How to Implement a Geriatric Assessment in Your Clinical Practice

The aim of this review is to describe what a geriatric assessment (GA) is and how to implement it in daily clinical practice for older adults with cancer in the oncology setting. The review provides an overview of commonly used tools, reviews key considerations, and provides some possible interventions for problems identified during the GA.

Abstract

Cancer is a disease that mostly affects older adults. Other health conditions, changes in functional status, and use of multiple medications change the risks and benefits of cancer treatment for older adults. Several international organizations, such as the International Society of Geriatric Oncology, the European Organization for Research and Treatment of Cancer, recommend the conduct of a geriatric assessment (GA) for older adults with cancer to help select the most appropriate treatment and identify any underlying undetected medical, functional, and psychosocial issues that can interfere with treatment. The aim of this review is to describe what a GA is and how to implement it in daily clinical practice for older adults with cancer in the oncology setting. We provide an overview of commonly used tools. Key considerations in performing the GA include the resources available (staff, space, and time), patient population (who will be assessed), what GA tools to use, and clinical follow-up (who will be responsible for using the GA results for developing care plans and who will provide follow-up care). Important challenges in implementing GA in clinical practice include not having easy and timely access to geriatric expertise, patient burden of the additional hospital visits, and establishing collaboration between the GA team and oncologists regarding expectations of the population referred for GA and expected outcomes of the GA. Finally, we provide some possible interventions for problems identified during the GA.

Implications for Practice:

This article explains how to conduct a geriatric assessment, how to implement it into clinical practice, and how to use the results of the assessment in clinical oncology practice. Furthermore, information is provided about available resources on geriatric assessment as well as geriatric assessment and screening tools, and important challenges of implementing geriatric assessment in practice are highlighted.

Introduction

Cancer is a disease that predominantly affects older adults [1, 2]. Older adults are very heterogeneous in terms of functional status [3]. Moreover, in general, older adults are more vulnerable to medical problems that are iatrogenic in nature, and the presentation of illnesses in this population is often atypical [4, 5]. There is currently limited evidence from clinical trials to inform practice because older adults have been underrepresented in clinical trials [6]. Older adults have been overdiagnosed and overtreated, as well as underdiagnosed and undertreated, which impacts their health and well-being as well as the resources available [7–20]. These factors combined necessitated the development and use of geriatric assessments (GA) in the oncology setting [4].

In order to help cancer specialists decide on the best treatment for their older patients, the U.S. National Comprehensive Cancer Network, the European Society of Breast Cancer Specialists, the International Society of Geriatric Oncology (SIOG), and the European Organization for the Research and Treatment of Cancer have recommended the conduct of a GA to help select treatment [21–26]. The aim of the GA is to identify issues and to develop an integrated plan for treatment and follow-up [27, 28]. A GA can thus help personalize the cancer treatment plan and thus avoid unnecessary overtreatment but also avoid undertreatment.

Several systematic reviews of the benefits of GA for older adults in the general population have been completed [29, 30] and showed that GA is beneficial in reducing the risk of adverse outcomes of death and functional decline. Several systematic reviews of the benefits of GA in the oncology setting [25, 31–37] have showed that there is moderately strong data from observational studies showing the benefits of GA for helping the cancer specialist to decide on the treatment plan as well as to identify unknown medical, functional, cognitive, and social issues that, if left untreated, can increase the risk of complications of treatment (e.g., undetected cognitive impairment can increase the risk of delirium after surgery or chemotherapy). The study by Kenis et al. [38] showed that 40% of patients had previously unknown functional impairments, 38% had malnutrition, 31% had falls, 27% had depression, and 19% had cognitive issues. Furthermore, components of the GA such as disability in activities of daily living (ADL) can predict adverse outcomes of treatment [25, 31, 32]. A recent review by Hamaker et al. [37] showed that GA impacted 39% of cancer treatment decisions; in two-thirds this consisted of decreasing treatment intensity. The study by Kenis et al. [38] also showed that when the GA results were known at the time of the treatment decision, in a quarter of the patients, geriatric interventions were implemented to address these issues. Therefore, older adults may benefit if GA is incorporated into standard clinical oncology care for older adults. However, because most health care professionals working in oncology settings are not trained in geriatrics, the aim of this review is to describe what a GA is and how to implement it in daily clinical practice for older adults with cancer in the oncology setting. We will review some of the common challenges and some interventions available for the issues identified in the GA.

