Older Adults, Anti\u2010Amyloid Therapy, and Frailty: What Oncology Can Teach Us

As a population ages, performing comprehensive geriatric assessment (CGA) is necessary to help clinicians manage older adults' conditions and to prevent or delay complications. CGA is now known as the best method by which to improve care outcomes and quality of life in older adults, and it requires a multidisciplinary approach. The aim of CGA is to identify older adults' needs, develop individual care plans, and improve care outcomes.1 Care outcomes are the results of treatment. They're also a key performance indicator for hospitals. The most common negative key performance indicators related to older adults are a long hospital stay, dying in the hospital, and unplanned readmission.2 The implementation of CGA may help control the care outcomes of older adults, as one of its main functions is to improve these outcomes. However, previous studies have shown inconsistent results related to CGA—although some have indicated that CGA improves care outcomes, others have found that CGA can worsen them. Specifically, many studies have reported that the implementation of the CGA model can reduce lengths of stay, readmission rates, and in-hospital mortality among hospitalized older adults, especially in the geriatric ward.3-6 However, others have reported these three care outcome parameters increased following the implementation of the CGA model.4-7 The reason for these inconsistencies requires further investigation. For example, it's possible that the method of CGA implementation varied among studies. As such, investigation is needed into how CGA is being conducted, especially the completeness of the CGA tool used; this is integral to achieving a comprehensive diagnosis and identifying appropriate interventions. Accordingly, this study was conducted to evaluate the completeness of the CGA tool and its relationship to care outcomes among older adults—especially readmission rates, lengths of hospital stay, and in-hospital mortality. Methods Investigators retrospectively evaluated older adults' medical records in one of the first—and largest—referral hospitals in Indonesia. To evaluate readmission rates, patients' medical records were reviewed for 30 days after discharge from the hospital. Included in this study was a sample of 222 hospitalized adults age 60 years or older who had a minimum of two diseases according to medical diagnosis. Older adults who were admitted or transferred to the ICU and those who were hospitalized for less than 24 hours were excluded from the study. The selection technique applied was stratified random sampling. Multiple logistic regression analyses were used to look for the predictor influence of the dependent variables of 30-day readmission and in-hospital death and examine the predictors of length of stay. Geriatric medical teams for participants performed various assessments to evaluate the completeness of the CGA. The researchers created this completeness evaluation, which comprised 4 domains (physical health, functional status, psychological health, and socioenvironmental status) broken into 21 items. The total completeness score ranged from 0 to 21. The data were then converted into percentages to facilitate analysis and evaluation. This evaluation utilized the observational checklist instrument, which had been tested for validity and reliability. Researchers conducted a pilot study to test this instrument and found it to be valid and reliable. It received a score of 0.89 using the content validity index (CVI). This CVI was reviewed by eight experts from Indonesia and Taiwan, including a geriatrician, a geriatric nurse, and gerontological nursing lecturers. The reliability test used an internal consistency and interrater reliability test. The internal consistency test analyzed by Kuder-Richardson Formula 20 with a result of 0.73 means the instrument is reasonably reliable in producing a consistent score. Results Completeness of CGA The overall average completeness of the CGA performed on the included patients was 68.19% (SD, 7.85). The CGA was more likely to be fully complete when conducted on the geriatric ward (71.99%; SD, 8.54) than on the nongeriatric ward (64.52%; SD, 4.85), with a significant difference (t = −7.99; P = .000). Table 1 presents a description of the CGA's completeness in terms of the total score and the score for each of the four evaluated domains. Table 1: - Description of the completeness of CGA (N = 222) Variables Mean ± SD Median (Range) 95% CI Completeness of CGA 68.19 ± 7.85 66.67 (52.38-85.71) 67.15-69.23 Physical health 84.73 ± 5.39 88.89 (77.78-88.89) 84.02-85.44 Functional status 39.34 ± 12.84 33.33 (33.33-66.67) 37.64-41.04 Psychological health 12.01 ± 25.68 00.00 (00.00-66.67) 8.62-15.41 Socioenvironmental status 86.04 ± 10.16 83.33 (50.00-100) 84.69-87.38 Looking at each domain in greater detail, only socioenvironmental status was completely evaluated by the medical care team. In each of the three other domains, at least one item wasn't examined at all. A detailed description of each item evaluated within the four domains is given below, and the data are presented in Table 2. Table 2: - Data distribution of the completeness of CGA for each item by ward type (N = 222) Type of ward Domain (mean ± SD)/Item, n (%) Nongeriatric (n = 113) Geriatric (n = 109) Total X2/U P Physical health 83.19 ± 5.58 86.34 ± 4.69 84.73 ± 5.39 4410 .000∗ Chief complaint 113 (100) 109 (100) 222 (100) - - Medical history 113 (100) 109 (100) 222 (100) - - Healthy behavior history 55 (48.7) 84 (77.1) 139 (62.6) 19.1 .000∗ Physical assessment 113 (100) 109 (100) 222 (100) - - Multimorbidity 113 (100) 109 (100) 222 (100) - - Polypharmacy 113 (100) 109 (100) 222 (100) - - Nutrition status 113 (100) 109 (100) 222 (100) - - Balance 0 0 0 - - Risk of fall 113 (100) 109 (100) 222 (100) - - Functional status 34.22 ± 5.38 44.65 ± 15.86 39.34 ± 12.84 4231 .000∗ Activity of daily living 113 (100) 109 (100) 222 (100) - - Instrumental of activity daily living 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Mobility 0 0 0 - - Psychological health 1.77 ± 10.77 22.63 ± 31.71 12.01 ± 25.68 4231 .000Re Cognition 