Comorbidity and polypharmacy in elderly cancer patients: The significance on treatment outcome and tolerance

Leveraging National Health Insurance Service Data for Public Health Research in Korea: Structure, Applications, and Future Directions

The National Health Insurance Service (NHIS) database serves as a crucial resource for public health research in Korea. As a comprehensive dataset within the single-payer healthcare system, NHIS data provides longitudinal insights into healthcare utilization, disease prevalence, and health outcomes. This review article explores the structure, characteristics, and applications of NHIS data, emphasizing its role in epidemiological studies, health policy evaluations, and clinical research. We discuss key methodological considerations, including data access procedures, outcome measures, and strategies to mitigate bias. Additionally, we highlight future directions, such as integrating NHIS data with other national health datasets and utilizing artificial intelligence for predictive analytics. By leveraging the NHIS database, researchers can enhance evidence-based policymaking and improve public health outcomes in Korea.

Seaweed-Derived Bioactive Compounds: Potent Modulators in Breast Cancer Therapy

Cancer remains a major global health concern, with breast cancer being particularly challenging. To address this, new therapeutic strategies are being explored, including natural alternatives. Seaweeds, rich in bioactive compounds, have gained attention for their therapeutic potential. Traditionally valued for their nutritional content, seaweed-derived compounds such as polysaccharides, polyphenols, sterols, vitamins, minerals, and carotenoids have shown anticancer properties. These compounds can modulate key cellular processes like apoptosis, angiogenesis, and inflammation-crucial in cancer progression. Their antioxidant, anti-inflammatory, and immunomodulatory effects make them promising candidates for complementary cancer therapies. Key bioactive components like fucoidans, laminarins, phlorotannins, and carotenoids exhibit antiproliferative, proapoptotic, antiangiogenic, and antimetastatic properties. Recent studies focus on the ability of these compounds to induce apoptosis in cancer cells. This review highlights the chemical constituents of various seaweed species with antitumor activity, their mechanisms of action, and the potential for integration into cancer treatments. It also addresses challenges in clinical applications and outlines future research directions for leveraging these marine resources in breast cancer therapy.

Frequency of use and characterization of frailty assessments in observational studies on older women with breast cancer: a systematic review

BACKGROUND

Breast cancer and frailty frequently co-occur in older women, and frailty status has been shown to predict negative health outcomes. However, the extent to which frailty assessments are utilized in observational research for the older breast cancer population is uncertain. Therefore, the aim of this review was to determine the frequency of use of frailty assessments in studies investigating survival or mortality, and characterize them, concentrating on literature from the past 5 years (2017-2022).

METHODS

MEDLINE, EMBASE and Cochrane Library were systematically queried to identify observational studies (case-control, cohort, cross-sectional) published from 2017-2022 that focus on older females (≥ 65 years) diagnosed with breast cancer, and which evaluate survival or mortality outcomes. Independent reviewers assessed the studies for eligibility using Covidence software. Extracted data included characteristics of each study as well as information on study design, study population, frailty assessments, and related health status assessments. Risk of bias was evaluated using the appropriate JBI tool. Information was cleaned, classified, and tabulated into review level summaries.

RESULTS

In total, 9823 studies were screened for inclusion. One-hundred and thirty studies were included in the final synthesis. Only 11 (8.5%) of these studies made use of a frailty assessment, of which 4 (3.1%) quantified frailty levels in their study population, at baseline. Characterization of frailty assessments demonstrated that there is a large variation in terms of frailty definitions and resulting patient classification (i.e., fit, pre-frail, frail). In the four studies that quantified frailty, the percentage of individuals classified as pre-frail and frail ranged from 18% to 29% and 0.7% to 21%, respectively. Identified frailty assessments included the Balducci score, the Geriatric 8 tool, the Adapted Searle Deficits Accumulation Frailty index, the Faurot Frailty index, and the Mian Deficits of Accumulation Frailty Index, among others. The Charlson Comorbidity Index was the most used alternative health status assessment, employed in 56.9% of all 130 studies. Surprisingly, 31.5% of all studies did not make use of any health status assessments.

