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INTEGRAL GERIATRIC VALUATION

INTEGRAL GERIATRIC VALUATION. ONE MORE STEP IN ELDERLY CANCER PATIENT´S MEDICAL RECORD. MARTA SARABIA UNIBASO IBÓN MENDIOLAGARAY BILBAO DR. JAVIER GONZALEZ HERNÁNDEZ. ¿WHY?. DIAGNOSTIC INFRAVALORATION Less radical treatments

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INTEGRAL GERIATRIC VALUATION

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  1. INTEGRAL GERIATRIC VALUATION ONE MORE STEP IN ELDERLY CANCER PATIENT´S MEDICAL RECORD MARTA SARABIA UNIBASO IBÓN MENDIOLAGARAY BILBAO DR. JAVIER GONZALEZ HERNÁNDEZ

  2. ¿WHY? • DIAGNOSTIC INFRAVALORATION • Less radical treatments • Minor quantity of clinical research teams Mean Age in Internal Medicine departments - 1985 60´6 years - 2010 79´9 years >65 years, main age group in Oncology HOWEVER… Therapeutic decisions should NOT BE INFLUENCED BY AGE but by the MEDICAL PRACTICE

  3. OBJECTIVE IGV way to TRIAGE elderly cancer patients Set another step in Medical Record Set up individualized treatment patterns FUTURE: Geriatricians, internists, oncologists, palliative care, general practisioners WALKING towards THE SAME GOAL ELDERLY CANCER PATIENT

  4. WORKING METHOD Students performing the Internal Medicine practices, will receive a notebook or a guide to make correctly the Medical Record With the guide they´ll receive a triptych with IGV TRIPTYCH = TRIAGE Pictogram Schulman´s clock test In Schulman´s test we ask the patient to draw a circle, put the numbers like a watch and set 11 : 10 Our clock in the pictogram is open and we´ll close and order it properly, when we finish correctly the Medical Record and the Integral Geriatric Valuation.

  5. MATERIALS • FRAGILITY • FUNCTIONAL ASESSMENT • MENTAL ASESSMENT • SOCIAL ASESSMENT • COMORBILITIES • MALNUTRITION • GERIATRIC SYNDROMES • DRUGS • BADL • IADL • AADL • Pfeiffer • Schulman IGV pictograms & tests Triptych Medical Record Guide + IGV

  6. LET´S ORDER IT!!

  7. 3 m FRAGILITY: TIMED UP & GO TEST • Deterioration of the phisiological reserves. • Makes de patient more vulnerable • Disturbs his reply to stress 0 – 10 s. = Normal 11 – 20 s. = Fragility 21 – 30 s. = Failure risk >31 s. = High risk FRAGILITY = DISABILITY RISK

  8. FUNCTIONAL ASESSMENT Basic Activities of Daily Living (BADL) (Barthel) 0: Dependent 5: Independent 0: Dependent 5: High failure risk 10: Low failure risk 15: Independent SCORE 0: Dependent <40: Severe dependence 40-60: Moderate dependence >60: Mild dependence 100: Independent 0: Dependent 5: Needs help 10: Independent

  9. ABVD (Barthel) FUNCTIONAL ASESSMENT 0: Dependent 5: High failure risk 10: Low failure risk 15: Independent • BADL scales: Barthel, Katz, Cruz Roja,… • Barthel Most commonly used (recommended by the British Geriatrics Society) • Advantage Quick, simple, complete and easy to score • Disadvantage “Ceiling – Floor” effect • We´ve chosen Barthel scale because: • - Katz scale is very complete and commonly used in practice but to make a • triage is slower and the scoring is more complicated. • - Cruz Roja´s scaletarget is disability. It doesn´t work like a functional • assesment test. Moreover is too subjective and with a high interviewer variability 0: Dependent 5: Needs help 10: Independent 0: Dependent 5: Independent 0: Dependent <40: Severe dependence 40-60: Moderate dependence >60: Mild dependence 100: Independent

  10. FUNCTIONALASESSMENT = 1 = 0 0= Totally Dependent 8= Independent Lawton & Brody Instrumental Activities of Daily Living (IADL)

  11. = 1 = 0 0 = Dependent 8 = Independent FUNCTIONAL ASESSMENT Lawton & Brody (AIVD) • IADL scales: Lawton & Brody, VIDA,… • Lawton & Brody: Most commonly used scale • Advantages: Quick and simple. • Disadvantages: Gender bias • VIDA test is a modification of the Lawton & Brody scale and is • very complete. It also overcomes the gender bias. But is slower • than Lawton´s to score. • IADL loss Fragility predictor SIU & Reuben (AADL) SIU & Reuben scale. We have cut some of AADL the items of the scale because some of them are repeated in BADL and other tests

