Geriatric Assessment

The Geriatric Assessment (Freiburg Version, 04/07)

Rationale for a Geriatric Assessment and definitions

Authors: Dr. B. Deschler, Prof. Dr. M. Lübbert, University Clinic of Freiburg - Dept. Hematology/Onkology, Hugstetter Str. 55, 79104 Freiburg/Germany, E-mail: barbara.deschler@uniklinik-freiburg.de

Individuals above the age of 65 years are more than 10 times as likely to develop cancer than younger ones in industrialized nations. (Ries et al.: SEER website, 2007) There is an increasing call for specific management of these patients. One approach to the problem of aging in the cancer patient, as it is a highly individualized process, is described by Extermann (Extermann M, et al., The Cancer Journal 2005;11(5):474-80)

The Comprehensive Geriatric Assessment (CGA) is a "multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus on the person's problems." (3) (Solomon D BA, Brummel-Smith K, et al. NIH Consensus Development Conference Statement: geriatric assessment methods for clinical decision-making. . J Am Geriatr Soc. 1988;36:342-7) The International Society for Geriatric Oncology (SIOG) defines in their guidelines for the Comprehensive Geriatric Assessment (CGA) as a " dynamic process that identifies patient's resources and needs and generates an individualized recommendation plan and follow up. Considering this aspect, GCS has not been explored in geriatric oncology until now. A GCA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The Task Force cannot recommend any specific tool or approach above others at this point." (Terret C; SIOG CGA Guidelines 2006, Crit Rev Onco Hemtol 2006; 60)
We now present a combination of geriatric instruments applied at the University Hospital Freiburg

We wish to point out that this is a rational selection of established and validated geriatric instruments for the evaluation of elderly patients with myelodysplastic syndromes and acute myeloid leukaemia. This battery of tests does not claim completeness but rather reflects current knowledge and recommendations. An introduction to these tests, guidelines for their implementation and relevant literature sources are given.

Geriatric Assessment Instruments (Freiburg Selection)

  1. Quality of Life Questionnaire EORTC-QOL C30
  2. Barthel: „Activities of Daily Living“ (ADL)
  3. „Instrumental Activities of Daily Living“ (IADL)
  4. Mini-Mental-Status-Examination (MMSE)
  5. Geriatric Depression Scale (GDS)
  6. up-and-go Test
  7. Comorbidities (Charlson-Index, "Hematopoietic Stem Cell Transplantation Comorbidity Index" (HCT-CI), also "modified Charlson Score")
  8. Performance Status (Karnofsky-Index, ECOG)

Quality of Life Questionnaire: QLQ-C30

The EORTC QLQ-C30 is a 30 item, cancer-specific questionnaire designed for patient self-completion. The development of the questionnaire has followed a theoretical construct that quality of life is a multidimensional measure within the human experience. It is understood that under the circumstances of a life-threatening disease certain areas of quality of life become of greater relevance for individual patients than others. Core matters relevant for quality of life are identifiable and measurable.

The questionnaire is organized into five functional scales (physical, role, cognitive, emotional and social), three symptom scales (fatigue, pain and nauseas and vomiting), and a global QL scale. The remaining single items assess additional symptoms commonly reported by cancer patients (dyspnoea, appetite loss, sleep disturbance, etc.). For ease of presentation and interpretation, all subscale and individual item responses are linearly converted to a 0-100 scale. For the functional and global QL scores, a higher score presents a better level of functioning. For the symptom scales and items, a higher score reflects a greater degree of symptoms. The time-frame of the questionnaire encompasses the previous week.
It is a copyrighted instrument, which has been translated and validated into 81 languages and is used in more than 3,000 studies worldwide.

Instructions:

Ask the patient to fill out the questionnaire. Duration: ~10 minutes

Scoring:

Obtain the free-of-charge "Scoring Manual" of the EORTC (s. Homepage: http://www.eortc.be/home/qol/)

Sources:

  • C. Terret, D. Pérol, G. Albrand, J. Droz "Quality of life (QOL): Use SF-36 or EORTC QLQ-C30 questionnaires in elderly cancer patients?" Journal of Clinical Oncology, 2005 ASCO Annual Meeting Proceedings. Vol 23, No. 16S, Part I of II (June 1 Supplement), 2005: 8091
  • Cheung YB, Goh C, Thumboo J, Khoo, Wee J. Variability and sample size requirements of quality-of-life measures: a randomized study of three major questionnaires. J Clin Oncol. 2005 Aug 1;23(22):4936-44
  • Aaronson NK, Ahmedzai S., Bullinger M, et al. The EORTC core quality of life questionnaire: Interim results of an international field study. Boca Raton, : CRC Press; 1993
  • Nordin K SJ, Hoffman K, Glimelius B. Alternative methods of interpreting quality of life data in advanced gastrointestinal cancer patients. Br J Cancer. 2001;85(9):1265-72

The Barthel Index of Acitivities of Daily Living (ADL)

The Barthel Index of Activities of Daily Living is a quick and reliable assessment of a person's mobility and ability to perform daily self-care tasks. It shows if disability is present and estimates its extent, and determines when a patient begins to need help. It is simple to use, as information can be obtained either from the patient's self-report or from other informed parties, such as the patient's relatives. In addition, it can be administered periodically to assess a patient's improvement over time.

