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Journal of Clinical Oncology, Vol 24, No 15 (May 20), 2006: pp. 2298-2303 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.02.8514 Geriatric Syndromes in Elderly Patients Admitted to an Oncology–Acute Care for Elders Unit
From the Division of Geriatrics and Nutritional Science, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, MO Address reprint requests to Kellie L. Flood, MD, Washington University School of Medicine, 4488 Forest Park Blvd, Ste 201, St Louis, MO 63144; e-mail: kflood{at}im.wustl.edu
Purpose The goal of this study was to characterize an elderly population admitted to a novel Oncology–Acute Care for Elders (OACE) unit, determine the prevalence of functional dependencies and geriatric syndromes, and examine their suitability for an interdisciplinary model of care. Patients and Methods We conducted a retrospective review of 119 patients age 65 years or older who had a primary oncologic or hematologic diagnosis and were admitted to the OACE Unit. Standard geriatric screens were administered to assess mood, functional, and cognitive status. Demographic and medical data were compiled by review of patients' medical records. Results The mean age of the patients was 74.1 years (standard deviation, 5.9 years). The sample was predominantly white, of equal sex, had limitations in instrumental and basic activities of daily living, and a mean length of stay of 6 days. Geriatric syndromes detected by the OACE interdisciplinary team included cognitive impairment (dementia and/or delirium), depression, weight loss, and use of high-risk medications. Adverse events such as falls, restraint use, and pressure sores were rare. Conclusion In this descriptive study, many older cancer patients were found to have geriatric syndromes by the OACE team and these patients were considered appropriate for an interdisciplinary model of care. Additional studies are needed to compare the outcomes of hospitalized older oncology patients receiving an OACE intervention with those patients receiving usual care.
Thirty-five percent to 50% of frail elderly patients will experience functional decline during hospitalization for an acute illness.1-3 This decline leads to an increased length of stay, higher hospital costs, and increased risk of temporary or permanent institutionalization for patients who were able to live at home before admission.4,5 In an effort to improve outcomes in hospitalized elderly patients, Acute Care for Elders (ACE) Units have been developed in medical centers nationwide. The ACE Unit model of care emphasizes patient-centered care, nurse-driven prevention protocols, frequent interdisciplinary-team rounds addressing geriatric syndromes, and discharge planning beginning from the day of admission. Randomized controlled trials of ACE Units show a preservation of physical functioning and independence in activities of daily living (ADLs),6,7 fewer in-hospital days,8,9 less use of restraints,10,11 improved patient and provider satisfaction,11 and reduced rates of institutionalization6,11 and mortality.12 Cancer is predominantly a disease of older adults. In 2002, cancer was the fourth most common chronic condition among elderly patients, with 25% of men and 18% of women aged 65 years and older carrying a cancer diagnosis.13 Based on aging demographics, we can expect a dramatic increase in the prevalence of cancer diagnoses over the ensuing decades. Rao et al14 retrospectively evaluated functional status in 99 hospitalized elderly cancer patients. Following stabilization of their acute illness, these patients continued to have severe limitations in performance of basic ADLs (ADL Index mean score, 0.6; standard deviation [SD], 0.4; range, 0 to 6) and the Physical Performance Test (mean score, 7.1; SD, 5.1; range, 0 to 28), with higher scores indicating better functioning on both measures. The 1-year mortality rate following discharge was 25%. Movsas et al15 prospectively evaluated cancer patients aged 27 to 86 years (median age, 65 years; SD, 11.7 years) admitted to a Veteran's Administration inpatient oncology unit. They noted 22% of patients had an impairment in at least one basic ADL, and 87% had a rehabilitation need on admission. Hospitalized cancer patients frequently require use of narcotics and other medications that place them at risk for adverse drug events. Gaudreau et al16 found exposure to high-risk medications such as benzodiazepines (daily dose > 2 mg) and opioids (daily dose > 90 mg) was an independent risk factor for developing delirium in hospitalized cancer patients. We have established a novel Oncology–ACE (OACE) unit that provides the standard ACE unit interdisciplinary model of care to cancer patients aged 65 years and older during hospitalization for an acute illness. The objective of this study was to characterize the population admitted to the OACE Unit, to determine the prevalence of functional dependencies and geriatric syndromes (eg, cognitive impairment, depression, weight loss, and the use of high-risk medications), and to determine the patients' suitability for interdisciplinary team care.