What Is GA?

A GA involves a multidisciplinary diagnostic process that systematically evaluates an older adult’s medical, psychological, social, and functional capacity with the aim developing an integrated plan for treatment and follow-up. A GA aims to uncover medical and functional issues that have previously not been identified and treated to improve outcomes, a benefit not only for older cancer patients but for all complex older patients [4].

A GA is thus a multicomponent assessment of the medical, psychological, social, and functional capacity with the aim of uncovering previously unknown issues as well as risk factors that put the older adult at increased risk for adverse outcomes such as hospitalization or severe treatment toxicity. Key disciplines involved in GA include physicians, social workers, nurses, and occupational therapists, as well as physiotherapists, dietitians, and pharmacists. It has been demonstrated that GA is feasible across settings and that its benefit is maximal in the context of frail elderly [5].

For clarity, we will use the term domain to indicate an area of health and well-being (for example, comorbidity), instrument for a specific measurement instrument that assesses a particular domain (for example, the Charlson comorbidity index), and GA tool for an assessment that consists of multiple domains and instruments (for example abbreviated comprehensive geriatric assessment). Table 1 provides an overview of domains and instruments commonly included in GA. The core domains that are evaluated in every older patient include functional status, cognitive function, nutritional status, comorbidities, polypharmacy, and socioeconomic status. Many geriatric oncology programs use a combination of established tools in geriatrics [38, 66], often preceded by a short screening tool to identify fit patients who do not need any GA at all (as described in the section “Which Patients to Assess”). The Moffitt Cancer Center in the United States has developed an abbreviated CGA tool [67, 68] where the existing GA tools were shortened. Most of the described tools are evaluated in principle by a health care worker, but the Cancer and Aging Research Group has developed a combination of tools, mainly completed by self-assessment for use with oncology patients [69] (an overview of different strategies to GA is given in Table 2).

Table 1.

Domains of geriatric assessment and commonly used instruments

Table 2.

Different approaches to GA used and their pros and cons

Functional Status and Falls

Typical GAs start with a review of functional status, measured by two widely used indicators: ADL and instrumental ADL (IADL). ADL concerns the person’s strengths and limitations in self-care, mobility and gait balance, and continence status; IADL pertains to the person’s ability in carrying out tasks such as shopping, cooking, household activities, and finances [4]. Additional crucial information is needed to interpret results of impairments in ADL and IADL. Such information includes the amount and type of caregiver support available and the presence and strength of the patient’s social network. This information is usually obtained by an experienced nurse or social worker.

Falls can be considered as being related to functional status. It can cause significant mortality and morbidity in older adults. According to the World Health Organization, approximately a third of those aged 65 and older fall each year, and approximately 5%–10% of those falls result in injuries [81]. Two of the most feared injuries of falls include hip fractures and traumatic brain injury. Cancer and its treatment can cause fatigue, muscle weakness, dizziness, and neuropathies that increase the fall risk on one hand. On the other hand, cancer patients during treatment often become inactive, and this sedentary lifestyle is associated with muscle loss in older adults. Currently, there is little research on the prevalence of falls and specific fall risk factors in older cancer patients [82–86, 90, 94]. The American Geriatrics Society has developed a screening guideline indicating that each older adult should be asked at least once per year how many falls they experienced in the past 12 months, as well as about gait difficulty [95].

