Background: Geriatric oncology incorporates comprehensive geriatric assessment (CGA) and traditional oncology care.
Objectives: The aims are to identify limitations reflected by mean scores on the CGA instruments and describe the CGA recommendations documented in the medical record.
Methods: CGA was administered and consisted of the Timed Up and Go Test, the Activities of Daily Living Scale, the Instrumental Activities of Daily Living Scale, grip strength, falls, pain, the Brief Fatigue Inventory, the Pittsburgh Sleep Quality Index, the Geriatric Depression Scale, the Mini-Cog, and the Mini Nutritional Assessment. CGA recommendations were obtained from the medical record. Descriptive statistics were used to analyze the data.
Findings: Most recommendations were for general cancer treatment, followed by fall referral/education.
Care of older adults diagnosed with cancer often includes a comprehensive geriatric assessment (CGA), conducted by an interprofessional team (Balducci & Yates, 2000; Biesma et al., 2011; Hurria et al., 2007, 2014; Vallet-Regi et al., 2017), to provide the foundation for oncologic treatment (Schulkes et al., 2017; van de Water et al., 2014) and continued supportive care (Balducci, Colloca, Cesari, & Gambassi, 2010). CGA is a battery of screening instruments used to detect emotional, physical, and cognitive limitations that can predict postoperative complications (Chao et al., 2014; Fukuse, Satoda, Hijiya, & Fujinaga, 2005), survival (Clough-Gorr, Thwin, Stuck, & Silliman, 2012; Denewet et al., 2016), caregiver burden (Rajasekaran et al., 2016), and toxicity associated with cancer treatment (Aaldriks et al., 2011; Hamaker et al., 2014; Park et al., 2015). CGA provides clinical data to develop treatment decisions and to illuminate the actual and potential patient limitations that require attention (Decoster et al., 2013; Hamaker et al., 2014; Vallet-Regi et al., 2017). Patients who receive CGA are more likely to complete cancer treatment (Kalsi et al., 2015) with the support of an interprofessional team to help navigate the landscape of living with cancer.
Data specific to CGA-derived healthcare recommendations in geriatric oncology are lacking. Recommendations can be designed to accommodate any type of health limitation that is detected as a result of CGA. Research on how to better implement CGA recommendations is needed to ameliorate the issue that many recommendations fail to be followed by the patients and their family members (Baitar et al., 2015; Girre et al., 2008; Kenis et al., 2013; Kenis, Heeren, et al., 2014). The purpose of the current study is to identify recommendations based on the CGA findings that are specific to older adult women diagnosed with breast cancer. This study provides the foundation for an intervention study to address and manage limitations that were detected as part of CGA in older adult women with breast cancer.
The following are the specific aims of the current study:
• Identify patient limitations as reflected by the mean scores of the CGA instruments (Timed Up and Go Test [TUG], Activities of Daily Living Scale [ADLS], Instrumental Activities of Daily Living Scale [IADLS], grip strength, falls, pain, Brief Fatigue Inventory [BFI], Pittsburgh Sleep Quality Index [PSQI], Geriatric Depression Scale [GDS], Mini-Cog, and Mini Nutritional Assessment [MNA]) in older adult women with breast cancer.
• Describe the types of CGA recommendations (fall referral/education, nutrition education, cognitive concerns, chemotherapy fitness, general cancer treatment recommendations, medication changes/education, sleep recommendations, referral to physical/occupational therapy, pain control/education, social worker recommendations, and surgical fitness) documented in the medical records of older adult women with breast cancer.
Comprehensive Geriatric Assessment in Geriatric Oncology
The International Society of Geriatric Oncology suggests that CGA is integral to the care of older adult patients with cancer and provides a view of health from a functional, psychosocial, emotional, and cognitive perspective (Extermann et al., 2005; Wildiers et al., 2014). CGA is defined as an assessment designed to extend beyond the boundaries of a traditional history and physical examination and evaluate domains of function, pain, fatigue and sleep, emotion, cognition, and nutrition. The rationale for conducting CGA is to detect minor problems before they escalate into independence-threatening concerns. Older adult patients can be vulnerable in terms of untreated geriatric syndromes, depression, and deficits in functional status (Girre et al., 2008; Tan et al., 2016). For older adult patients receiving chemotherapy for breast cancer, obtaining a baseline CGA helps anticipate toxicity and predict survival, particularly in patients with polypharmacy and comorbidities (Hamaker et al., 2014). CGA findings can influence chemotherapeutic dosing and the type of chemotherapy prescribed (Decoster et al., 2013; Girre et al., 2008).
Performing CGA provides the interprofessional team with critical data on which to build the cancer treatment plan. For each screening measure included in CGA, the interprofessional team must be prepared to recommend solutions for actual and potential limitations. The interprofessional team must regularly evaluate the identified limitation and effectiveness of the recommendation. Continued follow-up evaluation is essential to managing CGA recommendations in an ambulatory oncology care clinic (Overcash, 2015). Combining traditional oncology care with complex geriatric concerns requires clinic organization and thorough nursing follow-up. Unmanaged functional problems, emotional concerns, or physical limitations can negatively affect the cancer treatment plan.
Adherence to Recommendations
CGA in the geriatric oncology setting renders from two (Baitar et al., 2015) to seven (Morin et al., 2012) recommendations that often consist of referrals to other providers or specialists, medication changes, or homecare advice. The higher the number of recommendations, the less patients and providers tend to adhere to or implement the clinical plan (Esmail, Brazil, & Lam, 2000; Kenis, Decoster, et al., 2014; Morin et al., 2012). Implementation of CGA recommendations is as high as 97% when limited to four or fewer recommendations, as reported by Morin et al. (2012). Esmail et al. (2000) reported that 65% of CGA recommendations are implemented. Reuben et al. (1996) found that adherence to CGA recommendations in general geriatric practice was 83% when the recommendation was considered “most important.” If patients do not agree with or value the cancer treatment plan, they are less likely to adhere to the recommendation (Maly, Leake, Frank, DiMatteo, & Reuben, 2002). Minimizing the number of recommendations per clinical encounter helps patients and their family members organize and implement referral visits, obtain prescriptions, and arrange for other services without feeling too overwhelmed.
Provider workload is often a barrier to supporting patients in fulfilling CGA recommendations (Kenis, Heeren, et al., 2014). Many ambulatory clinics are busy, and recommendations can be omitted from the treatment plan because of poor communication and distractions. Financial constraints, staffing, and organizational issues are healthcare facility situations associated with lack of implementation of CGA recommendations (Kenis et al., 2016).
