Comprehensive pharmacological geriatric assessment compared to usual care in an older adult with cancer in the absence of polypharmacy.

INTRODUCTION: Medication reconciliation as part of a Comprehensive Geriatric Assessment by a specialist pharmacist is a process that has been shown to be beneficial in terms of medication adherence in patients taking oral anticancer medication and potentially cost-effective in cancer patients. Medication review guidelines in older adults with cancer suggest using polypharmacy (≥ 5 medications) as an indication for medication review in older adults with cancer. CASE REPORT: We present a case where a medication review as part of a Comprehensive Geriatric Assessment in the absence of polypharmacy resulted in two pharmacist interventions when standard care resulted in no intervention. A 71-year-old male prescribed capecitabine for rectal cancer had a medication reconciliation done as standard care before starting an oral anticancer medication. He then proceeded to get a medication review as part of a Comprehensive Geriatric Assessment and was deemed to have a potentially excessive anticholinergic burden and underprescribed gastro protection. This case is interesting as it occurred in a patient who would not have met the current inclusion criteria for a medication review as part of a Comprehensive Geriatric Assessment. MANAGEMENT AND OUTCOME: As a result of the Comprehensive Geriatric Assessment, a letter was written to the patient's general practitioner, recommending a change to anti-depressant therapy to optimise anticholinergic burden, as well as introducing a proton-pump inhibitor upon completion of the Capecitabine protocol concurrent with radiotherapy, to confer gastro-protection against the antidepressant medication, as per the START criteria. Upon discharge from medical oncology, neither of the changes had been adopted by the patient's general practitioner. This highlights one of the challenges facing clinical pharmacists in an outpatient setting, where evidence-based recommendations are not always implemented as care transitions from tertiary to primary care. CONCLUSION: Comprehensive Geriatric Assessment is a process that identifies potential issues in older adults with cancer that aren't identified with standard medication review. This is also evident for medication reviews as part of a Comprehensive Geriatric Assessment, and where resources allow, and recommendations are likely to be accepted, it should be offered to all older adults with cancer. Pharmacists are still faced with challenges in implementing recommendations from medication reviews, particularly in healthcare systems where pharmacist prescribing has yet to be introduced.

Aeromedical retrieval diagnostic trends during a period of Coronavirus 2019 lockdown.

BACKGROUND: Little is known on the trends of aeromedical retrieval (AR) during social isolation. AIM: To compare the pre, lockdown, and post-lockdown AR patient characteristics during a period of Coronavirus 2019 (COVID-19) social isolation. METHODS: An observational study with retrospective data collection, consisting of AR between 26 January and 23 June 2020. RESULTS: There were 16 981 AR consisting of 1983 (11.7%) primary evacuations and 14 998 (88.3%) inter-hospital transfers, with a population median age of 52 years (interquartile range 29.0-69.0), with 49.0% (n = 8283) of the cohort being male and 38.0% (n = 6399) being female. There were six confirmed and 230 suspected cases of COVID-19, with the majority of cases (n = 134; 58.3%) in the social isolation period. As compared to pre-restriction, the odds of retrieval for the restriction and post-restriction period differed across time between the major diagnostic groups. This included, an increase in cardiovascular retrieval for both restriction and post-restriction periods (odds ratio (OR) 1.12, 95% confidence interval (CI) 1.02-1.24 and OR 1.18 95%, CI 1.08-1.30 respectively), increases in neoplasm in the post restriction period (OR 1.31, 95% CI 1.04-1.64) and increases for congenital conditions in the restriction period (OR 2.56, 95% CI 1.39-4.71). Cardiovascular and congenital conditions had increased rates of priority 1 patients in the restriction and post restriction periods. There was a decrease in endocrine and metabolic disease retrievals in the restriction period (OR 0.72, 95% CI 0.53-0.98). There were lower odds during the post-restriction period for retrievals of the respiratory system (OR 0.78, 95% CI 0.67-0.93), and disease of the skin (OR 0.78, 95% CI 0.6-1.0). Distribution between the 2019 and 2020 time periods differed (P < 0.05), with the lockdown period resulting in a significant reduction in activity. CONCLUSION: The lockdown period resulted in increased AR rates of circulatory and congenital conditions.

Hospitalisation and adverse drug events in a geriatric oncology setting: A systematic review of the literature.

