Carolina Uranga provides an overview of geriatric oncology and offers assessment tools for providers to use to improve care of older adults with cancer.
Back to Symposium Page » I'm Carolina Ranga, and I'm a clinical nurse specialist and city Hope in the Center for Cancer and Aging. And I really like to thank everyone for the opportunity to talk about geriatric oncology with all of you. It's an honor and a privilege. Yeah. Okay. Okay. Just a quick funding disclosure. I'm part of a FISA grant that we just recently obtained where we're gonna look at our adherence and older adults with metastatic breast cancer. Mhm. Okay, just a quick overview of the agenda. Uh, a brief overview of geriatric oncology and when it all started, also gonna take a deep dive into some of the assessment tools that we use in geriatrics, which will provide a holistic approach to care of older adults with cancer. It's going to give you that opportunity to do that and then look at a couple of patients and how we use the tools and hopefully then provides some, you know, impetus for those of you who are here to think about what? How you can implement the tools in your practice settings. Oh, sorry. Went too fast. Yes. Introduction. Um, many of you know that cancers associated with aging and there is a projected rise of 67% in cancer incidence, and it's been happening since 2030 and will peak in 2030. Um, and you want one thing you want to consider when you're taking care of older adults is that you want to meet them where they are, ensuring that older adults receive optimal care that they deserve at every age, every stage of their older adult life is is challenging. And it does take a village to care for older adults, but understanding that you have some tools available and that can provide the opportunity to take those steps in improving care of older adults with cancer. With that, I'd like to have you take a quick poll, um, of of whether or not you've had taken a class in gerontology after nursing school. Eso If you could go ahead and answer the question related to your experience with gerontology after 19 school, that would be great. And if you could let me know whether or not you see any responses, yeah, mhm, yeah, mhm. And we can move onto the next one. While we're waiting here, there's actually a couple of questions. The other question is Do you feel you need more knowledge and managing older adults in your practice setting, and that will give me an idea of, you know, the audience and the needs related to that. You can let me know if I can advance. Yep. Go ahead. Okay. So we'll see what those responses are in in a minute. So one of things we want to go ahead and talk about our geriatric oncology and the timeline related to when it actually, uh, the specialty started to come about. So the birth of direct ecology started back in 1983. Uh, Dr. Rosemary Ancic presented perspectives on prevention and treatment in cancer in the elderly, and this was at a symposium sponsored by the N. C. A. The National Cancer Institute and the A. The National Institute on Aging. Then, in 1988 Dr B. J. Kennedy, who was the president asked at the time, did a presidential address calling for better understanding of the older adult and to study what aging has impact on cancer. Uh, and look at voice to prioritize geriatric oncology research on. Then, in 92 Dr Balducci, Dr Lyman and Dr Esler published the first textbook in the field of geriatric oncology. Um uh, in 95 the cancer that already working group was formed, and they look at shedding light, um, regarding the need for clinical studies in older adults. In 97 the John A Hartford Foundation we tweet brought leaders from geriatric oncology geriatric oncology together to really talk about how the two can work together. In 2000, the SAG was founded this International Society of Geriatric Oncology and this particular organization is really pushing out geriatric oncology assessment and all the tools that you can use. It's a really great place to go for information related to geriatric oncology. And then, in 2001 to 2000 and six, the Hartford Foundation, in collaboration with ASCO, created joint training programs in the fields of geriatric oncology to train positions, um, in both areas. And then in 2000 and seven, the cancer in aging research group or card was born, and that's was led by Dr Aarti Hurriyah and the that particular group, um, wanted to host its first natural meeting. It invited a many physicians, geriatricians and oncologist to coordinate. Resource is an expert expertise and data to support the research in older adults. So there's definitely new cases happening. Um, incidents of cancer in the In the older adult, the cancer of any site is most frequently diagnosed and those that are 65 to 74. It's about 53% total between the ages of 65 to 84 the median age of diagnosis is 66. So we know again that the risk of you developing cancer increases with age on. This is a video like for you to watch Dr Aarti. Hurriyah, um, definitely is a rock star when it comes to geriatric oncology. And she gave this talk inside in 2017, and she can say better than I can. How important it is to really assess your older adults using a comprehensive geriatric assessment not only for patients were newly diagnosed, they're thinking about beyond when, when their surviving from their treatments and their cancer. Eso cancer is a disease associated with aging. What we know is that the vast majority of cancers are diagnosed and older adults, and here, if we use the term older adults as meaning people aged 65 older, what we know is that 60% of cancers occur within that age group. 70% of cancer mortality occurs within that age group, and what's happened is that in the year 2011, the baby boomers turned age 65. So we are now having a rapid rise in the aging population and because cancer is a disease associated with aging. What we're seeing is that there is going to be a 67% increase in cancer incidents in those aged 65 plus from age from from 2010 to 2030 now. What does this mean for our society? Number one? We're going to be seeing a huge increase in the number of older adults with cancer. And they have unique problems, unique things that we need to consider as we're looking at their cancer treatment and, most importantly, thinking about their survivorship years. So when we interview older adults, what they tell us is that they're willing to take a treatment a zoo, long as it doesn't impact their function or their cognition, and hence understanding those end points in our research and including those within our research is so critical. So what do we know about the survivors of cancer who are older adults will first, the statistics. There are even more astounding eight million survivors age 65 older. Right