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Delirium 0 0 0 - - Mood 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Socioenvironmental status 83.33 ± 9.71 88.84 ± 9.9 86.04 ± 10.16 4512.5 .000∗ Marital status 113 (100) 109 (100) 222 (100) - - Guardian 113 (100) 109 (100) 222 (100) - - Caregiver 106 (93.8) 108 (99.1) 214 (96.4) 4.45 .066 Environmental support 108 (95.6) 108 (99.1) 216 (97.3) 2.59 .213 Financial situation 109 (96.5) 104 (95) 213 (95.9) 0.16 .745 Social activity 16 (14.2) 43 (39.4) 59 (26.6) 18.18 .000∗ ∗Correlation is significant at the alpha level (.05). Care outcomes As shown in Table 3, compared with the older adults on the nongeriatric ward, those on the geriatric ward experienced a lower rate of readmission (4.6% versus 8%) but a higher rate of in-hospital death (13.8% versus 2.7%). In addition, the older adults hospitalized on the geriatric ward stayed in the hospital significantly longer than did the older adults on the nongeriatric ward (U = 4854; P = .006). Table 3: - Care outcomes in relation to ward type Type of ward Care outcomes Total Geriatric Nongeriatric X2/U Score P 30-day readmission, n (%) 0.58 .448 Yes 14 (6.3) 5 (4.6) 9 (8) No 208 (93.7) 104 (95.4) 104 (92) In-hospital death, n (%) 7.76 .005∗ Yes 18 (8.1) 15 (13.8) 3 (2.7) No 204 (91.9) 94 (91.9) 110 (97.3) Length of stay, median (range) 8 (2-62) 10 (2-34) 7 (2-62) 4854 .006∗ ∗Correlation is significant at the alpha level (.05). Completeness of CGA in relation to care outcomes The length of hospital stay care outcome showed different results from the other two outcomes as shown in Table 4. In general, there was a significant relationship between the completeness of the CGA and the length of stay (r = 0.15; P = .028). When evaluating by ward type, a significant relationship between the two parameters was observed for patients on the geriatric ward (r = 0.19; P = .041) but not for those on the nongeriatric ward (r = −0.081; P = .393). In other words, the length of hospital stay was significantly correlated with the completeness of the CGA for the total sample and for the geriatric ward. Both correlations were positive and moderate, meaning that the more complete the CGA was, the longer the hospital stay. Table 4: - Completeness of CGA in relation to care outcomes Completeness of CGA Care Outcomes Total (n = 222) Geriatric (n = 109) Nongeriatric (n = 113) Mean ± SD t/r (P) Mean ± SD t/r (P) Mean ± SD t/r (P) 30-day readmission 1.13 (.272) 0.92 (.361) −0.70 (.483) Yes 66.67 ± 4.94 68.57 ± 7.22 65.61 ± 3.18 No 68.29 ± 8.00 72.16 ± 8.59 64.42 ± 4.97 In-hospital death −0.33 (.739) 0.89 (.372) 0.95 (.346) Yes 68.78 ± 8.68 70.16 ± 8.72 61.90 ± 4.77 No 68.14 ± 7.79 72.29 ± 8.52 64.59 ± 4.85 Length of stay 0.15 (.028)∗ 0.19 (.041)∗ −0.08 (.393) ∗Correlation is significant at the alpha level (.05). Correlation between completeness of CGA and care outcomes, controlling for other variables The multiple logistic regression analysis found no significant results related to readmission. Only the type of ward had a significant influence on in-hospital death (odds ratio [OR] = 7.28; P = .004). This indicates that older adults hospitalized on the geriatric ward had a probability of death that was seven times higher than those hospitalized on the nongeriatric ward. Further, analysis indicated that the only predictor of length of stay was comorbidity. However, upon examining this by ward type, the completeness of the CGA had a significant impact on and predicted length of stay only for patients on the geriatric ward (B = 0.02; t = 2.08; P < .05). This result indicates that every change by one unit in the completeness of the CGA increased the length of stay by 2 days. Study authors hypothesize that when a CGA is more complete, more problems are identified, necessitating further medical treatment; accordingly, providing a comprehensive intervention to manage all the identified problems might result in a longer length of stay.6,8 Discussion Completeness of CGA The completeness of the CGA was defined as how comprehensively the geriatric medical team assessed participants during hospitalization. The analyses conducted in this study indicated that, on average, the reviewed CGAs were only slightly more than 50% complete. Unfortunately, this result can't be compared with other studies because no previous studies have evaluated CGA completeness. Moreover, this result doesn't correspond to the concept of CGA, which is the primary recommended intervention for geriatric wards.4 Although policy requirements are in place regarding the use of CGA as part of the provision of geriatric services, the percentage of CGA completeness on the geriatric ward alone was only about 72%. A comprehensive CGA is vital to establish diagnoses and ensure that the interventions provided are appropriate and in accordance with each patient's needs. The results also showed that CGA wasn't optimally implemented in the hospital setting, as some items were frequently skipped. As such, other medical teams—especially nurses—must contribute to the CGA, as they spend a significant amount of time with patients; their input could reduce missing data, making the CGA more comprehensive and complete, enhancing care outcomes for older adults. Care outcomes 30-day readmission. Based on a review of all the older patients who were readmitted within 30 days after discharge from the hospital, individuals on the nongeriatric ward had twice as many readmissions as did those on the geriatric ward. Previous related studies found that patients who had been treated in the CGA group had fewer readmissions.3,5 In terms of the relationship between the completeness of the CGA and readmission, the total sample score of the average number of older adults who were readmitted was lower than that of patients who didn't require readmission. On the nongeriatric ward, patients who were readmitted had a higher CGA completeness score than those who weren't readmitted. Even though this difference wasn't statistically significant, it's possible that on the geriatric ward, the more complete a CGA is, the more likely it is that a readmission event can be avoided. This result could be explained by the fact that, on the geriatric ward, a predefined CGA intervention