William Dale

A pilot study of the vulnerable elders survey‐13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation

Impairments in geriatric domains adversely affect health outcomes of the elderly. The Comprehensive Geriatric Assessment (CGA) is a key component of the treatment approach for older cancer patients, but it is time consuming. In this pilot study, the authors evaluated the validity of a brief, functionally based screening tool, the Vulnerable Elders Survey‐13 (VES‐13), for identifying older patients with prostate cancer (PCa) with impairment in the oncology clinic setting.

Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006

OBJECTIVE This study used a large national administrative in-hospital database to compare utilization and age-specific outcomes between open repair (OAR) and endovascular (EVAR) repair for the treatment of abdominal aortic aneurysm (AAA). METHODS Discharges with the principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for EVAR and OAR and principal diagnosis code of intact AAAs were selected from the 2001 to 2006 Nationwide Inpatient Sample (NIS). Weighted least-square regression was used to test the trend of utilization by age. Multiple linear and logistic regression analyses were used to assess the risk-adjusted outcomes. RESULTS Nationally, the estimated number of elective AAAs treated with EVAR increased from 11,171 in 2001 to 21,725 in 2006 (P = .003). The number of elective AAAs treated with OAR declined from 17,784 to 8451 during the same period (P < .001). By 2006, EVAR was more frequently used than OAR for patients of all ages. Compared with the younger age groups, patients aged >or=85 years had a significant increase in the total number of asymptomatic AAA repairs, driven almost entirely by an increase in the use of EVAR. Compared with open patients, EVAR patients had a significantly shorter length of hospitalization (adjusted mean, 2.99 days [95% confidence interval (CI), 2.97-3.01] vs 8.78 days [95% CI, 8.53-8.57]), less in-hospital mortality (odds ratio [OR], 0.23; 95% CI, 0.19-0.28), fewer in-hospital complications (OR, 0.27; 95% CI, 0.25-0.28), and a higher likelihood of being discharged to home (OR, 3.95; 95% CI, 3.62-4.31). The reduction of complications from the use of EVAR versus OAR was most dramatic for the oldest patients. CONCLUSIONS As short-term surgical outcomes are consistently improving for patients undergoing AAA repair, elective EVAR has replaced OAR as the more common method of repair in the United States. The introduction of this technology has been rapidly adopted, particularly for the oldest-old surgical patients, aged >or=85 years, who previously may not have been offered surgical intervention for asymptomatic AAA. Further investigation is necessary to examine whether this trend improves the long-term survival and quality of life for this elderly population.

The role of anxiety in prostate carcinoma: a structured review of the literature.

Although the impact of anxiety on patients with some types of cancer is well recognized, to the authors knowledge its impact on patients with prostate carcinoma has not been studied as thoroughly. The authors conducted a systematic review of the medical literature for high‐quality articles that quantified anxiety levels in men with prostate carcinoma and identified 29 articles. Using the clinical timeline of prostate carcinoma to organize the articles, cross‐sectional studies that reflected anxiety prevalence in populations and longitudinal studies that reflected changes in anxiety over time were identified. Anxiety appeared to fluctuate over the clinical timeline in response to stressors and uncertainty (such as at the time of screening and/or biopsy), rising before these times and falling afterward. Although anxiety levels in men age > 55 years who were at risk for prostate carcinoma were modest (10–15%), multiple studies found that these levels were substantially higher in men who presented for screening (> 50%), and “seeking peace of mind” was the motivation cited most frequently for pursuing screening. Most studies demonstrated a significant decrease in anxiety levels after a normal screening or biopsy result, although the proportion of men who remained anxious afterward did not fall to baseline levels (20–36%). Men who presented for prostate‐specific antigen monitoring after treatment had elevated anxiety levels at the time of testing (23–33%). Many years after therapy for localized disease, anxiety levels were lower after prostatectomy (23%) compared with the levels after watchful waiting (31%). Cancer 2005.

Association of a cancer diagnosis with vulnerability and frailty in older Medicare beneficiaries.