CONCLUSION

Few observational studies examining mortality or survival outcomes in older women with breast cancer incorporate frailty assessments. Additionally, there is significant variation in definitions of frailty and classification of patients. While comorbidity assessments were more frequently included, the pivotal role of frailty for patient-centered decision-making in clinical practice, especially regarding treatment effectiveness and tolerance, necessitates more deliberate attention. Addressing this oversight more explicitly could enhance our ability to interpret observational research in older cancer patients.

Biomarker guided treatment in oncogene-driven advanced non-small cell lung cancer in older adults: A Young International Society of Geriatric Oncology Report

Lung cancer remains the leading cause of cancer-related deaths worldwide, with most patients diagnosed at an advanced age. The treatment of non-small cell lung cancer (NSCLC) has been revolutionized with the introduction of molecular guided therapy. Despites the challenges when considering treatment of older adults, they are still systematically underrepresented in registrational trials. This review aims to summarize the existing evidence on treatment of older patients with lung cancer with a targetable driver mutation or alteration (EGFR, ALK, ROS, BRAF^V600E, MET, RET, KRAS^G12C and NTRK), and consider the evidence from a geriatric oncology perspective. Early generation EGFR-tyrosine kinase inhibitors (TKIs). TKIs are fairly well-studied in older adults and have been shown to be safe and efficient. However, older adult-specific data regarding the standard-of-care first-line agent osimertinib are lacking. Erlotinib, dacomitinib, and afatinib may be more toxic than other EGFR-TKIs. Next generation ALK-TKIs are preferred over crizotinib due to increased efficacy, as demonstrated in phase III trials. Alectinib seems to be safer than crizotinib, while brigatinib is associated with increased toxicity. Lorlatinib overcomes most resistance mutations, but data regarding this agent have only recently emerged. Regarding ROS1-fusion positive NSCLC, crizotinib is an option in older adults, while entrectinib is similarly effective but shows increased neurotoxicity. In BRAF^V600E-mutant NSCLC, the combination darbafenib/tramectinib is effective, but no safety data for older adults exist. MET alterations can be targeted with capmatinib and tepotinib, and registrational trials included primarily older patients, due to the association of this alteration with advanced age. For RET-rearranged-NSCLC selpercatinib and pralsetinib are approved, and no differences in safety or efficacy between older and younger patients were shown. KRAS^G12C mutations, which are more frequent in older adults, became recently druggable with sotorasib, and advanced age does not seem to affect safety or efficacy. In NTRK-fusion positive tumors, larotrectinib and entrectinib have tumor agnostic approval, however, not enough data on older patients are available. Based on currently available data, molecularly-guided therapy for most alterations is safe and efficacious in older adults with oncogene-driven advanced NSCLC. However, for many TKIs, older adult-specific data are lacking, and should be subject of future prospective evaluations.

Using Geriatric Assessment to Guide Conversations Regarding Comorbidities Among Older Patients With Advanced Cancer

PURPOSE

Older patients with advanced cancer often have comorbidities that can worsen their cancer and treatment outcomes. We assessed how a geriatric assessment (GA)-guided intervention can guide conversations about comorbidities among patients, oncologists, and caregivers.

METHODS

This secondary analysis arose from a nationwide, multisite cluster-randomized trial (ClinicalTrials.gov identifier: NCT02107443). Eligible patients were ≥ 70 years, had advanced cancer (solid tumors or lymphoma), and had impairment in at least one GA domain (not including polypharmacy). Oncology practices (n = 30) were randomly assigned to usual care or intervention. All patients completed a GA; in the intervention arm, a GA summary with recommendations was provided to their oncologist. Patients completed an Older Americans Resources and Services Comorbidity questionnaire at screening. The clinical encounter following GA was audio-recorded, transcribed, and coded for topics related to comorbidities. Linear mixed models examined the effect of the intervention on the outcomes adjusting for practice site as a random effect.

RESULTS

Patients (N = 541) were 76.6 ± 5.2 years old; 94.6% of patients had at least one comorbidity with an average of 3.2 ± 1.9. The intervention increased the average number of conversations regarding comorbidities per patient from 0.52 to 0.99 (P < .01). Moreover, there were a greater number of concerns acknowledged (0.52 v 0.32; P = .03) and there was a 2.4-times higher odds of having comorbidity concerns addressed via referral, handout, or other modes (95% CI, 1.3 to 4.3; P = .004). Most oncologists in the intervention arm (76%) discussed comorbidities in light of the treatment plan, and 41% tailored treatment plans.

