The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Independence

Related Issues:

Social support, finances, mobility, deconditioning

Why Independence is Important:

• Increased risk of falls
• Increased risk of loss of independence from subtle alterations in functional status
• Deconditioning can lead to decline and dependency
• Increased need for social & environmental support
• To maintain self esteem
• To remain in familiar surroundings (McEvoy, 2016)

Normal Age-Related Changes:

• Sarcopenia (decreased muscle mass and strength)
• Slower motor response time
• Increased risk of postural hypotension
• Decreased bone density (osteoporosis and fracture risk)
• Visual changes--distorted depth perception causing inability to drive
• Cognitive/memory changes  (Bond, Davis & McEvoy, 2012)

Older adults are at risk if they have any of the following:

Conditions

• Live alone or are socially isolated
• Have inadequate support
• At risk for elder abuse (physical, emotional, financial neglect)
• Dementia or decreased cognition
• Have been recently hospitalized; deconditioning is associated with hospitalization for an acute stressor event (Cherulyot, Reinhard & Laoingco, 2013)

Medication-Related Risk Factors

• Polypharmacy
• Sleep aids
• Narcotics
• Use of multiple providers and multiple pharmacies
• Untoward side effects from medication

Behavioral Risk Factors

• Alcohol/ substance abuse
• Sedentary lifestyle
• Addictive behaviors (shopping, gambling, hoarding)

Chemotherapy-Related Risk Factors

• Neuropathy:
• Vinca alkaloids (vincristine, vinblastine, vinorelbine, vindesine)
• Platinum-based (cisplatin, oxaliplatin,carboplatin)
• Taxanes (paclitaxel, docetaxel)
• Podophyllotoxin (etoposide, teniposide)
• Other: thalidomide, bortezomib, lenalidomide, interferon
• Confusion:
• high dose ifosfamide,methotrexate, interleukin-2,interferon, cytarabine
• ​premedication regimes for chemotherapy that include lorazepam a/o diphenhydramine

Surgery-Related Risk Factors

• Neurologic procedures
• Ophthalmic procedures
• Surgery involving an extremity (i.e total joint replacement, IM rod, amputation)
• Surgery that results in prolonged debilitation (i.e Whipple, pelvic exoneration, spine surgery)

Radiation Risk Factors

• Brain-causing neurologic side effects
• Bone-causing impending or actual fracture

Cancer Diagnoses

• Primary brain cancer or brain metastases
• Bone cancer
• Advanced disease

Assessment:

1. Screening Questions

• Are you able to maintain your personal care (ADLs) and social network?
• Are you able to maintain adequate nutrition and follow your medication schedule?
• Are you able to keep up with your housework and finances?

2. Observations

• Confusion
• Difficulty ambulating
• Disheveled or unkempt appearance
• Underweight

3. Screening Tests and Measurements

• MSKCC 65+ Adult Health Assessment
• Occupational therapy evaluation
• Katz Index of Independence in Activities of Daily Living (see below)
• Lawton-Brody IADL Scale (see below)
• Cognitive screening tools: St. Louis University Mental Status Exam (SLUMS), Montreal Cognitive Assessment (MOCA), Folsteins Mini Mental Status Exam (MMSE)

4. Physical Assessment: Standard examination with focus on

• Motor response/reflexes
• Cardiopulmonary system
• Mental status (Palacios-Cena, Lavarez-Lopez & Cachon-Perez, 2009)

 

Nursing Intervention:

• Recognize that deconditioning will occur when an older adult experiences a reduction in physical activity
• Assist in determining underlying etiology of alterations in independence and correct if possible
• Discuss living conditions/social situation with patient and caregiver
• Initiate and coordinate appropriate referrals as appropriate:
• Evaluation by social worker
• Assess safety of home (VNS referral)
• Assess caregiver adequacy and arrange care-giver assist (HHA) if indicated
• PT/OT evaluation/therapy as indicated
• Referrals for assistive devices as indicated
• Provide education to patient and caregivers
• Falls prevention education
• Evaluate need for adaptive strategies (pre-cut foods,grab bars,shower seats)
• Collaborate with all other healthcare providers
• Evaluate effectiveness of interventions and modify as needed

Bond, S.M., Davis, M.E. & McEvoy, L.K. (2012). Physiology of aging and its impact on the older adult. In Cope, D. & McEvoy, L. (Eds.) Caring for the older adult with cancer in the ambulatory setting (9-36). Pittsburgh: Oncology Nursing Society.
Cherulyot, J., Reinhard, J. Laoingco, C. (2013). Knowledge of staff nurses on management of deconditioning in older adults: A cross-sectional study. Journal of Natural Science, 3(6), 82-91.
Gillis, A., McDonald, B. (2008). Nurses' knowledge, attitudes and confidence regarding preventing and treating deconditioning in older adults. Journal of Continuing Education Nursing, 39(12), 547-554.
Gosney, M. (2009). General Care of the Older Cancer Patient. Clinical Oncology, 21(2), 86-91. 
Hempen, C., Weiss, E., & Hess, C. (2002). Dexamethasone treatment in patients with brain metastases and primary brain tumors: Do the benefits outweigh the side-effects? Support Care Cancer Supportive Care in Cancer, 10(4), 322-328.
Lankveld, W., Goossens, J., & Franssen, M. (2011). The Gerontorheumatology Outpatient Service: Toward an International Classification of Function-Based Health Care Provision for the Elderly with Musculoskeletal Conditions. In Y. Nakasato (Ed.), Geriatric Rheumatology: A comprehensive approach (pp. 85-91). New York: Springer.
McEvoy, L.K. (2016). Deconditioning in older adults with cancer: a cascade to dependency. The ASCO Post, 7(1), 66-67.
Stark, M., Chase, C., & Deyoung, A. (2010). Barriers to Health Promotion in Community Dwelling Elders. Journal of Community Health Nursing, 175-186.
Palacios-Cena, D., Alvarez-Lopez, C., Cachon-Perez, M. (2009). Early detection of functional and cognitive decline after hospital discharge: the role of community nursing and multidisciplinary teams. Journal of Gerontology Nursing, 35(9), 13-17.
Stuck, A., Walthert, J., Nikolaus, T., Büla, C., Hohmann, C., & Beck, J. (1999). Risk factors for functional status decline in community-living elderly people: A systematic literature review. Social Science & Medicine 48(4), 445-469.​