OACE Unit Model of Care The OACE Unit is located on a designated nursing division at a nonprofit teaching hospital affiliated with the Washington University School of Medicine (St Louis, MO). In March 2000, the Unit was allotted 10 beds on the division for an internal medicine ACE Unit. With the emergence of a cancer center located near the Unit, the majority of ACE patients now have a primary cancer or hematologic diagnosis and the Unit is considered an OACE Unit. Cancer and hematology patients on the OACE Unit are admitted and managed by either a private or a university-based oncologist/hematologist. The OACE Unit implements an interdisciplinary team approach to identify and address geriatric syndromes in patients aged 65 years and over. The OACE model of care consists of: (1) administration of screens to identify geriatric syndromes; (2) OACE team daily rounds (Monday through Friday) that focus on patient-centered versus disease-centered care, medication use, cognitive and functional status, and early discharge planning; and (3) communication of team recommendations to the appropriate caregiver (ie, primary physician, nurse, family member, patient). Environmental modifications to the nursing division include installation of handrails in the hallway and chairs better designed to ease transfers in the congregate room. At the time of this study, the OACE team consisted of a gerontological clinical nurse specialist, a geriatrician, registered dietician, case coordinator, and representatives from physical and occupational therapy, social work, home health, and hospice, along with the patient's primary nurse. The members of the team, as well as division staff, received geriatric but not oncology-specific education. All OACE patients received care for their acute illness from their oncology/hematology physicians, who did not participate in the daily team rounds. OACE patients' functional dependencies were assessed by screening questionnaires for basic, using the Katz Index,17and instrumental, using the Lawton Index,18 ADLs. The Katz Index assesses performance of five basic ADLs (bathing, dressing, feeding, toileting, and transferring) based on patient (or collateral source) report of level of dependency for each activity. Total scores range from 0 (completely dependent) to 15 (completely independent). The Lawton Index uses a similar self-reporting questionnaire to assess level of dependency for eight instrumental ADLs (using the telephone, transportation outside the home, shopping, cooking, cleaning, laundry, medications, and finances) during the days immediately preceding hospitalization. Total scores range from 0 (completely dependent) to 26 (completely independent). Cognition was assessed with the Short Blessed Test of Orientation, Memory, and Concentration19and the Clock Completion Test.20 The Short Blessed Test scores range from 0 to 28, with scores of 9 or greater indicating increasing severity of cognitive impairment. The Clock Completion Test is scored by evaluating for accurate placement of digits in the four quadrants of a predrawn circle. Scores range from 0 to 7, with scores of 4 or more indicating cognitive impairment. On a case-by-case basis, the 15-item Yesavage Geriatric Depression Scale (GDS)21 was administered to screen for depressive symptoms. Scores range from 0 to 15, with a score of 6 or more indicating increasing severity of depressive symptoms. Patients had the option of declining participation in the screening questionnaires at any time. Geriatric screens were not completed in patients who refused or were too ill to participate, who were not available due to short length of stay, or in patients who were nonverbal or did not speak English. The OACE team also reviewed patients' medications to identify drugs known to predispose elderly patients to adverse drug events.22-25 Patients were assessed for pressure sores and risk factors for skin breakdown using the Braden Scale.26 Based on information gathered from the daily rounds and the geriatric screens, the OACE team provided recommendations for preventing and treating geriatric syndromes to patients, caregivers, nurses, and the primary physicians. Because the oncologists/hematologists were not present during team rounds, recommendations to the physician teams were made either in writing, via a yellow "Communication Sheet" placed in the progress note section of the patient's medical chart, or physicians were contacted by telephone if the issue was deemed urgent.