now what we know is that by 2020 it's gonna be 11 million survivors aged 65 plus 67% of all survivors will be in that age group. So, really, it's a group of individuals that are aging. They have a history of cancer and cancer treatment, and then they have other co morbid medical conditions that they're also dealing with. And really, the question that those survivors air asking us is, How does my cancer and how did my cancer treatment impact theeighties ing process? And that's a lot of really what the field of geriatric oncology is about. It's about how do we try to mitigate the impact of cancer cancer treatment on the aging process so that as our patients are diagnosed with cancer treated with cancer and make it through several years of survivorship, that they can continue to live healthy, productive lives as older adults? So the field of geriatric oncology is really emerging and has come to its own now and specifically focuses on this population thinks about. How should we be screening for cancer treatment? How should we be individualizing our treatment approach? And then how should we be caring for these individuals throughout the survivorship years and a hallmark of what we do is something called the jury at TriC Assessment. And within this assessment, what we do is we look at factors other than age that can identify what someone's risk of morbidity and mortality are. So in other words, we've got a passport age. People don't like to be thought of based upon their passport age. They wanna be thought of based upon their functional age. And that's really what a jury at Rick Assessment does. It says. Okay, ages one part of who you are. But much more importantly is what's your function? What are your other medical conditions? What is your memory like? What's your psychological state like? What is your social support? Are you on many medicines that might be interacting with one another? And when you take these things together, you get a picture of who that individual is, and you can predict with that what the risk of toxicity is from cancer therapy. You can utilize it to individualize treatment decisions, and you can use it as a framework of really thinking about the risks and benefits of treatment for these patients. Now, as these patients are surviving through cancer and cancer treatment, it becomes even more essential that we look at each of these different domains. And we think about how can we best support that older individuals and their caregiver through those survivorship years? So you heard it from Dr Hurriyah. The fact that it's very important for us to really look at older adults and how we can better assess the vulnerabilities aan den in 2018 esco put out a special article, um, very much recommending that patients that are 65 older should receive some sort of assessment to help identify those vulnerabilities that you may not be able to capture in an oncology assessment visit. And they found that the evidence supports that at a minimum, assessment should be done. Ah, function, comparability falls, nutrition, depression, um, cognition. And these should be done to help tailor your treatment for your older adult. And there's other institutions that also recommend geriatric assessment, and that would be the N. C. C n Sigh Agha. And then, of course, Asko. And so that was a nautical that was published in 2018 in August. Um, Dr Harry mentioned about passport age or chronological age. You should not mistake it for their functional age again meeting the patient where they are and looking at what needs they have related to function, especially because that definitely would be a determinant of their quality of life. And when the risk and benefits for that patient, um, with the treatment, you know you can tailor the treatment to them and and making sure that you don't impact there, um, functional status or you know what matters to them, what their goals of care are, but definitely making sure that you're not age bias and just looking at their age to say, Oh, no, this patient, you know, shouldn't get treatment or maybe shouldn't be on a clinical trial, because that's the other thing. That there has been a lack of older adults in clinical trials. So what is the C G A. Um C J will help reveal reversible geriatric concerns that again, you may not have a time to really find in an oncology care visit. It can help you predict risk of a toxicity, adverse effects from cancer treatment or any decrease in quality of life. And those things can trigger supportive care measures so it provides with provides you with information about that patient really detailed information that you can use to help you tailor their treatments. It can also have an important provide some important prognostic information, and that could be helpful again in estimating life expectancy to assistant treatment decisions. It can allow for those targeted interventions, which can improve quality of life and adherence to therapy. The main goal is finding out what you can do to help the patient with their side effects. How can you mitigate or prevent any side effects or control better? And it could be helpful improving communication. Three. Comprehensive geriatric assessment is a like a health questionnaire that you get to. Your patient has many questions from looking over various domains, and the patient provides this information, um, again self. It is a self reporting tool, but most of the time, when patients answer these questions, they're very candid in the way they answer them. Uh, triple CEO of the Association of Community Council sensors did a survey of health care providers back in, um last 2018, And what they found was that a lot of people thought, Oh yes, we strongly agreed or agreed that older adults should have a C G A, along with their regular oncology assessment before the start of treatment. So it's a very high percentage that the thought that this was very important, however, Onley 17% reported that they do this with their older adult patients, and then 26% are currently using tools, um, toe, identify at risk patients or identify patients who may have a need for comprehensive geriatric assessment. So the results just show a striking difference between what they think we should be doing and what they're actually doing. These are some of the barriers related Thio what they found in their survey time constraints, which probably is a barrier for many surveys that are done to assess whether or not we have time to do things. Or we can implement certain things also limited from a familiarity with the validated geriatric screening assessment tools. That was almost 50% limited personnel. You do need people to help with um not only assessment but actually providing interventions, uh limited or limited geriatric