Caregivers are central to adherence, particularly when in agreement with the recommendations (Bogardus et al., 2004). Caregivers and providers may not agree on or allocate the same level of priority to the recommendations (Bogardus et al., 2001); this difference may result in nonadherence. Caregivers often are responsible for transportation, errands, cooking, and perhaps the total care of the patient. Time, financial concerns, and other responsibilities compete with the ability to comply with healthcare recommendations. Engaging caregivers in discussions concerning CGA and recommendations can be a positive factor in motivating adherence to recommendations.
Types of Recommendations
The likelihood of a patient complying with a CGA recommendation depends on the type of recommendation and the time since assessment. Most CGA recommendations are carried out within three months of initial assessment by the interprofessional team (Freud et al., 2016). Patients are likely to comply with cancer treatment recommendations (Kalsi et al., 2015) and to conduct interventions to prevent or treat cancer-related side effects (Wells et al., 2016). Patients generally are willing to comply with referrals to specialists; however, counseling and diagnostic tests only have a 30% compliance rate (Bogardus et al., 2004). Adherence to recommendations associated with cognitive problems is 62% (Morin et al., 2012). Adherence to fall prevention recommendations (gait and balance, medications, orthostatic hypotension, incontinence) occurs in 46% (Mikolaizak et al., 2018) to 58% of patients (Milisen et al., 2006). Regarding medication, a high number of prescriptions or pill burden increases nonadherence to recommendations (Pasina et al., 2014). Adherence to medication recommendations is 72% at 6 months and 65% at 12 months following the recommendation (Lea et al., 2017).
Previously unidentified comorbidities often are detected and managed as a result of CGA screening (Horgan et al., 2012; Li, Chen, Li, Wang, & Wu, 2010). Many referrals are made to psychosocial providers to manage depression (Horgan et al., 2012), to dietitians to address malnutrition (Baitar et al., 2015), or to other providers to prescribe or deprescribe medications (Freud et al., 2016). However, the referrals least likely to be performed are those for geropsychology consultations, fall clinics, geriatric day clinics (Baitar et al., 2015), and memory disorder clinics (Morin et al., 2012).
The current study has a descriptive, cross-sectional design. Women diagnosed with any stage and type of breast cancer, aged 69 years or older, and receiving any type of treatment were invited to participate in the study. Participants were able to read and understand the consent form. Patients were recruited from the Ohio State University Stefanie Spielman Comprehensive Breast Center in Columbus. The center is an outpatient clinical and research facility. Patients from the geriatric oncology ambulatory care clinic (GOACC) at Ohio State University were invited to participate.
Patients who presented to the GOACC from 2013–2015 were invited to participate in the study. The geriatric nurse practitioner (GNP) obtained written consent from patients and their designated caregiver. Cancer diagnosis, staging, and treatment information were obtained from the medical record. The GNP completed CGA on each patient while in the examination room. All instruments included in the CGA are clinical tools used as part of the team discussion and the oncology planning process. Patients were surveyed once during their initial visit to the clinic; this survey required about 20 minutes. Functional status measures, such as the grip strength and gait and balance assessment, were conducted by the GNP. Cancer diagnosis was obtained from the medical record per HIPAA (Health Insurance Portability and Accountability Act) consent. Recommendations were obtained from the interprofessional team medical records on the date of the CGA encounter. Recommendations were defined as suggestions included in the plan of the medical record offered by each member of the interprofessional team working in the GOACC. Recommendations were categorized into 11 categories: fall referral/education, nutrition education, cognitive concerns, chemotherapy fitness, general cancer treatment recommendations (consideration for chemotherapy, hormonal therapies, or radiation therapy), medication changes/education, sleep recommendations, referral to physical/occupational therapy, pain control, social worker recommendations, and surgical fitness. Fitness for surgery and chemotherapy were determined by the interprofessional team and the results of the CGA according to the Balducci and Stanta (2000) classification of vulnerable (limitations on many of the assessment instruments and requires assistance in caring for self), frail (functionally dependent), or fit. A biographical data sheet was used to record the type of recommendations. The data were collected during the first GOACC visit. Data were entered into IBM SPSS Statistics, version 24.0, and analyzed.
Ethical Conduct of Research
The current study was approved by the Ohio State University Institutional Review Board (IRB). The study was explained, and the informed consent and HIPAA forms were signed by all participants according to the standards of the IRB. Participants were not compensated for inclusion in the study. Participants were not screened for cognitive deficits prior to informed consent; however, all participants were able to verbalize understanding of the purpose of the study and were able to read the informed consent and HIPAA forms. Based on reading and verbalization of understanding on the consent form, all participants were determined to have had decision-making ability and were competent to consent on their own behalf, consistent with the Office for Human Research Protections (2016).
CGA included the following screening instruments (see Table 1):
• The functional concerns of TUG, ADLS, IADLS, grip strength, and falls
• Pain using the Numeric Pain Rating Scale (NPRS)
• Fatigue and sleep concerns using BFI and PSQI
• Emotional concerns using GDS
• Cognitive concerns using the Mini-Cog
• Nutritional concerns using MNA
TUG (Podsiadlo & Richardson, 1991) considers gait and balance in the ability to rise from a sitting position, ambulate 9.8 feet, and return to the sitting position. TUG has been found to be correlated with falls (Shumway-Cook, Brauer, & Woollacott, 2000). A cutoff point for considering fall risk is 12 seconds or more (Bischoff et al., 2003). Inter-rater reliability is high at r = 0.98. TUG correlated well to the Berg Balance Scale (r = –0.55) (Berg, Wood-Dauphinee, Williams, & Maki, 1992), gait speed (r = –0.55), and Barthel Index scores (r = –0.51) (Collin, Wade, Davies, & Horne, 1988) on instrument development.
ADLS consists of six items: bathing, dressing, transferring, feeding, continence, and toileting. ADLS is a clinical tool that helps determine disability. If a person is dependent in any of the tasks, decisions concerning assistance and rehabilitation generally are explored (Katz, Downs, Cash, & Grotz, 1970). A limitation in any of the activities indicates a functional deficit.
IADLS evaluates more refined activities (Lawton & Brody, 1969), such as using the telephone, getting to places beyond walking distance, shopping for groceries, doing laundry, cleaning, housekeeping, and managing money. IADLS has 11 items, which are scored by calculating three points for performing a task without assistance, two points for some assistance, and one point for inability. Dependence is defined by any task that requires assistance (Lawton & Brody, 1969).
Grip strength was measured in the right and left hand using the Jamar Hydraulic Hand Dynamometer (Jamar, 2013). Grip strength measurements predict limitations in mobility for patients with breast cancer (Massy-Westropp, Gill, Taylor, Bohannon, & Hill, 2011). The average score of three grip strength measures for each hand can be compared to normative data in Jamar (2013). The cutoff point of 37 kg or less was used to determine strength difficulties for left and right hands for women (Jamar, 2013).
