Screening elderly cancer patients for disabilities: evaluation of study of osteoporotic fractures (SOF) index and comprehensive geriatric assessment (CGA)

Cystic Fibrosis in Adults: A Paradigm of Frailty Syndrome? An Observational Study

This study aimed to assess the main clinical and anamnestic characteristics of adult Cystic Fibrosis (CF) patients and to evaluate the association of frailty with the CF genotyping classification. In an observational cross-sectional study, all ambulatory CF patients over 18 years old who received a diagnosis at the Regional Cystic Fibrosis Center for adults were enrolled and assessed by spirometry for respiratory function, by ADL and IADL for functional status, and by the Study of Osteoporotic Fractures (SOF) Index for frailty. The study population consisted of 139 CF patients (mean age 32.89 ± 10.94 years old, 46% women). Most of the subjects were robust (60.4%). The pre-frail/frail group was more frequently females (p = 0.020), had a lower BMI (p = 0.001), worse respiratory function, a higher number of pulmonary exacerbations/years, cycles of antibiotic therapy, and hospitalization (all p < 0.001) with respect to robust patients. The pre-frail/frail subjects used more drugs and were affected by more CF-related diseases (all p < 0.001). In relation to logistic regression, the best predictor of the pre-frail/frail status was a low FEV1 level. The CF patients show similarities to older pre-frail/frail subjects, suggesting that CF might be considered an early expression of this geriatric syndrome. This finding could help to better define the possible progression of CF, but overall, it could also suggest the usefulness employing of some tools used in the management and therapy of frailty subjects to identify the more severe CF subjects.

Relationship between physical activity and perceptions of ageing from the perspective of healthy ageing among older people with frailty with chronic disease: a cross-sectional study

BACKGROUND

In Taiwan, the 2019 Elderly Frailty Assessment found that 11.2% of older people have frailty problems. Some researchers have found that older persons' negative perspectives on ageing aggravate the progression of frailty, thereby increasing their risk of disability. This study aimed to investigate associations of physical activity and perceptions of ageing on perspectives of healthy ageing in older people with frailty and chronic diseases and to compare the differences in their frailty status.

METHODS

This study used a descriptive cross-sectional design. Participants were recruited from community long-term care stations. The inclusion criteria were (1) no severe cognitive impairment and ability to communicate in Mandarin and Taiwanese; (2) over 65 years old; (3) at least one chronic disease; and (4) at least one debilitating item in the Study of Osteoporotic Fracture index. A total of 312 participants were recruited. The Brief Ageing Perceptions Questionnaire Chinese version, Healthy Ageing Perspectives Questionnaire, and Physical Activity Scale for the Elderly Chinese Version were used for measurement.

RESULTS

The study results found that demographic variables, perceptions of ageing, and physical activity were significantly correlated with perspectives on healthy ageing, including age, Activities of Daily Living, education, all domains of perceptions of ageing, and household- and work-related physical activity. With regard to the frailty status level, prefrailty was better than frailty from the perspective of healthy ageing in older people with chronic disease (t = 5.35, p < 0.05). Hierarchical regression analysis was used to predict the healthy ageing perspectives of older persons with chronic disease involving a chronic time-line, positive control, health-related changes, and work-related activities. Those domains could predict 21% of the variance in healthy ageing perspectives.

CONCLUSION

It is suggested that in community long-term care stations, health care providers can arrange activities to improve the perception of ageing that are acceptable for older people with frailty and chronic diseases and encourage older people to participate in service activities to achieve a sense of social participation.