BACKGROUND: Geriatric Oncology is a specialty where a multidisciplinary approach can address the unmet needs of older adults with cancer. Older adults are at increased risk of adverse drug events (ADE) due to age-related changes in pharmacokinetics and pharmacodynamics, increasing treatment complexity, and medication burden. OBJECTIVES: To review the literature to determine the incidence of unplanned hospitalisation due to ADE for all medications, both systemic anticancer therapy (SACT) and non-SACT medications. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The search included the following databases: PubMed, CINAHL, and Embase. A manual search of Scopus was then performed. Study quality was assessed using the Cochrane Handbook for Systematic Reviews of Interventions, Mixed Methods Appraisal Tool (MMAT) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. RESULTS: Overall, three studies were included. One observational study reported 19 % of unplanned hospital admissions due to ADE in patients aged ≥70 years with cancer. The first retrospective study reported 24 % of unplanned hospital admissions are due to ADE in patients aged ≥70 years with cancer, and the second retrospective study reported 26 % of patients with metastatic melanoma treated with immune checkpoint inhibitors had an unplanned hospital admission due to an ADE. CONCLUSION: There is a paucity of studies assessing unplanned hospitalisation due to ADE in older adults with cancer. Future studies are needed and should account for the reporting of potential ADE relative to supportive care, ancillary medications, and indeed chronic medications used to treat long-standing comorbidities.

Ageing-related considerations for medication used in supportive care in cancer.

Both randomized controlled trials (RCTs) and retrospective studies have shown that a comprehensive geriatric assessment (CGA) prior to a patient commencing systemic anti-cancer therapy (SACT) results in improved quality of life outcomes and is associated with a decreased risk of grade 3-5 toxicity; however, data are lacking in relation to adverse drug events (ADE) associated with supportive care medications. Supportive care medications are prescribed as prophylactic agents in a SACT regimen, for management of treatment related toxicity and for symptoms caused by the disease itself. While necessary, the commencement of SACT and supportive medications may cause, or exacerbate, a significant drug burden in older patients, some of whom may have existing comorbidities. For many medications, older adults are underrepresented in pharmacokinetic and pharmacodynamic modelling studies. In this article we will review ageing-related changes in pharmacokinetics and pharmacodynamics, as well as how these changes may impact supportive care medications. Additional considerations for prescribing these medications in older adults with cancer, such as polypharmacy, potentially inappropriate medications, drug-drug interactions, and anticholinergic burden, as well as ageing-related considerations and recommendations for supportive care medications commonly used in older adults with cancer are also reviewed.

Setting a Patient-Driven Agenda for Cancer Research Priorities in Geriatric Oncology: A Qualitative Study.

OBJECTIVES: This study aims to explore older adults' perceptions of priorities for research in cancer and hematological malignancies and proposes an agenda of patient-driven priorities for cancer care research in the field of geriatric oncology. DATA SOURCES: Sixteen older adults (≥65 years) living with or after a diagnosis of cancer participated in a descriptive qualitative study. Participants were purposively recruited via a regional cancer center and cancer advocacy organizations. Semistructured telephone interviews explored participants' experiences of cancer and perceptions of priorities for future cancer-related research. CONCLUSION: Participants reported positive experiences of cancer care. However, positive and negative experiences of information, symptoms, and support both within and beyond the hospital setting were highlighted. Forty-two research priorities in six thematic areas were identified: 1) recognition of the signs and symptoms of cancer; 2) research about cancer treatment; 3) assessment and management of comorbidities; 4) unmet needs of older adults living with and after cancer; 5) impact of COVID-19; and 6) impact on caregivers and family members of people living with and after cancer. IMPLICATIONS FOR NURSING PRACTICE: The results of this study provide a basis for future priority-setting activities that are culturally and contextually sensitive to health care systems, resources, and needs of older adults living with and after cancer. Based on the findings of this study, we make recommendations for the development of interventions that can build awareness, capacity, and competence in geriatric oncology among cancer care professionals and consideration of the diverse needs of older adults in the development of interventions to address unmet information and supportive care needs.

Hospitalization due to adverse drug events in older adults with cancer: A retrospective analysis.

