How many and which items of activities of daily living (ADL) and instrumental activities of daily living (IADL) are necessary for screening

Transcription

1 Critical Reviews in Oncology/Hematology 62 (2007) Contents How many and which items of activities of daily living (ADL) and instrumental activities of daily living (IADL) are necessary for screening Bernd Roehrig a,b, Klaus Hoeffken a, Ludger Pientka c, Ulrich Wedding a,c, a Clinic for Internal Medicine II, Department of Haematology and Medical Oncology, Friedrich-Schiller-University Jena, Erlanger Allee 101, Jena, Germany b Institute of Medical Biometry, Epidemiology and Informatics, Johannes Gutenberg University Mainz, Obere Zahlbacher Strasse 69, Mainz, Germany c Department of Geriatrics, Ruhr-University Bochum, Marienhospital Herne, Widumer Strasse 8, Herne, Germany Accepted 20 October Introduction Methods Patients Instruments of geriatric assessment Activities of daily living (ADL) Instrumental activities of daily living (IADL) Selection process Statistical methods Results Patients characteristics ADL ADL: single items and sum score ADL: selection process Summary ADL IADL IADL: single items and sum score IADL: selection process Summary IADL Correlation between ADL and IADL Discussion Reviewers References Biography Abstract Geriatric assessment (GA) in elderly cancer patients serves as screening instrument to identify patients who are vulnerable or frail. To reduce the diagnostic burden for patients and caregivers, we asked how many and which items of ADL and IADL questionnaires are necessary to identify those patients with limitations in the sum score of ADL or IADL. Data of 327 elderly patients (age 60 years), of whom 27.9% Corresponding author at: Klinik und Poliklinik für Innere Medizin, Erlanger Allee 101, Jena, Germany. Tel.: ; fax: address: Ulrich.Wedding@med.uni-jena.de (U. Wedding) /$ see front matter 2006 Elsevier Ireland Ltd. All rights reserved. doi: /j.critrevonc

2 B. Roehrig et al. / Critical Reviews in Oncology/Hematology 62 (2007) had limitations in ADL and 36.0% in IADL score, were entered in a forward selection model. Four out of ten items of ADL identified 95.3% of patients with limitations in ADL. Two out of eight items of IADL identified 97.4% of patients with limitations in IADL. The combined use of these items recognised 98.5% of patients with limitations in ADL or IADL score. If ADL and IADL scores are used for screening, we recommend an abbreviated version with 6 instead of 18 items Elsevier Ireland Ltd. All rights reserved. Keywords: Geriatric assessment; Activities of daily living (ADL); Instrumental activities of daily living (IADL); Elderly patients; Selection of items; Cancer; Geriatric oncology 1. Introduction Cancer is a major public health problem in the United States and other developed countries. Currently, one in four deaths in the United States is due to cancer. Cancer has surpassed heart disease as the leading cause of death for those younger than age 85. About 30% of all cancer deaths occur in patients aged 80 and older [1]. About 60% of patients diagnosed with cancer are older than 65 years of life. Due to the demographic changes, the number of elderly people will increase within the next decades. Together with the age associated rise in incidence of malignant tumours, this will lead to a substantial increase in the number of elderly people with cancer [2]. Geriatric assessment (GA) in elderly cancer patients shall identify those patients who are vulnerable or frail. Among other instruments (e.g. timed up&go test, mini-mental state examination (MMSE), mini-nutritional assessment (MNA), geriatric depression scale (GDS), etc.) GA includes activities of daily living (ADL) and instrumental activities of daily living (IADL) [3,4]. ADL describe activities essential for self-care like bathing, dressing and feeding. The ADL scale represents the most basic activities involved in everyday independent function. IADL describe activities necessary for adaptation to the environment and emphasise community activities like shopping, cooking, transportation and housekeeping. The activities of IADL are more cognitively influenced [5]. To conduct a complete GA is time consuming and a burden for patients and caregivers. A screening tool allows to recognise patients with limitations and reduces the number of patients with the need for a complete GA. Therefore the selection of the most sensitive items of the ADL and IADL scales seems reasonable. Overcash et al. described in a population of elderly cancer patients (>70 years, any diagnosis and stage of disease) the construction of an abbreviated comprehensive geriatric assessment (acga) with a reduced number of items for MMSE, GDS, ADL and IADL. They selected three out of six ADL items and 4 out of 10 IADL items. Their criterion for selection of an item was highest item-to-total correlation [6]. The aim of the presented study is to predict the dichotomous appraisal (i.e. patient with limitations or without limitations ) for the ADL and IADL sum score on the basis of a preferably low number of items. In a second step, the selected items are added to a combined score. 