CONCLUSION

Providing oncologists with a GA-guided intervention enhanced communication regarding comorbidities.

Prevention of Chemotherapy-Induced Nausea and Vomiting in the Older Patient: Optimizing Outcomes

Chemotherapy-induced nausea and vomiting (CINV) are still two of the most feared side effects of cancer therapy. Although major progress in the prophylaxis of CINV has been made during the past 40 years, nausea in particular remains a significant problem. Older patients have a lower risk of CINV than younger patients, but are at a higher risk of severe consequences of dehydration and electrolyte disturbances following emesis. Age-related organ deficiencies, comorbidities, polypharmacy, risk of drug–drug interactions, and lack of compliance all need to be addressed in the older patient with cancer at risk of CINV. Guidelines provide evidence-based recommendations for the prophylaxis of CINV, but none of these guidelines offer specific recommendations for older patients with cancer. This means that the recommendations may lead to overtreatment in some older patients. This review describes the development of antiemetic prophylaxis of CINV focusing on older patients, summarizes recommendations from antiemetic guidelines, describes deficiencies in our knowledge of older patients, summarizes necessary precautions, and suggests some future perspectives for antiemetic research in older patients.

Use of Non-Cancer Medications in New Zealand Women at the Diagnosis of Primary Invasive Breast Cancer: Prevalence, Associated Factors and Effects on Survival

Background: Assessing the use of multiple medications in cancer patients is crucial as such use may affect cancer outcomes. This study reports the prevalence of non-cancer medication use at breast cancer diagnosis, its associated factors, and its effect on survival. Methods: We identified all women diagnosed with primary invasive breast cancer between 1 January 2007 and 31 December 2016, from four population-based breast cancer registries, in Auckland, Waikato, Wellington, and Christchurch, New Zealand. Through linkage to the pharmaceutical records, we obtained information on non-cancer medications that were dispensed for a minimum of 90 days’ supply between one year before cancer diagnosis and first cancer treatment. We performed ordered logistic regressions to identify associated factors and Cox regressions to investigate its effect on patient survival. Results: Of 14,485 patients, 52% were dispensed at least one drug (mean—1.3 drugs; maximum—13 drugs), with a higher prevalence observed in patients who were older, treated at a public facility, more economically deprived, and screen-detected. The use of 2–3 drugs showed a reduced non-breast cancer mortality (HR = 0.75, 95%CI = 0.60–0.92) in previously hospitalised patients, with other groups showing non-significant associations when adjusted for confounding factors. Drug use was not associated with changes in breast cancer-specific mortality. Conclusions: Non-cancer medication use at breast cancer diagnosis was common in New Zealand, more prevalent in older and disadvantaged women, and showed no effect on breast cancer-specific mortality, but a reduction in other cause mortality with the use of 2–3 drugs.

Impact of a pharmacist and geriatrician medication review on drug-related problems in older outpatients with cancer

OBJECTIVES

Older patients with cancer have increased risk for comorbidity, polypharmacy (PP) and drug related problems (DRP). The aim of this study was to assess the effect of a clinical pharmacist and geriatrician medication review (MR) among older outpatients with cancer to optimize management of comorbidities during comprehensive geriatric assessment (CGA).

MATERIAL AND METHODS

We conducted a single-center prospective study among older outpatients with cancer (≥75 years). A pharmacist consultation was added into CGA process. The clinical pharmacist detected and assessed PP and DRP such as potentially inappropriate medications (PIM) according to the Laroche French list and STOPP criteria, START criteria and adverse drug events (ADE) risk. After a multidisciplinary MR, the proposals for prescription modification were sent to general practitioners (GPs).

RESULTS

Fifty-one consenting patients were recruited between May 2016 and March 2017, with a median age of 83 years. Prevalence of PP was 80.4%. 165 DRP were detected among 86% patients (median number of DRP = 3.0): 19.4% were misuse, 43.6% underuse, and 37.0% overuse. A significant decrease was observed in prevalence of PIM use (Laroche: 31.4% versus 5.9%, p = 0.002), START criteria (66.7% to 5.9%; P < 0.001) and ADE score (4.0 before MR versus 2.0 after, p = 0.023). A trend was observed for a lower number of medications (10.0 versus 8.0, p = 0.092) and on STOPP criteria prevalence (56.9% versus 31.4%, p = 0.12).