Short Physical Performance Battery and Study of Osteoporotic Fractures Index in the Exploration of Frailty Among Older People in Cameroon

Objectives: To investigate the relationship between the Short Physical Performance Battery (SPPB) and the Study of Osteoporotic Fractures (SOF) index. Methods: We present data from a cross-sectional survey conducted in Cameroon. Frailty was defined as an SOF index > 0. The sensitivity and specificity of the SPPB were investigated. Principal component analysis (PCA) was performed to assess the contribution of each subtest of the SPPB to the relationship with the SOF. Results: Among 403 people included (49.6% women), average age of 67.1 (±6.2) years, 35.7% were frail according to the SOF. After determining the best SPPB threshold for diagnosing frailty (threshold = 9, Se = 88.9%, Sp = 74.9%), 47.9% were frail according to the SPPB. The first dimension of PCA explained 55.8% of the variability in the data. Among the subtests of the SPPB, the chair stand test item was the component most associated with the SOF index. Conclusion: Despite the overlap between the SOF and the SPPB, our results suggest that a negative result on the five chair-stands test alone would be sufficient to suspect physical frailty.

Preserving bone in cancers of the elderly: A necessity

The occurrence of bone fractures is frequent in the elderly population, and in cancer patients, especially with bone metastases. The growing incidence of cancer associated with an aging population implies important health challenges, including bone health. Decisions on cancer care in older adults have to take into account older adults' specificities. Screening tools as G8 or VES 13 and evaluating tools as comprehensive geriatric assessment (CGA) do not include bone-related items. Bone risk assessment is indicated according to identification of geriatric syndromes such as falls, history, and the oncology treatment plan. Some cancer treatments disrupt bone turnover and decrease bone mineral density. This is mainly caused by hypogonadism, induced by hormonal treatments and some chemotherapies. Treatments can also cause direct (i.e., chemotherapy, radiotherapy or glucocorticoids) or indirect toxicity through electrolyte disorders (i.e., some chemotherapies or tyrosine kinase inhibitors) on bone turnover. Bone risk prevention is multidisciplinary. Certain interventions proposed in the CGA aim to improve bone health and reduce the risk of falling. It is also based on the drug management of osteoporosis, and the prevention of complications from bone metastases. Management of fractures, related or not to bone metastases relates to the concept of orthogeriatrics. It is also based on the benefit-risk ratio of the operation, access to minimally invasive techniques, prehabilitation or rehabilitation, but also the prognosis related to cancer and geriatric syndromes. Bone health is essential in older cancer patient's care. Bone risk assessment should be part of CGA in routine use and specific decision-making tools should be developed. Bone event management must be integrated throughout the patient's care pathway and oncogeriatrics multidisciplinarity should include rheumatological expertise.

Association between Elevated Magnesium Intake and Reduced Risk of Recurrent Falls and Frailty in Osteoarthritis: Data from the Osteoarthritis Initiative

OBJECTIVES

The objective of this 8-year follow-up study was to investigate the relationship between magnesium intake and frailty, as well as recurrent falls, in individuals diagnosed with Osteoarthritis (OA) or those at a heightened risk for developing the condition.

METHODS

This study utilized data from the Osteoarthritis Initiative (OAI) database and conducted a prospective cohort study with a 8-year follow-up period. Total magnesium intake from both food sources and supplements was assessed using a food frequency questionnaire (FFQ), while frailty and recurrent falls were evaluated through established criteria and self-report, respectively. To account for potential confounding factors, various covariates were considered, and statistical analyses, including generalized additive mixed models (GAMMs), were employed to examine the associations.

RESULTS

Among the 4,667 participants with OA, those with lower total magnesium intake were characterized by younger age, a higher proportion of African American individuals, higher body mass index (BMI), and lower dietary fiber intake (P<0.001). Notably, this group exhibited higher odds of experiencing recurrent falls and frailty (P = 0.034 and 0.006, respectively). Controlling for various factors, the GAMMs consistently revealed negative correlations between magnesium intake and the likelihood of frailty and recurrent falls, with each 1 mg/1000 kcal increase in magnesium intake associated with a 0.5% reduced frailty risk (p < 0.001) and a 0.2% decreased risk of recurrent falls (p = 0.001). Subgroup analyses suggested that increased total magnesium intake from both food sources and supplements may exert a more pronounced preventive effect on recurrent falls and frailty in men, older adults, individuals with normal BMI, and those with higher dietary fiber intake.