package was implemented that included multidimensional assessment, multidisciplinary specialty expertise, geriatric meetings, care plans focused on patient-centered goals based on CGA results, the implementation of care plans by geriatric nurse specialists, and a continuous review of progress and care planning.4 In-hospital death. The rate of in-hospital death on the geriatric ward was about five times greater than that on the nongeriatric ward. Considering that the CGA was applied on the geriatric ward in the hospital analyzed in this study, this result was quite surprising. Nevertheless, the characteristics of patients on the geriatric ward—for example, being older and having more diseases—could be the reason why the mortality was higher. These results are also in line with a previous study, which showed that more older adults died on the geriatric ward than on the general ward.7 The relationship between the in-hospital mortality and the completeness of the CGA wasn't statistically significant. However, the mean CGA completeness score for older adults who didn't die in the hospital tended to be higher than that for patients who did, for both wards. This result is consistent with previous research, which stated that CGA can reduce mortality among hospitalized older adults.3,4,6 Length of stay. Length of hospital stay wasn't significantly related to age but was significantly related to comorbidities and ward type. The more illnesses a patient had, the longer their hospital stay. Further, older adults on the geriatric ward with more illnesses also stayed in the hospital longer than did those on the nongeriatric ward. This aligns with a previous study indicating that prolonged hospital stays often occur in older adults because of the higher incidence of complications, such as multimorbidity.9 The completeness of the CGA had a significant relationship with length of stay. For the total sample and on the geriatric ward, the relationship was positive and moderate or typical. This means that the more complete the CGA was, the longer the patient stayed in the hospital. This positive relationship is supported by previous studies.5-7 Limitations This study only evaluated the assessment part of the CGA, although there are three steps in the CGA process and six key features of CGA. The assessment part is the first stage. For effective implementation to improve care outcomes, the entire process and all of the key features need to be completed, although this wasn't the subject of the present study. Second, this study excluded older adults who were transferred to the ICU, High Care Unit, and Intensive Coronory Care Unit while they were hospitalized. This exclusion criterion was designed to control the condition of the older adults in both wards, so they were similar in acuity. However, this means the results underestimate the possibility that the older adults could die in the hospital, thus influencing mortality data. Third, the data for readmission were measured only by counting the rate of participants readmitted to the same hospital. Investigators didn't collect the reason for the readmission nor account for the possibility of patients being readmitted to another hospital. This could underestimate the readmission rate of the older patients. Fourth, the independent variables were few: age, comorbidity, ward type, and the completeness of CGA. The complex care outcomes of older adults might be influenced by many other factors, such as healthcare and patient factors, that warrant further investigation. Finally, these study results can only be generalized to similar settings and populations. Further revision of the 21-item evaluation for the CGA should be investigated in future studies. Implications for nurse leaders Nurse leaders, especially in geriatric settings, should understand that the CGA may not be optimally implemented in a hospital setting, and note which items aren't frequently assessed. The domains of functional status and psychological health in particular had a low completion rate. Although the entire team is responsible for addressing this concern, the nurse leader must identify and educate those who don't regularly complete full and complete evaluations. Involving nurses in the completion of the CGA would lead to more comprehensive assessments that ultimately improve care outcomes for older adults. These authors also challenge nurse leaders to get involved with policymaking to provide regulations for all medical teams that treat older adults, particularly in relation to geriatric assessments including the CGA. Getting to 100% The average CGA completeness score in this study was 68.19%, and the completeness rate in the geriatric ward was significantly higher than in the nongeriatric ward. There were three items that weren't documented in this study population: balance in the physical domain, mobility in the functional domain, and delirium in the psychological domain; these items should be emphasized for staff because they're important parameters in assessing the condition of hospitalized older adults. Of the four CGA domains, psychological health had the lowest average completeness rate, whereas socioenvironmental status had the highest average score. The overall evaluation showed that the CGA assessment wasn't optimally performed, even in the geriatric ward where it was the policy to do so. The 30-day readmission rate was 6.3%; more patients who were readmitted came from the nongeriatric ward compared with the geriatric ward, although this finding wasn't statistically significant. Similarly, the CGA completeness score of patients who weren't readmitted after 30 days was slightly higher than those who were readmitted, but again, this finding didn't reach statistical significance. In-hospital mortality was 8.1%, and older adults in the geriatric ward had significantly more deaths than those in the nongeriatric ward. However, those patients in both wards who survived had a more complete CGA. The median length of stay was 8 days (range, 2 to 62 days) and the length of stay in the geriatric ward was significantly longer than in the nongeriatric ward. Ultimately, the more complete the CGA, the longer the patient's length of stay.

