The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Comorbidities

Why Comorbidities are Important:

• More than one in four Americans have at least two chronic conditions
• Prevalence of comorbidities rises with age affecting 70.2% of Americans aged 80 and older
• Two thirds of Medicare beneficiaries with comorbidities account for 96% of Medicare expenditures (Whitson & Boyd, 2015)
• Individuals with multiple chronic conditions are at heightened risk of significant adverse health outcomes (Barnett at al. 2012)
• Common comorbidities in the United States are hypertension, arthritis, heart disease, diabetes and cancer (Jorgensen, Hallas, Friis & Herrstedt, 2012)
• The burden of many chronic diseases and conditions varies widely by race and ethnicity (Siegel, Naishadham & Jemal, 2013)
• Chronic diseases can lead to limitation in daily activities, reduce health related quality of life and one's ability to cope (Kalyani, Corriere & Ferrucci, 2014)
• An acute health crisis may be the result of the culmination of several comorbidities interacting with the cancer diagnosis and treatment (Edwards et al., 2014)
• A patient with multiple comorbid conditions are at greater risk for:
• polypharmacy
• ​drug interactions
• limited cancer treatment options
• increased symptom burden
• multiple organ system compromise (Salive, 2013)

Normal Age-Related Changes:

• The process of normal aging is accompanied by diminishing physical, physiological and psychological reserves; at baseline, normal organ function is preserved, but in the setting of stressor events imposed by environment, disease, emotional turmoil or medical therapies, the ability to maintain homeostasis diminishes, reserve capacity is surpassed and deterioration ensues
• These age-related changes predispose older persons to greater risk for developing comorbid conditions and disease (Rodin, 2014)

Comorbidity is recognized as having an unfavorable effect on life expectancy of patients with cancer, as well as influencing clinical decision making; older adults are at increased risk of adverse health outcomes if they have any of the following:​

• Cardiovascular system:
  Hypertension, hyperlipidemia, coronary artery disease, peripheral vascular disease, acute coronary syndromes (MI), atrial fibrillation, cardiomyopathy, hypotension, congenital heart disease, edema, palpitations, angina, congestive heart failure, valvular heart disease, aortic stenosis, mitral regurgitation (Go et al., 2013)
• Pulmonary System:
  Asthma, sleep apnea, interstitial lung disease, COPD, emphysema, pulmonary fibrosis, pneumonia, sarcoidosis, tuberculosis (Van Remoortel et al., 2014)
• Gastrointestinal:
  GERD, peptic ulcer disease (PUD), reflux, Crohn's disease, chronic constipation, diarrhea, gallstones, liver disease, pancreatitis, irritable bowel syndrome (IBS), diverticular disease, dysphagia (Grassi, 2011)
• ​Renal and Genitourinary:
  Urinary incontinence, bacteriuria, BPH, acute renal failure, chronic renal insufficiency, dialysis (Smith & Cotter, 2012)
• Neurologic:
  Cerebrovascular disease, CVA, TIA, dementia, headaches, seizure disorder, multiple sclerosis, Parkinson's disease, shingles, chronic dizziness, neuropathy, pain (Savva, Wharton, Ince, Forster, Matthews, & Brayne, 2009)
• Endocrinology:
  Diabetes (IDDM or NIDM), hypothyroidism, hyperthyroidism, Grave's disease (Pappa & Alevizaki, 2012)
• Musculoskeletal: Osteopenia, osteoporosis, osteoarthritis, degenerative joint disease, rheumatoid arthritis, back pain, gout, fibromyalgia, Lyme disease, polymyalgia rheumatica​
• Dermatologic:
  Herpes zoster, rosacea, psoriasis, stasis dermatitis skin ulcerations, xerosis, pruitus, eczema (Farage, Miller, Berardesca, & Maibach, 2012)
• Ear/Nose/Throat:
  Hearing loss, tinnitus, temporomandibular disorder (TMJ), swallowing disorders, sleep apnea, sleep disturbance, balance disorders (Roberts, Lin, & Bhattacharyya, 2013)
• Psychiatric:
  Anxiety, depression, insomnia (Rodin, 2014)
• Hematologic:
  Iron deficiency, anemia, polycythemia, myelodysplastic syndromes (Della Porta & Malcovati, 2009)

Behavioral Risk Factors

• Misuse of medications/herbals
• Substance abuse
• Smoking

Medication-Related Risk Factors

• See Review of Medication

Chemotherapy-Related Risk Factors: (Lichtman et al. 2007 and Hurria et al., 2011)

(see chemotherapy index)

• Cardiac:
  Cardio-toxic drugs: anthracyclines (doxorubicin/Doxil, cyclophosphamide, trastuzumab, etc.); Exacerbation of hypertension: bevacizumab, sunitinib, sorafenib, cediranib, mitomycin; fluid retention-monitor for CHF: taxanes; Orthostatic hypotension: epipodophyllotoxins
• Neurologic
  ​Peripheral neuropathy: alkylating agents, plant alkaloids, taxanes​, anti-angiogenesis agents; Ototoxicity: alkylating agents; Cerebellar dysfunction: alkylating agents, antimetabolites.; neurotoxicity: antimetabolites, plant alkaloids, taxanes and vinca alkaloids
• Renal:
  ​Nephrotoxic: alkylating agents; Hemorrhagic cystitis: alkylating agents; Proteinuria: antiangiogenic agents
• Pulmonary:
  Pulmonary toxicity: antitumor antibodies, antimetabolites; Pulmonary fibrosis: bleomycin, carmustine (BCNU), methotrexate, alkylating agents, such as cyclophosphamide (Cytoxan) or busulfan (Busulfex)
• Gastrointestinal/Hepatic:
  Constipation: vinca alkaloids; gastrointestinal perforation: antiangiogenic agents; Hepatotoxicity: asparaginase, antitumor antibodies, nitrosureas, such as carmustine (BCNU), antimetabolites, such as methotrexate or cytarabine (Cytosar), cisplatin, cyclophosphamide, vinca alkaloids, such as vinblastine or vincristine (Oncovin); Diarrhea: 5-fluorouracil bolus or some combination therapies of irinotrecan and fluoropyrimidines (IFL, XELIRI), tyrosine kinase inhibitors

Radiation-Related Risk Factors

• Radiation therapy can exacerbate existing comorbidities
• Existing comorbid conditions can intensify radiation toxicity

Assessment:

1. Screening Questions

• What other chronic medical conditions do you have?
• Do you think your chronic medical conditions are well-controlled?
• Who manages/prescribes medications for your other medical conditions?
• How often do your see your primary care provider?
• How many specialists do you have?

2. Observations

• Assess potential burden comorbidities will have on patients (morbidity and mortality)

3. Screening Tests and Measurements

• Charlson Comorbidity Index (Charlson, 1994). A formula for predicting mortality at 1 year related to the existence of various comorbidities
• Cumulative Illness Rating Scale for Geratrics (CIRS-G). A scoring system which measures the chronic medical illness burden (morbidity) while taking into consideration the severity of chronic diseases in 14 items representing individual body systems

4. Physical Assessment:

• Comprehensive physical examination

Nursing Intervention:

• Coordinate cancer treatment with primary care practitioner
• Educate patient about:
• potential impact of co-morbidities on cancer treatment
• potential effect of cancer treatment on co-morbid condition(s)
• Health maintenance/disease prevention
• Ongoing monitoring for functional decline and/or alterations in health status
• Activate necessary referrals for assessed needs

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