2. Methods Within a larger prospective trial on decision making in elderly cancer patients, we have full data of ADL or IADL of 327 patients, thereof 198 elderly cancer patients and 129 elderly non-cancer patients, admitted for acute medical problems as in-patients to our hospital. The trial was approved by the ethical committee of Friedrich-Schiller-University in Jena and supported by the German Cancer Aid (Grant: Hö-3). Written informed consent was obtained after patients had been informed on their diagnosis and after the recommendation to treat their cancer with chemotherapy Patients Patients were recruited at the Department of Haematology and Oncology at the Friedrich-Schiller-University of Jena. Elderly Cancer patients (ECP) had to fulfil the following inclusion criteria: age 60 years and older, malignant tumour, independent of type of histology and stage of disease, newly treated with chemotherapy for this indication, ability to participate in the test battery and informed consent. Elderly medical patients (EMP) had to fulfil the following inclusion criteria: age 60 years and older, admitted as in-patients for acute hospital care due to non-cancer reasons. Exclusion criteria were defined for both groups as severe dementia or need of intensive care treatment Instruments of geriatric assessment Activities of daily living (ADL) ADL-score was assessed according to the Barthel-Index [7]. This questionnaire comprises 10 items ( eating, transferring from bed to chair, doing personal toilet, toilet use, taking a bath or a shower, walking on a corridor, ascend and descend stairs, dressing, bowel continence, urine continence ). The items of ADL represent physical self-maintenance and recognise limitations of persons in these fields. Each single item could be subsumed to the dichotomous outcome with help or independent. Full credit (this means independent ) for an activity/item was not given if the patient needed help. A sum score of all 10 items was calculated and patients were classified into those without limitations in case of full sum score (=100%) and those with limitations in case of sum score below <100%.

3 166 B. Roehrig et al. / Critical Reviews in Oncology/Hematology 62 (2007) Instrumental activities of daily living (IADL) IADL-score was assessed according to the score published by Lawton and Brody [8]. This questionnaire comprises eight items ( ability to use telephone, shopping, food preparation, housekeeping, laundry, travelling via car or public transportation, medication use, ability to handle finances ). The IADL-score is an enhancement to ADL describing everyday functional competence and the ability to adapt independently to the environment [5,9]. Analogous to the interpretation of the ADL, each single item of the IADL could be subsumed to the dichotomous outcome with help or independent. A sum score of all eight items was calculated and patients were classified in those without limitations in case of full sum score (=8) and into those with limitations in case of sum score <8. If at least one single item was assessed with help (score: =0), the dichotomous appraisal of this patient was with limitations Selection process Items were entered in a forward selection model step by step. In the first step the variable with the best predictive value concerning the dichotomous outcome with (i.e. sum score <100) or without limitation (i.e. sum score = 100) was selected. In the second step the variable from first step was combined with the second variable with the best additional predictive value for limitations in sum score (dichotomous outcome). This procedure was repeated as long as additional patients with limitation were recognised. The process was performed separately for ADL and IADL. Due to the coherence of ADL and IADL the items of both questionnaires were combined and predictive power of the separately selected items was calculated Statistical methods Data collection, data management and data analysis was performed with statistical packages SPSS Version 12 and SAS Release To assure high quality of data concerning completeness, rightness and consistency, plausibility checks were performed. Statistical measurements (frequency, relative frequency, mean and standard deviation (S.D.)) were calculated for the variables. To test statistical significance between groups Fisher s exact test was used. The outcome of a statistic test with p-value < 0.05 is called significant and with p-value < 0.10 a trend. 