Instructions:

Choose the scoring point for the statement that most closely corresponds to the patient's current level of ability for each of the following 10 items. Record actual, not potential, functioning. Information can be obtained from the patient's self-report, from a separate party who is familiar with the patient's abilities (such as a relative), or from observation. The need for supervision renders the patient not independent. It is widely used in geriatric assessment settings. Reliability, validity and overall utility are rated as good to excellent.
Usually the performance over the preceding 24–48 hours is important, but occasionally longer periods will be relevant. Use of aids to be independent is allowed. Duration of the test: 5-10 minutes

Scoring:

Sum the patient's scores for each item. Total possible scores range from 0–100, with lower scores indicating increased disability. If used to measure improvement after rehabilitation, changes of more than two points in the total score reflect a probable genuine change, and change on one item from fully dependent to independent is also likely to be reliable.

Remark: In the United States, the ADL Score according to Katz is frequently used

Sources:

  • Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? Int Disabil Stud. 1988;10(2):64-67
  • Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. Int Disabil Stud. 1988;10(2):61-63.
  • Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:61-65.

The Index of Instrumental Acitivities of Daily Living (IADL)

The Instrumental Activities of Daily Living (IADL) scale measures eight complex activities related to independent functioning, objectively evaluating a patient's ability to perform these functions and assessing how much assistance he or she requires for each activity, if any. The more these abilities are impaired, the more services will be necessary to maintain a person in an ambulatory setting.
The IADL scale is a brief tool that aids in the formulation, implementation, and evaluation of treatment plans. It is useful in elderly community populations and provides information about a patient's need for support services. It can be completed by obtaining the requested information from either the patient or an informant, such as a family member or other caregiver.

Instructions:

Circle the scoring point for the statement that most closely corresponds to the patient's current functional ability for each task. The examiner should complete the scale based on information about the patient from the patient him-/herself, informants (such as the patient's family member or other caregiver), and recent records. Duration of the test: 5 minutes.

Scoring:

The patient receives a score of 1 for each item labeled A – H if his or her competence is rated at some minimal level or higher. Add the total points circled for A – H. The total score may range from 0 – 8. A lower score indicates a higher level of dependence.

Sources:

  • Cromwell DA, Eagar K, Poulos RG. The performance of instrumental activities of daily living scale in screening for cognitive impairment in elderly community residents. J Clin Epidemiol. 2003;56(2):131-137.
  • Lawton MP. The functional assessment of elderly people. J Am Geriatr Soc. 1971;19(6):465-481.
  • Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.
  • Polisher Research Institute. Instrumental Activities of Daily Living Scale (IADL). Available at: http://www.abramsoncenter.org/PRI/documents/IADL.pdf. Accessed Jan. 23, 2007.

Mini Mental State Examination (MMSE)

The Mini Mental State Examination (MMSE, developed by Folstein 1975) is the most widely used instrument for assessing cognitive function, which takes up to 10 minutes. It is a widely used method to detect impairment, follow the course of an illness, and monitor response to treatment. The MMSE has also been used as a research tool to screen for cognitive disorders in epidemiological studies and follow cognitive changes in clinical trials. It assesses orientation, attention, immediate and short-term recall, language, and the ability to follow simple verbal and written commands. Furthermore, it provides a total score that places the individual on a scale of cognitive function. Further information on the test and its copy right considerations are to obtained from: www.minimental.com.

Instructions:

  • Ask the date.
  • Then ask specifically for parts omitted, for example, "Can you also tell me what season it is?"
  • Score 1 point for each correct.
  • Duration of the test: 5-10 minutes.

Scoring:

A score of 20 or less generally suggests dementia but may also be found in acute confusion, schizophrenia or severe depression. A score of less than 24 may indicate dementia in some patients who are well educated and who do not have any of the above conditions. Serial testing may be of value to demonstrate a decline in cognitive function in borderline cases.

Sources:

  • Folstein MF, Folstein, SE and McHugh PR (1975) : A practical method for grading the state of patients for the clinician, Journal of Psychiatric Research, 12: 189-198. - - Anthony JC, LeResche L, Niaz U, VonKorff MR and Folstein MF (1982) Limits of the mini-mental state as a screening test for dementia and delirium among hospital patients. Psychological Medicine, 12: 397-408.
  • Cockrell JR and Folstein MF (1988) Mini Mental State Examination (MMSE), Psychopharmacology, 24: 689-692.
  • Crum RM, Anthony JC, Bassett SS and Folstein MF (1993) Population-based norms for the mini-mental state examination by age and educational level, JAMA, 18: 2386-2391.

Geriatric Depression Scale (Short Form) GDS

The Geriatric Depression Scale (GDS) is a self-report questionnaire designed specifically to screen for depression in older adults. The GDS can be used with both cognitively intact patients and patients who have mild to moderate cognitive impairments. It has been used as an observer-rated questionnaire with mildly cognitively impaired patients. It is also effective in detecting depression among patients who have physical illnesses.