Data Collection Inclusion criteria for this study included patients: (1) aged 65 years and older; (2) having a primary oncology or hematology diagnosis; (3) receiving the OACE Unit interdisciplinary model of care during the study period; and (4) spending the entirety of their hospitalization on the OACE Unit. For patients admitted more than once to the Unit during the study period, only the index admission is included in this analysis. A retrospective review of 279 consecutive admissions to the OACE Unit from January to December 2002 was conducted. Of these admitted patients, 170 patients had a primary oncology or hematology diagnosis (and was designated an OACE patient), 100 were general internal medicine patients, and nine patients were cared for by other specialties. Of the 170 OACE admissions, 51 patients were excluded from the study: 26 patients did not spend the entirety of their hospitalization on the OACE Unit, 15 patients were repeat admissions following the index admission, nine patients were younger than 65 years, and one patient was excluded because the medical chart could not be located. The final sample consisted of 119 patients. Demographic, psychosocial, functional, and medical data obtained for analysis were compiled by reviewing patients' medical records and OACE screening questionnaires. The geriatrician scored the Katz Index of Basic ADLs, Lawton Index of Instrumental ADLs, Short Blessed Test, Clock Completion Test, and Geriatric Depression Scale, whereas a pharmacist reviewed all medication information. Medical data included medical diagnoses, number and classes of medications prescribed, adverse events (eg, falls, restraint use, skin breakdown), rehabilitative and nutrition consultations, and documentation of geriatric syndromes by nursing and oncology physician teams (separate from OACE team documentation). A patient was recorded as having documented cognitive impairment (ie, dementia and/or delirium) if the terms "dementia," "memory loss," "cognitive impairment," "delirium/delirious," "confusion," "mental status change," or similar citations were recorded by oncology/hematology providers in physicians' or nurses' notes. A patient was recorded as having documented depression if depression was recorded as a problem by oncology/hematology providers in physicians' or nurses' notes. A patient was noted to have weight loss if the oncology/hematology physician team documented "weight loss" or "malnutrition/poor nutrition" as a problem in the patient's admission or daily progress notes. For this study, "high-risk" medications included narcotics, benzodiazepines, diphenhydramine, sedating hypnotics, and tricyclic antidepressants. The institutional review board of the Human Studies Committee at Washington University School of Medicine approved this retrospective study.
Data Analysis
Patient Characteristics Baseline characteristics for the OACE population are listed in Table 1. The mean age of the patients was 74.1 years (SD, 5.9 years). The sample was predominantly white, of equal sex, and stayed on the OACE Unit an average of 6 days. Of the 119 OACE patients included in this analysis, 41% were under the care of a private oncologist. The primary oncology diagnoses and reasons for admission are listed in Table 1. Most OACE patients had a diagnosis of lung cancer, a gastrointestinal malignancy, or a hematologic malignancy. Seventeen percent of patients had a history of another malignancy before his/her current primary malignancy.
Functional Status and Geriatric Syndromes Dependence in at least one basic (45% all of the patients screened) or instrumental ADL (74% all of the patients screened) at the time of admission was common (Table 2). More than one half of patients reported needing assistance with laundry, cleaning, shopping, or transportation outside the home. Despite these impairments, of the 111 patients admitted from home, 97 patients (87%) were able to return home at discharge.
Abnormal cognition as detected by screening tests was prevalent (Table 3). Twenty-seven percent of the 93 patients who completed a Short Blessed Test screened positive for cognitive impairment (ie, underlying dementia and/or delirium). Of those patients with an abnormal Short Blessed Test, 36% of them had neither dementia nor delirium documented by their physicians in their medical record during this hospitalization. Only 9% of all 119 OACE patients had a history of dementia documented in their chart.
Forty-six OACE patients were screened for depressive symptoms with a Geriatric Depression Scale. Of the 11 patients (24%) with a positive GDS score, only seven had depression documented by their physician team. Of these seven, six patients were receiving antidepressant therapy at the time of discharge. A history of weight loss was documented in the charts of 42 OACE patients (35%). In these 42 patients, the most common primary malignancy was a gastrointestinal cancer (33%), and the most frequent reason for admission was nausea, vomiting, and/or dehydration (24%). Twenty percent of patients with documented weight loss had a body mass index (BMI) of less than 18.5, and 38% were placed on a restricted diet by their physician team at the time of admission. These diets included nothing by mouth, low fat, low cholesterol, low sodium, and diabetic diets. Seventy-six percent of these patients with weight loss received nutritional supplements. At discharge, patients on the OACE Unit averaged six routine medications, with 18% of patients taking nine or more drugs routinely (Table 3). Several patients were prescribed high-risk medications during hospitalization. Not surprisingly, narcotics were the most commonly prescribed high-risk medication. Benzodiazepines and sedating antihistamines were also prescribed frequently. Overall, adverse events were rare (Table 3), and only two patients were restrained (one by raising four side-rails of the bed and the other with a Vail bed). Table 4 lists the proportion of OACE patients receiving formal consultation from members of the OACE interdisciplinary team. Rehabilitative and/or nutrition referrals were made for the majority of OACE patients.