expertise within their programs. So not a lot of the people were familiar with the geriatric skills that are needed to help assassin screen patients. And then limited resource is to follow up on abnormalities that patients may have again. Whenever you screen or assess, you have toe be ableto have an intervention attached to that. Otherwise, why screen or assess on? And sometimes we have limited limited resources and community to help us with those things. So, geriatric oncology. We're gonna look at a comprehensive, geriatric assessment from the nursing perspective, and this is something again, doctor her. You did a lot of studies related to using a C G A, uh, in in oncology, um, to help drive interventions for patients and nurses were very much a collaborative partner with her. And we've done some things here at City of Hope to to help with that. She was a principal investigator in a grant that was received from the N. I H. And this was called geriatric oncology, educating her sister improve quality care. She, along with two nurses on Denise Economou and Peggy Burhan, they were the CO P ice on the study. But the aim of the grant was that we were going to develop and implement a national curriculum. Uh, Thio educate nurses on geriatric oncology, so giving the giving them the information and seeing how they can then disseminate this information. The second aim was to look at the effectiveness of this educational material by using cream post test participants evaluations. Faculty evaluations. Thirdly, evaluate the impact of geriatric oncology because one of the things that was part of this particular grant was that you came to the curriculum to the workshop, but you came with goals that you wanted to implement in your institution or your practice setting. So looking at how those goals were completed, what the outcomes of the goal was, what were the barriers and then disseminate the findings? So recently, we did have an article published related to the evaluation of the effectiveness of the geriatric oncology curriculum, and that is called geriatric oncology, workshop development and evaluation of nationwide nursing curriculum, and that we are still working on the nursing on college or the oncology nursing initiatives on Hope to have a manuscript, um, with regards to those findings hopefully by the end of the year. So the grow workshop showed, and it was four years from 2016 to 2019. Pre and post knowledge just showed a significant increase in knowledge was statistically significant. Um, the last workshop was done February 2019, and the collection of the goal outcome data was completed in August of this year. So we still gathering that information to see how well the goals were met and also what kind of goals were done for. You know, the groups, the different cohorts. So let's look at an older adult with breast cancer and see how we can incorporate some of our geriatric assessment tools. So this is an 82 year old female with diagnosis of Metastatic year to positive her two negative breast cancer. She's going to start a new chemo regimen of venereal being, and she lives with her daughter and her daughter works during the day. But she has a very supportive family that come with her to our clinic appointments. This is a of course, prick a bit. She doesn't have an advance directive, but she did complete a C g a. Um and if you want to get a better feel for what a C G is, you could go to the my car or website and actually look at the various tools that are available there. The there's the C G A. It's available in about nine other languages besides English so the patient can complete that online. And then at the end, you will get information related, you know, triggers regarding whatever answers the patient provided. So just thinking about what you know about the patient, I'd like for you to answer this question. What is the best approach regarding her ongoing care? Well, you review Lab Street is needed if she needs any hydration, electrolyte replacement of blood transfusion and then you start the chemo cycle is ordered. You can collaborate with premier in colleges, p T N OT, nutrition, social work and pharmacy as needed to prevent a minimize treatment related side effects. You can discuss, discuss the goals of care and ask for advance directives. Or you could just continue treatment as ordered. Um, if you can tell me what you think, um, what would you think about as your best approach regarding her ongoing care? And I don't know if we have a poll for this, and if we do, that's great. If not, um, okay, I can thank you. All right. I can move forward, I think, and we'll see the responses in a minute. So some of the tools you can use thes air geriatric screening tools. These tools have been around for a while. They validate us. You don't have to think about. Oh, I need to develop another tool. You don't. They're already a few of them out there. The variable older survey. It's a V S 13. There's 13 questions. That particular tool is like a pre screen tool for whether or not a patient may need a comprehensive geriatric assessment. And any scores three or higher indicate this, uh, individual as vulnerable in four times, likely for risk of death or functional decline. The mini cog is another tool that's been around for a while. To, um, this has available in many languages. Uh, and a score of 34 or five indicates lower likelihood that they have any dementia. But it does not rule out some degree of cognitive impairment the time that can go where the tug is also. Ah, tool that can be used to look at risk of falling, and anything greater than 12 seconds or longer would be indicative of that. The spices is a pneumonic and each word stand. Each letter stands for a cue for you toe. Ask about and you ask about sleep. Any problems with eating, feeding, incontinence, confusion, evidence of falls and skin problems? The car Chemo Toxicity Risk Tool is a tool to kind of help identify whether or not this patient would have any great 3 to 5 toxicities. Uh, scores between 05 are considered low risk. Between 69 medium and 10 to 19 are high risk. Looking at the V s a little bit more the the patient here would go ahead and complete this form. It's you could do a self report, or you can ask the questions, and it looks at age, self rated health limitations in physical function and functional disabilities. It's a little bit more functional status type of tool. Uh, there's other tools out there, such as the Geriatric eight, which is more nutrition. Any score greater than three or higher indicates risk for health deterioration, and in this case, her particular score was eight. So definitely she needs a comprehensive geriatric assessment. It also kind of gives us a little bit of a cute that she has some moderate