CONCLUSIONS

Elevated total magnesium intake from both food sources and supplements was found to be associated with a decreased risk of recurrent falls and frailty in individuals diagnosed with OA or those at risk of developing the condition. These findings imply that increased total magnesium intake might be beneficial in managing the risk of these outcomes, particularly within specific subgroups, including men, older adults, those with a normal BMI, and those with higher dietary fiber intake.

Association between frailty and cognitive function in older Chinese people: A moderated mediation of social relationships and depressive symptoms

BACKGROUND

To date, few studies have focused on examining either the direct or indirect effect of physical frailty on cognitive impairment. This study aimed to investigate the moderating effects of social relationships, including their individual components in the role of depressive symptoms as a mediator between frailty and cognitive impairment.

METHODS

This study included a total of 7525 Chinese older adults from the 2017-2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Mediation analyses and moderated mediation effect analysis fully adjusted for all potential confounding factors were conducted.

RESULTS

Significant correlations were found between frailty, depression, social relationships, and cognitive function. Depression partially mediated the association of frailty with cognitive function [B = -0.198; 95 % confidence interval (CI): (-0.258, -0.143)]. Social relationships moderated the effect of frailty on cognitive function through both path b (depression-cognitive function) [B = 0.137; 95 % CI: (0.045, 0.230)], and path c' (frailty-cognitive function) [B = 0.870; 95 % CI: (0.562, 1.178)]. In addition, social activities and social networks moderated both the direct and indirect effect of the moderated mediation model. Social support only moderated the direct effect.

LIMITATIONS

The cross-sectional design of this study precludes any conclusion from the results as to the causality of cognitive impairment.

CONCLUSIONS

Social relationships moderated both the direct and indirect effects of depressive symptoms on the association between frailty and cognitive impairment. The findings suggest that interventions, such as paying attention to the mental health of old people and improving the quality of social relationships, may help break the link between frailty and cognitive impairment.

Relationship between frailty and mortality after gastrectomy in older patients with gastric cancer

OBJECTIVES

Frail older adults with gastric cancer are at an increased risk of poor postoperative outcomes. We assessed whether geriatric frailty assessed using the Study of Osteoporotic Fractures (SOF) index could predict post-gastrectomy mortality.

MATERIALS AND METHODS

We retrospectively assessed older adults (age ≥ 65 years) who underwent gastrectomy for gastric cancer between April 2012 and September 2015. Frailty status was assessed using the SOF index (range, 0-3) and categorized as robust (0), pre-frail (1), and frail (2-3). The Kaplan-Meier method and log-rank tests were used to compare survival between frailty groups. Univariate and multivariate analyses were used to identify mortality-associated risk factors.

RESULTS

Among 231 patients (the median age 72.04 years and 140 (60.6%) men), 138 (59.7%) were robust, 58 (25.1%) were pre-frail, and 35 (15.2%) were frail. The mortality rate was 14.5% among robust patients, 20.7% among pre-frail patients, and 20.0% among frail patients (log-rank test, P = 0.032). Frail patients had more than a 3-fold increased risk of mortality compared with robust patients (adjusted HR = 3.331; 95% CI, 1.161-9.559). Multivariate analysis revealed that the SOF index and TNM stage were associated with increased mortality.

CONCLUSIONS

SOF index predicted post-gastrectomy mortality among older patients independently of age, sex, TNM stage, type of approach, gastrectomy type, and extent of lymph node dissection. SOF index may be used with ease to assess frailty status among older patients with gastric cancer in busy clinics and subgroups that may benefit from targeted frailty interventions before cancer treatments.

Our experience of nursing/allied health practitioner led geriatric screening and assessment of older patients with cancer - a highly accessible model of care

OBJECTIVE

Comprehensive Geriatric Assessment (CGA) has been proven to assist development of tailored treatment plans for older patients with cancer by identifying health issues affecting their ability to complete systemic therapy or cope with and recover from cancer treatment.