3. Results 3.1. Patients characteristics From 327 patients data of ADL or IADL items were available, thereof 198 ECP and 129 EMP. Characteristics of patients are summarised in Table 1. More men took part in the group of ECP (55.6%) compared to EMP (34.1%). The mean age of ECP was 70.3 (S.D. = 6.9) and of EMP 71.5 (S.D. = 7.1) years. Diagnoses of EMP were diabetes mel- Table 1 Patients characteristics (ECP, EMP) ECP (N, /%) EMP (N, /%) Total 198/41.0% 129/26.7% Sex Male 110/57.7% 44/34.1% Female 88/44.4% 85/65.9% Age groups years 128/55.4% 65/48.9% years 84/36.4% 48/36.1% >80 years 19/8.2% 20/15.0% Diagnosis Malignant lymphoma 51/25.8% Acute leukaemia 28/14.1% Colorectal cancer 17/8.59 Cardia und stomach cancer 14/7.1% Multiple myeloma 10/5.1% Pancreatic cancer 13/6.6% Carcinoma of unknown primary 9/4.5% Sarcoma 4/2.0% Chronic leukaemia 10/5.0% Oesophagus cancer 6/3.0% Lung cancer 9/4.6% Breast cancer 5/2.5% Others 22/11.1% Kind of tumour Haematological 105/53.0% Solid 93/47.0% Treatment approach Palliative 154/77.8% Curative 44/22.2% litus (43.4%), heart disease (13.2%), disorder of liver/gall bladder/pancreas (12.4%), benign haematological disease (10.1%), gastrointestinal tract disease (7.8%) and others (13.2%) ADL ADL: single items and sum score From 308 patients data of ADL without missing items were available. Table 2 shows the single items and sum score (dichotomous: with or without limitations) for the two groups of patients. Between ECP and EMP no statistically significant differences existed neither concerning the single items (p-values between and 1.000) nor concerning the sum score (pvalue = 0.369). Therefore the data were subsumed for the following selection process. The frequency of limitations in the ADL is little higher in elderly women (all 32.1%; ECP 32.5%; EMP 32.3%) than in elderly man (all 22.9%; ECP 21.0%; EMP 27.3%), but the results remained insignificant (p = 0.125). At single item level the difference between gender was significant in taking a bath or a shower (p = 0.025), a trend could be observed in transferring from bed to chair (p = 0.064) and in dressing (p = 0.060).

4 B. Roehrig et al. / Critical Reviews in Oncology/Hematology 62 (2007) Table 2 Frequency of the 10 items and sum score of the ADL (dichotomous: with or without help) depending on patients group (ECP, EMP) ADL Total Without help With help N % N % N % Eating ECP EMP Total Transferring from bed to chair ECP EMP Total Doing personal toilet ECP EMP Total Toilet use ECP EMP Total Taking a bath or a shower ECP EMP Total Walking on a corridor ECP EMP Total Ascend and descend stairs ECP EMP Total Dressing ECP EMP Total Bowel continence ECP EMP Total Urine continence ECP EMP Total Sum score ECP EMP Total ADL: selection process Eighty-six out of 308 patients (27.9%) had limitations in the ADL. The single item most often affected was ascending and descending stairs in 66 patients (21.4%) (Table 2). Furthermore, the patients showed restrictions in walking on a corridor (n = 48, 15.6%), transferring from bed to chair (n = 33, 10.7%), dressing (n = 25, 8.1%), taking a bath or a shower (n = 22, 7.1%) and urine continence (n = 19, 6.2%). Toilet use (n = 14, 4.5%), bowel continence (n =9, 2.9%), doing personal toilet (n = 7, 2.3%), and eating (n = 6, 1.9%) were of little importance only in these group of elderly patients. In the first step of the selection process, ascend and descend stairs recognised limitations of two third of the 86 restricted patients (n = 66, 76.7%) (Table 3). With the addition of urine continence as second item, the limitations of 74 patients (86.0%) could be recognised. The further inclusion of walking on a corridor recognised the limitations of 79 patients (91.8%). The addition of taking a bath or a shower recognised the limitations of 82 patients (95.3%). With the further inclusion of bowel continence and transferring from bed to chair, 97.7 and 100.0% of the patients with limitations in ADL could be recognised. It should be mentioned that the items ascend and descend stairs, walking on a corridor and transferring from bed to chair are not independent. The variables have a hierarchical structure. If patients need help in transferring from bed to chair, they also need help in walking on a corridor in 75.8% and in ascend and descend stairs in 90.9%. Patients who need help in walking on a corridor, in 89.6% need help in ascend