The concurrent presence of two or more poor conditions, or one severe condition, that are usually chronic in nature.
Disability or functional impairment
Conditions that cause dependency in order to perform tasks such as managing finances, meal preparation, and managing medications. Disability may prevent the person from living in the community and caring for himself.
Conditions that render a person vulnerable and frail, including depression, dementia, delirium, falls, osteoporosis with fractures, neglect and abuse, and a failure to thrive.
Consulting a theoretical table, no matter how well done, may be insufficient to help oncologists determine the health status of the patients who they see in the clinic. It's important to look beyond comorbidities because there are other geriatric conditions that influence life expectancy in very old patients, Dr. Mohile said, going on to define comorbidities and two other important geriatric conditions (see Table 1).
Dr. Mohile stressed that all three geriatric conditions need to be evaluated separately in the clinical setting as they may overlap or be mutually exclusive. "We know that these conditions are common in older patients with newly diagnosed cancer. A study by Siran M. Koroukian, PhD, showed that about 16% of patients with newly diagnosed colon cancer had all three entities: Disability, comorbidity, and geriatric syndromes. And about 12% of breast cancer patients that are newly diagnosed had all three entities. Someone may have no comorbidity and just have disability, or may have geriatric syndromes but have neither disability nor comorbidity" (J Clin Oncol 24:2304-2310, 2006).
|•||Have the highest level of health|
|•||Are at the top of life expectancy tables|
|•||Do not have disability, significant comorbidity, and/or geriatric syndromes|
|•||Have some dependence in instrumental activities of daily living (using telephone, taking medications) but not activities of daily living (bathing, providing transportation)|
|•||May have comorbidities, but they are not severe and are well controlled|
|•||May have mild geriatric syndromes such as memory disorder or depression|
|•||Have dependence in activities of daily living|
|•||Have three or more severe comorbidities or one life-threatening comorbidity|
|•||Have a clinically significant geriatric syndrome|
The comprehensive geriatric assessment (CGA) is an established diagnostic tool in geriatric medicine used to fully evaluate all three entities plus cognition, nutritional status, psychological status, and social status. A paper by Lodovico Balducci, MD, and Martine Extermann, MD, PhD, outlined the parameters that oncologists should use when assessing older patients (Oncologist 5:224-237, 2000). Dr. Mohile explained how this CGA framework can be used to assess the three stages of aging (see Table 2).
"Geriatric assessment can better estimate life expectancy by focusing on functional age rather than chronologic age. All fit elders should be considered for adjuvant therapy, but once a patient gets to be 85, they have to be very fit and one cannot look only at comorbidity to determine fitness," Dr. Mohile said. "So if you ask these questions of your patients in the clinic, you'll be better able to put them in the category of health status in which they belong."