The goal of this pilot study was to determine the prevalence of functional dependencies and geriatric syndromes in this patient population and to further examine their suitability for an interdisciplinary model of care. To our knowledge, this is the first study that examines an interdisciplinary model of care in acutely ill, hospitalized, elderly oncology patients. At our institution, the criterion for evaluation by the OACE Unit team was simply patient age. This appears to have been a reasonable proxy for identifying frail cancer patients, as was confirmed by the degree of dependence in basic (45%) and instrumental ADLs (74%), and by the prevalence of geriatric syndromes. As expected, we found geriatric syndromes were prevalent and appropriate for interdisciplinary care. Twenty-seven percent of OACE patients completing a Short Blessed Test scored in the abnormal range, however 36% of these patients had neither dementia nor delirium documented in their medical record. Several studies have documented the prevalence of unrecognized cognitive impairment in hospitalized general medicine patients.4,8,27Although OACE patients were not formally evaluated for dementia or delirium, the high prevalence of abnormal cognitive screens suggests a significant number of these patients may have underlying dementia. Malnutrition and depression are both associated with an increased risk of functional decline and death following a hospitalization, independent of other comorbidities and severity of illness.28-31 One third of OACE patients with a positive score on the GDS did not have depression documented in their medical chart and were not receiving antidepressant therapy. Again, although a formal evaluation for major depression was not performed, these data suggest that many of these patients may have undertreated depression. Thirty-five percent of all OACE patients had weight loss documented in their medical record, and 11% were deemed underweight with a BMI of less than 18.5.32 Almost half of OACE patients received a formal nutrition consult. Unfortunately, many patients with a history of weight loss were placed on restricted diets at the time of admission. Several of the OACE patients received high-risk medications. Often these medications, such as diphenhydramine, were prescribed as a routine component of hematology/oncology treatment and transfusion protocols. Administering diphenydramine to elderly hospitalized patients has been associated with an increased risk of developing delirium and urinary retention.33 Most of the OACE patients who received diphenhydramine before a blood transfusion did not have a history of prior transfusion reaction. The OACE team provided recommendations to the oncology/hematology physician teams, such as discontinuation or avoidance of medications with CNS adverse effects, increased supervision with ADLs at discharge, specific antidepressant pharmacologic therapies, liberalizing diets, and adding supplements. Additionally, the team made referrals to spiritual care, oncology psychologists, registered dieticians, rehabilitative services, and arranged home safety evaluations, Meals–On–Wheels (Alexandria, VA), and chore workers. This study has several limitations. The results of the ADL screens may be biased because most patients gave a self-report of their functional status without informant corroboration. Taking into account the prevalence of cognitive impairment, self-report may represent an overestimation of functional status. While the OACE team made several recommendations aimed at preventing or managing geriatric syndromes, the patients' primary physicians were not a part of the OACE team rounds. Implementation of recommendations was at the physicians' discretion. The presence of the OACE team and their recommendations could have influenced chart documentation of geriatric syndromes. In addition, scoring in the abnormal range on a screening test does not necessarily indicate a patient has a specific syndrome. We did not quantify the number of consultations that resulted directly from OACE team recommendations. Other OACE team recommendations, such as increased supervision and safety at home, were not analyzed. Ongoing efforts to increase awareness among oncologists of the potential benefits of an OACE Unit model of care and encourage their participation in the daily rounds will likely further enhance the ability of the OACE team to impact patient care. Randomized trials are needed to determine whether an OACE team model of care makes a significant difference in the recognition and management of geriatric syndromes, incidence of adverse events, functional status, and discharge location of hospitalized patients with cancer. Pilot studies evaluating the utility of geriatric assessments in elderly cancer patients have been performed in the outpatient setting. These studies have demonstrated that the recognition of cognitive or functional disability in older cancer patients is often missed using standard oncology performance assessment scales,34 and that the management of geriatric syndromes can have a direct influence on cancer treatment.35 The only randomized controlled trial evaluating the impact of geriatric assessment in older oncology patients was conducted in patients aged 60 to 92 years following tumor resection. Late-stage patients who were randomly assigned to receive management by a nurse practitioner in addition to usual postoperative care had increased 2-year survival.36 A recent retrospective study evaluated outcomes in 36 elderly male patients with cancer who were admitted with functional decline to a Rehabilitative Geriatric Evaluation and Management Unit. More than 75% of these patients achieved previously unmet goals of symptom relief, functional improvement, or caregiver support under the care of the interdisciplinary team.37 In this descriptive study of an OACE Unit for elderly cancer patients, we found that functional dependencies and geriatric syndromes were prevalent and appropriate for interdisciplinary team care. Guidelines calling for geriatric assessment in all cancer patients aged 70 years and older have been developed under the auspices of the National Comprehensive Cancer Network.38 An OACE Unit can serve as one means of fulfilling this guideline. Additional studies are needed to compare outcomes of hospitalized older oncology patients receiving an OACE team intervention with those receiving usual care.
