed to the
4:09
chair and back and either select
4:11
independent or you can select needs
4:13
minor help with verbal or physical help
4:16
or needs major help one or two people
4:18
doing it physically but the person is
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able to sit by himself or herself or is
4:23
unable to do any of that So let's say
4:25
this person needs some major help And
4:28
then the next question would be on
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mobility on level surfaces Here you can
4:32
be independent You can use some aids
4:34
like cane or walker but you should be
4:37
able to walk more than 50 yards The next
4:39
option is that you need help from one
4:41
person either or physical but you're
4:43
able to walk more than 50 yards The
4:45
third option is that you're wheelchair
4:46
independent including corners but you're
4:49
able to do that for more than 50 yards
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And then the last option is either
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you're immobile let's say bedridden or
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you're able to walk less than 50 yards
4:58
So for this person let's say the patient
5:00
is able to walk with the help of one
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person And then the last one is stairs
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So you can be independent on going up
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and down the stairs or you may need some
5:09
help either verbal physical or carrying
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aid like a chairlift or you're unable to
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do that So let's say you need some help
5:16
with that too So now you see that the
5:19
total score is 50 points and this person
5:21
is partially dependent Then you can
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click on the next steps It tells you
5:25
that lower scores indicate increasing
5:27
disability and greater need for skilled
5:29
care The total score and categorization
5:31
may be used to help guide the extent of
5:33
the interventions necessary in the
5:34
management However scores within each
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variables are also important in guiding
5:38
the focus of the treatment such as if
5:40
you have problem with just transfers or
5:41
baiting or grooming And then it provides
5:43
some basic and general suggestions and
5:46
recommendations So the followings are
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the basic measures that may be
5:49
beneficial for patients but should be
5:51
considered within the context of each
5:53
patient So develop a comprehensive care
5:55
plan involving a multi-disiplinary team
5:57
Educate and train the family members and
5:58
caregivers in providing assistance
6:01
Ensure the patient has access to
6:02
necessary resources for activities of
6:04
daily living Educate the patient on
6:06
energy conservation techniques and safe
6:08
ways to perform activities of daily
6:09
living Refer for occupational physical
6:11
therapy structure to their needs to
6:14
improve and maintain function Introduce
6:16
adaptive equipment to assist with daily
6:18
activities such as a special utensils
6:20
for eating Grab bars and transfer boards
6:23
Evaluate and modify the home environment
6:25
to optimize safety such as wheelchair
6:27
accessibility hospital bed and bedroom
6:30
and bathroom aids arrange for community
6:33
support services such as home meal
6:35
delivery and home health aids and
6:37
conduct regular assessments to monitor
6:39
progress and adjust care plans
6:40
accordingly So for patients with minimal
6:43
to no needs schedule periodic checkups
6:45
to ensure continued independence and
6:48
continue to focus on health maintenance
6:49
and preventive care and encourage
6:51
participation in physical and social
6:54
activity Excellent Let's move on to
6:56
Charleston coorbidity index Again we go
6:58
to the medal.com and in the search box
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type Charleston and then it brings it up
7:05
So here you see that this assessment has
7:08
a bunch of questions One of them is
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about age and the rest of it is about
7:12
the medical conditions that you may have
7:15
So let's start with the case Let's say
7:17
you are 75 years old So you select 70 to
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79 years category And as you select the
7:24
age it gives you the estimated 10ear
7:27
survival So even if you have none of the
7:30
illnesses that we're going to talk about
7:32
the likelihood of you surviving 10 years
7:35
is 77% because you are in this age
7:38
category Now for the sake of argument
7:40
let's say you're 82 As you see that 77%
7:44
likelihood of you surviving 10 years is
7:46
going to drop to 53% So that's how these
7:49
sort of numbers do change as you enter
7:52
different answers So now let's go back
7:53
