Understanding and meeting the needs of the older population: Acknowledgements. The Shifting Face of Health Care

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1 Understanding and meeting the needs of the older population: a global l challenge Howard Bergman, MD Jewish General Hospital/ Montréal, Canada Groupe de recherche Université de Montréal/ sur les services intégrés pour les personnes âgées /Université de Montréal Research Group on Integrated Services for Older Persons SIOG main session Version Hôpital général juif Sir Mortimer B. Davis Jewish General Hospital Centre d épidémiologie clinique et de recherche en santé publique, Institut Lady Davis Centre for Clinical Epidemiology and Community Studies, Lady Davis Institute Understanding and Meeting the Needs of the Older Population: A Global Challenge Howard Bergman, MD The Dr. Joseph Kaufmann Professor and Director Division of Geriatric, Co-Director: Solidage Research Group Director Quebec Research Network in Ageing Fonds de Recherche en Santé du Québec Chair Advisory Board, Institute of Aging Canadian Institutes of Health Research Université de Montréal Département d administration de la santé Groupe de recherche Interdisciplinaire en santé (GRIS) Institut universitaire de gériatrie de Centre de recherche Montréal Acknowledgements Canadian Initiative on Frailty and Aging International working meeting on Frailty and Aging (Lausanne 23; Montreal 26) Solidage (/UdeM)-CIHR funded research team on frailty and aging Frele; International Database Inquiry on Frailty (FrDATA study) SIPA project Paris COPA project: Isabelle Vedel, Matthieu DeStampa, Joel Ankri Clair Commission Quebec Alzheimer Task Force Beijing Forum: Aging and Chronic Disease: A Global Challeng /JGH Research and Training Program Montreal (/UdeM) Consortium for the Study of Aging and Chronic Disease (MCSAC) The Shifting Face of Health Care From acute to chronic disease From institutions to networks of care; from a single site (hospital, nursing home) to many sites: home, assisted living, supportive housing, gpy physician s office, community clinics, ambulatory care centers, community hospitals, academic health centers, rehabilitation facilities, nursing homes, palliative care centers From a single professional, generally a physician to many health care professionals: family doctors, specialists, nurses, physical therapists, nutritionists, social workers, psychologists, etc. Expectations/knowledge/Involvement of patients and family Heath care systems and the challenge of aging Potential for promotion/prevention promoting healthy aging and in at least delaying onset of frailty and Interaction: health/functional status/social status and support Importance of chronic disease and impact on quality of life and progression to complex interventions (technology/medication) in increasingly older persons Health care systems poorly adapted to the management of chronic disease, frailty and dependency; complexity of treating chronic diseases and frail older persons The Demographic Transition: Life expectancy at birth (UN 21)

2 The Demographic Transition: Distribution of the world population aged 8 and over by development region, (UN, 21) The Demographic Transition: Proportion of the population aged 65 years and over in France et Mexico, over time France Mexico and over % population aged 65 years year Projected main causes of death by World Bank income group, all ages, 25 Factors affecting the epidemiologic transition rate per 1, Age-standardised death r Communicable diseases Chronic diseases Injuries Low income Lower middle income Upper middle income High income World bank income group World UNDERLYING SOCIOECONOMIC, CULTURAL, POLITICAL AND ENVIRONMENTAL DETERMINANTS Globalization Urbanisation Population aging COMMON RISK FACTORS Unhealthy diet (fast food) Physical activity Tb Tobacco use Age (prolonged exposure to risk factors) chronic disease mortality MAIN CHRONIC DISEASES Heart Disease Stroke Cancer Chronic respiratory disease Diabetes Rapid increase in chronic disease, life expectancy and number of older persons Incidence and mortality of cancer increase with age 6 4 Increase in number of older persons with disabilities 4 2 fem m es hom m es Increased burden: older person, family, community and society e t + Cancer incidence in Québec : Projection et + Cancer mortality in Québec : Projection 24