Although all authors completed the disclosure declaration, the following author or immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.
Dollar Amount Codes (A) < $10,000 (B) $10,000-99,999 (C)
We thank the nurses, staff, and Oncology–Acute Care for Elders Unit team members for their dedication to providing the highest quality of care to elderly patients admitted to Division 3200 at Barnes-Jewish Hospital (St Louis, MO).
Supported by grants from the Barnes-Jewish Hospital Foundation and the Division of State, Community, and Public Health, Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS), under Grant No. K01HP00079-01. The content and conclusions are those of the authors and should not be construed as the official position or policy of the BHPr, HRSA, DHHS, or the US Government, nor should any endorsements be inferred. Presented in part as posters at the Annual Meeting of the American Geriatrics Society, Las Vegas, NV, April 30-May 4, 2004, and at the Geriatric Oncology Consortium Multi-Disciplinary Conference, Washington, DC, September 9-12, 2004. Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
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Gaudreau JD, Gagnon P, Harel F, et al: Psychoactive medications and risk of delirium in hospitalized cancer patients. J Clin Oncol 23:6712-6718, 2005 17. Katz S, Ford AB, Moskowitz RW, et al: Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function. JAMA 185:914-919, 1963 18. Lawton MP, Brody EM: Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 9:179-186, 1969[Medline] 19. Katzman R, Brown T, Fuld P, et al: Validation of a short orientation memory-concentration test of cognitive impairment. Am J Psychiatry 140:734-739, 1983 20. Watson YI, Arfken CL, Birge SJ: Clock completion: An objective screening test for dementia. J Am Geriatr Soc 41:1235-1240, 1993[Medline] 21. Yesavage JA: Geriatric depression scale. Psychopharmacol Bull 24:709-711, 1988[Medline] 22. Fick DM, Cooper JW, Wade WE, et al: Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Intern Med 163:2716-2724, 2003 23. Inouye SK: Delirium in hospitalized older patients. Clin Geriatr Med 14:745-764, 1998[Medline] 24. Tinetti ME, Baker DI, McAvay G, et al: A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 331:821-827, 1994 25. Wang PS, Bohn RL, Glynn RJ, et al: Zolpidem use and hip fractures in older people. J Am Geriatr Soc 49:1685-1690, 2001[CrossRef][Medline] 26. Bergstrom N, Braden BJ, Laguzza A, et al: The Braden Scale for predicting pressure sore risk. Nurs Res 36:205-210, 1987[CrossRef][Medline] 27. Naylor MD, Stephens C, Bowles KH, et al: Cognitively impaired older adults: From hospital to home. Am J Nurs 105:52-61, 2005[Medline] 28. Covinsky KE, Fortinsky RH, Palmer RM, et al: Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med 126:417-425, 1997 29. Roach MJ, Connors AF, Dawson NV, et al: Depressed mood and survival in seriously ill hospitalized adults. Arch Intern Med 158:397-404, 1998 30. Covinsky KE, Kahana E, Chin MH, et al: Depressive symptoms and 3-year mortality in older hospitalized medical patients. Ann Intern Med 130:563-569, 1999 31. Covinsky KE, Martin GE, Beyth RJ, et al: The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients. J Am Geriatr Soc 47:532-538, 1999[Medline] 32. Stevens J: Impact of age on associations between weight and mortality. Nutr Rev 58:129-137, 2000[Medline] 33. Agostini JV, Leo-Summers LS, Inouye SK: Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Arch Intern Med 161:2091-2097, 2001 34. Repetto L, Fratino L, Audisio RA, et al: Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: An Italian group for geriatric oncology study. J Clin Oncol 20:494-502, 2002 35. Extermann M, Meyer J, McGinnis M, et al: A comprehensive geriatric intervention detects multiple problems in older breast cancer patients. Crit Rev Oncol Hematol 49:69-75, 2004[Medline] 36. McCorkle R, Strumpf NE, Nuamah IF, et al: A specialized home care intervention improved survival among older post-surgical cancer patients. J Am Geriatr Soc 48:1707-1713, 2000[Medline] 37. Garman KS, McConnell ES, Cohen HJ: Inpatient care for elderly cancer patients: The role for Geriatric Evaluation and Management Units in fulfilling goals for care. Crit Rev Oncol Hematol 51:241-247, 2004[CrossRef][Medline] 38. Balducci L, Yates J: General guidelines for the management of older patients with cancer. Oncology (Williston Park) 14:221-227, 2000[Medline] Submitted May 26, 2005; accepted February 28, 2006.
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
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