BACKGROUND Few studies have evaluated the independent effect of a cancer diagnosis on vulnerability and frailty, which have been associated with adverse health outcomes in older adults. METHODS We used data in the 2003 Medicare Current Beneficiary Survey from a nationally representative sample of 12,480 community-dwelling elders. Multivariable logistic regression models were used to evaluate whether cancer was independently associated with vulnerability and frailty. Measures of vulnerability and frailty included disability, geriatric syndromes, self-rated health, and scores on two assessment tools for elderly cancer patients-the Vulnerable Elders Survey-13 (VES-13) and the Balducci frailty criteria. All statistical tests were two-sided. RESULTS Diagnosis of a non-skin cancer was reported by 18.8% of the respondents. Compared with respondents without a cancer history, respondents with a personal history of cancer had a statistically significantly higher prevalence of limitations in activities of daily living (31.9% vs 26.9%), limitations in instrumental activities of daily living (49.5% vs 42.3%), geriatric syndromes (60.8% vs 53.9%), low self-rated health (27.4% vs 20.9%), score of 3 or higher on the VES-13 (45.8% vs 39.5%), and satisfying criteria for frailty as defined by Balducci (79.6% vs 73.4%) (P < .001 for all characteristics). After adjustment for confounders, a cancer diagnosis was found to be associated with low self-rated health (adjusted odds ratio [OR] = 1.46, 95% confidence interval [CI] = 1.30 to 1.64; relative risk [RR] = 1.33), limitations in activities of daily living (adjusted OR = 1.19, 95% CI = 1.06 to 1.33; RR = 1.13), limitations in instrumental activities of daily living (adjusted OR = 1.25, 95% CI = 1.13 to 1.38; RR = 1.13), a geriatric syndrome (adjusted OR = 1.27, 95% CI = 1.15 to 1.41; RR = 1.11), VES-13 score of 3 or higher (adjusted OR = 1.26, 95% CI = 1.13 to 1.41; RR = 1.14), and frailty (adjusted OR = 1.46, 95% CI = 1.29 to 1.65; RR = 1.09) as defined by Balducci criteria. CONCLUSION Diagnosis of a non-skin cancer was associated with increased levels of having disability, having geriatric syndromes, and meeting criteria for vulnerability and frailty.

Falls and Physical Performance Deficits in Older Patients With Prostate Cancer Undergoing Androgen Deprivation Therapy

OBJECTIVES Men experience a decrease in lean muscle mass and strength during the first year of androgen deprivation therapy (ADT). The prevalence of falls and physical and functional impairment in this population have not been well described. METHODS A total of 50 men aged 70 years and older (median 78) receiving ADT for systemic prostate cancer (80% biochemical recurrence) underwent functional and physical assessments. The functional assessments included Katzs Activities of Daily Living (ADLs) and Lawtons Instrumental Activities of Daily Living (IADLs). Patients completed the Vulnerable Elders Survey-13, a short screening tool of self-perceived functional and physical performance ability. Physical performance was assessed using the Short Physical Performance Battery. The history of falls was recorded. Of the 50 patients, 40 underwent follow-up assessment with the same instruments 3 months after the initial assessment. RESULTS Of the 50 men, 24% had impairment in the ADLs, 42% had impairment in the IADLs, 56% had abnormal Short Physical Performance Battery findings, and 22% reported falls within the previous 3 months. Within the Short Physical Performance Battery, deficits occurred within all subcomponents (balance, walking, and chair stands). On univariate analysis, age, deficits in ADLs and IADLs, and abnormal cognitive and functional screen findings were associated with an increased risk of abnormal physical performance. ADL deficits, the use of an assistive device, and abnormal functional screen findings were associated with an increased risk of falling. CONCLUSIONS The results of our study have shown that older men with prostate cancer receiving long-term ADT exhibit significant functional and physical impairment and are at risk of falls that is greater than that for similar-aged cohorts. Careful assessment of the functional and physical deficits in older patients receiving ADT is warranted.

Integrating Palliative Medicine into the Care of Persons with Advanced Dementia: Identifying Appropriate Medication Use

OBJECTIVES: To evaluate the feasibility of developing consensus recommendations for appropriate prescribing for patients with advanced dementia using a new conceptual framework and to determine the frequency of inappropriate medication use based on these recommendations in a small sample of patients with advanced dementia.

Does Androgen-deprivation Therapy Accelerate the Development of Frailty in Older Men With Prostate Cancer? A Conceptual Review

The majority of men with prostate cancer are aged ≥65 years. Men, as they age, are more likely to suffer from impaired physical function. The standard treatment for recurrent prostate cancer is androgen‐deprivation therapy (ADT). Well‐established toxicities from ADT include lean weight loss or sarcopenia, muscle weakness, fatigue, and reduced activity levels. Frailty is a term from geriatrics that describes older individuals with limited physiologic reserve who are at significant risk for adverse outcomes, including falls, disability, hospitalization, and death. An increasingly accepted definition of frailty is a syndrome in which ≥3 of the following are present: unintentional (lean) weight loss ≥10 pounds in the past year, weakness (measured by grip strength), slow walking speed, self‐reported exhaustion, and low physical activity. This clinical syndrome overlaps closely with the known toxicities of ADT. In addition, alterations in the inflammatory system, neuroendocrine system, and energy production are associated with this syndrome, as evidenced by biomarkers such as C‐reactive protein, interleukin‐6, and tumor necrosis factor‐α. For this article, the authors reviewed the evidence for the effect of ADT on each of the 5 frailty components plus the identified biomarkers, and the evidence indicates that ADT may accelerate the development of frailty in vulnerable older men with prostate cancer. Given the association of frailty with important clinical outcomes such as hospitalization and death, this potential consequence of ADT should be considered carefully when initiating therapy in older patients with recurrent prostate cancer. Cancer 2007.