Tailoring Vascular Access for Dialysis: Can Frailty Assessment Improve the Fit?

Optimizing emergency care for the aging population is a major challenge. Older adults account for a disproportionate share of 30% of all Emergency Department (ED) visits. A third of all older adults experiences adverse outcomes after an ED visit, with an increased risk in the first 3 months. This increased risk seems irrespective of their disease severity, but might be explained by frailty. Frailty is a state of decline in multiple physiological systems, faster and proportionally more than can explained by aging only. Frailty screening can select patients who may benefit benefit from a comprehensive geriatric assessment, and targeted interventions already at the ED or during hospital admission. Second, frailty screening can guide decisions and treatment goals. Last, it creates awareness among health care professionals about the patients context. Objections to frailty screening in busy EDs are the amount of administrative workload, and the tendency of healthcare professionals to trust their own clinical judgment over formal screening tools. Frailty screening may also negatively contribute to age discrimination. Frailty screening instruments are typically standardized multi-domain questionnaires with a hard cut-off. Discrepancies exist in derivation populations, outcome measures, and follow-up periods. We found a fair to moderate level of agreement between commonly used instruments. Prognostic accuracy was below thresholds reliable enough for clinical use in our head-to-head comparison. Calibration was poor to reasonable calibration. Clinical judgment, polypharmacy and nonspecific complaints associated with adverse health outcomes in older adults at the ED. Although their prognostic accuracy is poor to moderate, these determinants are known for every older adult at the ED visits and should be considered as red flags. We found only fair level of agreement between clinical judgment and a screening instrument or patient-perceived frailty. The prognostic accuracy of clinical judgment is poor to moderate. Combining clinical judgment with a validated screening instrument or patient-perceived frailty did not improve prognostication. Polypharmacy is highly prevalent in older patients at the ED, and associated with increased 3-month mortality. Polypharmacy was also associated with readmission and self-reported falls, but not after adjustment for chronic comorbidity and frailty. This study illustrates the complexity of the observed polypharmacy–mortality association, given the confounding effects of chronic comorbidity and frailty. 26% of the ED patients present with NSC, mostly older and frail patients. NSC was associated with a twofold increased risk of functional decline and institutionalization, even after adjustment for baseline frailty, comorbidities and activities of daily live functioning. 50% received a specific diagnosis after additional analysis during ED or hospital stay. In conclusion, frailty assessment should be part of the initial evaluation of older patients at the ED, although accurate prediction of adverse health outcomes on individual level seems almost impossible. Frailty screening can help selecting patients needing standard care (preventing undertreatment) patients who benefit from geriatric interventions, and the severe frail patients deserving palliative care (preventing overtreatment). The goal of frailty screening should shift from predicting adverse health outcomes to creating awareness among healthcare professionals about the patients context. In the absence of an ideal frailty screening instrument, practical considerations can lead the choice of instrument to suit local implementation. Besides frailty screening with formal screening instruments, presentation with a nonspecific complaint and polypharmacy can be considered as red flags for adverse health outcomes. Health care professionals should consider the results of frailty screening not as absolute thresholds, but rather incorporate the findings of frailty assessment in tailored cure or care, aligned with patients preferences and performances. Next, the findings of ED frailty assessment should be available for all involved healthcare professionals to streamline care processes and ensure geriatric follow-up of these patients.