CONCLUSION

A clinical pharmacist and a geriatrician MR is effective to detect and reduce DRP in older outpatients with cancer.

Polypharmacy in elderly cancer patients: Challenges and the way clinical pharmacists can contribute in resource-limited settings

The aim of this study was to address the problems associated with polypharmacy in elderly cancer patients and to highlight the role of pharmacists in such cases in resource-limited settings. A narrative review of existing literature was performed to summarize the evidence regarding the impact of polypharmacy in elderly cancer patients and the pharmaceutical strategies to manage it. This review emphasizes the significance of polypharmacy, which is often ignored in real clinical practice. Polypharmacy in the elderly cancer population is mainly due to: chemotherapy with one or more neoplastic agents for cancer treatment, treatment for adverse drug reactions due to neoplastic agents, the patient's comorbid conditions, or drug interactions. The role of the clinical pharmacist in specialized oncology hospitals or oncology departments of tertiary care hospitals is well established; however, this is not the case in many developing countries. A clinical pharmacist can contribute to solving the problems associated with polypharmacy by identifying the risks associated with polypharmacy and its management in resource-limited settings. As in many developed countries, the involvement of a clinical pharmacist in cancer care for elderly patients may play a vital role in the recognition and management of polypharmacy-related problems. Further research can be conducted to support this role.

Treatment of advanced non-small cell lung cancer in the elderly

INTRODUCTION

Lung cancer is predominantly a disease that affects the elderly; about 30-40% of lung cancers are diagnosed in patients aged 70 or more. The increasing number of elderly patients over the next decades is generating a new social and health problem; despite that, these patients are underrepresented in clinical trials and undertreated in clinical practice. Areas covered: The main difficulty in treating elderly patients is to maximize the therapy benefits while minimizing the treatment risk. Elderly patients show a vulnerable clinical profile due to the higher prevalence of comorbid disease, higher polypharmacy interactions and aged organ dysfunction that increase the risk of mortality and toxicity with cancer treatments compared to younger patients. Expert commentary: The choice to treat or not to treat elderly patients cannot be taken only on the basis of the chronological age. Thus, the clinical approach should be to select patients who are effectively suitable for treatment having a better individual functional reserve and a better life expectancy. Elderly patients are a heterogeneous population and those who are fit to receive cancer treatment can be treated similarly to younger patients.

Anticancer activity of seaweeds

Cancer is a major health problem worldwide and still lacks fully effective treatments. Therefore, alternative therapies, using natural products, have been proposed. Marine algae are an important component of the marine environment, with high biodiversity, and contain a huge number of functional compounds, including terpenes, polyphenols, phlorotannins, and polysaccharides, among others. These compounds have complex structures that have shown several biological activities, including anticancer activity, using in vitro and in vivo models. Moreover, seaweed-derived compounds target important molecules that regulate cancer processes. Here, we review our current understanding of the anticancer activity of seaweeds.

Incorporating Geriatric Medicine Providers into the Care of the Older Adult with Cancer

A significant proportion of cancer patients and survivors are age 65 and over. Older adults with cancer often have more complex medical and social needs than their younger counterparts. Geriatric medicine providers (GMPs) such as geriatricians, geriatric-trained advanced practice providers, and geriatric certified registered nurses have expertise in caring for older adults, managing complex medical situations, and optimizing function and independence for this population. GMPs are not routinely incorporated into cancer care for older adults; however, their particular skill set may add benefit at many points along the cancer care continuum. In this article, we review the role of geriatric assessment in the care of older cancer patients, highlight specific case scenarios in which GMPs may offer additional understanding and insight in the care of older adults with cancer, and discuss specific mechanisms for incorporating GMPs into oncology care.

Risk factors associated with treatment refusal in lung cancer

Background

The incidence of lung cancer is increasing with longer life expectancy. Refusal of active treatment for cancer is prone to cause patients to experience more severe symptoms and shorten survival. The purpose of this study was to define the factors related to refusal or abandonment of active therapy in lung cancer.

Methods

We retrospectively reviewed the data of 617 patients from medical records from 2010 to 2014. Two groups were formed: 149 patients who refused anti‐cancer treatment and allowed only palliative care were classified into the non‐treatment group, while the remaining 468 who received anti‐cancer treatment were classified into the treatment group.