The gold standard for fall screening is the simple question of whether a fall has occurred within the past six months (American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopaedic Surgeons Panel on Falls Prevention, 2001).
Pain: NPRS was used to measure pain (McCaffery & Beebe, 1989). Patients were asked to describe their current pain on a scale from 0 (no pain) to 10 (extreme pain). A score of 1–3 was considered mild pain, 4–6 was considered moderate pain, and 7–10 was considered severe pain. A cutoff point of 3 or more was used to represent a rating of mild to moderate pain.
Fatigue and sleep: BFI (Mendoza et al., 1999) consists of nine items, each of which has a numeric rating from 0–10. BFI is scored as a continuous variable in that the higher the score, the more fatigue. Three items on the instrument define the severity of fatigue, and the remaining items consider the extent to which fatigue affects normal life activities. Construct validity assessed for the nine items ranges from 0.81 (usual fatigue) to 0.92 (activity). Concurrent validity was evaluated with Functional Assessment of Cancer Therapy–Fatigue (Cella et al., 1993). Cronbach coefficient alphas showed high reliability (alpha > 0.95). BFI is an acceptable subjective tool in the measurement of fatigue in patients with cancer. For this study, mild fatigue was considered with a score of 3 or less (Chang et al., 2007).
PSQI (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) is a commonly used instrument for the measure of quality of sleep. Scores on the measures range from 0–21, with increasing scores indicating worse sleep quality. A score greater than 5 indicates poor sleep. The instrument has a sensitivity of 0.89% and a specificity of 0.86%.
Emotional: GDS is a 15-item “yes” or “no” scale that helps a clinician screen for depression (Yesavage et al., 1982). More than five items scored as indicating depression are considered a positive screen, and the patient should be referred for additional diagnostic assessment. Validation was shown by comparison with two well-known measures of depression: the Zung (1965) Self-Rating Depression Scale and the Hamilton (1960) Rating Scale for Depression.
Cognitive: Mini-Cog (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000) is an assessment instrument that combines the clock-drawing test with three-item recall. Three-item recall is an assessment of short-term memory and is used as part of the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). Mini-Cog is a valid and reliable clinical instrument that can help detect dementia and is recommended by the Hartford Institute for Geriatric Nursing (2018) and the National Comprehensive Cancer Network (2017) for clinical assessment and patient care. Scoring is calculated for two sections; recall is scored from 0–3, and clock-drawing is scored from 0–2. A total score of 3 or less (sometimes 2 or less is used as a cutoff point) was used for this study to indicate cognitive impairment. The sensitivity for Mini-Cog is 0.99 and 0.96 in diagnostic value (Borson et al., 2000). Inter-rater scoring on the clock-drawing portion of Mini-Cog is r = 0.97 (Borson et al., 2000).
Nutritional: MNA is an instrument that is commonly used to assess for malnutrition (Kaiser et al., 2009) and is made up of six items. MNA is validated in older adult patients (mean age = 82 years) and is scored from 0–14. Normal nutritional status is 12–14 points, risk of malnutrition is 8–11 points, and malnourished is 0–7 points. A score of 11 has a sensitivity of 90% and a specificity of 76%, with an area under the curve of 95%. Therefore, 11 or less is used as a cutoff point in this study.
To address the specific aims of the study, the demographic characteristics of the sample were calculated using descriptive statistics. To describe the incidence of positive CGA screening, means were calculated (aim 1). Frequencies were used to calculate the number of recommendations (aim 2). Recommendations were defined as a task performed by one of the interprofessional team members as a result of CGA.
The mean age of the participants (n = 35) was 79.1 years (range = 69–93 years), and the mean number of recommendations was 2.1. Of the 35 participants, 25 were diagnosed with infiltrating ductal carcinoma, 29 did not have metastatic disease, and 14 underwent a lumpectomy (see Table 2).
To address the first aim of the study, which was identifying limitations as a result of CGA, most issues detected on CGA were in grip strength to the left (n = 24) and right hands (n = 20). Other functional status limitations were detected using TUG (n = 11), ADLS (n = 8), and IADLS (n = 11).
Seven participants reported pain. Using BFI, nine participants screened positive for fatigue. Fifteen participants reported poor sleep quality. Five participants screened positive on GDS, and 11 participants screened positive on Mini-Cog. Fourteen participants screened positive for nutritional deficits (see Table 3).
Of the 35 participants, 31 had recommendations in the medical record. The mean number of recommendations was 2.1 (range = 0–7). Seventy-seven recommendations were noted in the medical record for all participants (see Table 4). Most recommendations were for general cancer treatment (n = 14), fall referral/education (n = 11), social work (n = 8), cognitive concerns (n = 7), surgical fitness (n = 6), physical/occupational therapy referral (n = 6), chemotherapy fitness (n = 5), nutrition education (n = 3), medication changes/education (n = 3), sleep (n = 3), and pain control/education (n = 2). Nine had no limitations detected on CGA.
This sample of participants was relatively functional and independent, despite a diagnosis of cancer. The mean number of recommendations was 2.1, which is consistent with a prior study that also found a mean of two recommendations in an older adult population (Baitar et al., 2015). Five participants did not have any breast surgery prior to CGA because they were referred to the senior adult oncology program to determine surgical fitness. It was possible for patients to not have positive screening scores or limitations on CGA but still have recommendations based on patient and family requests.
Most CGA recommendations were related to general cancer treatment decisions, such as cancer management plan (treatment with chemotherapy, radiation, or hormonal therapy). Recommendations associated with chemotherapy and surgical fitness were referrals to determine risk and expectations of the visit. In the current study, CGA was designed to influence cancer treatment decisions. Conducting CGA in ambulatory oncology clinics is relatively common; however, the specific ability of CGA to influence cancer treatment decisions is not well-defined (Decoster et al., 2013).
Functional assessment limitations (TUG, ADLS, IADLS, grip strength, falls) often motivated fall education. Many limitations were in grip strength, particularly in the left hand, which is supported by research indicating that 50%–90% of people are right-handed (Holder, 1997). No established norms for grip strength in people aged 75 years or older are included in Jamar (2013). More research is needed to develop norms to determine when physical or occupational therapy may be helpful. The current study did not record the self-recognized dominant hand of each participant.