The GDS Short Form, included here, is comprised of 15 yes/no items and can be completed in approximately five minutes.

Instructions:

Ask the patient to choose the best answer for how he/she felt over the past week. Duration of the test: ~5 minutes.

Scoring:

Answers indicating depression are in bold and italicized; score one point for each one selected. A score of 0 to 5 is normal. A score greater than 5 suggests depression.

Sources:

  • Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986 June;5(1/2):165-173.
  • Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24(4):709-711.
  • Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982-83;17(1):37-4

Up-and-Go Test

The Get-up and Go Test is a brief assessment of gait and balance in older patients that has been used in the clinical setting. The patient is asked to stand up from a chair, walk a short distance, turn around, return to the chair, and sit down again.

Instructions:

Ask the patient to perform the following series of maneuvers:

  • Sit comfortably in a straight-backed chair.
  • Rise from the chair.
  • Walk a short distance (approximately 3 meters).
  • Turn around.
  • Walk back to the chair.
  • Turn around.
  • Sit down in the chair

Scoring:

< 10 sec.: no impairment in mobility
> 20 sec.: relevant impairment in mobility

Sources:

  • Mathias S, Nayak USL, Isaacs B. Balance in elderly patients: the "get-up and go" test. Arch Phys Med Rehabil. 1986;67:387-389.
  • Podsiadlo D et al. (1991): J. Am. Psychiatr. Soc. 39:142-148

Comorbidities

(Charlson-Index and the Hematopoietic Stem Cell Transplantation Comorbidity Index (HCT-CI), also "modified Charlson Index")

Comorbidity describes any distinct additional clinical entity that has existed or may occur during the clinical course of a patient with a primary (index) disease. There is currently no consensus on how to quantify comorbidities but several scales and indices are available.

The Charlson Comorbidity Index (CCI) is the most frequently used in oncology and recently has been applied in the HCT setting. It has a good reliability, excellent correlation with mortality and progression-free survival outcomes. Basic limitations include preservation of data only for the 19 conditions listed in the index, the exclusion of non-malignant hematologic disease, such as anemia, and reduced predictive ability for outcomes < 6months. It is praised for its ease of use, short rating time, extractability from other indices, and widespread use

Instructions:

Mark the mentioned relevant comorbidity and add scores

Scoring:

Comorbidities increase the risk for mortality and morbidity.

Sources:

  • Sorror ML, Maris MB, Storb R, Baron F, Sandmaier BM, Maloney DG, Storer B. Hematopoietic cell transplantation (HCT)-specific comorbidity index: a new tool for risk assessment before allogeneic HCT. Blood. 2005 Oct 15;106(8):2912-9.
  • Charlson MA PP, Ales K, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40(5):373-83
  • Extermann M, Overcash J, Lyman GH, Parr J, Balducci L. Comorbidity and functional status are independent in older cancer patients. J Clin Oncol. 1998 Apr;16(4):1582-7
  • Artz, Pollyea DA, Kocherginsky M, Stock W, Rich E, Odenike O, et al. Performance status and comorbidity predict transplant-related mortality after allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2006 Sep;12(9):954-64

Performance Status (Karnofsky-Index, ECOG)

David A Karnofsky and colleagues described the first performance status (PS) in 1948. Each patient was given a score on a linear scale between 0 (dead) and 100 (normally active), summarising their ability to perform daily activities, and the level of assistance they required in order to do so. This scoring system was subsequently used throughout oncology practice as a numerical guide to patients' general health. In 1960, the Eastern Co-operative Oncology Group (ECOG) introduced a simpler "ECOG performance status" scale, similar to the Karnofsky PS (KPS) scale, with only five points. This is now termed the ECOG/WHO score (1982). Generally, the two scores have been proven interchangeable (Taylor et al), although the ECOG is often preferred for its simplicity.Sources:

  • Karnofsky DA AW, Craver LF, Burchenal JH. The use of nitrogen mustard in the palliative treatment of carcinoma. With particular reference to bronchogenic carcinoma. Cancer. 1948;1:634-56
  • Oken MM, Creech RH, Tormey, Horton J, Davis TE, McFadden ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982 Dec;5(6):649-55
  • Taylor AE, Olver IN, Sivanthan T, Chi M, Purnell C. Observer error in grading performance status in cancer patients. Support Care Cancer. 1999 Sep;7(5):332-5
  • Blagden SP, Charman, Sharples LD, Magee LR, Gilligan D. Performance status score: do patients and their oncologists agree? Br J Cancer. 2003 Sep 15;89(6):1022-7
  • Roila F, Lupattelli M, Sassi M, Basurto C, Bracarda S, Picciafuoco M, et al. Intra and interobserver variability in cancer patients' performance status assessed according to Karnofsky and ECOG scales. Ann Oncol. 1991 Jun;2(6):437-9.

Annex: Instruments

Instruments for the Geriatric Assessment

application/pdf Questionnaires (147KB)
GA_Instruments_final.pdf

Links