Association of Cancer With Geriatric Syndromes in Older Medicare Beneficiaries

PURPOSE To identify whether a history of cancer is associated with specific geriatric syndromes in older patients. PATIENTS AND METHODS; Using the 2003 Medicare Current Beneficiary Survey, we analyzed a national sample of 12,480 community-based elders. Differences in prevalence of geriatric syndromes between those with and without cancer were estimated. Multivariable logistic regressions were used to evaluate whether cancer was independently associated with geriatric syndromes. RESULTS Two thousand three hundred forty-nine (18%) reported a history of cancer. Among those with cancer, 60.3% reported one or more geriatric syndromes as compared with 53.2% of those without cancer (P < .001). Those with cancer overall had a statistically significantly higher prevalence of hearing trouble, urinary incontinence, falls, depression, and osteoporosis than those without cancer. Adjusting for possible confounders, those with a history of cancer were more likely to experience depression (adjusted odds ratio [OR], 1.15; 95% CI, 1.02 to 1.30; P = .023), falls (adjusted OR, 1.17; 95% CI, 1.04 to 1.32; P = .010), osteoporosis (adjusted OR, 1.21; 95% CI, 1.06 to 1.38; P = .004), hearing trouble (adjusted OR, 1.28; 95% CI, 1.08 to 1.52; P = .005), and urinary incontinence (adjusted OR, 1.42; 95% CI, 1.20 to 1.69; P < .001). Analysis of specific cancer subtypes showed that lung cancer was associated with vision, hearing, and eating trouble; prostate cancer was associated with incontinence and falls; cervical/uterine cancer was associated with falls and osteoporosis; and colon cancer was associated with depression and osteoporosis. CONCLUSION Elderly patients with cancer experience a higher prevalence of geriatric syndromes than those without cancer. Prospective studies that establish the causal relationships between cancer and geriatric syndromes are necessary.

Designing therapeutic clinical trials for older and frail adults with cancer: U13 conference recommendations.

A majority of cancer diagnoses and deaths occur in patients age ≥ 65 years. With the aging of the US population, the number of older adults with cancer will grow. Although the coming wave of older patients with cancer was anticipated in the early 1980s, when the need for more research on the cancer-aging interface was recognized, many knowledge gaps remain when it comes to treating older and/or frailer patients with cancer. Relatively little is known about the best way to balance the risks and benefits of existing cancer therapies in older patients; however, these patients continue to be underrepresented in clinical trials. Furthermore, the available clinical trials often do not include end points pertinent to the older adult population, such as preservation of function, cognition, and independence. As part of its ongoing effort to advance research in the field of geriatric oncology, the Cancer and Aging Research Group held a conference in November 2012 in collaboration with the National Cancer Institute, the National Institute on Aging, and the Alliance for Clinical Trials in Oncology. The goal was to develop recommendations and establish research guidelines for the design and implementation of therapeutic clinical trials for older and/or frail adults. The conference sought to identify knowledge gaps in cancer clinical trials for older adults and propose clinical trial designs to fill these gaps. The ultimate goal of this conference series is to develop research that will lead to evidence-based care for older and/or frail adults with cancer.

Geriatric assessment improves prediction of surgical outcomes in older adults undergoing pancreaticoduodenectomy: a prospective cohort study.

Objective:To prospectively evaluate the additional value of geriatric assessment (GA) for predicting surgical outcomes in a cohort of older patients undergoing a pancreaticoduodenectomy (PD) for pancreatic tumors. Background:Older patients are less often referred for possible PD. Standard preoperative assessments may underestimate the likelihood of significant adverse outcomes. The prospective utility of validated GA has not been studied in this group. Methods:PD-eligible patients were enrolled in a prospective outcome study. Standard preoperative assessments were recorded. Elements of validated GA were also measured, including components of Frieds model of frailty, the Vulnerable Elders Survey (VES-13), and the Short Physical Performance Battery (SPPB). All postoperative adverse events were recorded, systematically reviewed, and graded using the Clavien-Dindo system by a surgeon blinded to the GA results. Multivariate regression analyses were conducted. Results:Seventy-six older patients underwent a PD. Significant unrecognized vulnerability was identified at the baseline: Frieds “exhaustion” (37.3%), SPPB <10 (28.5%), and VES-13 >3 (15.4%). Within 30 days of PD, 46% experienced a severe complication (Clavien-Dindo grade ≥III). In regression analyses controlling for age, the body mass index, the American Society of Anesthesiologists score, and comorbidity burden, Frieds “exhaustion” predicted major complications [odds ratio (OR) = 4.06; P = 0.01], longer hospital stays (&bgr; = 0.27; P = 0.02), and surgical intensive care unit admissions (OR = 4.30; P = 0.01). Both SPPB (OR = 0.61; P = 0.04) and older age predicted discharge to a rehabilitation facility (OR = 1.1; P < 0.05) and age correlated with a lower likelihood of hospital readmission (OR = 0.94; P = 0.02). Conclusions:Controlling for standard preoperative assessments, worse scores on GA prospectively and independently predicted important adverse outcomes. Geriatric assessment may help identify older patients at high risk for complications from PD.