Results

The groups differed significantly in age, employment, relationship status, number of offspring, educational status, body mass index, presence of chest and systemic symptoms, Charlson Comorbidity Index, Eastern Cooperative Oncology Group score, and tumor node metastasis stage (P < 0.05). In logistic regression analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.07–1.13), educational status lower than high school (OR 1.95, 95% CI 1.2–3.2), no history of surgery (OR 2.29, 95% CI 1.4–3.7), body mass index < 18.5 (OR 2.49, 95% CI 1.3–4.7), and a high Eastern Cooperative Oncology Group score of 3 or 4 (OR 5.02, 95% CI 2.3–10.8) were significant factors for refusal of cancer treatment.

Conclusion

Individual factors, such as old age, low educational status, low weight, and poor performance status can influence refusal of cancer treatment in patients with lung cancer, and should be considered prior to consultation with patients.

Comorbidity, physical and mental health among cancer patients and survivors: An Australian population-based study

AIM

To assess the prevalence of comorbidities and measures of physical and mental health among the cancer patients and survivors compared with the general population.

METHODS

Data collected by the Australian Bureau of Statistics from 2011-2012 National Health Survey were utilized for this cross-sectional study. Comparisons were made between adults aged 25 years and over with history of cancer (n = 2170) and those respondents who did not report having had a cancer (n = 11 592) using logistic regression models. Analyses were repeated according to cancer status (current cancer vs. cancer survivor).

RESULTS

People with history of cancer had significantly higher odds of reporting mental and behavioral problems (overall cancer group adjusted odds ratio 1.36, 95 percent confidence interval 1.20-1.54; current cancer 2.53, 1.97-3.27; cancer survivor 1.20, 1.05-1.38), circulatory conditions (overall cancer group 1.25, 1.12-1.39; current cancer 1.38, 1.08-1.76; cancer survivor 1.22, 1.09-1.38), musculoskeletal conditions (overall cancer group 1.37, 1.24-1.52; current cancer 1.66, 1.30-2.12; cancer survivor 1.33, 1.19-1.48) and endocrine system disorders (overall cancer group 1.19, 1.06-1.34; current cancer 1.29, 1.00-1.66; cancer survivor 1.17, 1.04-1.33) compared with the noncancer group. Cancer patients and survivors were more likely to report poor health status, a higher level of distress, and a greater number of chronic conditions compared with the noncancer group.

CONCLUSION

Poor health and comorbidity is more prevalent among cancer patients and survivors than the noncancer population. Our results further support the need to develop models of care that effectively address multiple chronic conditions experienced by the cancer population.

Cancer Screening and Early Detection in Older People: Considerations for Nursing Practice

OBJECTIVE

To synthesize relevant issues in cancer screening for older people for nursing practice.

DATA SOURCES

Published scientific literature, clinical literature, and published cancer screening guidelines from the United States and Canada.

CONCLUSION

Nurses are caring for increasing numbers of older patients and, with this demographic shift, face increasing demands to address cancer screening and detection in both primary and specialty practice.

IMPLICATIONS FOR NURSING PRACTICE

Ageism, self-stereotyping, cancer fear and fatalism, and cancer survivorship experiences influence cancer screening and generate the need for improved awareness of these issues to advance nursing practice.

A Comprehensive Look at Polypharmacy and Medication Screening Tools for the Older Cancer Patient

: Inappropriate medication use and polypharmacy are extremely common among older adults. Numerous studies have discussed the importance of a comprehensive medication assessment in the general geriatric population. However, only a handful of studies have evaluated inappropriate medication use in the geriatric oncology patient. Almost a dozen medication screening tools exist for the older adult. Each available tool has the potential to improve aspects of the care of older cancer patients, but no single tool has been developed for this population. We extensively reviewed the literature (MEDLINE, PubMed) to evaluate and summarize the most relevant medication screening tools for older patients with cancer. Findings of this review support the use of several screening tools concurrently for the elderly patient with cancer. A deprescribing tool should be developed and included in a comprehensive geriatric oncology assessment. Finally, prospective studies are needed to evaluate such a tool to determine its feasibility and impact in older patients with cancer.