3 Heath care systems and the challenge of aging Potential for promotion/prevention promoting healthy aging and in at least delaying onset of frailty and Interaction: health/functional status/social status and support Importance of chronic disease and impact on quality of life and progression to complex interventions (technology/medication) in increasingly older persons Health care systems poorly adapted to the management of chronic disease, frailty and dependency; complexity of treating chronic diseases and frail older persons The Research Challenge Median age of newly diagnosed lung cancer patients in clinical trials is 6 (vs median 69 according to SEER) Despite receiving less chemotherapy compared to young patients, elderly patients derive a substantial survival benefit from adjuvant therapy Chemotherapy in the adjuvant setting should not be withheld from elderly patients on the basis of age alone Patients aged >75 require further study Carmela Pepe et al. Adjuvant Vinorelbine and Cisplatin in Elderly Patients: Analysis of National Cancer Institute of Canada Clinical Trials Group and Intergroup Study JBR.1 (Submitted) : the clinical challenge Factors influencing treatment decisions Patient related Life expectancy Health and functional status Family/social support/organisation Patient/family attitudes/preferences Cancer related Prognosis/treatment Physician related knowledge/attitudes/preferences Time/patience/organisation/infrastructure : the clinical challenge Underdetection / undertreatment / overtreatment Difficulty for physicians lies in selection of appropriate older person Those who appear too old or with too many comorbidities may be appropriate p Those who appear fit may be more vulnerable than we think Tailor treatment decisions on the basis of health and functional status rather than on the basis of age or impression Anticipate/prevent complications Comments by Cancer Specialists We lack tools to better evaluate chemotherapy risks in these patients. Some >8 tolerate very well chemo as opposed to others. Other than Karnofsky/ECOG, it would be interesting to have "metabolic" evaluation tools on the potential risk of toxicity from chemotherapy. Very nice work, continue! There is a need for a partnership between Oncology and Geriatrics to improve the care of older cancer patients.» Doreen Wan-Chow-Wah, Wh Johanne Jh Monette, Mihèl Michèle Monette et al. A census of cancer physicians in the province of Quebec: clinical experience with elderly patients (26-27) It would be great if we could more collaborate with geriatrician. The optimal collaboration should be in a form of a clinic present on site so in our department and participation in tumour board» Martine Puts, Véronique Girre, Johanne Monette et al. Clinical experience of physicians working in oncology and geriatric medicine involved in cancer care of older patients: a qualitative interview (26-27) Present proposed approach: geriatric assessment for all older persons presenting to oncology Core of geriatric assessment based on assessment of ADL/IADL and mental status (Folstein) Geriatric assessment not intended for independent patients affected by only one severe medical condition Older persons presenting to oncology are healthier and more independent than those presenting to geriatrics Ceiling effect if only traditional geriatric assessment is used.

4 Health and functional status of elderly cancer patients Repetto 1998 Serraino 21 Repetto 22 Exterman 23 Maione 25 Patients Age ECOG PS -1 ADL independent IADL independent (med) Comorbidities 12% <3 56% (med) xx 75 (med) % 62% 74% 83,2% 81% - 83% 86% 78,8% 85% - 41% 52% 43,8% 33% 43% 59% 64% = (Charlson) 6% = (CIRSG) 11% <3 6% MMSE - - < 24 = 33% < 26 = 25% - 2 I skate where the puck will be Wayne Gretsky IUMSP Institut universitaire de médecine sociale et préventive, Lausanne Potential Relevance of the Frailty Syndrome Improves our understanding of the aging process and ability to characterise the heterogeneity of older persons At population and clinical level: characterises health and functional status beyond and co morbidity Potential for modification, at least in early stages Frailty and are dynamic states opportunities for health promotion, prevention Gill TM et al: N Engl J Med 22 Targeting risk in non disabled older persons with chronic disease Understand health/functional characteristics Predict /expect/plan outcomes and complications Tailor intervention Cacciatore et al. Eur J Clin Invest 25 Ferrucci et al. Reviews in Oncology/Hematology 23 Retornaz et al Journal of Geronto: med sciences 28 Puts M Cancer and Aging longitudinal study Afillalo J. Cardiac surgery and Aging Bergman S General Surgery and Aging Health and functional status of cancer patients, aged 7 years and older referred for chemotherapy- preliminary findings % % (n=6) Without frailty markers or IADL / ADL 42% (n=21) With frailty markers but without IADL / ADL 3% (n=15) IADL disabled without ADL 16% (n=8) ADL disabled Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H. Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for chemotherapy Journal of Gerontology; Medical Sciences 28 Objectives of the /JGH longitudinal study on Cancer and Aging To identify clinical, functional and biological predictors based on frailty and oncology literature for adverse treatment outcomes in newly diagnosed cancer patients and to investigate health and functional trajectories of older cancer patients during a two- to -five year period. To develop of a screening tool to be used by oncologists to identify older patients with potential vulnerabilities and with health problems that should be addressed before ordering cancer treatment. These patients could then benefit from a Geriatric consultation or other types of intervention. Puts M, Monette J, et al Collaboration with Singapore and France Embracing the heterogeneity and complexity Healthy older persons Primary medical care, Health assessment/promotion/prevention Early frail/low risk/chronic disease Primary medical care, Chronic disease management, detection of vulnerability Medium risk/mild-moderate Primary medical care and home care, chronic disease management. Specialized Geriatric care, Disability and complex systems of integrated care End of life care

5 La Chaire D Objectives r Joseph Kaufmann en gériatrie Improve care of older persons with cancer by promoting increased population, biological, clinical (including clinical trials) research on older persons with cancer A better understanding of the health and functional characteristics and the trajectories of older persons with cancer Tailor treatment decisions on the basis of health and functional status rather than on the basis of age or impression Anticipate/prevent complications Objectives Develop a systematic clinical approach to the assessment and management of older persons with the appropriate instruments for oncologists, geriatricians, primary care physicians and other specialists and health care professionals Develop an appropriate collaborative care model among oncology, geriatric medicine and primary care Education/training for MD s, nurses and other professionals Promote informed attitudes and decision making for clinicians, patients and families based on evidence Acknowledgements Investigators: Doreen Wan-Chow-Wah MD Johanne Monette MD MSc Carmela Pepe MD MSc (cand) Christina Wolfson PhD Gerry Batist MD Howard Bergman MD Post doc: Martine Puts PhD Fellows: Frédérique Retornaz MD Véronique Girre MD Research associates: Michèle Monette MSc Nadia Sourial MSc