Older Patients With Blood Cancer Should Discuss Daily Function With Their Health Care Team

Older patients with blood cancers should be formally assessed for instrumental activities of daily living (IADLs) as part of routine oncology care, according to study findings published in the Journal of the American Geriatrics Society.

These instrumental activities are described as shopping, preparing meals, housework, taking medication and handling finances — activities necessary for a patient to live on their own in the community. Basic activities of daily living (ADLs), such as bathing, dressing, grooming, getting from a chair to a bed, eating and using the toilet, were also examined.

“The assessment of older adult function, or the ability to complete activities necessary to live independently at home (ADLs) and in the community (IADLs), is a principle component in assessing older adult health — more formally called the geriatric assessment,” first author Clark DuMontier, a geriatrician who focuses on the study and care of older adults with cancer at Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, said in an interview with CURE®. “Maintaining independence is often the primary goal of older adults and central to their quality of life.”

The researchers suspected that being unable to perform daily activities would mean higher rates of death, unplanned emergency department visits and admissions to the hospital, according to a press release.

To evaluate whether older patients’ ability to manage daily activities was associated with living longer, the researchers examined 464 patients with hematologic malignancies —myelodysplastic syndrome, leukemia, myeloma or lymphoma — from Dana-Farber Cancer Institute in Boston who were a mean age of 79.7 years and mostly men (65%). Thirty-eight percent of patients had aggressive disease. And the mean follow-up was 13.8 months. At the time of diagnosis, patients were asked whether they were able to complete the activities independently, with assistance or entirely dependent on other people.

Fifty-three patients (11.4%) reported having trouble with at least one activity of daily living and 124 patients (26.7%) were dependent for at least one instrumental activity of daily living.

The researchers then examined emergency department visits in 318 patients and found that 53 patients (16.7%) had at least one visit and 60 people (18.9%) had at least one unplanned hospitalization. The most common reasons for all hospitalizations included pneumonia (13.8%), fever (8.5%), sepsis (6.4%), pain (6.4%) and congestive heart failure (5.3%).

They found that those who had difficulty performing at least one instrumental activity of daily living had higher risk of death, emergency department visits and unplanned hospitalizations. However, the risk was not affected by age, chronic illness, cancer aggressiveness or treatment intensity, according to the study.

“While we predicted that dependency in functioning would be linked to our outcomes, we were surprised to see that being dependent in basic activities of daily living, which is considered the most severe form of functional impairment, was not strongly associated with our outcomes,” DuMontier said. “This is likely because we had so few of these patients present in our study — a reflection of which older patients are sent for evaluation for systemic cancer treatment. An oncologist is less likely to treat an older adult who is so frail that, for instance, they need help transferring to and from their chair.”

Researchers also determined that patients who relied on help from others also had higher rates of age-related conditions, including memory loss, mobility problems, loneliness or depression. “Limitations in IADLs reflect deficits in the higher-order functioning needed to adhere to cancer therapies and/or overcome complications associated with hematologic malignancies,” DuMontier said. “Dependency in IADLs likely reflects problems in other geriatric domains.”

In screening for these conditions and function, the researchers concluded that it may help older adults with blood cancers tolerate the stress of the disease and treatment.

“Tell your doctor if you have any difficulty in your daily functioning and ask how this difficulty may impact and be impacted by your cancer and its treatment,” DuMontier said. “Ask your doctor if there are treatments or services to help optimize your functioning, such as a geriatrician affiliated with the cancer clinic or one locally to which your specialist can refer you to. Focusing on function with your providers is not only important for your quality of life but may also help you stay out of the hospital and live longer.”