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Comprehensive Geriatric Assessment (CGA) of the older patient with cancer

The validity of geriatric assessment questionnaires to predict outcome and adverse events during the management of the elderly with cancer is now demonstrated. Yet comprehensive geriatric assessment (CGA) is often not feasible in all elderly patients with cancer. Consequently, patients could be first proposed screening before considering CGA.

Screening for vulnerability

When the physician faces an older patient with cancer, the first thing to perform is a screening for frailties which will allow identifying patients who may benefit from further evaluation, ideally CGA. A few tools have been developed and validated.
For general review, please read the SIOG Taskforce paper:

To further work on this topic, reference papers for each of the major tools and link to reference papers are outlined below.

 

1. G8

The G8 has been specifically developed in oncology (Bellera 2012) and consists of eight items: seven items issued from MNA questionnaire and one item relative to age of patient (<80; 80-85; >85).  Items selected from MNA concern nutritional status, weight loss, body mass index, motor skills, psychological status, number of medications, and self-perception of health. The score ranges from 17 (not at all impaired) to 0 (heavily impaired). A score lower or equal to 14 requires CGA. It is most often performed by a nurse or a clinical research associate. It takes less than 10 minutes to complete this questionnaire (median: 4 min.) (Soubeyran 2014). It is validated (Soubeyran 2014, Kenis 2014).

Reference papers:

Link to tool: G8 questionnaire (French) ; PDF icon8_quetsionnaire (English)

 

2. Triage Risk Screening Tool (TRST)

The TRST was developed in 2003 to identify older patients of the emergency department considered at risk of being re-admitted to the emergency department within 30 or 120 days of their discharge (Meldon 2003). It concerns patients aged 75 years and over. This tool includes five yes/no items concerning: cognitive impairment, walking ability, number of medications, attending an emergency department in the last 30 days or hospitalization during the previous 90 days, and live alone or not (Hustey 2007). Time to complete is around two minutes. The Flemish version of the TRST (fTRST) is a slightly adapted version of the original one to evaluate older persons of having a geriatric risk profile. In the oncological population, a score greater than 1 is considered as being a risk for a geriatric profile. (Kenis 2014)

Reference papers:

Link to tool: TRST[U1] questionnaire PDF icontriage_risk_screening_tool

 

3. Vulnerable Elders-13 Survey (VES-13)

This VES13 tool is a self-administrated questionnaire (Saliba 2001). Aim of this tool is to identify community older people (≥65 years) with increased risk of death or functional decline. It includes 13 items concerning: perception of health status, example of everyday activity, difficulty performing activities related to his health or physical condition. Time to complete this questionnaire is less than 10 min. (median: 4’) (Soubeyran 2014). A vulnerable individual is screened by a score greater than or equal to 3 (Saliba 2001, Mohile 2007). It has been validated in oncology (Soubeyran 2014).

Reference papers:

Link to tool: VES-13 questionnaire

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Comprehensive Geriatric Assessment (CGA)

When screening suggests potential frailties, performance of CGA is the optimal approach to better identify risks and consequently tailor treatment, as demonstrated in numerous papers and recently reviewed in a SIOG Taskforce (Wildiers 2014). The main geriatric domains to be assessed in CGA are functional status (FS), fatigue, comorbidity, cognition, mental health, social support, nutrition and geriatric syndromes (e.g. dementia, delirium, falls, incontinence, osteoporosis or spontaneous fractures, neglect or abuse, failure to thrive, constipation, polypharmacy, pressure ulcers, and sarcopenia) (Wildiers 2014). Many tools are available. Some of them are outlined below.

 

1. Activities of Daily Living (ADL)

This tool, designed in 1963, is a measure of functional basic activities of daily living in elderly patients (Katz 1963, Katz 1970). It explores six basic functions of everyday life: bathing, dressing, toileting, continence, transferring and feeding. The score ranges from 6 (patient independent) to 0 (patient very dependent). It allows following variation of patient's independence to perform basic activities during treatment. This questionnaire is usually administered by a nurse (with help of the family if necessary) and time to fill in is between 5 and 10 minutes.

Reference papers:

Link to tool: ADL questionnaire

 

2. Instrumental Activities of Daily Living (IADL)

This IADL scale is a measure of more elaborate functional activities in elderly patient. It was created in 1969 (Lawton 1969). It includes eight items: ability to use the phone, shopping, food preparation, housekeeping, laundry, mode of transportation responsibility for own medications, and ability to handle finances. The score ranges from 8 (high function, independent) to 0 (low function, dependent) for women and from 5 to 0 for men (because 3 questions concern only women: food preparation, housekeeping, laundry). It allows following variation of patient's independence to perform basic activities during treatment. This questionnaire is usually administered by a nurse (with help of the family if necessary) and time to fill it is below 10 min.