e24012 Background: Frailty is an under recognized yet clinically important consideration in treatment decision making for older adults with cancer. The Comprehensive Geriatric Assessment (CGA) is considered gold standard for recognition of frailty and is endorsed by the International Society of Geriatric Oncology. Additionally, multiple screening tools have been validated to reliably detect frailty. Nevertheless, studies suggest that formal screening for frailty is not prevalent in community oncology practices and that oncologists’ clinical judgement is not as sensitive in identifying frailty as CGA. This survey was designed to assess the perceptions of frailty amongst oncology providers, as well as the prevalence and method of frailty screening in these practices. Methods: After approval by an independent research ethics board, a secure online survey was circulated amongst community oncology providers within the TriHealth Cancer Institute, including MD’s, DO’s, and NP’s, via email. Survey was live from January 24th to February 12th. Data was analyzed using descriptive statistics. Results: There were 20 total respondents from medical, surgical, gynecologic, and radiation oncology, 70% MD/DO. 70% of total respondents reported having &gt; 50% of their patients over the age of 65. All respondents reported being familiar with the concept of frailty and the ECOG performance status, while only 45% had heard of CGA. 40% respondents reported that they screen for frailty and all used ECOG alone or along with Karnofsky, none used CGA or other validated screening tools. 60% respondents did not formally assess frailty, however all but one felt frailty assessment to be beneficial. Most commonly cited barriers to screening were time restraints and lack of availability of follow up services. Conclusions: Despite proven clinical benefit of CGA and various validated screening tools, few oncology providers screen for frailty. Furthermore, only 45% report having heard of CGA while none incorporate it in their practice. This shows that professional education amongst oncology providers is needed to promote the use of CGA or alternative frailty screening measures to improve outcomes in older adults with cancer. Additionally, strategies must be implemented that would mitigate time restraints and lack of access to follow up services so that these providers may be more inclined to conduct such frailty assessments. Limitations of this study include potential for reporting bias and indeterminate generalizability. Next steps include quality improvement initiative of implementing a frailty screening tool in these practices.

209 Background: The VES-13 is a well-studied brief frailty screening tool for ≥ 65 older adults (OAs) in the oncology setting. Vulnerable patients (scoring ≥ 3) are at higher risk for adverse outcomes and will benefit from a Comprehensive Geriatric assessment (CGA) and cancer treatment decision optimization. Whether the VES-13 is effective specifically in patients with Genitourinary (GU) malignancies remains to be established. Primary objective: to determine if the VES-13 can predict which OAs with GU cancer (Bladder, Prostate, Kidney) had subsequent treatment modification after CGA. Secondary objective: to investigate if there is any association between VES-13 score with comorbidity and chemotherapy toxicity prediction tool (CARG). Methods: The VES-13 was administered to consecutive patients referred to the geriatric oncology (GO) clinic from GU site at the Princess Margaret Cancer Centre, Canada. All patients underwent CGA. CGA assess 8 domains including cognition, comorbidities, function, falls risk. Among patients referred for pre-treatment assessment, we examined whether the VES-13 predicted changes in the final treatment plan after CGA. Descriptive statistics were used to describe the VES-13 scores and final treatment impact. Results: From July 2015-October 2019, 77 were included in this analysis. The VES-13 ≥ 3 group were 52/77 (67.5%), and significantly associated with higher comorbidities (P = 0.003) and worse CARG scores (P = 0.005). The final treatment plan was modified in 36/77 (47%). In univariate analysis, the odds ratio (OR) for VES-13 ≥3 was 1.92 (95% CI 0.72-5.12) for change in final treatment, which was not statistically significant likely due to modest sample size. Interestingly in the same univariate analysis, there was a strong association between final treatment plan with falls risk (OR 2.63, 95% CI 1.03-6.72), physical performance (OR 2.51, 95% CI 0.98-6.45) and cognition (OR 3.95, 95% CI 1.19-13.19). Conclusions: The VES-13 identified vulnerable GU patients who will benefit from CGA and may predict treatment optimization by identifying patients at higher risk of chemotherapy toxicity and higher comorbidity.

Perspectives of healthcare professionals on frailty assessment among older patients with colorectal cancer: A qualitative study.