deficits in 80 Els and ideals, and the actual C G A could also give you a little bit more information about that. She definitely would be a good candidate for O. T. Because some of the questions how she answered some of the questions. The other tool, which is the mini cog, um, is a three minute instrument that you can help that you can use to help to get cognitive impairment. It consists of a three item recall test for memory and a simply scored clocky clock during test, and this particular form is available with the clock circle already there, the patient would just have to complete the numbers and then put their hands in the appropriate um, place. You would ask that she put 10 past 11, and this is the actual clock that she drew Ondas. You can see the It's not a perfect clock our particular score was to, and at this point, um, you know you can do other things. You can maybe do another cognitive tool. You can use the B, o M C or maybe even the mocha. But for right now, what we did was look at her labs. Sometimes just that would be the first thing you might want to do unless it was really, um you think Oh, no. This patient has some dimension going on. Um, B 12 and TSH would be labs that you could order to see if there's any things that could be causing her cognition issues. The time's up and go is assesses for functionality. And again, score greater than 12 or more indicates risk for falls. She This tool also provides the opportunity to observe, gait and balance. So again, ah, lot of the questionnaire is something they complete. They do a self report. But here you want to observe. Um, how long did it take the person to walk? 10 ft. It only takes three minutes. You need a chair, stopwatch and 10 ft of walkway. And in her case, she scored 23 seconds with a cane, and she did identify that she has a history of falls, so she would be a very good candidate from doing something like this to consider a referral to Petey. Oftentimes we hear of patients who fall, they come to clinics and we know they've fallen. And then all we you know, sometimes what we say is we provide education about falling risk. Um, but the next step would be to give them something to help with gait and balance and fall prevention, and maybe even assessing what their home situation is. Do they need a home? Health is just look for a safety. What things they could do to improve their home environment to help with falls. Okay, the spices again. That's a pneumonic. You would ask questions yes or no related to sleep disorders, any eating or feeding issues, incontinence, evidence of falls in skin breakdown. And this, too, has been around since the nineties. It was developed by Terry Fulmer. She is, ah, a prominent figure in geriatrics and nursing and gerontology, and it's available from the try. This Siri's now she indicated she has problems with sleep incontinence and skin rash, and for her what we provided with some education, sleep, hygiene, education, incontinence, education, skincare tips. Her skin rash was more related to her incontinence, and she use a adult brief and, you know, telling her about lotion she could put on or ointments that you can put on with regards to sleep hygiene, getting a little bit more information about why she's not sleeping all. Is it because she's drinking liquids before bedtime? Is it because she's taking daytime naps and then educated in the patient about that? You can at least try to see how you could help them with some of these issues. And these are geriatric syndromes that are highly prevalent and older adults, and a lot of often they are multifactorial, and many things could be causing some of these issues. This is the geriatric assessment tool. Chemo Toxicity Prediction Tool. This is available also at the My card website, my car dot org's and answering all these questions. You can do it in the tool, and I'm sorry on the website for her. She scored 15, which is a 92% risk of grade 3 to 5 Texas cities. So for her, you want to make sure that, of course, the physician understands that she has this risk. And then how can you help, um, provide further education about what these Texas cities are how to mitigate or be more proactive to help her get through her chemo regimen with her, there would be probably more close monitoring related to her side effects and, again, more education to the patients. So there are alerted as to what toxicities might come up with the treatment and how we can then help her get through the regimen and maybe even a discussion with the physician related to, um, dose reduction, if that's what needs to happen. There is another tool called crash chemotherapy Risk assessment scale for high, um, age patients, and that's more specific to hematology patients. This particular tool has been validated in medical oncology or solid tumor patients. So now we're looking back at what you know about her. You can look at the labs and see whether or not um, what? What would be your best bet to, um, take care of her? Uh, you know, best approach regarding her ongoing care. If you can go ahead and answer the question, Okay, let's see, What do you think would be the best approach that would be yes. Just to be sure that you of thinking about your patients may be a different perspective. But let's look at another patient. This is Mrs G. She's 78 years old. She has a diagnosis of malignant neo plasm of the right breast, Cira, Dina Carson over the uterus and melanoma. She had an Austin Me A colostomy last year due to some complications she had with surgeries. She's currently being treated for high grade, serious endometrial carcinoma. Stage one B. She's on a weekly cover, Platinum and Impact the Tax Hall. She does live with her spouse and has adult Children that live in the area. Mrs. G works part time. She did complete a C G A and some of the other geriatric tools that we just mentioned. So she triggered for fatigue, Difficulty A, D, l's and, um, walking one block. She has some anxiety. She's had some weight loss of greater than 5% in the last six months. Just as Poly Pharmacy, her chemo talks risk was 66% or a great 3 to 5, making her medium risk, she expressed some sexual concerns. She's not satisfied. She also has concerns required regarding quality of life and emotional well being. So thinking about her now, what would be your best approach regarding her ongoing care. Andi, uh, I'll go to the next slide. Okay? I'll see the answers in a bit. So one of things that we've done, um, in my particular facility is we've taken a journey to aging. Wellness, um, using the forums framework. This is age friendly health systems, um, to start a clinic clinic that sees older adults. And I'll give you a timeline of what we've done so far and where we're at with regards to our journey to