INTRODUCTION: Geriatric oncology is a rapidly evolving field of practice, where comprehensive geriatric assessments (CGA) and multidisciplinary team (MDT) input have the potential to improve patient outcomes. Polypharmacy and potential drug interactions (PDI) have been associated with an increased risk of adverse outcomes in older adults with cancer, receiving systemic anti-cancer therapy (SACT). Our aim was to assess the incidence of unplanned hospitalization in older adults with cancer attending medical oncology outpatient clinics and to determine whether an unplanned hospitalization was potentially due to an adverse drug event (ADE). MATERIALS AND METHODS: We identified patients who attended a medical oncology outpatient appointment from January 1 to March 31, 2018. Medical records were examined to identify any unplanned hospital admissions between the clinic visit date and three and six months after initial clinic visit. Incidences of unplanned hospitalization were assessed to determine if an ADE potentially occurred. RESULTS: Data collected from 174 patients were analyzed. Over half (57%) were female, median age was 75 years and 53% had a favorable performance status. The most common malignancies were gastrointestinal (GI) at 31% (n = 54), breast 29% (n = 51), and genitourinary 22% (n = 37). Seventy-two percent had advanced disease (stage III/IV) and 61% had systemic therapy (SACT and hormonal therapy). Polypharmacy (≥5 medications) was observed in 77% of patients. The total number of admissions at six months was 99, with 55% of these potentially due to an ADE. On multivariate analysis breast cancer (p ≤0.001), lung cancer (p = 0.034), performance status (p ≤0.001), monochemotherapy (p = 0.012), polychemotherapy (p ≤0.001), and radiotherapy (p = 0.048) were independent predictors of unplanned hospitalization. Breast cancer (p = 0.008), GI cancer (p = 0.019), monochemotherapy (p = 0.039), and polychemotherapy (p ≤0.001) were independent predictors of unplanned hospitalization due to ADE on multivariate analysis. DISCUSSION: We observed that older adults with cancer have a high risk of unplanned hospitalization due to ADE. Medication review as part of a CGA in newly diagnosed older adults with cancer by a clinical pharmacist is recommended. This may identify opportunities to avoid medications that could potentially lead to unplanned hospitalization.

Loneliness in older adults living with cancer: A scoping review of the quantitative and qualitative evidence on behalf of the International Society of Geriatric Oncology Nursing and Allied Health Interest Group.

INTRODUCTION: Loneliness is common in older adults. Cancer and its treatments can heighten loneliness and result in poor outcomes. However, little is known about loneliness in older adults with cancer. Our objective was to provide an overview of the prevalence of loneliness, contributing factors, evolution during the cancer trajectory, impact on treatment, and interventions to reduce loneliness. MATERIALS AND METHODS: We conducted a scoping review including studies on loneliness in adults with cancer aged ≥65. Original, published studies of any designs (excluding case reports) were included. A two-step screening process was performed. RESULTS: Out of 8,720 references, 19 studies (11 quantitative, 6 qualitative, 2 mixed-methods), mostly from the United States, Netherlands, and/or Belgium, and most published from 2010, were included. Loneliness was assessed by the De Jong Gierveld Loneliness Scale, and the UCLA loneliness scale. Up to 50% of older adults felt lonely. Depression and anxiety were often correlated with loneliness. Loneliness may increase over the first 6-12 months during treatment. One study assessed the feasibility of an intervention aiming at reducing primarily depression and anxiety and secondarily, loneliness in patients with cancer aged ≥70 after five 45-min sessions with a mental health professional. No studies investigated the impact of loneliness on cancer care and health outcomes. DISCUSSION: This review documents the scarcity of literature on loneliness in older adults with cancer. The negative impacts of loneliness on health in the general population are well known; a better understanding of the magnitude and impact of loneliness in older adults with cancer is urgently warranted.

A scoping review of ageism towards older adults in cancer care.

INTRODUCTION: Ageism towards older adults with cancer may impact treatment decisions, healthcare interactions, and shape health/psychosocial outcomes. The purpose of this review is twofold: (1) To synthesize the literature on ageism towards older adults with cancer in oncology and (2) To identify interventions that address ageism in the healthcare context applicable to oncology. MATERIALS AND METHODS: We conducted a scoping review following Arksey and O'Malley and Levac methods and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted an exhaustive multi-database search, screening 30,926 titles/abstracts. Following data abstraction, we conducted tabular, narrative, and textual synthesis. RESULTS: We extracted data on 133 papers. Most (n = 44) were expert opinions, reviews, and letters to editors highlighting the negative impacts of ageism, expressing the need for approaches addressing heterogeneity of older adults, and calling for increased clinical trial inclusion for older adults. Qualitative studies (n = 3) described healthcare professionals' perceived influence of age on treatment recommendations, whereas quantitative studies (n = 32) were inconclusive as to whether age-related bias impacted treatment recommendations/outcomes or survival. Intervention studies (n = 54) targeted ageism in pre/post-licensure healthcare professionals and reported participants' improvement in knowledge and/or attitudes towards older adults. No interventions were found that had been implemented in oncology. DISCUSSION: Concerns relating to ageism in cancer care are consistently described in the literature. Interventions exist to address ageism; however, none have been developed or tested in oncology settings. Addressing ageism in oncology will require integration of geriatric knowledge/interventions to address conscious and unconscious ageist attitudes impacting care and outcomes. Interventions hold promise if tailored for cancer care settings. 249/250.