MATERIALS AND METHODS

Metro North Hospital and Health Service (MNHHS) has significant older population with cancer. Geriatric Oncology services were commenced in February 2018 at two facilities of MNHHS [North Lakes Cancer Care Services/Caboolture Hospital (NLCCS/CBH) Cancer services and Redcliffe Hospital (RH) Cancer services]. The Geriatric 8 (G8) screening tool was administered to predict patient vulnerability and need for CGA. A bespoke CGA suite comprising of 16 assessments was used. A clinical nurse or Allied Health (AH) practitioner conducted screening, followed by CGA. Proposed care was discussed at multidisciplinary case conference and AH interventions were provided.

RESULTS

From February'2018 to July'2019, the G8 was administered to 1380 patients between the two facilities (918 patients at NLCCS/CBH and 462 patients at RH), comprising oncology and haematology patients. 825 patients (59%) showed impairment on G8 and were recommended for CGA. Another 50 patients were referred for CGA as per clinical assessment despite normal G8. 65% (572) of recommended CGAs were conducted. The most common impairments identified on CGA leading to AH referrals were timed up & go >13 s, malnutrition, polypharmacy and low mood & depression.

CONCLUSION

The nursing/AH practitioner led Geriatric Oncology service is feasible, applicable and beneficial to patients. Further study is planned to assess the impact of the service on patients' health related quality of life and chemotherapy completion rates.

Modeling individual and relative accuracy of screening tools in geriatric oncology

Background

Classification probabilities reflect to what degree a screening test represents the true disease state and include true positive (TPF) and false positive fractions (FPF). With two tests, one can compare TPF and FPF using relative probabilities which offer advantages in terms of interpretation and statistical modeling. Our objective was to highlight how individual and relative TPF and FPF can be easily estimated and compared within a regression modeling framework. This allows the modeling of tests' accuracy while adjusting for multiple covariates, and thus provides valuable information in addition to the crude TPF and FPF. We illustrate our purpose with the G8 and VES-13 screening tests aimed at identifying elderly cancer patients in need for a comprehensive geriatric assessment (CGA).

Methods

Prospective cohort with a paired design. TPF and FPF of each test, as well as relative TPF and FPF were modeled using log-linear models.

Results

G8 detected patients in need for CGA better than VES-13 at the expense of misclassifying a large number of normal patients. Both tests had better TPF with older age and poorer performance status (PS), and for all cancer subtypes compared with prostate cancer. Effect of age and PS on TPF was more pronounced with VES-13. Age affected FPF, but not differentially.

Conclusions

Regression modeling helps provide a thorough assessment of the accuracy of diagnostic tests and should be used more frequently. In the context of screening, we encourage the use of G8 as failing to identify patients in need of a CGA might be more problematic than over-detection. Moreover, although we identified variables associated with the sensitivity of these tests, this association was less pronounced for the G8.

Implications of frailty screening in clinical practice

PURPOSE OF REVIEW

Many frailty screening instruments have been proposed due to the lack of consensus on a unified operational definition of frailty. This review reports on recent frailty screening tools in addition to revisiting the frailty concept.

RECENT FINDINGS

Although there are two representative frailty models, both have issues that prevent them from being implemented in clinical settings despite their remarkable advantages. Due to their different characteristics, these models are thought to be complementary rather than substitutive. The recent introduction of frailty identification into primary care and specific clinical settings has led to both a focus on its importance and the development of new screening methods.

SUMMARY

The phenotype model is rather faithfully based on biological change with aging, while the deficit model comprehensively captures risk of disability. Most of the current frailty screening tools are based on these models. Screening tools based on the former model primarily capture declines in physical functions, whereas screening tools based on the latter model involve questionnaires that examine functional impairments in multiple domains. Implementation of a model in a clinical setting depends on both the model characteristics and the clinical settings.