aging. Wellness. So I work at City of Hope were comprehensive Cancer Center. It's in Duarte, California, which is about, I don't know, maybe 20 minutes or so on the freeway from downtown Los Angeles. Um, our main population that we see is medical oncology and surgical oncology patients 65 older. Our goal is to provide that holistic care to older adults with cancer, and the team is comprised of three advanced practice nurses to geriatric and peace and one adult Daryl CNS. All our patients that we see complete a comprehensive health questionnaire which is a c g a. And that's done before they come to their first visit. What? We've done is we really worked hard to provide this particular questionnaire via the my chart portal, which is it's actually assigned to them in their health portal, and they do it at home now if for some reason they don't have the opportunity to finish at home when they come to the first clinic appointment, we make sure that it gets completed because again, that's going to give us the information we need to provide those interventions that the patient needs to start their treatment And, you know, be sure they have a untoward, um, treatment regimen. We do see many patients. We have about over 170,000 patients we see a year through our not our clinic specifically been through our organization in the outpatient basis. So this is the timeline for our clinic back in April of 2019, we have, uh, we decided to go ahead and approach our CNO with our plan to go ahead and open this clinic. Now. What really was the catalyst behind this clinic was the fact that we worked with Dr Hurry and she's done many studies using the C. J. Um, the visibility of using C J the feasibility of using tablets that have the patients complete the c g A and the interventions that we provided. So we knew this could be done. And actually the A. P. M. Who are part of this clinic where the main people who were following these patients during those studies and then in May we got the blessing from our CNO. And in May, we met with our clinic manager and service line operations to discuss clinic space because that was one of the things you know, there's never enough clinic space. Um, but we did were able to get a Wednesday from 8 to 12 to have to see patients. We also looked at our tools, and one of the things that we really did to help us along is we worked with our I t people, and we actually embedded some of these tools in our electronic medical record. The C G A was embedded, and so that's how the patient could get this particular health questionnaire sent to them via their my chart in July. We also discuss what the building requirements would be and the coding so that we could have a, you know, again a PM who are the ones practicing in this clinic? In August of 2019, we presented this information to the staff that we're gonna be helping us with our patients and also the physician. So they know that this clinic is available for them to refer to. So September 2019 is when the clinic was opened that we had our first patient on 9 11 and I was a little bit of a soft roll that for the that quarter, because again you have to have referrals and physicians are not so inclined or they don't know about us, then they may not refer. In November, we did have a ah poster that we are abstract that we submitted which got accepted, which which was presented at this O. N s 45th Congress. And that was just looking at the development and implementation of an AP and lead geriatric Consul clinic at a comprehensive cancer center in March. In April of 2020 we had already seen 28 in person consoles since our initial opening in September of 2019. But of course that's when Cove it hit and a lot of our patients were converted to telehealth. Now the one of the things that we were had an advantage of is that one of our nurses are a PMS, and this clinically in a Chan had already done a study using telehealth on that was again Dr Hurriyah, who said, I think we need to provide telehealth for our patients. And it was a research study that was done showing that, yes, it can be done via telehealth. And this was used to that particular study was looking at providing telehealth services and a comprehensive geriatric assessment to those patients who are living in rural areas. And this was a study that was merely, um, with patients living in the Antelope Valley, which is about two hours away from Los Angeles. In July 2020 we received our fighter rent 250,000. We'll we'll be looking at Orrell adherence. Older adults with metastatic breast cancer and well, hopefully start accruing patients in late November or late December and then October 2020. We were recognized as an age friendly health system committed to care excellence for our particular clinic. So, looking at the domains of comprehensive geriatric assessment, there's various domains and measures that go along with theirs validated tools related to functional status. As you can see, a D l s, um, ideals. Number of falls in the last six months time that you go for cognition. We use the mini cog and the blessed orientation memory concentration test. Now that particular tool, the B. O. M. C, is probably a better fit for telehealth because patients answer questions. Whereas the mini cog they have to, you know, draw the clock. So it just depends. And maybe if the patient, um, use the mini cock and you think, Oh, I better do another tool. You might want to go ahead and do the BMC comparability. There's actual questions in the CJ that specifically asked about comparability what other chronic illnesses they have on how it's impacting their health. Um, psychological, state and social activity and social support. There's all these tools available within the questionnaire that target those areas for depression, anxiety, um, social activity, social support. I mean, one of the questions you ask is if you were bed ridden, do you have anybody who can help you? Who can take you to the doctors who can come and help you with meals. Who can help you if you don't have anybody that you're living with to help you? And, of course, interest in looking at an intentional weight loss and body mass index. So there's already all these tools out there that you can use. You don't have to reinvent the wheel. Um, you just have to see what tools work best for you that you could incorporate. And, of course, the actual c g A that we have in the mic. Our website would be a great place to start just to see what it's all about and and see if you could incorporate this particular comprehensive Jared cassettes into your practice. So again, I mentioned earlier about art geriatric assessment and the four EMS for EMS is a great way to really start to see how you can incorporate what matters to the patient. What medications they're