to the 75 year old So you start with 77%
7:57
likelihood of living within the next 10
7:59
years The first illness is mioardial
8:02
inffection So if you have had heart
8:03
attack so if you select yes for that
8:06
just because of that it drops from 77%
8:09
to 53% The next question is on heart
8:11
failure shortness of breath leg swelling
8:14
etc Let's say you did not have that
8:16
peripheral vascular disease which is
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defined by intermittent claudication or
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past bypass for chronic arterial
8:23
insufficiency history of gang green or
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acute arterial insufficiency or
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untreated thoracic or abdominal aneurysm
8:30
which is more than 6 cm Let's say you
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did not have that The next illness is on
8:34
cerebrovascular accident or transending
8:37
schemic attack Let's say you had that
8:39
And as you see with that yes you're now
8:41
at 21% likelihood of living within the
8:44
next 10 years You do not have dementia
8:47
You were a former smoker and as a result
8:49
of that you have some chronic pulmonary
8:51
disease So you select yes And now we are
8:54
at just 2% estimated 10ear survival So
8:58
the rest which is the connective tissue
9:00
disease peptic ulcer disease liver
9:02
disease diabetes hemipalgia moderate or
9:06
severe chronic kidney disease and
9:07
whether you even have had solid tumors
9:09
or not We are just focusing on that
9:12
remaining 2% of estimated likelihood of
9:15
living within that 10-year time frame So
9:18
it's very important for you to take
9:20
these numbers into account when you're
9:22
deciding whether you should receive
9:24
treatment or what sort of treatment for
9:26
your cancer Let's say you're 75 years
9:29
old but you have none of these illnesses
9:32
that I just mentioned So let's select no
9:35
for all of these So you see you are at
9:37
77% likelihood of 10ear survival Now if
9:41
you have a localized colon cancer that
9:44
is going to drop to 21% So it's very
9:47
important for you to think about these
9:49
numbers when you decide whether you
9:51
should have treatment for your localized
9:53
or metastic cancer or not Obviously the
9:55
more coorbidities the less likelihood
9:57
that you're going to live within that 10
9:59
years even without a diagnosis of cancer
10:01
So that may be helpful in your decision
10:03
making Excellent Let's move on to the
10:06
next calculator So again we go to MD
10:09
calculator and we are going to type pom
10:12
p su m This is pom for operative
10:16
morbidity and mortality risk So this
10:19
risk calculator has two main scores One
10:22
is the physiological score and the other
10:24
one is operative severity score So let's
10:27
first focus on physiological score The
10:30
first point is your age Let's say you're
10:33
82 Then it asks you about your cardiac
10:36
condition So if you're not in heart
10:38
failure you click on no failure If
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you're using some water pills or some
10:43
other medications you select this one If
10:46
you have had peripheral edema like leg
10:48
swelling or if you're on blood tuners
10:50
like warerin you select this and
10:53
obviously this one is a lot more severe
10:55
than the others Let's say you do not
10:57
have any cardiac failure So you select
11:00
no failure The next organ that it
11:02
focuses on is respiratory So if you have
11:05
no shortness of breath or dysna you
11:07
select no dysna If you have a mild
11:10
chronic obstructive pulmonary disease or
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you have some shortness of breath when
11:14
walking you select this one If you have
11:16
moderate chronic obstructive pulmonary
11:18
disease or you have a shortness of
11:20
breath that is limiting you more you
11:22
select this third option And then
11:23
obviously the fourth option is always a
11:25
lot more severe So let's say you have
11:27
some mild shortness of breath Then it
11:30
ask you about your systolic blood
11:32
pressure This is the high number on when
11:35
you get your blood pressure So like
11:37
usually 120 or 80 130 over 70 It's
11:40
asking you about the higher number So
11:42
let's say you usually run 140 And then
11:45
it ask you about your heart rate So
11:47
let's put it at 75 Glasco comma scale
11:50
Again the higher number means that
11:52
you're more alert and oriented You're
11:55
conscious and so on This one I would
11:57
suggest that you put 15 That's the type
12:00
of patients that you're talking about
12:01
Then it asks you about your hemoglobin
12:03
or your red blood cells whether you're
12:05
anemic or not So this is you can find it
12:08
in your blood work result So let's say
12:10
you're at 12.5 Then the next question is
12:13
your white blood cell count Let's say
12:15
you're 4.5 Then this is the bun or bun
12:20
You can find that in the routine blood
12:22