IMPLICATIONS FOR PRACTICE

The prevalence of polypharmacy increases with advancing age. Older adults are more susceptible to adverse effects of medications. "Prescribing cascades" are common, whereas "deprescribing" remains uncommon; thus, older patients tend to accumulate medications over time. Older patients with cancer are at high risk for adverse drug events, in part because of the complexity and intensity of cancer treatment. Additionally, a cancer diagnosis often alters assessments of life expectancy, clinical status, and competing risk. Screening for polypharmacy and potentially inappropriate medications could reduce the risk for adverse drug events, enhance quality of life, and reduce health care spending for older cancer patients.

Potential cytochrome P-450 drug-drug interactions in adults with metastatic solid tumors and effect on eligibility for Phase I clinical trials

PURPOSE

Potential cytochrome P-450 (CYP) drug-drug interactions in adults with metastatic solid tumors and their effect on eligibility for Phase I clinical trials were characterized.

METHODS

This study included adult patients with metastatic solid tumors seen by a medical oncologist from January 2008 through July 2011. The medications used by these patients were identified. Each medication's potential for interacting with CYP isozymes was also characterized. Medication changes required to meet Phase I trial eligibility criteria were also reviewed.

RESULTS

Data from 1773 patients were analyzed: 1489 were not enrolled in a Phase I trial and 284 were enrolled in a Phase I trial. Polypharmacy was significantly more prevalent in the group enrolled in a Phase I trial compared with those not enrolled (95% versus 80%, p < 0.001). The majority of patients not enrolled in a Phase I trial were taking at least one CYP isozyme inhibitor (87%) and at least one CYP isozyme inducer (45%). In a separate analysis, four Phase I trials were evaluated. Of 295 screened patients, 3.2% could not enroll due to concurrent medications. Charts from 74 enrolled patients revealed 655 concurrent medications—93 medications required further review for eligibility involving 51 (69%) of patients. Of the 93 medications, 38 (41%) were stopped and 41 (44%) were changed for the study.

CONCLUSION

Polypharmacy and the use of medications that interact with CYP isoyzmes were common in adult patients with metastatic solid tumors. Patients enrolling in Phase I studies often require medication changes to meet eligibility requirements.

A review of the management of elderly patients with non-small-cell lung cancer

Most patients with non-small-cell lung cancer (NSCLC) are elderly but evidence to guide appropriate treatment decisions for this age group is generally scant. Careful evaluation of the elderly should be undertaken to ensure that treatment appropriate for the stage of the tumour is guided by patient characteristics and not by age. The Comprehensive Geriatric Assessment (CGA) remains the preferred option, but briefer tools may be appropriate to select patients for further evaluation. The predicted outcome should be used to guide management decisions together with a reappraisal of polypharmacy. Patient expectations should also be taken into account. Management recommendations are generally similar to those of general guidelines for the NSCLC population, although the risks of surgery and toxicity of chemotherapy and radiotherapy are often increased in the elderly compared with younger patients; therefore, patients should be closely scrutinised and subjected to a CGA to ensure suitability of the planned treatment. If surgery is indicated, then lobectomy is generally the preferred option, although limited resection may be more feasible for some. Radiotherapy with curative intent is an alternative, with stereotactic body radiotherapy the most likely preferred modality. Adjuvant chemotherapy is also an appropriate approach, whereas adjuvant radiotherapy is generally not recommended. Concurrent chemoradiotherapy should be considered for elderly patients with inoperable locally advanced disease and chemotherapy for advanced/metastatic disease. Efforts should also be made to increase participation of elderly patients with NSCLC in clinical trials, thereby enhancing evidence-based treatment decisions for this majority group. This will require overcoming barriers relating to trial design and to physician and patient awareness and attitudes.

Models of Care in Geriatric Oncology

Cancer is common in older adults and the approach to cancer treatment and supportive measures in this age group is continuously evolving. Incorporating geriatric assessment (GA) into the care of the older patient with cancer has been shown to be feasible and predictive of outcomes, and there are unique aspects of the traditional geriatric domains that can be considered in this population. Geriatric assessment-guided interventions can also be developed to support patients during their treatment course. There are several existing models of incorporating geriatrics into oncology care, including a consultative geriatric assessment, geriatrician "embedded" within an oncology clinic and primary management by a dual-trained geriatric oncologist. Although a geriatrician or geriatric oncologist leads the geriatric assessment, is it truly a multidisciplinary assessment, and often includes evaluation by a physical therapist, occupational therapist, pharmacist, social worker and nutritionist.