taking, what they're meditation is like mobility. Each of these areas really look at How can you align care with the older adults? Specific health outcomes and goals? Eso really what matters to the patient? Medication wise? Other medications they're taking, um, impacting or interfering with what matters their meditation of their mobility and then meditation again, preventing, identifying and treating those areas in the realm of dementia, depression and delirium across the settings of care and then mobility, which is all about function, ensures that older adults move freely and safely in order to maintain their function and to do what matters to them. So for us we went ahead and we're asking a question is part of our visit And the question is, what concerns you most when you think about your health and health care in the future. And a lot of times these question trigger for the discussion about goals of care, we check to see if they have an advanced directive in their HR. And if not, then we asked them if they'd like to complete one. Ah, lot of times patients have one. They just haven't brought him into our facility so we could have a record of it. But what matters is it the fact that they want to make it to this, make the treatment on stay on treatment? Or maybe they have future goals of seeing, you know, their loved one. Maybe their granddaughter, their grandson, who's getting married? You know, those are the kind of questions that come up when you're talking to them about what really matters to them. Also, looking at medication uh, Poly Pharmacy is very common in older adults. They usually have 56 or more question medications that they're taking. And what we do is actually have. Our pharmacist will be the medications. And based on the recommendations, we can either deep prescribe or just provide more education about the medications they're taking. Ah, lot of times, you know, if they're taking, um, Dancer Tran and or Zafran encompassing together, those could really impact qg prolongation and just making sure that the patients understand either minimize the intake of, you know, the composing because that also may make them sedated a little bit or or just knowing that, Hey, if you have any cardiac issues coming up, then we need to know about that. Because if if these medications are creating some issues, then we want to know and be able to, you know, be proactive about it. Meditation. Um, I talked already about different tools that BMC the mini cog, but the questionnaire also has questions related to depression. Um, and these things can further trigger more assessments. Like I said, Labs using the MoCA or maybe getting social work involved or psychiatry. Mobility. There's various tools that look at function. The V s 13 80. Els the tug And with telehealth, the tug is not easy to do. So there's another one called Sit to Stand where you count how many times the patient consent and stand in 30 seconds. How many can they do? And then, of course, there's the obvious fall screening questions. Have you fallen? Do you have fear falling? Um, that kind of thing. Uh, spices, which I reviewed earlier, can also provide some abnormal triggers for you, so ah, lot of the times Patients may need a referral to p. T know t. And now you have some information that can guide you. Thio make those referrals. So the patient senator approach for us is looking at the first of all the primary oncology team because you want to provide, uh, good communication with the primary in college because you're working together and then nursing would be there to help making sure that we're looking at those vulnerabilities identifying them. Assessment of functionality falls, comparability, depression well being, uh, cognition, nutrition, social support and then looking at advanced care planning for these patients. Do we have an advance directive? Do they have a pulsar leader pulse and really providing that holistic approach to, um to care? Ah, lot of times may be the primary ecology team only has time to really look at the disease process. Can the patient get chemo? Can they not get chemo? We're looking at trying Thio Look at the big picture. And that, like I mentioned earlier, does require a village so working with the multi disciplinary team and collaborating to make sure that your patients get the, uh the resource is they need We have P, T and O T that can provide home safety about, um or make sure that we have that available for them Assistance with a D s. Ideals, ability, physical endurance. What can they do and educate patients about fall prevention looking at fatigue, uh, nutrition, weight loss, or even education about what foods they should be eating during the treatment are supportive. Care team can further, um, provide treatment related to pain and symptom management and goals of care. Social work also can be very effective in getting at the psychosocial concerns well being. Concerns provide support to the caregiver and chaplain. Um, pharmacy review is very important because they can look at that verse drug reactions that patients may have and interactions. Many times, our patients are taking their medications over the counter medications and also herbals. And many times, some of these herbal, um uh, pills that they're taking or supplements that they're taking could interfere with their chemo. So having a pharmacy review is really important to help your patient. So, looking at some of the initiatives at City of Hope, we mentioned the aging Wellness Clinic. So for our clinics in September 11th, we've had about 212 visits completed. Uh, and this has been again the three of us working together. The major book of the visits have been with the geriatric and peace off those 212. We have about 91 individual patients that have been seen, and this information is from September. So one year and then approximately 105 televisions telehealth visits have been done, and the going with telehealth has really increased the numbers of patients that we can see because now we're not tied to a specific date in time. And it definitely allows for more flexibility, if not only for the the nurses or the AP ends, but also for the patients. And some of the outcomes that we're looking for in the future will be how many referrals have been completed that we've made on what, whether or not the providers, what is their satisfaction related to having this other resource for them to help with patients. And I just wanted to go over a couple of patients stories. The lady on your right, which is not really her. But she had questions about her medications, and review of the medications really indicated that, um, she wasn't taking it. And the reason why she wasn't taken it was because it wasn't covered. So the nurse further looked at that