and descend stairs Summary ADL We summarise that the four items ascend and descend stairs, urine continence, walking on a corridor and taking a bath or a shower recognise 95.3% of the patients with limitations in the ADL. For recognition of all patients with limitations, the two items bowel continence and transferring from bed to chair had to be added IADL IADL: single items and sum score For 325 patients data of IADL without missing items were available. Table 4 shows the single items and the sum score (dichotomous: with or without help) of IADL for the two patient groups. No significant differences existed between ECP and EMP, neither in single items nor in the sum score (p-values between and 1.000). Therefore the data were subsumed for the selection process. The frequency of limitations in the IADL was higher in elderly women (all 39.5%; ECP 41.4%; EMP 37.6%) than in elderly man (all 32.0%; ECP 33.0%; EMP 29.5%), but the result remained insignificant (p = 0.167). On single item level, in six out of eight items women had higher frequencies of the

5 168 B. Roehrig et al. / Critical Reviews in Oncology/Hematology 62 (2007) Table 3 Selection of the best suitable predictors for the ADL (ECP + EMP) Step Items N Frequency of patients with limitations (%) First Ascend and descend stairs Second +Urine continence Third +Walking on a corridor Fourth +Taking a bath or a shower Fifth +Bowel continence Sixth +Transferring from bed to chair Relative frequency of recognised patients with limitations (%) Table 4 Frequency of the eight items and sum score of the IADL (dichotomous: with or without help) depending on patients group (ECP, EMP) IADL Total Without help With help N % N % N % Ability to use telephone ECP EMP Total Shopping ECP EMP Total Food preparation ECP EMP Total Housekeeping ECP EMP Total Laundry ECP EMP Total Travelling via car or public transportation ECP EMP Total Medication use ECP EMP Total Ability to handle finances ECP EMP Total Sum score ECP EMP Total dichotomous outcome with help, but only in shopping this was significant (p < 0.001) IADL: selection process One hundred and seventeen out of 325 patients (36.0%) had limitations in the IADL. Shopping with limitations in 96 patients (29.5%) was the most affected item (Table 4). Furthermore, the patients showed restrictions in food preparation (n = 77, 23.7%), wash clothes (n = 40, 12.3%) and medication use (n = 23, 7.1%), travelling via car or public transportation (n = 14, 4.3%) and housekeeping (n = 14, 4.3%). Ability to use telephone (n = 2, 0.6%) and ability to handle finances were of minor importance. In the first step of the selection process, shopping recognised the limitations of n = 96 (82.1%) of the 117 patients with limitations (Table 5). Together with the next best additional predictor food preparation, 97.4% (n = 114) of the restricted patients could be recognised. The further inclusion of items like medication use, laundry and travelling via car or public transportation improved the model about one recognised patient to recognition rates of 98.3%, 99.1 and 100.0%, respectively Summary IADL The two items shopping, and food preparation recognised 97.4% of the patients with limitations in the IADL. For recognition of all patients with limitations the three items medication use, laundry and travelling via car or public transportation had to be added Correlation between ADL and IADL Sum score of ADL and IADL as well as some single items of both measures highly correlate. Spearman correlation coefficient of sum scores of ADL and IADL amounted to r = Strong correlation exists also between the two items of ADL ascend and descend stairs and walking on a corridor and the two items of IADL shopping and food preparation (Spearman correlation coefficients amounted from 0.46 to 0.52). The 57.8% of patients with limitations in the IADL had also limitations in the ADL. On the other hand, patients with limitations in the ADL had a 73.3% chance to be limited in the IADL (Table 6). Only 20.9% of the patients without limitations in the ADL had limitations in the IADL. Only