  12. FUNCTIONAL ASESSMENT Advanced Activities of Daily Living (AAVD) SIU - Reuben

  13. = 1 = 0 0 = Dependent 8 = Independent FUNCTIONAL ASESSMENT Lawton & Brody (AIVD) • IADL scales: Lawton & Brody, VIDA,… • Lawton & Brody: Most commonly used scale • Advantages: Quick and simple. • Disadvantages: Gender bias • VIDA test is a modification of the Lawton & Brody scale and is • very complete. It also overcomes the gender bias. But is slower • than Lawton´s to score. • IADL loss Fragility predictor SIU & Reuben (AADL) SIU & Reuben scale. We have cut some of AADL the items of the scale because some of them are repeated in BADL and other tests

  14. MENTAL ASESSMENT Pfeiffer test + Schulman • Pfeiffer test vs Minimental • Quicker • Easier • Less influenced by the • educational and cognitive • level, etnia and age. >5 points Pathological score

  15. MATERIALS • FRAGILITY • FUNCTIONAL ASESSMENT • MENTAL ASESSMENT • SOCIAL ASESSMENT • COMORBILITIES • MALNUTRITION • GERIATRIC SYNDROMES • DRUGS • BADL • IADL • AADL • Pfeiffer • Schulman IGV pictograms & tests Triptych Medical Record Guide + IGV

  16. GERIATRICSYNDROMES • Typical disorders in elderly patients • Deterioration of elderly´s health • Appearence Cumulative effect • Make the patient more frail • Know them will help us to follow a right • propaedeutic • Incontinence • Constipation • Gait disturbance • Immobility • Decubitus ulcers • Sarcopenia • Dementia • Sensory deprivation • Dreaming disorders • Dehydration

  17. SCHULMAN IGV TRIPTYCH

  18. = 1 = 0 CLINICAL ASESSMENT ABVD (Barthel) GERIATRIC SDs. (10) Incontinence Constipation Gait disturbance Immobility Decubitus ulcers Sarcopenia Dementia Sensory deprivation Dreaming Disorders Dehydration DRUGS Number ____ Duplicity YES NO Interaccions YESNO 0: Dependent 5: High failure risk 10: Low failure risk 15: Independent 3m <10s = Normal 11 - 20s = Frail 21 – 30s = Failure risk >31s = High risk TIME UP & GO GERIATRIC SDs. • BADL (BARTHEL) • IADL (LAWTON) • AADL (SIU) SCHULMAN 0: Dependent 5: Needs help 10: Independent FUNCTIONAL ASESSMENT 0: Dependent <40: Severe dependence 40-60: Moderate dependence >60: Mild dependence 100: Independent 0: Dependent 5: Independent MENTAL ASESSMENT (Pfeiffer + Schulman) COMORBILITY IADL MENTAL ASESSMENT (4) NUTRITION • SOCIAL ASESSMENT • Family • Family economy • Dwelling • Connivance • ZBI APETITE/ANOREXIA 8 = Independent 0 = Dependent NUTRITIONAL VALUATION (last 3 months) EMACIATION (>10% peso/3kg) IMC (<19) CP(<31) Pathological score: >5 errors

  19. IGV Group III FRAIL • Group II • Dependent for 1 or more AIVD • or • 1 – 2 comorbilities Group I Independent without comorbilities Life expectancy > cancer + Treatment tolerance Life expectancy< cancer YES NO BALDUCCI´S ALGORITHM PALLIATIVE CARE CURATIVE TREATMENT

  20. CONCLUSIONS • The main conclusion we have reached is that IGV is BENEFICIAL to both the PATIENT and the STUDENTS and DOCTORS. • Beneficial to the patient Individualized treatment • Beneficial to the students, doctors Despite the tests and scales help us to triage and diagnose the patients and as a consecuence, help us to decide a treatment… Global view of the elderly cancer patient´s fragility SHOULD NOT SUBSTITUTE ANYTIME THE MEDICAL CRITERIA

  21. NOT SEE THE FOREST FOR THE TREES!!

  22. CONCLUSIONS • Male. Age 72. Dispatched to Internal Medicine department because of diarrhea and constipation intermitent episodes, dehydration, malaise. HTN controlled with medication (IECAs). No other patologies. • Colonoscopy and Biopsy confirm suspicion. Colorrectal carcinoma stage III • In your opinion what option you choose: a) Radical surgery and lymphadenoctomy b) RT (35-40 Gy) + Qx c) QT (oxaliplatine) d) After IGV we´ll decide the best treatment

  23. BIBLIOGRAPHY • Casademont, Jordi; Francia, Esther; Torres, Olga.Publicado en Med Clin (Barc). 2012;138:289-92. - vol.138 núm 07 • Balducci L, Extermann M. Management of cancer in the older person: a practical approach. Oncologist 2000; 5:224-37 •  E. HORTONEDA BLANCO. SINDROMES GERIATRICOS ERGON, 2007 • Abizanda P, Navarro JL, Romero L, Leon M, Sanchez-Jurado PM, Domínguez L. Upper extremity function, an independent predictor of adverse events in hospitalized elderly. Gerontology 2007; 53:267-73 • Extermann M, Hurria A. Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol. 2007 May 10;25(14):1824-31.

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