and found out that the building was done incorrectly. That's why she was, you know, having to pay for it. And once they figured out that that was an error than the patient got the medication and she started to take it, it was like a reading treatment, and that was really impacting her quality of life because she was having problems breathing. And when she did that and that corrected, the patient then was much better on DSHEA continued her treatment. Thea other thing with the patient would be that, um, goals of care and whether or not she can have options available to her not only advanced directives but the end of life option, which she got more information about. The other example is with telehealth. It really has provided a better communication or fostering communication with patients and their families or caregivers. One of things that covert has done is really impacted our visitor policies. So you know, not patients are not allowed to have visitors for their clinic visits unless it's extremely necessary. So with telehealth, patients are able to, uh, have their caregiver. Their answer questions, Um, making sure that you know multiple people have the information that they need to help with their care. So it's provided that engagement with family and caregivers, which right now with the regular clinic visit, might be difficult. You can call it in, but it's much easier if you can see each other and talk to each other. Virtually these were some of the resource is available to you we have American geriatric society card, uh, and sigh og car gets free. You can go on there and look at all their tools on Do use the website A GS and saw you could become members, but they also have a plethora of tools that you can look at information about caring for older adults. The consul Jerry, try this. Siri's is also a free website. All the tools that are in the try this Siris are all validated tools. Um, there's over 20 tools that you can use its from function to incontinence to hearing, uh, sleep, and so that you could better assess your patient. The prognosis tool is a way for you to look at. What kind of diagnosis? I'm sorry, what kind of prognosis? Uh, the patient has and it factors in all the, you know, the diagnosis, the age, what kind of treatments they're going through stage and all of that. And you can find out whether or not your patient has, you know, potentially a future of six year and that kind of thing the geriatric at your fingertips is available as a book. It's ah, small textbook or, um, you know, paper a printed copy on and then also an app. The APP is about $20 on. You can find all this information on your phone if you were to download the app. Um, one Stone Kettering has a really great pneumonic called geriatric plan. It's for outpatient, and you go ahead and each letter kind of gives you a little reminder of what things you should assess for. G s for gate is for years and eyes, um R s for review of medications. Eyes for independence, alert and oriented for a T is for toilet ing. Uh, ours for respiratory eyes for Integra mentoring or skin C is for comparability, ease piece for pain and palliative care. Ellis for labs is for advance care planning, and and it's for nutrition. So that kind of gives you a ah guide to help you figure, What are the things that I need to get more information about or access for your patient? The mini cog. We've gone over that one again. It's available in many languages. It's been around for a while. The many nutritional assessment besides the fact that the patient they just lost some weight or has a higher Libyan mind, you could do a more detailed assessment of their nutritional status. And then, of course, we have the N, C. C N. Or the National Cancer. Comprehensive Cancer Network has guidelines for older adults oncology, and they have the most current work version, which is 2020. And that really provides release. Um, good guidance on C g. A. The tools that are out there for older adults. It's very comprehensive. And then the V s 13. Um, you could go there and find the form itself. We've embedded that into our electronic medical record, and it's, um, easy for you to use that. We've actually had a lot of our staff who do the screening tool for us. They do the tug, they do the spices, and we actually developed a whole list of screening tools that are available in the outpatient area. Um, for those that are 65 older so that we can little by little, we'll start to integrate more of those tools. Uh, you know, that could be used routinely for our patients. So in summary, I'd like to just talk about a little bit about doctor Hurry a stream, she said. it was a by mission or dream is I like to call it that older adults with cancer received personalized taylor care utilizing evidence based medicine with a multi disciplinary approach. She really was passionate about really pushing out on making sure that everybody knew about geriatric oncology and the fact that there is this great tool called the Comprehensive Jerry assessment and how it can be used. She a lot of her studies really showed the feasibility of using this tool. Yes, it does take a little time, but older adults need more time. They need to be looked at holistically. Um, not just okay, we're gonna give your chemo and let's see how you do really looking at the whole person, looking at their function and meditation, what medications they're taking. So they do need a little more time, and it does take a village. And I don't know if you know this, but doctor hurry passed away about two years ago. Tomorrow is her two year anniversary, and her favorite quote was, If you wanna go fast, go alone. If you want to go far, you go together. And she really was very, um, passionate about collaboration she especially like to collaborate with nurses, and, uh, really She she saw the the the fact that we could really help her get the word out and do the things that need to be done so that the patients received an optimal care that they deserve. And with that, I think I am done. Uh, if you have any questions, you can reach me here at my email address. I'm happy to see how we can help you if seeing some of the tools that I reviewed today that you want to go ahead and implement in your practice setting, Um, the information is out there. The guidelines out there just a matter really incorporating integrated them into your work flow into the care that you provide to the older adults with cancer. With that, I'll stop talking. I'm not too sure if there's any questions. Um, thank you, Doctor. Or that Carolina. That was really very interesting. And I apologize. I lost my connection. So I didn't get to introduce you, uh, in the beginning, but we do have some questions. Um, so a question from Leah. Our practices participating