6 B. Roehrig et al. / Critical Reviews in Oncology/Hematology 62 (2007) Table 5 Selection of the best suitable predictors for the IADL (ECP + EMP) Step Items N Frequency of patients with limitations (%) First Shopping Second +Food preparation Third +Medication use Fourth +Laundry Fifth +Travelling via car or public transportation Relative Frequency of recognised patients with limitations (%) Table 6 Association of ADL and IADL (ECP + EMP) IADL a <8 =8 Total N Row (%) Column (%) N Row (%) Column (%) N Row (%) Column (%) ADL b < = Total a IADL = 100: without limitations; IADL < 100: with limitations. b ADL = 8: without limitations; ADL < 8 with limitations. 11.7% of patients who had no limitations in IADL were limited in the ADL. In our trial, 23 patients out of 306 (7.5%) were involved. It should be mentioned that 21 of these 23 patients (91.3%) had a relative high ADL sum score of 90 or 95 (lowest ADL sum score = 80). If one combines items out of the 10 items of the ADL and the eight items of the IADL to define patients with limitations either in IADL or in ADL, the six selected items (four selected items of ADL, two selected items of IADL) recognise 130 of the 132 (98.5%) patients with limitations. This means that sensitivity of predicting patients with limitations is 98.5%. Specificity of predicting patients without limitation in ADL or IADL was 100.0%, this means that all patients without limitations (patients have no item with help) were recognised correctly. 4. Discussion GA is part of an integral care for elderly patients. It is a diagnostic tool, which recognises deficits and resources of the old patient. Detected deficits have to be addressed by more detailed diagnostic procedures, which enable a precise diagnosis and then treatment or interventions. Within the last years, data on its integration into the care for elderly patients with cancer have been published [17]. Limitations in IADL and ADL have been identified as of prognostic significance for survival in an unselected group of elderly cancer patients [10] and IADL limitations as predictive for survival in elderly patients with advanced non-small cell lung cancer (NSCLC) [11] and in patients with acute myeloid leukaemia (AML) [12]. Thus a number of recently published data demonstrate that geriatric assessment in general [13] and ADL and IADL limitations especially are of prognostic relevance in elderly patients with cancer. It is therefore recommended to perform a comprehensive geriatric assessment when treating elderly patients with cancer [3,4,14]. Within a geriatric assessment, a stepwise process is useful to identify in a first step those patients who screen negative for limitations in geriatric assessment and to perform a complete assessment only in those patients who are identified within the screening as being at high risk for detection of further limitations [15]. The aim of the present study is to provide a tool which is able to identify patients with limitations of ADL and IADL with a minimum of suitable items and consequently works as a screening instrument. ADL and IADL were assessed in two patient groups, ECP and EMP. It is remarkable that between the different patient groups neither in ADL nor in IADL statistical significant differences concerning sum score as well as single items were found. Differences to the data reported by other authors, which are summarised in Table 7, might been related to the fact that we included quite young patients (aged 60 years and older), that our population includes a unproportional high number of patients with haematological malignancies, and that very common cancer types such as breast cancer and lung cancer are underrepresented. Data showed that the use of the four selected items ascend and descend stairs, urine continence, walking on a corridor and taking a bath or a shower recognised 95.3% of the limitations in ADL in a sample of older patients. For recognition of all patients with limitations in the ADL, two items ( bowel continence and transferring from bed to chair ) must be added. Instead of assessing urine continence and bowel continence separately the item continence could be used. This is in coherence with the questionnaire of Katz et

7 170 B. Roehrig et al. / Critical Reviews in Oncology/Hematology 62 (2007) Table 7 Results of ADL and IADL measurement in elderly patients with cancer No. of patients Median age (range) limits Percent of patients with dependence in ADL Percent of patients with dependence in IADL Reference (65 94) [21] (63 91) [18] (65 92) [22] (60 88) Present report al. [16], in which only six items are used to determine ADL of patients. Due to the hierarchical structure of the three items concerning movement ( ascend and descend stairs, walking on a corridor and transferring from bed to chair ), a stepwise assessment is possible. If patients need help with ascend and descsend stairs, then the two movement-related items walking on a corridor and transferring from bed to chair need not be asked. Additionally, if patients need help with walking on a corridor, then the item transferring from bed to chair need not be asked. It can be concluded that the variables continence, taking a bath or a shower as well as ascend and descend stairs and (if the patient needs