Frailty and sarcopenia in elderly

Frailty is a pre-disability syndrome where an older person can be identified as being at risk when exposed to stressors associated with high risk for disability or needing to be hospitalized. Two major frailty definitions exist. The physical phenotype of frailty and the multiple deficit model. A simple frailty screening tool-FRAIL-has been validated. Treatment of frailty involves resistance exercise, optimization of nutrition, and treatment of fatigue (sleep apnea, depression), treatable causes of weight loss and adjustment of polypharmacy. Sarcopenia (decline in function with low muscle mass) is a major cause of frailty. A simple sarcopenia screening tool-SARC-F-has been validated. The multiple causes of sarcopenia are reviewed. Optimal treatment is resistance exercise, leucine-enriched essential amino acids and vitamin D replacement.

How should older adults with cancer be evaluated for frailty?

Traditionally used as a descriptive term, frailty is now a recognized medical syndrome identifying individuals with decreased physiologic reserve. Frailty is characterized by diminished strength, endurance, and reduced physiologic function. Several valid frailty screening tools exist in the literature, and these measures have been used to relate frailty to outcomes important to the older patient with cancer. Frail adults are at increased risk of adverse surgical outcomes and early findings suggest that frailty predicts poor chemotherapy tolerance. While much research is needed to explore the biologic relationships between frailty and cancer, there is an urgent need to implement frailty screening and management into the care of the older patient with cancer in order to improve outcomes in this vulnerable subset. The purpose of this paper is to provide an introduction of frailty to oncologists including a review of the definition, frailty screening tools, its clinical relevance to older patients with cancer, and a brief guide to frailty management.

Prognostic factors for the feasibility of chemotherapy and the Geriatric Prognostic Index (GPI) as risk profile for mortality before chemotherapy in the elderly

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multidimensional method to detect frailty in elderly patients. Time saving could be accomplished by identifying those individual items that classify elderly cancer patients at risk for feasibility of chemotherapy and for mortality.

MATERIAL AND METHODS

Patients older than 70 years of age were assessed before the first chemotherapy administration. GA consisted of the Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE). Predictive individual items for feasibility of chemotherapy and mortality were entered in the multivariable logistic regression and Cox-regression models, and a three-item sum scale was constructed: the Geriatric Prognostic Index (GPI).

RESULTS

The 494 patients had a median age of 75 years (range 70-92 years). The majority of the patients had malignancies of the digestive tract (41.7%) followed by hematological tumors (22.3%). Three items of the MNA ('psychological distress or acute disease in the past three months', 'neuropsychological problems' and 'using > 3 prescript drugs') independently predicted for feasibility of chemotherapy. Two items of the MNA and one of the GFI ('declining food intake in past 3 months', 'using > 3 prescript drugs', and 'dependence in shopping') independently predicted for mortality. In comparison with patients without any positive item on the three-item GPI, patients with one, two or three positive items had hazard ratios (HRs) of 1.58, 2.32, and 5.58, respectively (all p < 0.001).

CONCLUSIONS

With only three items of the MNA, feasibility of chemotherapy can be predicted. The three-item GPI may help to identify elderly cancer patients at elevated risk for mortality.

The prevalence and outcomes of frailty in older cancer patients: a systematic review

BACKGROUND

Frailty is a state of vulnerability to poor resolution of homeostasis following a stressor event, such as chemotherapy or cancer surgery. Better knowledge of the epidemiology of frailty could help drive a global cancer care strategy for older people. The aim of this review was to establish the prevalence and outcomes of frailty and pre-frailty in older cancer patients.

METHODS

Observational studies that reported data on the prevalence and/or outcomes of frailty in older cancer patients with any stage of solid or haematological malignancy were considered. We searched Medline, CINAHL, Cochrane Library, EMBASE, Web of Science, Allied and Complementary medicine, Psychinfo and ProQuest (1 January 1996 to 30 June 2013). The primary outcomes were prevalence of frailty, treatment-related side-effects, unplanned hospitalization and mortality. Risk of bias was assessed using the Newcastle-Ottawa checklist.