Fall recommendations commonly were offered by the interprofessional team. The medical center where this study was conducted has a fall clinic, and appointments were made for further evaluation for fall risk. The other fall intervention was education on fall risk reduction. Many patients and families welcomed the teaching and were provided information on high-risk activities associated with falls. Older adults have a higher risk of falls before a cancer diagnosis versus after a cancer diagnosis (Huang, Blackwood, Godoshian, & Pfalzer, 2017). Patients who were classified by TUG as being impaired are at greater risk for falls as well (Kang et al., 2017; Overcash & Rivera, 2008).
ADLS (23%) and IADLS (32%) scores reflected lower functional impairment compared to screening among older adult inpatients with cancer (64%) (Morin et al., 2012). In situations in which TUG was 12 seconds or more, combined with self-reported ambulatory difficulty, physical therapy was consulted. In many cases, patients can qualify for physical therapy services in their home to enhance lower extremity strength and balance. Patients who had limitations on ADLS and IADLS often required general homecare services, such as help with cleaning and basic activities of daily living. It is important to address any functional limitations to increase physical ability, particularly in people who have mild limitations in activities of daily living (Stineman et al., 2013). Functional limitations were also the motivation for referrals to physical or occupational therapy and to social work.
In the current study, a social worker arranged for housekeeping and other services that met some of the ADLS and IADLS deficits. Transportation, housekeeping, and homecare services were arranged frequently. The social worker also provided emotional and coping support and arranged for participation in the many support groups and activities offered by the cancer center.
Although pain is a serious concern in geriatric oncology, the mean pain score was considered mild (0–3). Pain should be assessed at each visit and should be part of the ongoing management plan.
According to the assessment, depression was documented in five participants. Rates of depression increase with age in patients with cancer, with the oldest adults screening highest on GDS (Goldzweig, Baider, Rottenberg, Andritsch, & Jacobs, 2018). In the current study, when patients were offered antidepressants or referred for mental health counseling, many refused. Reluctance to implement depression-related interventions is noted in the literature (Baitar et al., 2015). Continued invitations to participate in social support groups, cancer center–sponsored group activities, and medication treatment can be helpful because many older adults tend to isolate themselves when they are depressed or have pain (Wilkie et al., 2016).
Patients who screened positive for cognitive limitations were referred back to their primary care provider (PCP) for continued care. Only seven participants received cognitive-related recommendations; however, 11 participants screened positive for impairment on Mini-Cog. Some patients and their families refused further cognitive assessment. Cognitive changes inspire difficult conversations, which tend to occur over time to cultivate trust. In people aged older than 80 years, cognitive limitations detected on Mini-Cog can be as high as 30% (Trowbridge et al., 2016). Accessing services and healthcare teams to evaluate and treat cognitive or memory disorder can be difficult. Referral to a neuropsychologist following a positive screen for cognitive limitations can inspire recommendations related to further diagnostics, employment, education, rehabilitation, and mental health care (Meth, Bernstein, Calamia, & Tranel, 2018).
Pain, Fatigue and Sleep, and Nutritional Concerns
Nutrition education, pain control/education, and medication changes/education were not common recommendations reflected in the medical record. Despite the high number of patients who reported sleep problems, nutritional deficits, and problems with fatigue, very few recommendations were reported in the medical record.
The number of recommendations not recorded in the medical record was concerning. Four patients who underwent screening with CGA did not have any recommendations recorded in the medical record. Failing to record CGA recommendations greatly reduces the effectiveness of GOACC. Detailing the recommendations helps the interprofessional team and other providers understand the complete geriatric oncology plan. Follow-up interventions, continued education needs, and supportive and survivorship care all should be recorded in the medical record. Medical records that reflect the work of the interprofessional team help illuminate the relevant, comprehensive work of GOACC.
Recommendations that were most likely to be implemented generally are based on the types of services associated with the geriatric oncology team (Baitar et al., 2015). Referrals to dietitians, social workers, and psychologists tend to be conducted when the services are readily available (Baitar et al., 2015). The types and numbers of recommendations tend to be similar among the published studies (Baitar et al., 2015; Decoster et al., 2013; Morin et al., 2012).
Many patients did not have any limitations detected on CGA. People aged 70 years or older may experience cancer as their first major illness and have been considered healthy for the span of their lives. Recommendations may be warranted, despite no limitations detected on screening with CGA. Proactive care delivery is important to helping many older adult patients experience improved quality of care (Vestjens, Crann, & Nieboer, 2018).
The current study has several limitations. Recommendations can be difficult to track and may not always be included in the medical record. The current study did not track the outcomes of the recommendations, which will be the focus of additional studies. Modifying the GOACC electronic medical record to reflect specific recommendations will help capture more of this important information. Also, the current study included a small sample size. GOACC does not have a dietitian on the team, and more recommendations concerning diet may have been executed if a person had been available for referrals.
Implications for Nurses
Nurses have a critical role in fostering the implementation of the CGA recommendations. Often, cancer treatment plans are not shared outside the cancer center, which is a barrier to patient care (Lawrence, McLoone, Wakefield, & Cohn, 2016). Communication between the PCP and oncology team to discuss the oncology treatment plan and findings on CGA is a principal role of oncology nurses. Direct contact with providers enhances the probability that patients will fulfill the CGA recommendations (Freud et al., 2016). CGA is the link between oncology specialty providers and PCPs caring for older adults (North, 2016). PCPs may manage the comorbid conditions and require oncology information to consider dosages of medications, cardiac concerns related to chemotherapy, and functional or fall risk. The PCP also may have conducted CGA, and sharing the findings can be helpful in evaluating the geriatric instrument scoring trends and how cancer treatment may be affecting health and independence. Nurses are a vital contact among providers and a conduit for communication that can enhance geriatric care (Morgan & Tarbi, 2016).
The oncology nurse educator role is important to the patient’s and family member’s abilities to adhere to the CGA recommendations. Patient teaching increases adherence to oral chemotherapy recommendations (Boucher, Lucca, Hooper, Pedulla, & Berry, 2015; Sommers, Miller, & Berry, 2012; Yeoh, Tay, Si, & Chew, 2015), increases compliance to medication recommendations (Vollmer et al., 2014), and supports continued management of nonmalignant comorbidities (Wild et al., 2016). In addition, education increases adherence to cancer screening (Phillips, Hendren, Humiston, Winters, & Fiscella, 2015), increases patient satisfaction (Yount et al., 2014), and reduces 30-day readmission rates (Lee, Yang, Hernandez, Steimle, & Go, 2016).
Nurses tend to have a favorable attitude toward caring for older adult patients with cancer (Burhenn, Ferrell, Johnson, & Hurria, 2016). Nursing knowledge of common geriatric conditions, use of restraints, skin breakdown, incontinence, and sleep are within the scope of practice when caring for older adult patients with cancer (Burhenn et al., 2016). It is important that nurses who work in geriatric oncology enhance their skills and knowledge of caring for older adult patients. A great deal of the work performed by the geriatric oncology team rests with the nurse, who must be competent in gerontology and oncology (Koll et al., 2016).
