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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Comorbidities

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

C=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

C=Comorbidities

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

References

Go, A.S.Mozaffarian, D.Roger, V.L.Benjamin, E.J.Berry, J.D.Borden, W.B.Bravata, D.M.Dai, S.Ford, E.S.Fox, C.S.Franco, S.Fullerton, H.J.Gillespie, C.Hailpern, S.M.Heit, J.A.Howard, V.J.Huffman, M.D.Kissela, B.M.Kittner, S.J.Lackland, D.T.Lichtman, J.H.Lisabeth, L.D.Magid, D.Marcus, G.M.Marelli, A.Matchar, D.B.McGuire, D.K.,Mohler, E.R.Moy, C.S.Mussolino, M.E.Nichol, G.Paynter, N.P.Schreiner, P.J.Sorlie, P.D.Stein, J.Turan, T.N.Virani, S.S.Wong, N.D.Woo, D.Turner, M.B.American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2013). Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation, 127(1): e6-e245.
Barnett, K. Mercer, S.W. Norbury, M. Watt, G. Wyke, S., & Guthrie, B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet 380(9836): 37-43.
Charlson, M., Szatrowski, T.P., Peterson, J., Gold, J. (1994). Validation of a combined comorbidity index. J Clin Epidemiol, 47(11): 1245-51.
Della Porta, M.G. & Malcovati, L. (2009). Clinical relevance of extra-hemotologic comorbidity in the management of patients with myelodysplastic syndrome. Haematologica, 94(5): 602-606.
Edwards, B.K.Noone, A.M.Mariotto, A.B.Simard, E.P.Boscoe, F.P.Henley, S.J.Jemal, A.Cho, H.Anderson, R.N.Kohler, B.A.Eheman, C.R.Ward, E.M. (2014). Nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer. Cancer 120(9): 1290-314.
Farage, M.A., Miller, K.W., Berardesca, E., Maibach, H.I. (2009). Clinical implications of aging skin: cutaneous disorders in the elderly. American Journal of Clinical Dermatology, 10(2): 73-86.
Fejer, R. & Ruhe, A. (2012). What is the prevalence of musculoskeletal problems in the elderly population in developed countries? A systematic critical literature review. Chiropractic & Manual Therapies, 20(1): 31.
Grassi, M., Petraccia, L., Munnini, G., Fontana, M., Scarno, A., Sabetta, S., Fraioli, A. (2011). Changes, functional disorders, and diseases in the gastrointestinal tract of elderly. Nutr Hosp, 26(4): 659-668.
Hurria, A., Togawa, K., Mohile, S.G., Owusu, C., Klepin, H.D., Gross, C.P., Lichtman, S.M., Gajra, A., Bhatia, S., Katheria, V., Klapper, S., Hansen, K., Ramani, R., Lachs, M., Wong, F.L., Tew, W.P. (2011). Predicting chemotherapy toxicity in older adults with cancer: A prospective multicenter study. Journal of Clinical Oncology, 29(25): 3457-3465.
Jorgensen, T.L., Hallas, J., Friis, S., & Herrstedt, J. (2012). Comorbidity in elderly cancer patients in relation to overall and cancer-specific mortality. British Journal of Cancer, 106(7), 1353-1360.
Kalyani, R.R., Corriere, M., & Ferrucci, L. (2014). Age-related and disease-related muscle loss: the effect of diabetes, obesity, and other diseases. The Lancet Diabetes & Endocrinology, 2(10), 819-829.
Lichtman, S.M., Wildiers, H., Chatelut, E., Steer, C., Budman, D., Morrison, V.A., Tranchard, B., Shapira, I., Aapro, M.; International Society of Geriatric Oncology Chemotherapy Taskforce(2007). International Society of Geriatric Oncology Chemotherapy Taskforce: evaluation of chemotherapy in in older patients--an analysis of the medical literature. Journal of Clinical Oncology, 25(14): 1832-1843.
Pappa, T. & Alevizaki, M. (2012). Mechanisms in endocrinology: endogenous sex steroids and cardio- and cerebro-vascular disease in the postmenopausal period. European Journal of Endocrinology, 167(2): 145-156.
Roberts, D.S., Lin, H.W., & Bhattacharyya, N. (2013). Health care practice patterns for balance disorders in the elderly. Laryngoscope, 123(10): 2539-2543.
Rodin, J. (2014). Health, control, and aging. In M.M. Baltes & P.B. Baltes (Eds.), The psychology of control and aging (139-165). Psychology Press.
Salive, M.E. (2013). Multimorbidity in older adults. Epidemiologic reviews, 35: 75-83.
Savva, G.M., Wharton, S.B., Ince, P.G., Forster, G., Matthews, F.E., & Brayne, C. (2009). Age, neuropathology, and dementia. New England Journal of Medicine, 360(22): 2303-2309.
Siegel, R., Naishadham, D., & Jemal, A. (2013). Cancer Statistics, 2013. CA: A Cancer Journal for Clinicians, 63(1): 11-30.
Smith, C.M. & Cotter, V.T. (2012). Age related changes in health. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.) Evidence-based geriatric nursing protocols for best practice (4th ed.). New York: Springer Publishing.
Van Remoortel, H., Hornikx, M., Langer, D., Burtin, C., Everaerts, S., Verhamme, P., Boonen, S., Goselink, R., Decramer, M., Troosters, T., & Janssens, W. (2014). Risk factors and comorbidities in the preclinical stages of chronic obstructive pulmonary disease. American Journal of Respiratory Critical Care Medicine, 189(1): 30-38.
Whitson, H.E., Boyd., C.M. (2015). Managing multiple comorbidities. In K.E. Schumader & H.N. Sokol (Eds.), Uptodate. Retrieved from http://www.uptodate.com/contents/managing-multiple-comorbidities.