Chemotherapy Toxicity in Older Adults Optimized by Geriatric Assessment and Intervention: A Non-Comparative Analysis.

The Comprehensive Geriatric Assessment (CGA) is recommended to guide treatment choices in older patients with cancer. Patients ≥ 70 years referred to our oncology service with a new cancer diagnosis are screened using the G-8. Patients with a score of ≤14 are eligible to attend the Geriatric Oncology and Liaison (GOAL) Clinic in our institution, with referral based on physician discretion. Referred patients undergo multidimensional assessments at baseline. CGA domains assessed include mobility, nutritional, cognitive, and psychological status. Chemotherapy toxicity risk is estimated using the Cancer Aging and Research Group (CARG) calculator. We undertook a retrospective analysis of patients attending the GOAL clinic over a 30-month period to April 2021. The objective was to determine rates of treatment dose modifications, delays, discontinuation, and unscheduled hospitalizations as surrogates for cytotoxic therapy toxicity in these patients. These data were collected retrospectively. Ninety-four patients received chemotherapy; the median age was 76 (70-87) and 45 were female (48%). Seventy-five (80%) had an ECOG PS of 0-1. Seventy-two (77%) had gastrointestinal cancer, and most had stage III (47%) or IV (40%) disease. Chemotherapy with curative intent was received by 51% (n = 48) and 51% received monotherapy. From the CGA, the median Timed Up and Go was 11 s (7.79-31.6), and 90% reported no falls in the prior 6 months. The median BMI was 26.93 (15.43-39.25), with 70% at risk or frankly malnourished by the Mini Nutritional Assessment. Twenty-seven (29%) patients had impaired cognitive function. Forty-three (46%) had a high risk of toxicity based on the baseline CARG toxicity calculator. Twenty-six (28%) required dose reduction, 55% (n = 52) required a dose delay, and 36% (n = 34) had a hospitalization due to toxicity. Thirty-nine patients (42%) discontinued treatment due to toxicity. Despite intensive assessment, clinical optimization and personalized treatment decisions, older adults with cancer remain at high risk of chemotherapy toxicity.

International trends in cancer incidence in middle-aged and older adults in 44 countries.

OBJECTIVE: We examine international incidence trends of lung, colorectal, prostate, and breast cancers, as well as all cancers combined excluding non-melanoma skin cancer (NMSC) in adults aged 50 and older, over a fifteen-year period using data from 113 high quality population-based cancer registries included in the Cancer in Five Continents (CI5) series and NORDCAN. MATERIALS AND METHODS: We calculated annual incidence rates between 1998 and 2012 for ages 50-64, 65-74, and 75+, by sex and both sexes combined. We estimated average annual percentage change (AAPC) in rates using quasi-Poisson regression models. RESULTS: From 1998 to 2012, incidence trends for all cancers (excluding NMSC) have increased in most countries across all age groups, with the greatest increase observed in adults aged 75+ in Ecuador (AAPC = +3%). Colorectal cancer incidence rates increased in the majority of countries, across all age groups. Lung cancer rates among females have increased but decreased for males. Prostate cancer rates have sharply increased in men aged 50-64 with AAPC between 5% and 15% in 24 countries, while decreasing in the 75+ age group in 21 countries, by up to -7% in Bahrain. Female breast cancer rates have increased across all age groups in most countries, especially in the 65-74 age group and in Asia with AAPC increasing to 7% in the Republic of Korea. CONCLUSIONS: These findings assist with anticipating changing patterns and needs internationally. Due to the specific needs of older patients, it is urgent that cancer systems adapt to address their growing number.

The Role of Family Caregivers in the Care of Older Adults with Cancer.

OBJECTIVES: To provide an overview on the role of family caregivers (FCGs) in the care of older adults with cancer and review quality of life needs for FCGs. DATA SOURCES: Journal articles, research reports, state of the science papers, position papers, and clinical guidelines from professional organizations were used. CONCLUSION: The high prevalence of multiple comorbidities and the associated burden of geriatric events in older adults have a substantial impact on the quality of life of their FCGs. Practical and efficient models of comprehensive assessment, interventions, and caregiving preparedness support are needed to improve outcomes for both older adults with cancer and their FCGs. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses practicing in clinical and research settings have a responsibility to prepare themselves with evidence-based knowledge and resources to include the needs of FCGs in the care provided to older adults with cancer.