Cognitive Function

The assessment of cognitive function encompasses the examination of the degree to which the person is alert, oriented, able to concentrate, and perform complex mental tasks, as well as the person’s affective functions [4]. Although few patients with moderate to severe dementia tend to be referred to oncology centers [96], several studies have reported that a substantial proportion has mild cognitive impairment or mild dementia [31, 70, 97–99]. It is important to assess cognitive functioning to make sure older adults understand what their disease, prognosis, and treatment plan entail (so they can make an informed decision), as well as their ability to contact health care professionals in case they experience potentially life-threatening side effects (e.g., febrile neutropenia). Furthermore, cognitive impairment may impact adherence to cancer treatment. Nonadherence to cancer treatment in older adults is not uncommon [100]. With the increase in oral chemotherapy agents and targeted therapy, adherence to treatment becomes the responsibility of the older adult (or caregiver) [101–103]. In addition, cancer treatments, especially for breast cancer, have been reported to impact cognitive function during and after treatment completion, but the mechanisms are not completely clear yet [104–112]. However, despite no clear causal pathway, it is important, if the older adult complains about “chemobrain” or “chemofog,” to have a full workup to exclude any other cause of cognitive issues (for example, vitamin B₁₂ deficiency) and to educate and support the patient and family because this condition may create a significant amount of anxiety that impacts their psychosocial well-being [110]. Lastly, cognitive impairment impacts overall survival [113, 114] and thus is important to take into account when making treatment decisions.

It is important to assess cognitive functioning to make sure older adults understand what their disease, prognosis, and treatment plan entail (so they can make an informed decision), as well as their ability to contact health care professionals in case they experience potentially life-threatening side effects (e.g., febrile neutropenia).

Nutritional Status

Nutritional deficiency and malnutrition are common among older patients. In many, malnutrition is related to inadequate caloric intake. Potential vitamin D deficiency should also be assessed because it may be linked to osteoporosis and fractures [115].

Comorbidities

Many geriatric cancer patients also have comorbidities that can have direct or indirect impact on the cancer prognosis and treatment tolerance. Comorbidities include cardiovascular problems, diabetes, renal insufficiency, chronic infections pressure ulcers, dementia, osteoporosis, and prior cancer diagnosis.

Polypharmacy

Polypharmacy can be defined as the use of an excessive number of medications (usually five or more), using more than what is clinically indicated, use of potentially inappropriate medications, and medication duplication [87]. The use of multiple medications can increase the incidence of adverse drug reactions and drug-to-drug interactions [88]. Adverse drug events are a significant cause of morbidity and mortality in older adults and are associated with substantial health care resource use [116–119]. In several countries, the Beers Criteria are used to avoid prescribing potentially inappropriate medications to older adults; this list was last updated in 2012 [55]. Recent studies have shown that currently most adverse drug events are related to drugs not on the Beers list [117, 119], stressing the importance of a comprehensive drug review. Among cancer patients receiving systematic anticancer therapy, one or more drug-to-drug interactions occurred in 27% of the patients [91, 92]. Medication review, which includes all prescription and over-the-counter medications, vitamins, and supplements, should be performed at every visit to detect any duplication and inappropriate use. Other tools developed to assess appropriateness of prescribing include the STOPP/START criteria [120]. For older adults with several medications for comorbid conditions who are facing cancer treatment, the help of a pharmacist can be very beneficial to optimize the medication regimen and avoid potential adverse drug events.

Socioeconomic Status

Social ties and support network have been identified as among the most significant predictors of mortality in older adults [89]. In a study of older breast cancer patients (n = 2,835), those who were socially isolated had a higher risk of mortality [93]. Social support should be an integral part of geriatric assessment. Also, the person’s living conditions, financial status, and availability and adequacy of caregiver should also be taken into consideration [139]. Assessment of adequate financial resources is important, and if there are any issues, referral to a social worker is indicated to see whether financial assistance is available to help pay for cancer treatment costs. In older adults, assessment should include an inspection for signs of abuse, especially if the older adult is in poor physical health, cognitively impaired, and/or functionally dependent on others [121]. The GA should include a physical examination [4], and this provides an excellent opportunity to inspect for evidence of abuse and neglect.

Geriatric Syndromes

A geriatric syndrome refers to a health condition that is prevalent in older adults, has multifactorial etiology, and is often associated with substantial morbidity and mortality [122]. Geriatric syndromes subsume dementia, depression, delirium, osteoporosis, falls, fatigue, and frailty, all of which are common among geriatric patients with cancer [94, 123]. Geriatric syndromes are sometimes approached separately in geriatric literature, but most are detected by the previously mentioned tools (including evaluation of comorbidity), so we do not mention these syndromes separately.

