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what do or can geriatricians do for
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older adults with cancer i've been asked
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this question many times i have taken
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care of many older adults with cancer
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for the past 12 years i'm going to tell
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you what geriatrician and geriatric care
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providers can provide why you need one
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if you're diagnosed with cancer and what
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will you be missing if you don't have
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one we all know that the number of older
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people with cancer is increasing this is
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a big challenge to doctors and hospitals
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older patients often have other health
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issues may have difficulty to live
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independently and might have problems
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with thinking clearly and they can be
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more easily harmed by treatments to
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address this challenge we suggest that
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all order cancer patients should go
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through a special evaluation called
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geriatric assessment this assessment
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helps find problems that might be missed
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during your routine visit with other
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doctors this assessment also suggests
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ways to help patients stay as functional
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as possible which might even help them
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live longer unfortunately these
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comprehensive assessments and coming up
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with effective solutions can be tough
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for cancer doctors they may not have the
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training time or the resources as needed
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in this article that we have published
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about 10 years ago we have explained how
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the geriatric service cares for patients
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with cancer from when they first
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diagnosed to the end of their lives we
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emphasize how important geriatric
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assessment is at each it stage of cancer
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treatment and how special tools are used
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to personalize a treatment so let's
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discuss major points of this article the
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most important thing is to focus on what
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the patient needs and wants this is
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especially true for older cancer
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patients because a disease center
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approach might ignore other important
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factors in this article we also discuss
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the value of teamwork between cancer
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doctors and geriatric nurse
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practitioners and how parts of this team
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approach can be used in a busy cancer
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practices as the population ages the
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number of cancer cases is also expected
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to increase the way that some tumors
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behave can change with age and aging
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process itself can cause changes in the
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body that affects how well organs work
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it's important to remember that patients
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functional age how well they function
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can be different from their actual age
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this needs to be considered when
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deciding on the best cancer treatment
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some older patients might be very
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healthy while others might have some
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decline in their physical condition and
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some might be frail it's crucial to
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identify patients who are in good shape
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because they are more likely to handle
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standard treatments well healthy older
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adults usually don't have many other
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health conditions they are able to
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function independently and don't have
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issues like frequent falls or dementia
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on the other hand frail patients have
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multiple health problems they struggle
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with their independence they may have
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cognitive impairment and they are more
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likely to experience negative effects
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from treatment because of these factors
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frail patients might not benefit as much
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from cancer treatment i'm sure you've
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heard about the term patient centered
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care this type of care is a major goal
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in our healthcare system this means
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providing care that respects patients
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preferences needs and values the goal is
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to make sure that patients values guide
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all of our treatment decisions the
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patient center approach is especially
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important for older cancer patients who
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often see as many doctors and receive
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treatments for these patients is
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essential to assess their functional
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abilities cognitive function and other
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aspects of their health using a
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comprehensive geriatric assessment in
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the case that I'm going to discuss we
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are going to show you how patient
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centered principles are used in the care
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cancer this is a 88-year-old woman with
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a history of high blood pressure
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osteoarthritis and reflux who came to
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the hospital with abdominal pain and
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anemia colonoscopy showed that the
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patient has had colon cancer the
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standard treatment was to remove part of
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her colon and she was referred to
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geriatric service for an evaluation
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before surgery older surgery patients
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have a specific needs that go beyond
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their usual pre-surgery checkup older
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patients may have reduced physical
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reserve that aren't always obvious and
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unfortunately at times common assessment
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tools are not good at predicting
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surgical risks geriatricians use
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geriatric assessment which is a more
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in-depth evaluation that often uncovers
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issues that a regular exam might miss
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geriatric assessment is a valuable tool
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for predicting surgical outcomes and
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guidelines recommend using it for
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surgical older surgical patients however
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unfortunately only a small percentage of
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surgeons routinely use this assessment
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for this patient in addition to the
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usual preoperative evaluation she
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underwent geriatric assessment and was
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found to be in good shape she had few
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other healthy conditions she was
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independent and she had good social
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support so now let's briefly talk about