no help in this item) walking on a corridor and (if the patient needs no help in this item) transferring from bed to chair recognised all (100%) patients with limitations in ADL. Our results are very similar with the study of Overcash et al. [6]. Within a selection process they identified the three items bathing, continence and transfer for an abbreviated assessment of the ADL of old cancer patients (>70 years). The similarity of our results with that of Overcash et al. is especially remarkable because they used a different selection process. Their selection used the highest item-to-total correlation. In IADL, the two items shopping and food preparation identify 97.4% of patients with limitations in IADL. For recognising all limited patients the three variables medication use, laundry and travelling via car or public transportation must be added. Again, the result of the selection of items is very similar with the study of Overcash et al. [6]. The authors selected in their study out of ten the four items shopping meal preparation, housekeeping and laundry for an assessment of the IADL. Their exact criteria for the complete item-total correlation score (for ADL as well as IADL) are not reported, including the fact that Lawton and Brody [8] reported only 8 items for assessment of the IADL in their initial work. Peel et al. found in a sample of 998 Medicare beneficiaries aged >65 years a correlation coefficient of r = 0.68 between ADL and IADL, which is similar to that found in our patients, r = 0.65, and that reported by Extermann et al. [17,18]. Due to the high correlation of ADL and IADL, the construction of a common scale seems possible. The construction of one scale with the items of ADL and IADL was supported by Spector and Fleishman [19]. The authors demonstrate with factor analyses and item response theory feasibility and validity of combining the ADL and IADL into one scale. They emphasise that a common scale yield to an overall measure of functional disability and represent therefore a larger range compared to scales based solely on ADL or on IADL. In another study Spector et al. demonstrated that ADL and IADL functions can be combined to a single hierarchical scale with discriminative and predictive validity [9]. The ADL and IADL questionnaires have a hierarchical order, IADL represent the higher degree of limitation. Mahoney and Barthel discussed that patients with no limitations in ADL (sum score = 100) may not be able to cook, keep house, and meet the public [7]. On the other hand, patients who need help in transferring from bed or walking on a corridor probably need also help in shopping. In contrast, limitations in IADL (sum score < 8) give no hint for limitations in ADL. In our sample, 42.2% of the patients with limitation in IADL had no limitations in ADL. Otherwise only 11.7% of patients without limitations in the IADL (sum score = 8), had limitations in the ADL (sum score < 100). The holistic approach of functional status is mentioned by Katz [20] and Garman and Cohen [5]. From their point of view, assessing self-maintenance of a patient contains the three components basic ADL, mobility and IADL. The building of a common scale for ADL and IADL for the recognition of patients with limitations should include in a first step the two selected items of IADL shopping and meal preparation. If the patient needs help in at least one of these two items it can be concluded automatically that he has limitations, and the decision to perform a complete instead of an abbreviated assessment can be made at this early stage. If the patient does not need any help within these two questions, the four selected items of the ADL should be determined in the order ascend and descend stairs, urine and bowel continence, walking on a corridor and taking a bath or a shower. With these six selected items, 98.5% of the patients with limitations in ADL or IADL can be recognised. The sensitivity of the screening test is 98.5%. The selected items for a subsumed ADL and IADL scale comprises the three scales basic ADL, mobility and IADL, as suggested by Katz [20]. Some authors mention that the frequencies of the single ADL- and especially the IADL-items are different for women and men [4]. We found that only in taking a bath or a shower and in shopping women had significantly higher frequencies of limitations than men. Within the other selected items, significant differences between women and men could not be found. In accordance with the suggestion of Garman and Cohen [5], we gave advice to ask the items in the form can you do. Thus men can also answer items concerning housework, e.g. food preparation, laundry or housekeeping.

