ebmt nap meeting

EBMT NAP Meeting - 18th November 2011

Professor Margot Gosney

University of Reading and

The Royal Berkshire NHS Foundation Trust, UK

Care of the older HSCT recipient – physical and

psychological perspective


May be older and physically robust

May be younger and physically frail

Will have underlying physical and psychological needs

Will not be the workload of the majority of Haematology units

The Patient


An endangered species

To wrap in cotton wool and keep out of public view

or allow to roam freely in the hope of natural

selection allowing their survival?

The Geriatrician


What is a Geriatrician?

1909 Nascher invented the work “Geriatrics”

1947 Founding of the British

Geriatrics Society

1948 Geriatric Medicine became a speciality in the United Kingdom


Why do we need them?

Care of dependent, aged and chronic sick was

the responsibility of the state for four centuries

Much care was carried out in Workhouse

Infirmaries (warehouses for bedfast patients

who were undiagnosed and untreated)

Marjory Warren, Medical Officer at the West

Middlesex Hospital, inaugurated rehabilitation


Four aspects of Marjory Warren’s message

Geriatrics is an important subject for the teaching of medical students

Care of the chronic sick should comprise an essential part of training student nurses

For the proper care of the chronic sick full facilities of a general hospital are necessary both to establish the diagnosis and for treatment

It is important to encourage research work on diseases of old age


Are Geriatricians involved in the care of older people with cancer?

In UK 76% of cancer deaths are in people over 64 years

In UK 47% of cancer deaths are in people over 74 years

Increasing old age

Increasing diagnostic certainty

Increasing survival

Increase in number of older patients with co-morbidity


Remember it is often difficult to separate symptoms of cancer from

symptoms of “old age”

Constipation

Weight loss

Malaise

Fatigue

Breathlessness


Physical problems of elderly people

Poor eyesight therefore more problems with colostomy

Decreased mobility; colostomy etc

Manual dexterity; prostheses etc

Increased incidence of confusion

Constipation more likely

Incontinence may be precipitated or worsen

Pressure area instability


Psychological problemsin elderly people

Body integrity; co-morbidity, new impairment

Constraints; physical, mobility, ADL

Dependency; financial, social,

transport

Comfort; lonely, emotional

equilibrium

Loss; status, role

Future; uncertain survival, impending treatment


Remember Most performance measures in Oncology are

alien to those used by Geriatricians

What is more important: PS on the day of the Haematology opinion or that 2 months earlier ….. are we measuring pre-morbidity or cancer

morbidity?

If you see no patients with cognitive decline you are not seeing a typical population


Remember Should we be treating the patient or the scans….

if the patient, then why do we continue to waste money on investigations that do not alter management?

What is quality of life?

Loss of status when we finish

reproducing or retire!

Lots of cancer specific QoL and Elderly specific but little validated in elderly people with cancer e.g. HAD

Is an MDT an MDT if it lacks a Geriatrician?


Areas often forgotten bycancer specialists

Remember that you can persuade most elderly people to do what you want them to do

Many symptoms that you are trying to palliate may not be from the cancer e.g. OA

Hospitalisation alone can cause delirium

Is the disease worse than the treatment?

Must not allow relatives to make all decisions for elderly patients


Decreased cardiac index

Decreased glomerular filtration

Decreased vital capacity

Decreased renal blood flow

Altered pharmacokinetics

Altered pharmacodynamics

The Normal Elderly


In 1985 19,945 papers on cancer management

Only 11 were specifically about the elderly

In 1995 32,421 papers on cancer management

Only 26 were specifically about the elderly

In 2005 67,500 on cancer management

18,600 specifically about the elderly

Treatment of Elderly Patients


The truth

Equal access

Choice of therapy

Multidisciplinary input

Decision-making on clinical grounds not by age

What do patients want?


Before treatment

During treatment

After treatment

Old age specific or oncology specific?

Is there a gold standard?

AssessmentWhy do we need it?


No such thing as a typical 80 year old

Effect of pre-morbid state

Physical, social and psychological

Effect of gender, age, marital status,

Country and wealth

Why do we need assessment?