Introduction International guidance on conducting medication reviews in older adults with cancer was published in June 2022,[1] and current clinical practices have been outlined by pharmacists working in this field.[2] This process includes assessing for drug-drug interactions (DDIs), potentially inappropriate medications (PIMs), and assessing anticholinergic burden (ACB), all of which have been associated with poorer outcomes in older adults with cancer.[2] Since July 2022, the Geriatric Oncology Assessment and Liaison (GOAL) Clinic in our tertiary cancer centre has offered a comprehensive geriatric assessment (CGA) to patients ≥70 years, which includes a comprehensive geriatric pharmacological assessment (CGPA), performed by the primary author. Aim Identify pharmacist interventions that resulted in a reduction of medication use in older adults attending a geriatric oncology clinic. Methods Data were collected between July 2022 and September 2023 inclusive. Patients who attended the GOAL clinic consented and underwent a CGPA. The CGPA database was analysed to assess for recommendations that reduced medication usage via two metrics: (i) reduced doses of medications; (ii) deprescribing of medications. Descriptive statistics were used to analyse the data (Table 1). Results One hundred and seventy four patients (98%) consented to a CGPA. Interventions to reduce medication use occurred in 120 patients (69%). There were 199 total number of interventions, with some patients having more than one intervention. The nature of the interventions are described in Table 1. Conclusion A structured medication review in the form of a CGPA, alongside a multidisciplinary CGA is effective at identifying potential areas to reduce medication usage in older adults with cancer, through appropriate dose reductions and deprescribing strategies. This service is unique as the GOAL clinic is Ireland’s only dedicated geriatric oncology clinic. The utilisation of a clinical pharmacist in a geriatric oncology outpatient clinic can effectively identify opportunities to reduce inappropriate medication, with almost 70% of patients being identified as being prescribed potentially inappropriate medications. This study was limited to the outpatient setting only. Future research should consider the impact of pharmacist review of medications for older adults with cancer at transitions of care.

Introduction: Cancer is a major health concern in Portugal, especially among older adults, who represent nearly half of new cases. Radiation therapy (RT) is crucial in their treatment, emphasizing the need for improved education in geriatric oncology for radiation oncologists (RO). Methods: A pretested 22-item online survey on RO’s geriatric oncology knowledge was disseminated. Results: The analysis involved 52 respondents, including 13 residents (25%) and 39 consultants (75%); RO were asked to specify the age threshold they considered to define an older cancer patient. Their responses were as follows: 60 years (n = 2, 3·8%), 65 years (n = 7, 13·5%), 68 years (n = 1, 1·9%), 70 years (n = 29, 55·8%), 75 years (n = 10, 19·2%) and 80 years (n = 2, 3·8%). Forty-six respondents (88·5%) acknowledged an observed increase in the number of older cancer patients in RT departments. Twenty-nine participants (55·8%) reported that age was considered either most of the time or always in clinical decisions. Regarding frailty screening, it was performed by 15 participants (28·8%), while four participants (7·7%) stated that frailty was assessed during comprehensive geriatric assessment in another department. Of those implementing screening tools, nine (17·3%) utilized the G8 tool, and two respondents (3·8%) employed the Triage Risk Screening Tool. Most respondents reported a lack of awareness regarding specific guidelines for older cancer patients, and 98·1% expressed the need for enhanced training in geriatric oncology. Conclusion: The study highlights a critical need for improved training in geriatric oncology among RO professionals. Furthermore, the findings underscore the imperative for treatment decisions to reflect an understanding beyond chronological age, emphasizing the necessity of addressing this knowledge gap in clinical practice.

Cancer disproportionately affects older adults, who account for the majority of diagnoses and deaths globally. However, research and clinical care often fail to adequately address their unique needs. This collection of studies in Age and Ageing highlights challenges and opportunities in geriatric oncology. The rising incidence of cancer in the older population, driven by demographic shifts and socioeconomic factors, underscores the need for targeted prevention and control strategies. Despite this, older adults remain underrepresented in clinical trials, with barriers including social isolation, healthcare professionals' biases and a lack of dedicated studies. Frailty assessment is gaining ground as a key tool in geriatric oncology. Studies on frailty scores such as the Hospital Frailty Risk Score, and comprehensive geriatric assessment (CGA), show their ability to predict outcomes and guide interventions. CGA-based care has been shown to reduce treatment toxicity without compromising survival, yet its integration into routine practice remains limited. Treatment challenges are common, particularly with novel therapies like immune checkpoint inhibitors, which carry age-specific risks of adverse events. Tailored services are essential to address the diverse needs of older cancer patients. Research highlights the importance of improving communication around cancer screening for older adults and developing specialised care pathways for vulnerable populations, such as those with dementia. Continuity of care remains a significant challenge, requiring better coordination across healthcare providers. These findings emphasise the urgent need for age-attuned research, frailty-informed care models and tailored interventions to improve outcomes for older adults with cancer.