Pain

Older adults with pain have been underassessed and undertreated [124, 125]. Older cancer patients may have pain as a result of their comorbid conditions. Persistent pain is difficult to treat, but it affects function [126–131]. Having persistent pain affects all areas of function and negatively affects quality of life. Research has shown that increasing age is associated with less appropriate pain management. Because older adults more often have advanced cancer at diagnosis, along with one or more comorbidities that contribute to pain (e.g., arthritis), pain management should be an important treatment goal. The American Geriatric Society has developed guidelines for persistent pain management [132].

What to Do With the Results of the GA

GA instruments mainly identify potential problems. These detected problems generally require more extensive (diagnostic) evaluation. In an office setting, a streamlined approach is often necessary because of the constraints of time and availability of physicians and/or other health care professionals. Setting priorities among the problems for initial evaluation and treatment is a crucial first step. Often the priority is the problem that bothers the patient the most or that interferes with the ability to deliver cancer treatment and/or one that affects the ability to manage other problems, such as alcoholism or depression. The second step after performing a GA is to understand the exact nature of the disability through performing a task or symptom analysis. In a nonspecialized setting, when the disability is mild or clear-cut, this often involves taking a careful history. However, when the disability is more severe, detailed assessment is need, ideally performed by an interdisciplinary team. Once the nature of the disability is identified, systematic physical assessment and ancillary investigations are needed to clarify the cause of the problem. For instance, difficulty in dressing can be due to a number of causes ranging from cognitive impairment, poor finger mobility and dexterity, impaired movement of shoulders, back, or hip, etc. Evaluation by a physiotherapist of occupational therapist may be needed to pinpoint the problem adequately. Evaluation by a social worker may be necessary to determine the extent of family dysfunction engendered by or contributing to the dependency. In general, one impairment may lead to another. Impaired gait may contribute to depression and deterioration in social functioning. Even once the cause of the problem has been addressed, there may be residual impairment in performance of ADL because of deconditioning and loss of function.

Once the disability and cause are understood, the treatment and management strategies often become clear. In Table 3 some interventions are listed for commonly identified issues. It should be acknowledged that the main benefit of a “geriatric approach” relies on actions/interventions based on the GA results. Just doing a GA and not doing anything with it will provide little to no benefit to older patients.

Table 3.

What to do with the data obtained with the geriatric assessment

Which Patients to Assess

Because the GA is best used for frail elderly, it depends on the clinical setting in which older adults are at risk for adverse outcomes. Many GA programs in oncology start screening at age 70 because physiological reserves and diminished treatment tolerance start playing a role in treatment choice above this age cutoff, but it should be acknowledged that this cutoff is a pragmatic choice; patients younger than 70 can be extremely frail, whereas very old persons can still be fit. A full comprehensive GA is time-consuming; it has been reported to take on average between 30 and 120 minutes [31, 32]. In oncology settings, where 60%–70% of newly diagnosed cancer patients are older, it might not be feasible to give all older adults a full comprehensive GA because of lack of resources. Several screening instruments have been developed, such as the Groningen Frailty Indicator [133], the G8 screening tool [75], and the Vulnerable Elders Survey [134]. SIOG has just published recommendations with regard to screening instruments, and no particular screening instrument was recommended [76], although the data (sensitivity, specificity, and prediction of mortality) were somewhat more robust for G8) because there are conflicting findings with regard to the prognostic value across tumor types and treatment regimens for cancer treatment outcomes such as treatment toxicity and overall survival [135–137]. However, in clinical settings where there are high volumes of older adults with cancer that are seen in the oncology clinics, a two-step screening process can be used (Fig. 1). In the first step, all older adults will be screened using a screening tool. In the second step, those older adults who scored above the cutoff of the screening instrument (i.e., were deemed at risk) will be seen for a full GA. Commonly used GA and screening tools and their cutoffs have been described on the SIOG website by Wildiers and Kenis [138], in the Senior Adult Oncology Guideline [139], and the ConsultGeriRN website (http://consultgerirn.org) of the Hartford Institute for Geriatric Nursing [140].