In the current study, compromised functional concerns were a common limitation found using CGA. Other limitations were pain, fatigue and sleep problems, emotional and cognitive concerns, and nutritional deficits. Based on the limitations uncovered using CGA, the mean number of recommendations was 2.1. Most CGA recommendations were general cancer treatment recommendations, determining fitness for chemotherapy and surgery, social worker recommendations, and fall referral/education. Many older adult patients diagnosed with cancer were found to have no limitations with CGA.
About the Author(s)
Janine Overcash, PhD, GNP-BC, FAANP, FAAN, is an associate clinical professor in the College of Nursing at the Ohio State University in Columbus. The author takes full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Overcash can be reached at email@example.com, with copy to CJONEditor@ons.org. (Submitted September 2017. Accepted December 1, 2017.)
Aaldriks, A.A., Maartense, E., le Cessie, S., Giltay, E.J., Verlaan, H.A., van der Geest, L.G., . . . Nortier, J.W. (2011). Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Critical Reviews in Oncology/Hematology, 79, 205–212. https://doi.org/10.1016/j.critrevonc.2010.05.009
American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopaedic Surgeons Panel on Falls Prevention. (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49, 664–672. https://doi.org/10.1046/j.1532-5415.2001.49115.x
Baitar, A., Kenis, C., Moor, R., Decoster, L., Luce, S., Bron, D., . . . Wildiers, H. (2015). Implementation of geriatric assessment-based recommendations in older patients with cancer: A multicentre prospective study. Journal of Geriatric Oncology, 6, 401–410. https://doi.org/10.1016/j.jgo.2015.07.005
Balducci, L., Colloca, G., Cesari, M., & Gambassi, G. (2010). Assessment and treatment of elderly patients with cancer. Surgical Oncology, 19, 117–123. https://doi.org/10.1016/j.suronc.2009.11.008
Balducci, L., & Stanta, G. (2000). Cancer in the frail patient. A coming epidemic. Hematology/Oncology Clinics of North America, 14, 235–250. https://doi.org/10.1016/S0889-8588(05)70286-0
Balducci, L., & Yates, J. (2000). General guidelines for the management of older patients with cancer. Oncology, 14(11A), 221–227.
Berg, K.O., Wood-Dauphinee, S.L., Williams, J.I., & Maki, B. (1992). Measuring balance in the elderly: Validation of an instrument. Canadian Journal of Public Health, 83(Suppl. 2), S7–S11.
Biesma, B., Wymenga, A.N., Vincent, A., Dalesio, O., Smit, H.J., Stigt, J.A., . . . Groen, H.J. (2011). Quality of life, geriatric assessment and survival in elderly patients with non-small-cell lung cancer treated with carboplatin-gemcitabine or carboplatin-paclitaxel: NVALT-3 a phase III study. Annals of Oncology, 22, 1520–1527. https://doi.org/10.1093/annonc/mdq637
Bischoff, H.A., Stahelin, H.B., Monsch, A.U., Iversen, M.D., Weyh, A., von Dechend, M., . . . Theiler, R. (2003). Identifying a cut-off point for normal mobility: A comparison of the timed ‘up and go’ test in community-dwelling and institutionalised elderly women. Age and Ageing, 32, 315–320. https://doi.org/10.1093/ageing/32.3.315
Bogardus, S.T., Bradley, E.H., Williams, C.S., Maciejewski, P.K., van Doorn, C., & Inouye, S.K. (2001). Goals for the care of frail older adults: Do caregivers and clinicians agree? American Journal of Medicine, 110, 97–102. https://doi.org/10.1016/S0002-9343(00)00668-9
Bogardus, S.T., Jr., Bradley, E.H., Williams, C.S., Maciejewski, P.K., Gallo, W.T., & Inouye, S.K. (2004). Achieving goals in geriatric assessment: Role of caregiver agreement and adherence to recommendations. Journal of the American Geriatrics Society, 52, 99–105. https://doi.org/10.1111/j.1532-5415.2004.52017.x
Borson, S., Scanlan, J., Brush, M., Vitaliano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15, 1021–1027. https://doi.org/10.1002/1099-1166(200011)15:11<1021::AID-GPS234>3.0.CO;2-6
Boucher, J., Lucca, J., Hooper, C., Pedulla, L., & Berry, D.L. (2015). A structured nursing intervention to address oral chemotherapy adherence in patients with non-small cell lung cancer. Oncology Nursing Forum, 42, 383–389. https://doi.org/10.1188/15.ONF.383-389
Burhenn, P.S., Ferrell, B., Johnson, S., & Hurria, A. (2016). Improving nurses’ knowledge about older adults with cancer. Oncology Nursing Forum, 43, 497–504. https://doi.org/10.1188/16.ONF.497-504
Buysse, D.J., Reynolds, C.F., 3rd, Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213. https://doi.org/10.1016/0165-1781(89)90047-4
Cella, D.F., Tulsky, D.S., Gray, G., Sarafian, B., Linn, E., Bonomi, A., . . . Brannon, J. (1993). The Functional Assessment of Cancer Therapy Scale: Development and validation of the general measure. Journal of Clinical Oncology, 11, 570–579. https://doi.org/10.1200/JCO.19188.8.131.520
Chang, Y.J., Lee, J.S., Lee, C.G., Lee, W.S., Lee, K.S., Bang, S.M., . . . Yun, Y.H. (2007). Assessment of clinical relevant fatigue level in cancer. Supportive Care in Cancer, 15, 891–896. https://doi.org/10.1007/s00520-007-0219-x