Increasing awareness on frailty in the management of hypertensive older adults.

BackgroundThe comprehensive geriatric assessment (CGA) is the gold standard in geriatric oncology to identify patients at high risk of adverse outcomes and optimize cancer and overall management. Many studies have demonstrated that CGA could modify oncologic treatment decision. However, there is little knowledge on which domains of the CGA are associated with this change. Moreover, the impact of frailty and physical performance on change in cancer treatment plan has been rarely assessed.MethodsThis is a cross-sectional study of older patients with solid or hematologic cancer referred by oncologists for a geriatric evaluation before cancer treatment. A comprehensive geriatric assessment was performed by a multidisciplinary team to provide guidance for treatment decision. We performed a multivariate analysis to identify CGA domains associated with change in cancer treatment plan.ResultsFour hundred eighteen patients, mean age 82.8 ± 5.5, were included between October 2011 and January 2016, and 384 of them were referred with an initial cancer treatment plan. This initial cancer treatment plan was changed in 64 patients (16.7%). In multivariate analysis, CGA domains associated with change in cancer treatment plan were cognitive impairment according to the MMSE score (p = 0.020), malnutrition according to the MNA score (p = 0.023), and low physical performance according to the Short Physical Performance Battery (p = 0.010).ConclusionCognition, malnutrition and low physical performance are significantly associated with change in cancer treatment plan in older adults with cancer. More studies are needed to evaluate their association with survival, treatment toxicity and quality of life. The role of physical performance should be specifically explored.

Background and rationaleThyroid dysfunction in older adults often mimics the signs of aging, impacting metabolism and overall physiological balance. While age-related chronic conditions have been extensively studied, the relationship between thyroid function and frailty remains underexplored.ObjectiveThis study aimed to evaluate the effects of thyroid dysfunction on frailty among individuals aged 65 years and older. Thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), and thyroid peroxidase antibody (anti-TPO) levels were analyzed. The study further examined the correlation between thyroid dysfunction, chronic diseases, sociodemographic factors, and optimal TSH levels in relation to frailty, using the Study of Osteoporotic Fractures (SOF), Edmonton Frail Scale (EFS), and FRAIL scales.MethodsThis cross-sectional study included 220 older adults with either treated or untreated thyroid dysfunction. Comprehensive geriatric assessments were conducted, including detailed medical histories, sociodemographic data collection, and thyroid function tests. Frailty was assessed using the SOF, EFS, and FRAIL scales. Multivariate logistic regression analyses were performed to identify significant associations between thyroid parameters and frailty.ResultsThe median age of participants was 73 years, and 68.2% (n = 150) were women. Frailty prevalence was significantly higher in individuals with abnormal TSH levels (outside the 0.5–6 mIU/L range). Lower fT3 levels and the fT3/fT4 ratio were significantly associated with frailty, particularly as assessed by the SOF and EFS scales. In contrast, the FRAIL scale revealed a significant association between increased frailty and lower fT3 levels only. Subgroup analysis indicated that in individuals aged ≥ 80 years, a lower fT3/fT4 ratio was consistently associated with frailty across all frailty scales, whereas in those aged < 80 years, lower TSH levels showed a strong association with frailty as assessed by the FRAIL scale. These findings underscore age-specific variations in the relationship between thyroid function and frailty.ConclusionThis study highlights the significant impact of thyroid dysfunction on frailty in older adults. Lower fT3 levels and the fT3/fT4 ratio emerged as key indicators of increased frailty, particularly on the SOF and EFS scales. Subgroup analysis further emphasized the importance of age-specific assessments, with a lower fT3/fT4 ratio being a critical indicator of frailty in individuals aged ≥ 80 years, while lower TSH levels were significant in those aged < 80 years. Abnormal TSH levels were strongly associated with frailty on the SOF scale, suggesting the need to consider thyroid dysfunction as a modifiable risk factor. Additionally, factors such as age, sex, education, thyroid medication use, and comorbidities influenced frailty status. Incorporating thyroid function tests into frailty assessments could enhance early identification and targeted interventions for at-risk older adults, particularly when age-specific thresholds are applied.

