The role of the Geriatrician

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1 Post-operative management of the older adults with cancer The role of the Geriatrician Sofia Duque Hospital Beatriz Ângelo Geriatric University Unit Faculty of Medicine of Lisbon Geriatrics Study Group Portuguese Society of Internal Medicine European Academy for Medicine of Aging

2 The heterogeneity of patients Cancer Diagnosis (or suspicion) Preoperative Comprehensive Geriatric Assessment No Cancer Diagnosis W/O Preoperative Comprehensive Geriatric Assessment Neoadjuvant Treatment Elective Surgery Urgent / Emergency Surgery Prostatic Colorectal Bladder Gastric Curative Palliative

3 The heterogeneity of patients TREATMENT SIDE EFFECTS & TOXICITY Hanson LC, et al. J Clin Oncol. 2010;28(12):1975-6

4 The heterogeneity of patients Different patients... Different scenarios Robustness / Frailty Chronic conditions Geriatric syndromes Age-related changes Life expectancy Type of cancer, staging and prognosis Type of surgery & physiological & functional implications Treatment complications Previous & Next Treatments Goals Social & Economic Support Expectations (patient, family, oncologist, surgeon) QoL and symptoms

5 The heterogeneity of patients COMPREHENSIVE GERIATRIC ASSESSMENT INDIVIDUALIZE The role of the Geriatric Interdisciplinary Team Cesari M et al. J Am Med Dir Assoc Feb;12(2):153-9

6 The heterogeneity of patients COMPREHENSIVE GERIATRIC ASSESSMENT COGNITION NUTRITION SENSORY FUNCTIONS EMOTIONS ACUTE COMPLICATIONS CHRONIC DISEASES MOBILITY FUNCTIONAL STATUS SOCIAL & FINANCIAL SUPPORT QUALITY OF LIFE Caillet P et al. Interv Aging. 2014;9:

7 Acute Complications CARDIOVASCULAR Heart Failure Myocardial infarction Arrhythmia Hypotension HYDROELECTROLYTIC AKI (prerenal) Hypovolemia Hypokalemia Hyponatremia THROMBOEMBOLISM RESPIRATORY Atelectasis Hypoxia / Hypercarbia Pneumonia INFECTIONS Surgery wound Respiratory Urinary Sepsis ANEMIA Loran DB et al. Surg Clin North Am. 2005;85: CONSTIPATION

8 Acute Complications GERIATRIC SYNDROMES DELIRIUM AKI (prerenal) Hypovolemia PAIN Hypokalemia Hyponatremia Atelectasis Hypoxia / Hypercarbia Pneumonia MALNUTRITION INFECTIONS IMMOBILITY Surgery wound Respiratory Urinary Sepsis Prevalent Underdiagnosed Undertreated Loran DB et al. Surg Clin North Am. 2005;85:

Acute Complications DELIRIUM Post surgery prevalence 10-80% Challenging diagnosis to untrained healthcare professionals (hypoactive) Underlying medical condition Several predisposing factors in older

9 Acute Complications DELIRIUM Post surgery prevalence 10-80% Challenging diagnosis to untrained healthcare professionals (hypoactive) Underlying medical condition Several predisposing factors in older people Several precipitating factors in post surgery Use of physical restraints Immobilization Malnutrition Respiratory failure Dehydration Uncontrolled pain Predictor of poor surgical outcome, morbidity and mortality Post operative (Irreversible) Cognitive Dysfunction

Acute Complications PAIN Cause of delirium and respiratory complications Challenging diagnosis in depressed and cognitive impaired patients Consider age-related

10 Acute Complications PAIN Cause of delirium and respiratory complications Challenging diagnosis in depressed and cognitive impaired patients Consider age-related changes in pharmacokinetics and pharmacodynamics on analgesics prescription and drugs interactions (polypharmacy) Prescription of non pharmacological interventions

Acute Complications MALNUTRITION Cancer and surgery as risk factors Predictor of poor surgical outcome, postoperative complications, functional decline,

11 Acute Complications MALNUTRITION Cancer and surgery as risk factors Predictor of poor surgical outcome, postoperative complications, functional decline, morbidity and mortality Predictor of chemotherapy intolerance and treatment side effects Nutritional Intervention Marin Caro MM, et al. Clin Nutr. 2007;26:

Acute Complications IMMOBILITY Negative impact on several organ systems Malnutrition and muscle wasting Delirium Orthostatic hypotension Respiratory complications

12 Acute Complications IMMOBILITY Negative impact on several organ systems Malnutrition and muscle wasting Delirium Orthostatic hypotension Respiratory complications Pressure ulcers Deep Venous Thrombosis Functional decline Gait impairment Early Physiotherapy and Occupational Therapy Balducci L, et al. Acta Oncol. 2013;52:233-8

Planning discharge Preparing future Restart / Review chronic medication Assessment & Management of Geriatric Syndromes Motor & Functional Rehabilitation Optimize Nutritional Status and Mood

13 Planning discharge Preparing future Restart / Review chronic medication Assessment & Management of Geriatric Syndromes Motor & Functional Rehabilitation Optimize Nutritional Status and Mood (Depression) Education about new conditions (catheters, ostomies, ) Palliation of disturbing symptoms (QoL) Prepare transitions of care Provide nurse care, social services and financial support Prepare for future treatments (compensation of chronic diseases, anticipation of complications and toxicities, education of patient and caregivers) Clarify patients expectations

14 TAKE HOME MESSAGES The role of the Geriatric Interdisciplinary Team To understand heterogeneity and vulnerability of the surgical oncologic older patient To individualize care To anticipate, prevent and treat Acute Complications To detect previous or new Geriatric Syndromes To plan rehabilitation to restore previous functional status To plan discharge and transitions of care To prepare for future treatments

15 Thank You for Your attention! Sofia Duque

16 The Geriatrician philosophy Diagnosis PALLIATIVE CARE (=supportive, symptom-oriented) CURATIVE TREATMENT (=disease-specific, life-prolonging, restorative) Death

Summary of Delirium Clinical Practice Guideline Recommendations Post Operative

Summary of Delirium Clinical Practice Guideline Recommendations Post Operative Intensive Care Unit Clinical Practice Guideline for Postoperative Clinical Practice Guidelines for the Delirium in Older Adults;