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cancer surgery in older adults majority
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of patients with colorectile cancer are
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older than age 65 and 70% of them have
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early stage disease for these patients
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surgery could be curative
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age alone shouldn't be a reason to avoid
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a standard treatment however older
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patients may have other health
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conditions that increase the risk of
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complication after surgery we need to
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carefully select patients for surgery
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because frail early patients are at
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complications this patient had an
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average risk of complication but a
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higher risk of needing to go to the
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nursing home or rehab facility after
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surgery we discussed that risk with the
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patient and the family and family was
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prepared to take care of her at home
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should she need some additional
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care following surgery the patient
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recovered well and was discharged after
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5 days guriatric service work with the
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surgical team to prevent delirium which
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is a state of confusion after surgery
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and encouraged physical therapy we also
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educated the patient and her family on
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the importance of deep breathing
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exercises and because she recovered
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quickly and had support at home she was
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discharged without needing additional
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services let's briefly talk about
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challenges after cancer
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surgery older patients are at high risk
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for complications after surgery such as
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delirium poor nutrition pressure ulcers
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falls and functional decline delirium is
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particularly concerning because it can
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increase length of stay in the hospital
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costs risk of further health problems
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and even death it can also lead to the
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need for long-term care facilities which
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can significantly impact the patients
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and families quality of life it's
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important to educate older patients and
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their families about the possibility of
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post-operative delirium we also focus on
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managing pain educating patients on
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breathing exercises encouraging early
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movement and taking steps to reduce the
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delirium about a year later this patient
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developed metastic disease and began
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chemotherapy in another institution
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unfortunately she experienced
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complications and sought further
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us in our institution we discussed her
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life expectancy treatment goals and the
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risk and benefits of chemotherapy with
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her and her family because the patient
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wanted to pursue anti-cancer treatment
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she was referred to geriatric service
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for help with managing symptoms and
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providing supportive care another
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geriatric assessment was performed which
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showed that she is now more frail than
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before we refer her to a nutritionist
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because she has lost significant amount
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of weight and physical therapist because
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she had fallen multiple times
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geriatric assessment can help doctors
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make better treatment decisions based on
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the result we can reduce the intensity
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of chemotherapy or provide additional
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support so the patient is able to
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tolerate treatment much better geriatric
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assessment can also help personalize
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treatment for older patients who may be
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toxicity for this patient a tool was
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used to predict the patient risk of
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chemotherapy toxicity based on the
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result and in discussion with the
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patient and her family she was started
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on reduced dose of chemotherapy
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geriatric service nurse practitioner
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closely monitor her to provide
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supportive care in a collaborative
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geriatric oncology model oncologist and
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geriatric nurse practitioners work
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together to care for older patients with
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multiple health conditions this model
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includes the patient their support
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system the oncologist and a geriatric
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nurse practitioner who communicates with
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the patients primary care provider they
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work together to create a patient
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plan given the limited number of
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geriatricians in the United States
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geriatric nurse practitioners play a
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crucial role in providing geriatric care
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to cancer patients geriatric nurse
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practitioners are involved in education
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prevention supportive care and symptom
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management focusing on early assessment
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timely interventions follow-up and care
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coordinations our patient tolerated the
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reduced chemotherapy well and the
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geriatric nurse practitioner assessed
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various issues such as side effects
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uncontrolled hypertension constipation
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weight loss and vitamin D deficiency
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we were able to maintain her quality of
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life for the most of the treatment and
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she was able to see her first great
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grandchild as eventually her disease
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progressed geriatric service was
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actively involved in goals of care
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conversation answering all of her and
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her family's questions and providing
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emotional support for her and her
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family she was enrolled in hospice and
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passed away in peace with her family
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in summary as you see in this case
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geriatric service is very much needed
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for the care of older adults with cancer
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there are significant gaps in the care
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of older adults with cancer that only
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geriatric care providers are able to
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fill it's also important to note that
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geriatric care is and should not be a
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one-stop shop it should be across cancer
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continuum providing dynamic support for
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everchanging needs of older adults with
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cancer and their families