RESULTS

Data from 20 studies evaluating 2916 participants are included. The median reported prevalence of frailty and pre-frailty was 42% (range 6%-86%) and 43% (range 13%-79%), respectively. A median of 32% (range 11%-78%) of patients were classified as fit. Frailty was independently associated with increased all-cause mortality [adjusted 5-year hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.36-2.57]. There was evidence of increased risk of postoperative mortality for both frailty (adjusted 30-day HR 2.67, 95% CI 1.08-6.62) and pre-frailty (adjusted HR 2.33, 95% CI 1.20-4.52). Treatment complications were more frequent in those with frailty, including intolerance to cancer treatment (adjusted odds ratio 4.86, 95% CI 2.19-10.78) and postoperative complications (adjusted 30-day HR 3.19, 95% CI 1.68-6.04).

CONCLUSIONS

More than half of older cancer patients have pre-frailty or frailty and these patients are at increased risk of chemotherapy intolerance, postoperative complications and mortality. The findings of this review support routine assessment of frailty in older cancer patients to guide treatment decisions, and the development of multidisciplinary geriatric oncology services.

Screening for vulnerability in older cancer patients: the ONCODAGE Prospective Multicenter Cohort Study

Background

Geriatric Assessment is an appropriate method for identifying older cancer patients at risk of life-threatening events during therapy. Yet, it is underused in practice, mainly because it is time- and resource-consuming. This study aims to identify the best screening tool to identify older cancer patients requiring geriatric assessment by comparing the performance of two short assessment tools the G8 and the Vulnerable Elders Survey (VES-13).

Patients and Methods

The diagnostic accuracy of the G8 and the (VES-13) were evaluated in a prospective cohort study of 1674 cancer patients accrued before treatment in 23 health care facilities. 1435 were eligible and evaluable. Outcome measures were multidimensional geriatric assessment (MGA), sensitivity (primary), specificity, negative and positive predictive values and likelihood ratios of the G8 and VES-13, and predictive factors of 1-year survival rate.

Results

Patient median age was 78.2 years (70-98) with a majority of females (69.8%), various types of cancer including 53.9% breast, and 75.8% Performance Status 0-1. Impaired MGA, G8, and VES-13 were 80.2%, 68.4%, and 60.2%, respectively. Mean time to complete G8 or VES-13 was about five minutes. Reproducibility of the two questionnaires was good. G8 appeared more sensitive (76.5% versus 68.7%, P =  0.0046) whereas VES-13 was more specific (74.3% versus 64.4%, P<0.0001). Abnormal G8 score (HR = 2.72), advanced stage (HR = 3.30), male sex (HR = 2.69) and poor Performance Status (HR = 3.28) were independent prognostic factors of 1-year survival.

Conclusion

With good sensitivity and independent prognostic value on 1-year survival, the G8 questionnaire is currently one of the best screening tools available to identify older cancer patients requiring geriatric assessment, and we believe it should be implemented broadly in daily practice. Continuous research efforts should be pursued to refine the selection process of older cancer patients before potentially life-threatening therapy.

An update on the management of metastatic colorectal cancer in the elderly

SUMMARY 

The availability of new chemotherapeutic and targeted agents has changed the life expectancy of patients with metastatic colorectal cancer thanks to the possibility of sequentially administering fluoropyrimidines combined with irinotecan and oxaliplatin plus monoclonal antibodies. This approach is seldom feasible in the elderly, especially because of the poor tolerability of some agents. Frail patients should only receive palliative treatment. Oppositely, fit elderly patients can be treated with more aggressive therapies, similarly to the younger ones. What is not sufficiently known is how to manage the elderly categorized as intermediate. In the coming years, it appears necessary how to accurately differentiate the elderly through a comprehensive geriatric assessment performed with validated scales and uniformed criteria simpler than those currently available.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.