8 B. Roehrig et al. / Critical Reviews in Oncology/Hematology 62 (2007) An abbreviated GA makes the performance of a GA in elderly cancer patients easier, faster and cheaper. We provide an abbreviated form of the ADL and IADL. As screening tool 6 items can be used instead of 18. Reviewers Jean-Pierre Droz, Professor, Centre Léon Bérard, Department of Medical Oncology, 28 rue Laennec, Lyon 29008, France. Johann W.R. Nortier, Professor, Leiden University Medical Center (LUMC), Department of Clinical Oncology, K1-P, P.O. Box 9600, Leiden 2300 RC, The Netherlands. References [1] Jemal A, et al. Cancer statistics. CA Cancer J Clin 2006;56(2): [2] Edwards BK, et al. Annual report to the nation on the status of cancer, , featuring implications of age and aging on U.S. cancer burden. Cancer 2002;94(10): [3] Friedrich C, et al. Comprehensive geriatric assessment in the elderly cancer patient. Onkologie 2003;26(4): [4] Extermann M, et al. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005;55(3): [5] Garman KS, Cohen HJ. Functional status and the elderly cancer patient. Crit Rev Oncol Hematol 2002;43(3): [6] Overcash JA, et al. The abbreviated comprehensive geriatric assessment (acga): a retrospective analysis. Crit Rev Oncol Hematol 2005;54(2): [7] Mahoney FI, Barthel DW. Functional Evaluation: the Barthel Index. Md State Med J 1965;14:61 5. [8] Lawton MP, Brody EM. Assessment of older people: selfmaintaining and instrumental activities of daily living. Gerontologist 1969;9(3): [9] Spector WD, et al. The hierarchical relationship between activities of daily living and instrumental activities of daily living. J Chronic Dis 1987;40(6): [10] Zagonel V, et al. The comprehensive geriatric assessment (CGA) predicts mortality among elderly cancer patients (ECP). Proc Am Soc Clin Oncol 2002;21. p [Abstract]. [11] Maione P, et al. Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: a prognostic analysis of the multicenter Italian lung cancer in the elderly study. J Clin Oncol 2005;23(28): [12] Wedding U, et al. Prognostic significance of functional status for survival in patients with acute myeloid leukaemia. J Cancer Res Clin Oncol 2006;132(10): [13] Freyer G, et al. Comprehensive geriatric assessment predicts tolerance to chemotherapy and survival in elderly patients with advanced ovarian carcinoma: a GINECO study. Ann Oncol 2005;16(11): [14] Bernabei R, et al. The comprehensive geriatric assessment: when, where, how. Crit Rev Oncol Hematol 2000;33(1): [15] Lachs MS, et al. A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med 1990;112(9): [16] Katz S, et al. Studies of illness in the aged. The index of Adl: a standardized measure of biological and psychosocial function. JAMA 1963;185: [17] Peel C, et al. Assessing mobility in older adults: the UAB Study of Aging Life-Space Assessment. Phys Ther 2005;85(10): [18] Extermann M, et al. Comorbidity and functional status are independent in older cancer patients. J Clin Oncol 1998;16(4): [19] Spector WD, Fleishman JA. Combining activities of daily living with instrumental activities of daily living to measure functional disability. J Gerontol B Psychol Sci Soc Sci 1998;53(1):S [20] Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 1983;31(12): [21] Serraino D, Fratino L, Zagonel V. Prevalence of functional disability among elderly patients with cancer. Crit Rev Oncol Hematol 2001;39(3): [22] Repetto L, 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 2002;20(2): Biography Ulrich Wedding is physician (general internal medicine) and is specialist in haematology, oncology, and palliative care. He serves as a consultant at the Department of Haematology and Medical Oncology at the University Hospital of the Friedrich-Schiller-University Jena in Germany. Currently, he is research fellow of the Robert Bosch Foundation. His main interest in clinical research is geriatric oncology. He is active member of national and international working parties in the field of geriatric oncology.