Barthel’s Index of activities of daily living (BAI)1. Bowel Status 0 points – Incontinent (or needs to be given enema)

1 point – Occasional accident (once a week)

2 points – Fully Continent

2. Bladder Status 0 points – Incontinent or catheterized and unable to manage

1 point – Occasional accident (max once per 24 hours)

2 points – Continent (for more than seven days)

3. Grooming 0 points – Needs help with personal care: face/hair/teeth/shaving

1 point – independent (implements provided)

4. Toilet Use 0 points – Dependent

1 point – Needs some help but can do something alone

2 points – Independent (on and off/wiping/dressing)

5. Feeding 0 points – Unable

1 point – Needs help in cutting/spreading butter/ etc

2 points – Independent (food provided within reach)

6. Transfer 0 points – Unable (as no sitting balance)

1 point – Major help (physical/one or two people)

2 points – Can sit minor help (verbal or physical)

3 points – Independent

7. Mobility 0 points – Immobile

1 point – Wheelchair-independent (including corners etc)

2 points – Walks with help of one person (verbal or physical)

3 points – Independent

8. Dressing 0 points – Dependent

1 point – Needs help but can do about half unaided

2 points – Independent (including buttons/zips/laces etc)

9. Stairs 0 points – Unable

1 point – Needs help (verbal/physical/carrying aid)

2 points – Independent up and down

10. Bathing 0 points – Dependent

1 point – Independent bathing or showering

Barthel Score (max 20):___________


Incontinence-faecal and urinary

Instability and falls

Impaired hearing and vision

Intellectual decline-dementia and delirium

The Giants of Geriatric Medicine


Associated with poor mobility and impaired

cognition

Effect on pressure area integrity

Associated with depression and socialwithdrawal

May be caused or worsened by cancer therapy

e.g. post hemicolectomy, TURP or drugs

Incontinence


Impaired homeostasis with ageing

Predisposed to by polypharmacy

Often scares off surgeons, oncologists and haematologists

Coincidental osteoporosis and muscular frailty

may be worsened by steroids or other drugs e.g. vincristine etc

Instability and Falls


Delirium common post operatively and

associated with infection, under nutrition and

electrolyte disturbances

Dementia associated with paraneoplastic

phenomena

Should mild cognitive impairment prohibit

palliative treatment?

Intellectual Decline


Problems with colostomy

Problems with temperature checking

Problems with access to buildings for treatment

and follow up

Sensory deprivation increases likelihood of

delirium

How can you effectively consent somebody

who hears only 50% of the conversation?

Impaired Vision and Hearing


In post operative patients:

Low preoperative MMSE

Cognitive impairment (x12 – x17 )

Age > 80 (x 2 )

What are the risk factors for developing delirium?


Who and When?

Most common in those > 70 years

Prevalence may be as high as 24%

in A&E

Hospitalised 14 – 56%

Post operative 0 – 74% - (36.8%)

Community studies 10-25%

# NoF 25% - 65%


Why does it matter?

Patients have high mortality rates and longer lengths of stay

Often not recognised

Can be poorly managed

Can be prevented in 1/3 of patients

How many of you are Geriatricians or nurses with a special interest in elderly care

medicine?

How many of you have been trained in Geriatric Medicine?

How would you feel if someone with no formal training in your specialty started to profess an expertise?

How many of you do a formal AMTS when you meet an older patient for the first time?

Questions


Can you diagnose depression, dementia and pseudo-dementia?

What proportion of 70 year olds fall each year? What is the commonest treatable cause of falls? What proportion of this group of fallers have cancer?

A test of your Geriatric Medicine skills


Act as patients advocate Screening/early detection Treatment decisions Support of patient and carers Palliative care/End of life care Management of multiple pathology Education re ageing Liaison with other specialties

What is the role of the Geriatrician?


More likely to be wives than husbands Wives provide twice the hours of care that husbands provide Female patients have more outside care than

males In 82% of cases caregivers were spouses of

patients

Carers


What is quality of life? Questionnaires specific to cancer Questionnaires specific to specific site Questionnaires specific to older people Development of new questionnaires

Quality of life


When Casanova was 68, a correspondent called him a ‘vulnerable old man’ to which he replied ‘ I have not yet reached that wretched age at which one can no longer make any claim to life.’

What is old or elderly?


Tolstoy learnt to ride a bicycle when he was 67,he played tennis and bathed in the ice cold river. Aged over 70 his health began to fail and a fit of malaria obliged him to take to his bed. He reconciled himself with the idea of dying but recovered and went to the Crimea for a rest. He had episodes of pneumonia and of typhoid. But he did not give up the struggle.

Are all older people the same?


Increase working between haematologists and geriatricians

Sharing of expertise within the MDT Increased awareness of extension of intensive

therapies for older people Validation of different assessment methodologies Increased research funding and joint working

For the future


ebmt nap meeting - 18th november 2011 professor margot gosney university of reading and the royal...

Documents

geriatrician slide

patient slide

co morbidity slide

care of older people

impending treatment

diseases of old age

uk care