Figure 1.

Overview of two-step screening process to identify those who may benefit from GA.

Abbreviation: GA, geriatric assessment.

How to Organize the Assessment

An important aspect in the decision of which patients to assess is who will assess the patients. There have been several models of GA reported in the literature for oncology settings [25, 31, 33] (Table 2). This is largely a result of the differences in practices across treatment centers and local resources, because many countries have specialized comprehensive cancer centers, where all cancer treatments are centralized and therefore the facilities might not always have access to geriatric expertise on site, whereas in other countries the cancer treatment may be provided in general hospitals that have other medical specialties available, and thus more direct access for oncologic patients to geriatric expertise is available. In most countries, the majority of cancer patients are seen in outpatient clinics. Furthermore, in most developed countries, older adults often depend on others such as family members and friends for transportation to cancer treatment centers and thus may not come back for GA if it requires additional hospital visits. Furthermore, these caregivers may need to take time off work for each appointment, and this can lead to considerable expenses during the diagnostic and treatment phase. In addition, there may be a waiting list for geriatric medicine clinics, and thus the oncological team has to decide a treatment plan before the patient can be seen for a GA in a geriatric medicine clinic. In North America, the nurse practitioner may be a good person to conduct the GA because they are trained to conduct extensive health assessments as well as have the authority to prescribe medication and order diagnostic tests [141–148]. For the management of other chronic diseases, research has shown that the nurse practitioner can manage these well, and some evidence is also emerging for nurse practitioners in oncology settings [142, 146, 148].

Another important consideration is the location of where the assessment takes place. Many older adults have either vision impairment, hearing impairment, or both [149]. Older adults might also have physical and cognitive impairments, making the location where the GA takes place very important. Going for assessments at different locations may create undue hardship for these patients. It is also important to consider the time of appointments, because appointments early in the morning may be more difficult if one is dependent on caregivers to help with daily ADLs and/or IADLs such as dressing and transport to the hospital. Also caregivers may need time to get to the older person to pick them up and take them to hospital appointments.

Challenges

In starting a GA service for older adults with cancer, one may experience some challenges. These challenges include patient-related challenges, as well as those related to the collaboration between the oncology team and GA team [150–152]. In Table 4, we have summarized some of the challenges and provided some potential solutions. From the patient perspective, long hospital visits and multiple hospital visits are burdensome because they often rely on others for transportation. Considering that the target population for GA are frail older adults, it is important to optimize their hospital visits, reduce the burden of lengthy hospital visits, and coordinate patient care. One of the biggest challenges for collaboration between the oncology and GA team is to have clear arrangements about who will be referred for GA and what results are expected by the oncology team (e.g., input on the treatment decision or not), as well as time frame (when they can expect the results). Therefore, it is important to have both specialties’ input prior to the start of a GA program.

Table 4.

Potential challenges and solutions

Considering that the target population for GA are frail older adults, it is important to optimize their hospital visits, reduce the burden of lengthy hospital visits, and coordinate patient care.

Conclusion

We have provided the reader with an overview of how to conduct a GA, how to implement it into clinical practice, and how to use the results of the assessment in clinical oncology practice. Furthermore, we have provided the reader with information about available resources on GA, as well as GA tools, and highlighted some important challenges related to implementing GA in practice.

This article is available for continuing medical education credit at CME.TheOncologist.com.

Author Contributions

Conception/Design: Schroder Sattar, Shabbir M.H. Alibhai, Hans Wildiers, Martine T.E. Puts

Collection and/or assembly of data: Schroder Sattar, Shabbir M.H. Alibhai, Hans Wildiers, Martine T.E. Puts

Data analysis and interpretation: Schroder Sattar, Shabbir M.H. Alibhai, Hans Wildiers, Martine T.E. Puts

Manuscript writing: Schroder Sattar, Shabbir M.H. Alibhai, Hans Wildiers, Martine T.E. Puts

Final approval of manuscript: Schroder Sattar, Shabbir M.H. Alibhai, Hans Wildiers, Martine T.E. Puts

Disclosures

The authors indicated no financial relationships.