Older adults with cancer tend to face more complex health needs than their younger counterparts. Patients > 65 years of age are recommended for comprehensive geriatric assessment (CGA) to capture and address age-related vulnerabilities. Access to geriatrics services is limited, and our baseline audit of geriatric referrals in 2019 from the cancer program revealed that only 30% of patients referred received a CGA. The aim of this study was to assess the implementation of a geriatric oncology (GO) clinic that employs CGA and determine patient outcomes. We conducted a retrospective cohort study at a single institution. Data collection included baseline characteristics, GO clinic findings and characteristics, recommendations/referrals, and emergency room (ER) visits/hospitalizations within 6 months of CGA. Descriptive statistics were used for analysis. A total of 100 patients were included, with a median (range) age of 80 (63–97) years; 70% were female, and the most common cancer type was breast (31%). Through the GO clinic, patients were seen in a timely manner, with a median of 3 weeks, compared to our historical baseline of 11 weeks. Cognitive decline (32%) and pre-treatment CGA (22%) were the most common reasons for referral, and the most common new diagnosis was cognitive impairment (65%). For pre-treatment CGA, 16 (48%) patients were deemed suitable for treatment and 10 (30%) were recommended for modified treatment; 34 (94%) referring physicians followed the recommendation. In addition, most (68%) patients received an allied health referral. One third of patients visited the ER and 30 (30%) patients were hospitalized. Overall, the GO clinic resulted in greater access to CGA in a timely manner, enhanced access to allied health, and assisted in treatment decision-making.

821 Background: A FI-CGA-10 is a recently developed measure of frailty in the geriatric oncology setting [Oncologist, 26, e1751 (2021)]. Our objective was to compare the multidimensional frailty assessment by FI-CGA-10 with PS assessed by a primary oncologist in older adults with cancer. Methods: This study included 790 older adults with GI cancer who underwent a CGA before cancer treatment decisions at a geriatric oncology service between September 2018 and May 2024, and whose PS was documented in the electronic medical record by a primary oncologist. Fitness and frailty level were evaluated using the FI-CGA-10, which assesses 10 domains: cognition, mood, communication, mobility, balance, nutrition, basic and instrumental activities of daily living, social support, and comorbidity. Deficits in each domain were scored as 0 (no problem), 0.5 (minor problem), and 1.0 (major problem). FI-CGA-10 scores (range 0-1) were calculated by dividing the sum of the scores for each domain by 10 and then categorized as fit (&lt;0.2), pre-frail (0.2–0.35), and frail (&gt;0.35). The strength of the ordinal association between the frailty category and each CGA domain score was assessed using Spearman’s non-parametric correlation coefficient (rho). Results: The median age was 79 years; 60% were male, 62% had GI tract cancer (esophageal, gastric, colorectal), 20% had hepatobiliary cancer, 15% had pancreatic cancer, and 46% had stage 4 disease. Overall (n=790), 25% of patients were fit, 40% were pre-frail, and 35% were frail (Table). Among patients with PS 0-1 (n=633), 30% were classified as fit, 48% as pre-frail, and 22% as frail. Among PS 0-1 patients, Spearman's rho was greater than 0.5 for the association between the frailty category (fit, pre-frail and frail) and cognition, IADL, and mobility domains. In this subcohort (PS 0-1), the proportion of patients with a cognition domain score of 0.5 (mild cognitive impairment) or 1.0 (dementia) was 7%, 30%, and 78% in the fit, pre-frail, and frail groups, respectively; the proportion of those with an IADL domain score of 0.5 (OARS IADL = 12-13) or 1.0 (OARS IADL ≤ 11) was 5%, 46%, and 92%, respectively; the proportion of those with a mobility domain score of 0.5 (0.8 m/s ≤ gait speed &lt; 1.0 m/s) or 1.0 (gait speed &lt; 0.8 m/s) was 45%, 85%, and 98%, respectively. Conclusions: In this study, 70% of older adults with GI cancer whose PS was scored as 0-1 by a primary oncologist were classified as pre-frail or frail when assessed using FI-CGA-10. Among patients with PS 0-1, there were strong correlations between the frailty levels and impairment levels in the cognition, IADL, and mobility domains, indicating that these domains are major contributors to the frailty classification (fit, pre-frail, and frail). All patients (n=790) Fit Pre-frail Frail PS 0 (n=351), n (%) 145 (41) 163 (46) 43 (12) PS 1 (n=282), n (%) 45 (16) 141 (50) 96 (34) PS 2-3 (n=157), n (%) 4 (3) 18 (11) 135 (86)

Frailty and sarcopenia have emerged as important syndromes in geriatrics. Their impact is far reaching and are associated with many poor outcomes in older adults. Assessment of frailty and sarcopenia should form part of the assessment in older adults at all encounters between healthcare staff and older adults, coupled with comprehensive geriatric assessment. Early interventions are warranted based on existing consensus guideline recommendations. Recently, strict lockdown measures to protect at-risk groups during the coronavirus disease 2019 pandemic may have led to worsening of frailty and sarcopenia among older adults, owing to social isolation, reduced access to care, and physical inactivity. Assessment and prevention of frailty and sarcopenia are of particular importance during pandemics. Further study is warranted to find the best strategies for managing frailty and sarcopenia.