with Medicare pilot study called O C. M. oncology care module. This focuses on the Medicare patient on treatment. Are you familiar with this program? Not personally. But I know there's various models and, you know, um, CMS really is the way to look at, you know, looking at CMS and what they want to push out. And I'm sure they have Jerry Hetrick oncology in mind because they want to be sure they improve outcomes for our patients. Um, those Medicare patients? Uh, definitely. There's various models out there how to incorporate a geriatric oncology, Uh, and we've actually gone more the route of the nurse driven model. But we do have access to our multidisciplinary group, and we also have access to a physician so we can go ahead and talk about how can we, you know, try to troubleshoot certain areas that are more difficult because there's definitely more patients that are more complicated than others. Thank you. Um, so can you tell us, can you add the assessment tools into my chart? Ordell, Right now, the C g a. The comprehensive one, which is we're calling the patient Health Questionnaire is the one that's in my card. So it's about 100 plus questions and the patient answers this it takes about, on average, from the studies. We've done about 20 minutes to complete. Sometimes the patients may take a little longer. Sometimes they completed on their own. Sometimes they completed with a caregiver. Um, but most of the patients can complete it before they come to the clinic appointment. Um, a lot of time. That's one of the things that people always so long. But really, it can take 20 minutes. And it could provide a wealth of information about how you can really make an impact in interventions that you can provide for the patient. Because I think this goes along with it. How do you assist patients and signing up for telehealth? Uh, do you support of staff for I? For i t. Many of the geriatric patients that Patricia sees in the clinic are not computer savvy and declined virtual visit. So one of things that we have here if we do have volunteers because we telehealth you know they have to go on that particular portal toe, do the virtual. Um, what we do, though, is if the patient does not have my my chart, which is what we call it here. We make sure they get it so that we can send the questionnaire to them now. If they don't want Thio or maybe they don't have the technology to do it, then what we can do is mail it to them, and then we put it into their into their chart. So there's various ways that we can get that tool into the system. Very not very often do we have to do that. We do have the like, I said, the C G is available in various languages. If for some reason they don't have a computer with a camera, we could always do a telephone appointment. The regular old fashioned Call me kind of thing and we can get our what we need through that. Do any of the assessment tools help provide indicators of elderly patients going to surgery and the risk of developing confusion? Post operatively. Yeah, the mini cock and the BMC would be one way are not currently doing too many of, you know, pre surgery kinds of assessments. But there's definitely, uh, M S. K has a program where they do a rapid C G A on those air for patients who are gonna go under undergo surgery on Definitely. You know, just doing a mini cog could give you an indication of whether or not this patient could have untoward outcomes related to their cognition. And and sometimes you just need to know that that risk is out there on then have interventions in place so that you can minimize it, you know, so that it's not a long term kind of thing. But, um, do you share the patient centered approach multi disciplinary diagram, the one that you presented towards the end of your with circles? Um, and each discipline of specific to the role. So that's on your slide deck that is available to the attendees? Yes. So what we do is we do have a geriatric council and we have opportunity to talk to our provider, the one that we report to who is in supportive care medicine. But oftentimes what we do is email our physician, the one who is the primary physician and talk about, you know, of course, they could look at our note to see all the things that we're doing. The team, which is the MP and the physician and so we communicate with them some of the things that we're doing, especially if we think there's something that they should be alerted to about the patient. Sometimes it's related to the fact that, you know, you've talked to the patient. I had one patient that I spoke to just in the initial just getting them to see if they wanted to come to our clinic, Uh, and found out that the patients that No, I'm not gonna do chemo anymore. And I haven't even really seen the patient yet. But just talking to them they had issues about treatment and so right away, contacting the the primary and colleges to tell them this is what they're telling me right now. The patient did start treatment, but then, um, they decided not to continue. But there was already some little, you know, red flags out there to kind of let the physician know about about what they were thinking about treatment and Amandine had. Another question is that she has an 82 year old patient and her family members who are already being seen by supportive care, not understand why they're geriatric concert was necessary on dso question from Elizabeth Could you please go through the spice? You moronic again? Yes. So ask stands for sleeping disorders or sleep disorders. P is problems with eating or feeding. I is incontinence. C is episodes of confusion is for evidence of falls and the last s is skin problems. Okay, that that tool is available in console jerry dot organ that try this Siri's. It's like I said, it's been around for a long time. It's a really quick tool to use on. Nurses could ask these nurses. Emma's could ask this question because they're really not assessing. They're just asking the questions. And you can further assess when you see the patient and then dig, dig, dig deep in tow What the issues are. Well, thank you very much. Carolina. That was extraordinary, I think a topic that is all near to dear to us as, um, really oncology and cancer incidence is gonna increase in the elderly population as we all do to go march down that trajectory. Eso you appreciate that and City of Hope has done a great job around this topic. So I applaud. Applaud your organization and all that you've done. Yeah, yeah, yes, Exactly. Exactly. so? All right, well, thank you very much. We now have our lunch break. Um, so from 12. 30 to 1 30 Pacific Central time, we will have lunch. So we hope that you will join us back again at 1. 30 and have a great afternoon topics as well. So have a great break. Thank you.