Polypharmacy

Normal physiologic changes that accompany aging can also cause changes in the pharmacokinetics and pharmacodynamics of cancer therapy. Older adults lose muscle and gain fat as they age. Total body water decreases while percentage of body fat increases, a fact that alters the distribution of drugs in the body. In addition, renal clearance decreases, even if no elevation in blood urea nitrogen or creatinine is detected. Finally, with increasing age, blood flow to the liver is less vigorous than at younger ages, and the liver shrinks in size. These changes have an impact on hepatic metabolism.

As the body ages, it can accumulate chronic diseases such as diabetes mellitus and hypertension. Many older adults who present with a new cancer diagnosis are already taking multiple medications, and cancer treatment and its side effects will likely add more. While there have been few studies about the impact of polypharmacy in cancer treatment, we do know from geriatric literature that the more medications someone is taking, the higher the risk of an adverse drug reaction (ADR).[52,53]

A thorough review of a patient's medications, both prescribed and over-the-counter, can help decrease the risk of ADRs. Such an assessment allows for the identification of potential drug interactions or the need for dose adjustments to accommodate age-related changes in organ function, as well as the elimination of unnecessary medications. Having the patient bring all medication bottles to an outpatient visit provides the most accurate picture of what the person has access to and is taking. It can also corroborate compliance with a treatment regimen.

Psychosocial Support

In recent years, cancer care has moved from the inpatient to the outpatient setting. While beneficial on many levels for both the patient and the health-care system, this shift has thrust family and friends into caregiving roles that were previously performed by trained hospital staff. This can be particularly problematic for patients who have no social network of support, and it may be why such isolation has been associated with a greater mortality risk.[54] Asking simple questions such as: “Who would you call in an emergency?” and “Who is available to help you in times of need?” can help identify patients who are socially isolated.

Depression has been shown to increase the risk of functional decline and increase health-care resource use. It is also associated with poorer survival for cancer patients. While some studies have demonstrated that a more comprehensive screen for depression is needed,[55] other studies have demonstrated that an effective screening tool for depression is to simply ask the patient if he or she feels depressed or sad.[56,57] A positive answer should be followed with further questioning for common depressive symptoms, such as anhedonia, changes in sleep patterns, crying spells, etc. The oncologist can then ask if the patient would be interested in counseling, medication, or both. These few questions can help guide the plan for further evaluation and treatment of a mood disorder.

Integrating Geriatric Assessment Tools Into Oncology Practice

In this article we reviewed some practical tools for assessing the functional status of older adults with cancer, as well as highlighted other domains that may affect an older adult's ability to tolerate cancer therapy. A comprehensive geriatric assessment and intervention has proven clinical benefit for optimizing health outcomes as well as improving function and quality of life in older adults.[58,59]

The feasibility of including a geriatric assessment[60] as part of the baseline evaluation of older adults on clinical trials is being studied by the Cancer and Leukemia Group B Cancer in the Elderly Committee. Other approaches have been described in the literature, including a mailed geriatric assessment completed by the patient prior to an office visit, a primarily self-administered geriatric assessment, or an abbreviated geriatric assessment.[5,60-63] Studies are underway to evaluate which domains and questions from a geriatric assessment are predictive for the risk of chemotherapy toxicity. These data can guide subsequent studies of interventions to help improve tolerance to cancer therapy in older adults. Ultimately, the integration of knowledge learned in the fields of both geriatrics and oncology will optimize cancer care for older adults.

This article is reviewed here:

Translation Requires Evidence: Does Cancer-Specific CGA Lead to Better Care and Outcomes?

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