Chao, C., Page, J.H., Yang, S.J., Rodriguez, R., Huynh, J., & Chia, V.M. (2014). History of chronic comorbidity and risk of chemotherapy-induced febrile neutropenia in cancer patients not receiving G-CSF prophylaxis. Annals of Oncology, 25, 1821–1829. https://doi.org/10.1093/annonc/mdu203
Clough-Gorr, K.M., Thwin, S.S., Stuck, A.E., & Silliman, R.A. (2012). Examining five- and ten-year survival in older women with breast cancer using cancer-specific geriatric assessment. European Journal of Cancer, 48, 805–812. https://doi.org/10.1016/j.ejca.2011.06.016
Collin, C., Wade, D.T., Davies, S., & Horne, V. (1988). The Barthel ADL Index: A reliability study. International Disability Studies, 10, 61–63. https://doi.org/10.3109/09638288809164103
Decoster, L., Kenis, C., Van Puyvelde, K., Flamaing, J., Conings, G., De Grève, J., . . . Wildiers, H. (2013). The influence of clinical assessment (including age) and geriatric assessment on treatment decisions in older patients with cancer. Journal of Geriatric Oncology, 4, 235–241. https://doi.org/10.1016/j.jgo.2013.04.010
Denewet, N., De Breucker, S., Luce, S., Kennes, B., Higuet, S., & Pepersack, T. (2016). Comprehensive geriatric assessment and comorbidities predict survival in geriatric oncology. Acta Clinica Belgica, 71, 206–213. https://doi.org/10.1080/17843286.2016.1153816
Esmail, R., Brazil, K., & Lam, M. (2000). Compliance with recommendations in a geriatric outreach assessment service. Age and Ageing, 29, 353–356. https://doi.org/10.1093/ageing/29.4.353
Extermann, M., Aapro, M., Bernabei, R., Cohen, H.J., Droz, J.P., Lichtman, S., . . . Topinkova, E. (2005). Use of comprehensive geriatric assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Critical Reviews in Oncology/Hematology, 55, 241–252. https://doi.org/10.1016/j.critrevonc.2005.06.003
Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. https://doi.org/10.1016/0022-3956(75)90026-6
Freud, T., Punchik, B., Biderman, A., Peleg, R., Kagan, E., Barzak, A., & Press, Y. (2016). Out of sight, out of mind? Does terminating the physical presence of a geriatric consultant in the community clinic reduce the implementation rate for geriatric recommendations. Archives of Gerontology and Geriatrics, 64, 115–122. https://doi.org/10.1016/j.archger.2016.01.010
Fukuse, T., Satoda, N., Hijiya, K., & Fujinaga, T. (2005). Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. Chest, 127, 886–891. https://doi.org/10.1378/chest.127.3.886
Girre, V., Falcou, M.C., Gisselbrecht, M., Gridel, G., Mosseri, V., Bouleuc, C., . . . Mignot, L. (2008). Does a geriatric oncology consultation modify the cancer treatment plan for elderly patients? Journal of Gerontology Series A, 63, 724–730. https://doi.org/10.1093/gerona/63.7.724
Goldzweig, G., Baider, L., Rottenberg, Y., Andritsch, E., & Jacobs, J.M. (2018). Is age a risk factor for depression among the oldest old with cancer? Journal of Geriatric Oncology. Advance online publication. https://doi.org/10.1016/j.jgo.2018.03.011
Hamaker, M.E., Seynaeve, C., Wymenga, A.N., van Tinteren, H., Nortier, J.W., Maartense, E., . . . Smorenburg, C.H. (2014). Baseline comprehensive geriatric assessment is associated with toxicity and survival in elderly metastatic breast cancer patients receiving single-agent chemotherapy: Results from the OMEGA study of the Dutch breast cancer trialists’ group. Breast, 23, 81–87. https://doi.org/10.1016/j.breast.2013.11.004
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56–62. https://doi.org/10.1136/jnnp.23.1.56
Hartford Institute for Geriatric Nursing. (2018). Try this: ® series. Retrieved from https://consultgeri.org/tools/try-this-series
Holder, M,K. (1997, August). Why are more people right-handed? Scientific American. Retrieved from https://www.scientificamerican.com/article/why-are-more-people-right
Horgan, A.M., Leighl, N.B., Coate, L., Liu, G., Palepu, P., Knox, J.J., . . . Alibhai, S.M. (2012). Impact and feasibility of a comprehensive geriatric assessment in the oncology setting: A pilot study. American Journal of Clinical Oncology, 35, 322–328. https://doi.org/10.1097/COC.0b013e318210f9ce
Huang, M.H., Blackwood, J., Godoshian, M., & Pfalzer, L. (2017). Prevalence of self-reported falls, balance or walking problems in older cancer survivors from Surveillance, Epidemiology and End Results-Medicare Health Outcomes Survey. Journal of Geriatric Oncology, 8, 255–261. https://doi.org/10.1016/j.jgo.2017.05.008
Hurria, A., Lichtman, S.M., Gardes, J., Li, D., Limaye, S., Patil, S., . . . Kelly, E. (2007). Identifying vulnerable older adults with cancer: Integrating geriatric assessment into oncology practice. Journal of the American Geriatrics Society, 55, 1604–1608. https://doi.org/10.1111/j.1532-5415.2007.01367.x
Hurria, A., Wildes, T., Blair, S.L., Browner, I.S., Cohen, H.J., Deshazo, M., . . . Sundar, H. (2014). Senior adult oncology, version 2.2014: Clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network, 12, 82–126. https://doi.org/10.6004/jnccn.2014.0009
Jamar. (2013). Jamar hydraulic hand dynamometer owner’s manual. Bolingbrook, IL: Sammons Preston Roylan.