work that every patient has Let's put 25
12:25
Then you have your sodium and potassium
12:27
For sodium let's put 140 here for
12:29
potassium that's before And then the
12:32
next one it asks you about your EKG So
12:34
if your EKG is normal you select this
12:36
one If you're having a condition called
12:38
atrial fibrillation or irregular heart
12:40
rhythm you select this So to keep things
12:43
simple let's select normal for your EKG
12:46
So that is your physiological scores
12:48
Then we move on to the operative
12:49
severity score So operative severity for
12:53
the sort of surgeries that we are
12:55
talking about you are either undergoing
12:58
major or major plus surgery Let's select
13:01
major and then at times surgeons need to
13:04
do more than one procedure at the same
13:07
time So that's why this is a number of
13:09
procedures one two or more than two
13:11
Let's select one Estimated blood loss
13:14
your surgeon has an idea about what
13:16
would be the expectation for blood loss
13:19
especially if you're undergoing
13:20
laparoscopy surgery blood loss is going
13:22
to be fairly minimal maybe 50 ml so
13:26
let's say your surgeon is expecting that
13:28
there might be just 50 cc's of blood
13:30
loss the next question is on the peronal
13:33
soiling again this is something that you
13:35
need your surgeon's help but for the
13:38
sake of argument let's select none and
13:40
the next one is presence of malignancy
13:42
diagnosed before or during surgery Let's
13:45
say you're undergoing colon surgery So
13:47
now you know that you have colon cancer
13:50
So it's going to be either primary only
13:53
whether there's lymph metastasis or this
13:54
and metastases This metastases are
13:57
obviously clear from the pre-operative
13:59
imaging At times the lymph node status
14:01
is unknown until the surgery is done But
14:04
you can play with this So you can either
14:06
select primary only first and then lymph
14:08
node metastasis and see if the numbers
14:10
change significantly and whether you
14:12
need to take that into consideration
14:14
Let's say you only have primary tumor
14:16
and then the mode of surgery elective
14:18
emergency within 24 hours or emergency
14:20
within 2 hours If you're presenting to
14:23
the emergency room with severe abdominal
14:25
pain and the surgeon needs to operate on
14:27
you right away that risk and stress of
14:30
that surgery on your body just increases
14:32
significantly So the expectation that
14:35
you presented to the emergency room and
14:37
you underwent surgery and as a result
14:39
it's going to be a safe surgery I think
14:41
at times is unrealistic expectation
14:43
Let's say this is an elective surgery
14:45
You've been diagnosed with cancer and
14:47
the surgeon has scheduled you to undergo
14:49
surgery in a matter of few weeks or so
14:51
that is elective surgery So then it
14:54
gives you these numbers that are very
14:56
important for you to take into
14:58
consideration So the likelihood of you
14:59
dying during and little bit after the
15:03
surgery usually within 30 days is 4.9%
15:07
And then the predicted morbidity if you
15:09
have complications or functional decline
15:12
or additional assistant with your daily
15:14
activities it is around 27 28% As you
15:18
see the risk for both mortality and
15:20
morbidity for this patient that we
15:22
talked about is not 0% but it's also not
15:24
50% The most important question for you
15:26
is whether you think 5% risk of dying
15:30
during and within 30 days after surgery
15:33
is worth going over is worth going
15:35
through that surgery or not and how much
15:38
this 27 28% likelihood of functional
15:40
decline needing some assistance maybe
15:42
going to the rehab and so on would
15:44
impact your decision making Again you
15:47
can see how do these things change So we
15:49
talked about the mode of surgery So this
15:50
was for elective But now let's say you
15:52
have had colon cancer but for variety of
15:55
reason you needed to be rushed to the
15:58
emergency room because of severe
15:59
abdominal pain and they found that you
16:01
have a bowel obstruction and now they
16:04
need to do surgery maybe within 24 hours
16:06
Right so now instead of doing the
16:08
surgery on elective manner let's do it
16:10
in emergency within 24 hours and see how
16:12
these numbers change So as you see now
16:15
the likelihood of you dying during and
16:18
within that 30 day of surgery has
16:20
increased to 7.7% And you're more than
16:23
40% likely to have some morbidity and
16:27
complications from that surgery Let's
16:29
say this is now has become a very e
16:31
surgery The surgery within 2 hours and
16:34
that the numbers just jump significantly
16:36
So that is why this calculator in my
16:38
opinion is important It's a little bit
16:41
complicated You may need some help from
16:43
your doctors surgeons and primary care
16:46
providers find the right answers for
16:49
these questions But overall I think this
16:51
will give you some idea about how things
16:53
are
#Aging & Geriatrics
#Health Conditions
#Cancer