Tailored approach of the older person with a haematological malignancy

A significant increase has been seen in the number of older patients with cancer due to population ageing. Ageing however is a highly individualized and very heterogeneous process with a broad spectrum ranging from older persons who are functionally independent to those who are at high risk of functional decline and mortality and all the others in between. Fit older patients should logically receive the same treatment as their younger counterparts. The main problem however is the group of frail patients at increased risk for treatment complications. The main aim of this doctoral thesis was to explore whether in older patients with haematological malignancies a geriatric approach, and in particular a comprehensive geriatric assessment (CGA), might be worthwhile in the selection of patients with a geriatric profile, in the detection of geriatric syndromes and in the prediction of patient outcomes. In this thesis, we demonstrated that, also in patients with a haematological malignancy, a CGA can identify previously unknown geriatric problems in an individual. Through nutritional screening a large majority of patients was identified with potential nutritional problems. Given the negative impact of malnutrition on an anticancer treatment, regular follow-up and implementation of specific interventions, in collaboration with a dietician, are essential, even though efficacy of these interventions has not yet been adequately proven. Moreover, geriatric evaluation in this thesis has clearly proven that chemotherapy, and inherent use of supportive medication, leads to polypharmacy and frequent changes in medication regimen. Because of this, more than half of the patients are no longer able to manage their medication independently. As most older patients are living alone or are taken care of by a partner of the same age, their current care pathway should include a structured and repeated evaluation of functional autonomy with regard to medication management. This thesis did focus not only on the detection of geriatric syndromes, but also on a correct selection of patients with a geriatric profile, as the administration of a CGA is time and staff-consuming. Therefore a two-step approach is proposed with the use of a screening tool to identify those patients that subsequently would benefit most from a CGA. During the conduct of our study we tested the performance of two different screening tools. G8 (with a cut-off of ≤14) could be validated for use in older patients with haematological malignancies. In contrast with G8, an 8-item questionnaire, hand grip strength is a performance-based measure and therefore a more objective reproduction of a patient’s functional reserves. In contrast with healthy individuals, we found that hand grip strength was reduced in patients with haematological malignancies, even before onset of treatment. Using a Martin vigorimeter, we also determined minimum values for hand grip strength in men and women. Below these values, all patients should be referred for further geriatric evaluation. This doctoral thesis should be considered a first onset in the development of a multidisciplinary approach in older patients with haematological malignancies. Further research should focus for one thing on interventions that, before start of treatment, can optimize the functional reserves of a frail patient, and for another thing on new treatment modalities incorporating the results of the CGA. Integration of the results of both lines of investigation should eventually lead to a treatment plan tailored to the individual patient

The process of decline in advanced activities of daily living: a qualitative explorative study in mild cognitive impairment

Background: The notion of "minimal impairment in instrumental activities of daily living (i-ADL)" is important in the diagnosis of mild cognitive impairment (MCI), but is presently not adequately operationalized. ADL is stratified according to difficulty, complexity, and also to vulnerability to early cognitive changes in a threefold hierarchy: basic activities of daily living (b-ADL), i-ADL, and advanced activities of daily living (a-ADL). This study aims to gain a deeper understanding of the functional decline in the process of MCI. Methods: In a qualitative design, 37 consecutive patients diagnosed with amnestic (a)-MCI and their proxies were interviewed at two geriatric day hospitals. Constant comparative analysis was used for the analysis. Results: The a-ADL-concept emerged as important in the diagnosis of MCI. All participants were engaged in a wide range of activities, which could be clustered according to the International Classification of Functioning, Disability and Health (ICF). Participants reported subtle difficulties in performance. A process of functional decline was identified in which adaptation and coping mechanisms interacted with the process of reduced skills, leading to an activity disruption and an insufficiency in functioning. Conclusion: This study asserts the inclusion of an evaluation of a-ADL in the assessment of older persons. When evaluating ADL at three levels (b-ADL, i-ADL, and a-ADL), all the activities one can perform in daily living are covered

Can usual gait speed be used as a prognostic factor for early palliative care identification in hospitalized older patients? A prospective study on two different wards

Background Timely palliative care in frail older persons remains challenging. Scales to identify older patients at risk of functional decline already exist. However, factors to predict short term mortality in older hospitalized patients are scarce. Methods In this prospective study, we recruited patients of 75 years and older at the department of cardiology and geriatrics. The usual gait speed measurement closest to discharge was chosen. We used the risk of dying within 1 year as parameter for starting palliative care. ROC curves were used to determine the best cut-off value of usual gait speed to predict one-year mortality. Time to event analyses were assessed by COX regression. Results On the acute geriatric ward (n = 60), patients were older and more frail (assessed by Katz and iADL) in comparison to patients on the cardiology ward (n = 82); one-year mortality was respectively 27 and 15% (p = 0.069). AUC on the acute geriatric ward was 0.748 (p = 0.006). The best cut-off value was 0.42 m/s with a sensitivity and specificity of 0.857 and 0.643. Slow walkers died earlier than faster walkers (HR 7.456, p = 0.011), after correction for age and sex. On the cardiology ward, AUC was 0.560 (p = 0.563); no significant association was found between usual gait speed and survival time. Conclusions Usual gait speed may be a valuable prognostic factor to identify patients at risk for one-year mortality on the acute geriatric ward but not on the cardiology ward

Posterieur reversibel encefalopathiesyndroom als oorzaak van veranderd bewustzijn : een diagnostische uitdaging

Het posterieur reversibel encefalopathiesyndroom (PRES) is een meestal goedaardige hersenaandoening die gepaard gaat met hoofdpijn, convulsies, verwardheid en visusstoornissen. Dit artikel beschrijft een casus van een 82-jarige vrouw met PRES als gevolg van een ontregelde arteriële hypertensie. De patiënte bood zich in het ziekenhuis aan met een veranderd bewustzijn en een corticale blindheid. Op de MRI zag men het typische beeld van een vasogeen oedeem occipitaal. Na de behandeling van de hypertensie en de epilepsie klaarden zowel het klinische als het radiografische beeld volledig op. Het belang van een vroegtijdige diagnosestelling wordt benadrukt en de onderliggende pathogenese en de differentiaaldiagnose worden besproken