Kaiser, M.J., Bauer, J.M., Ramsch, C., Uter, W., Guigoz, Y., Cederholm, T., . . . Sieber, C.C. (2009). Validation of the mini nutritional assessment short-form (MNA-SF): A practical tool for identification of nutritional status. Journal of Nutrition, Health and Aging, 13, 782–788. https://doi.org/10.1007/s12603-009-0214-7
Kalsi, T., Babic-Illman, G., Ross, P.J., Maisey, N.R., Hughes, S., Fields, P., . . . Harari, D. (2015). The impact of comprehensive geriatric assessment interventions on tolerance to chemotherapy in older people. British Journal of Cancer, 112, 1435–1444. https://doi.org/10.1038/bjc.2015.120
Kang, L., Han, P., Wang, J., Jai, L., Fu, L., Chen, X., . . . Guo, Q. (2017). Timed Up and Go can predict recurrent falls: A longitudinal study of the community-dwelling elderly in China. Clinical Interventions in Aging, 28, 2009–2016. https://doi.org/10.2147/CIA.S138287
Katz, S., Downs, T.D., Cash, H.R., & Grotz, R.C. (1970). Progress in development of the index of ADL. Gerontologist, 10, 20–30. https://doi.org/10.1093/geront/10.1_Part_1.20
Kenis, C., Bron, D., Libert, Y., Decoster, L., Van Puyvelde, K., Scalliet, P., . . . Wildiers, H. (2013). Relevance of a systematic geriatric screening and assessment in older patients with cancer: Results of a prospective multicentric study. Annuals of Oncology, 24, 1306–1312. https://doi.org/10.1093/annonc/mds619
Kenis, C., Decoster, L., Van Puyvelde, K., De Grève, J., Conings, G., Milisen, K., . . . Wildiers, H. (2014). Performance of two geriatric screening tools in older patients with cancer. Journal of Clinical Oncology, 32, 19–26. https://doi.org/10.1200/JCO.2013.51.1345
Kenis, C., Heeren, P., Bron, D., Decoster, L., Moor, R., Pepersack, T., . . . Wildiers, H. (2014). Multicenter implementation of geriatric assessment in Belgian patients with cancer: A survey on treating physicians’ general experiences and expectations. Journal of Geriatric Oncology, 5, 431-438. https://doi.org/10.1016/j.jgo.2014.06.043
Kenis, C., Heeren, P., Decoster, L., Van Puyvelde, K., Conings, G., Cornelis, F., . . . Wildiers, H. (2016). A Belgian survey on geriatric assessment in oncology focusing on large-scale implementation and related barriers and facilitators. Journal of Nutrition, Health and Aging, 20, 60–70. https://doi.org/10.1007/s12603-015-0538-4
Koll, T., Pergolotti, M., Holmes, H.M., Pieters, H.C., van Londen, G.J., Marcum, Z.A., . . . Steer, C.B. (2016). Supportive care in older adults with cancer: Across the continuum. Current Oncology Reports, 18(8), 51. https://doi.org/10.1007/s11912-016-0535-8
Lawrence, R.A., McLoone, J.K., Wakefield, C.E., & Cohn, R.J. (2016). Primary care physicians’ perspectives of their role in cancer care: A systematic review. Journal of General Internal Medicine, 31, 1222–1236. https://doi.org/10.1007/s11606-016-3746-7
Lawton, M.P., & Brody, E.M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179-186. https://doi.org/10.1093/geront/9.3_Part_1.179
Lea, S.C., Watts, K.L., Davis, N.A., Panayiotou, B., Bankart, M.J., Arora, A., & Chambers, R. (2017). The potential clinical benefits of medicine optimization through comprehensive geriatric assessment, carried out by secondary care geriatricians, in a general practice care setting in North Staffordshire, UK: A feasibility study. BMJ Open, 7, e015278. https://doi.org/10.1136/bmjopen-2016-015278
Lee, K.K., Yang, J., Hernandez, A.F., Steimle, A.E., & Go, A.S. (2016). Post-discharge follow-up characteristics associated with 30-day readmission after heart failure hospitalization. Medical Care, 54, 365–372. https://doi.org/10.1097/MLR.0000000000000492
Li, C.M., Chen, C.Y., Li, C.Y., Wang, W.D., & Wu, S.C. (2010). The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: A randomized, controlled trial. Archives of Gerontology and Geriatrics, 50(Suppl. 1), S39–S42. https://doi.org/10.1016/S0167-4943(10)70011-X
Maly, R.C., Leake, B., Frank, J.C., DiMatteo, M.R., & Reuben, D.B. (2002). Implementation of consultative geriatric recommendations: The role of patient-primary care physician concordance. Journal of the American Geriatrics Society, 50, 1372–1380. https://doi.org/10.1046/j.1532-5415.2002.50358.x
Massy-Westropp, N.M., Gill, T.K., Taylor, A.W., Bohannon, R.W., & Hill, C.L. (2011). Hand grip strength: Age and gender stratified normative data in a population-based study. BMC Research Notes, 4, 127. https://doi.org/10.1186/1756-0500-4-127
McCaffery, M., & Beebe, A. (1989). Pain: Clinical manual for nursing practice. St Louis, MO: C.V. Mosby Company.
Mendoza, T.R., Wang, X.S., Cleeland, C.S., Morrissey, M., Johnson, B.A., Wendt, J.K., & Huber, S.L. (1999). The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer, 85, 1186–1196. https://doi.org/10.1002/(SICI)1097-0142(19990301)85:5<1186::AID-CNCR24>3...
Meth, M.Z., Bernstein, J.P.K., Calamia, M., & Tranel, D. (2018). What types of recommendations are we giving patients? A survey of clinical neuropsychologists. Clinical Journal of Neuropsychology, 30, 1–18. https://doi.org/10.1080/13854046.2018.1456564
Mikolaizak, A.S., Lord, S.R., Tiedemann, A., Simpson, P., Caplan, G., Bandall, J.C., . . . Close, J. (2018). Adherence to a multifactorial fall prevention program following paramedic care: Predictors and impact on falls and health service use. Results from an RCT a priori subgroup analysis. Australasian Journal on Ageing, 37, 54–61. https://doi.org/10.1111/ajag.12465
Milisen, K., Dejaeger, E., Braes, T., Dierickx, K., De Bondt, K., Smeulders, W., . . . Boonen, S. (2006). Process evaluation of a nurse-led multifactorial intervention protocol for risk screening and assessment of fall problems among community-dwelling older persons: A pilot-study. Journal of Nutrition, Health and Aging, 10, 446–452.
Morgan, B., & Tarbi, E. (2016). The role of the advanced practice nurse in geriatric oncology care. Seminars in Oncology Nursing, 32, 33–43. https://doi.org/10.1016/j.soncn.2015.11.005
Morin, T., Lanièce, I., Desbois, A., Amiard, S., Gavazzi, G., & Couturier, P. (2012). Evaluation of adherence to recommendations within 3 months after comprehensive geriatric assessment by an inpatient geriatric consultation team [Article in French]. Geriatrics and Psychology Neuropsychiatry of Aging, 10, 285–293. https://doi.org/10.1684/pnv.2012.0359
National Comprehensive Cancer Network. (2017). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®): Older adult oncology [v.2.2017]. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf
North, C. (2016). Comprehensive geriatric assessment of a mental health service user with safeguarding needs. Nursing Older People, 28(5), 25–29. https://doi.org/10.7748/nop.28.5.25.s25
Office for Human Research Protections. (2016). Regulations and policy. Retrieved from http://www.hhs.gov/ohrp/regulations-and-policy/index.html
Overcash, J. (2015). Integrating geriatrics into oncology ambulatory care clinics [Online exclusive]. Clinical Journal of Oncology Nursing, 19, E80–E86. https://doi.org/10.1188/15.CJON.E80-E86
Overcash, J.A., & Rivera, H.R., Jr. (2008). Physical performance evaluation of older cancer patients: A preliminary study. Critical Reviews in Oncology/Hematology, 68, 233–241. https://doi.org/10.1016/j.critrevonc.2008.07.001
Park, S., Hong, J., Hwang, I., Ahn, J.Y., Cho, E.Y., Park, J., . . . Lee, J.H. (2015). Comprehensive geriatric assessment in elderly patients with newly diagnosed aggressive non-Hodgkin lymphoma treated with multi-agent chemotherapy. Journal of Geriatric Oncology, 6, 470–478. https://doi.org/10.1016/j.jgo.2015.10.183
Pasina, L., Brucato, A.L., Falcone, C., Cucchi, E., Bresciani, A., Sottocorno, M., . . . Nobili, A. (2014). Medication non-adherence among elderly patients newly discharged and receiving polypharmacy. Drugs and Aging, 31, 283–289. https://doi.org/10.1007/s40266-014-0163-7
Phillips, L., Hendren, S., Humiston, S., Winters, P., & Fiscella, K. (2015). Improving breast and colon cancer screening rates: A comparison of letters, automated phone calls, or both. Journal of the American Board of Family Medicine, 28, 46–54. https://doi.org/10.3122/jabfm.2015.01.140174
Podsiadlo, D., & Richardson, S. (1991). The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39, 142–148. https://doi.org/10.1111/j.1532-5415.1991.tb01616.x
Rajasekaran, T., Tan, T., Ong, W.S., Koo, K.N., Chan, L., Poon, D., . . . Kanesvaran, R. (2016). Comprehensive Geriatric Assessment (CGA) based risk factors for increased caregiver burden among elderly Asian patients with cancer. Journal of Geriatric Oncology, 7, 211–218. https://doi.org/10.1016/j.jgo.2016.03.003
Reuben, D.B., Maly, R.C., Hirsch, S.H., Frank, J.C., Oakes, A.M., Siu, A.L., & Hays, R.D. (1996). Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment. American Journal of Medicine, 100, 444–451. https://doi.org/10.1016/S0002-9343(97)89521-6
Schulkes, K.J., Souwer, E.T., Hamaker, M.E., Codrington, H., van der Sar-van der Brugge, S., Lammers, J.J., . . . van den Bos, F. (2017). The effect of a geriatric assessment on treatment decisions for patients with lung cancer. Lung, 195, 225–231. https://doi.org/10.1007/s00408-017-9983-7
Shumway-Cook, A., Brauer, S., & Woollacott, M. (2000). Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Physical Therapy, 80, 896–903.
Sommers, R.M., Miller, K., & Berry, D.L. (2012). Feasibility pilot on medication adherence and knowledge in ambulatory patients with gastrointestinal cancer [Online exclusive]. Oncology Nursing Forum, 39, E373–E379. https://doi.org/10.1188/12.ONF.E373-E379
Stineman, M.G., Zhang, G., Kurichi, J.E., Zhang, Z., Streim, J.E., Pan, Q., & Xie, D. (2013). Prognosis for functional deterioration and functional improvement in late life among community-dwelling persons. PM and R, 5, 360–371. https://doi.org/10.1016/j.pmrj.2013.02.008
Tan, T., Ong, W.S., Rajasekaran, T., Nee Koo, K., Chan, L.L., Poon, D., . . . Kanesvaran, R. (2016). Identification of comprehensive geriatric assessment based risk factors for malnutrition in elderly Asian cancer patients. PLOS One, 11(5), e0156008. https://doi.org/10.1371/journal.pone.0156008
Trowbridge, E.R., Kim, D., Barletta, K., Fitz, V., Larkin, S., & Hullfish, K.L. (2016). Prevalence of positive screening test for cognitive impairment among elderly urogynecologic patients. American Journal of Obstetrics and Gynecology, 215, 663. https://doi.org/10.1016/j.ajog.2016.06.012
Vallet-Regi, M., Manzano, M., Rodriguez-Mañas, L., Checa López, M., Aapro, M., & Balducci, L. (2017). Management of cancer in the older age person: An approach to complex medical decisions. Oncologist, 22, 335–342. https://doi.org/10.1634/theoncologist.2016-0276
van de Water, W., Bastiaannet, E., Egan, K.M., de Craen, A.J., Westendorp, R.G., Balducci, L., . . . Extermann, M. (2014). Management of primary metastatic breast cancer in elderly patients—An international comparison of oncogeriatric versus standard care. Journal of Geriatric Oncology, 5, 252–259. https://doi.org/10.1016/j.jgo.2014.02.005
Vestjens, L., Crann, J.M., & Nieboer, A.P. (2018). An integrated primary care approach for frail community-dwelling older persons: A step forward in improving the quality of care. BMC Health Services, 18, 28. https://doi.org/10.1186/s12913-017-2827-6
Vollmer, W.M., Owen-Smith, A.A., Tom, J.O., Laws, R., Ditmer, D.G., Smith, D.H., . . . Rand, C.S. (2014). Improving adherence to cardiovascular disease medications with information technology. American Journal of Managed Care, 20(11, Spec No. 17), SP502–SP510.
Wells, K.J., Pan, T.M., Vázquez-Otero, C., Ung, D., Ustjanauskas, A.E., Munoz, D., . . . Quinn, G.P. (2016). Barriers and facilitators to endocrine therapy adherence among underserved hormone-receptor-positive breast cancer survivors: A qualitative study. Supportive Care in Cancer, 24, 4123–4130. https://doi.org/10.1007/s00520-016-3229-8
Wild, S.H., Hanley, J., Lewis, S.C., McKnight, J.A., McCloughan, L.B., Padfield, P.L., . . . McKinstry, B. (2016). Supported telemonitoring and glycemic control in people with type 2 diabetes: The Telescot Diabetes Pragmatic Multicenter Randomized Controlled Trial. PLOS Medicine, 13(7), e1002098. https://doi.org/10.1371/journal.pmed.1002098
Wildiers, H., Heeren, P., Puts, M., Topinkova, E., Janssen-Heijnen, M.L., Extermann, M., . . . Hurria, A. (2014). International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. Journal of Clinical Oncology, 32, 2595–2603. https://doi.org/10.1200/JCO.2013.54.8347
Wilkie, R., Blagojevic-Bucknall, M., Belcher, J., Chew-Graham, C., Lacey, R.J., & McBeth, J. (2016). Widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults: A prospective cohort study in primary care. Medicine, 95(31), e4111. https://doi.org/10.1097/MD.0000000000004111
Yeoh, T.T., Tay, X.Y., Si, P., & Chew, L. (2015). Drug-related problems in elderly patients with cancer receiving outpatient chemotherapy. Journal of Geriatric Oncology, 6, 280–287. https://doi.org/10.1016/j.jgo.2015.05.001
Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M., & Leirer, V.O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49.
Yount, S.E., Rothrock, N., Bass, M., Beaumont, J.L., Pach, D., Lad, T., . . . Cella, D. (2014). A randomized trial of weekly symptom telemonitoring in advanced lung cancer. Journal of Pain and Symptom Management, 47, 973–989. https://doi.org/10.1016/j.jpainsymman.2013.07.013
Zung, W.W. (1965). A Self-Rating Depression Scale. Archives of General Psychiatry, 12, 63–70.