Reference paper:

Link to tool: IADL

 

3. Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)

The MMSE tool is used to evaluate cognitive function in clinical practice patients (Folstein 1975). It includes 30 items encompassing orientation, registration, attention and calculation, recall and language, while the last item asks the patient to copy a complex polygon figure. A score less than or equal to 23 is indicative of cognitive impairment. This questionnaire is usually administered by a nurse or physician and it takes 5 to 10 minutes to fill it in. Yet MMS is not a diagnostic test but a screening tool for dementia.

The MMSE is a copyright protected instrument and another tool, without copyright is available, the Montreal Cognitive Assessment (MoCA). It was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. Time to administer the MoCA is approximately 10 minutes. The total possible score is 30 points; a score of 26 or above is considered normal.

Reference paper:

Link to tool: MMSE, MOCA

 

4. Geriatric Depression Scale (GDS)

The GDS scale is a self-administrated questionnaire. The first version (GDS-30 - Sheikh 1986, Yesavage 1988) was developed in 1982, while the short version (GDS-15) emerged in 1986 (Arthur 1999, Almeida 1999). Its aim is to rate depression in elderly people but is not a diagnostic instrument (see DSM IV for this purpose). This tool groups 15 yes/no items concerning the vision of life, feelings, etc ...Time to fill in this scale is 5-10 minutes.

Reference papers:

Link to tool: GDS

 

5. Mini nutritional assessment (MNA)

Mini nutritional assessment was validated in 1994 (Guigoz 1994). This questionnaire scores 18 items including six belonging to the "screening part" and 12 to the "assessment part". A score of 24 to 30 identifies patients with a normal nutritional status. A score between 17 and 23.5 identifies patients at risk for malnutrition, and a score below 17 points identifies malnourished patients. Time to fill it in is between 10 and 15 minutes (Vellas 2006). A revised MNA short form has been developed and validated (Kaiser 2009).

Reference paper:

Link to tool: MNA; MNA-SF

 

6. “Timed Get up and go” (TGUG)

The Get up and Go test, created in 1986 (Mathias 1986), evaluates gait and balance. The physician asks the patient to get up from an armchair, walk a short distance (three meters back and forth), turn around itself and then return and sit down. Physician observes patient’s movements and assigns a score ranging from 1 (normal) to 5 (severely abnormal). A score of 3 and over identifies a patient at risk of falling. Because of its subjectivity, it has been replaced by the Timed Get up and Go which is validated in the elderly (Podsialo 1991)

Reference paper:

Link to tool: TGUG

 

7. Cumulative Illness Rating Scale for Geriatrics (CIRS-G)

This tool is used to score co-morbidities. It was first designed in 1968 (Linn 1968). A comorbidity score is attributed for each major area of health (heart, vascular, hematopoietic, etc). It is administered by the physician by questioning the patient or his/her relatives. Time to fill it in is around 20 minutes and it takes 5-10 minutes to score. Total number of categories endorsed, total score and severity index (total score/total number of categories endorsed) are calculated (Parmelle 1995, Extermann 2000).

Reference papers:

Link to tool: CIRS-G

 

8. ACE 27

The ACE-27 is a 27-item validated comorbidity index for use in patients with cancer. It grades specific diseases and conditions into 1 of 3 levels of comorbidity, grade 1 (mild), grade 2 (moderate), or grade 3 (severe), according to the severity of individual organ decompensation and prognostic impact. Once the patient’s individual diseases or comorbid conditions are classified, an overall comorbidity score (none, mild, moderate, or severe) is assigned based on the highest ranked single ailment. In the cases in which 2 or more moderate ailments occur in different organ systems or disease groupings, the overall comorbidity score is designated as severe (Piccirillo 2004).

Reference papers:

Link to tool: ACE 27

 

9. QLQ-C30

This tool is a self-administrated questionnaire, designed in 1993 (Aaronson 1993) to assess quality of life of patients. It includes 30 items about walking, health perception, physical condition and symptoms, as well as one visual analog scale for global health status and one for global quality of life. Time to fill in this questionnaire is around 11-12 minutes. It is a copyrighted instrument, which has been translated and validated into 81 languages. A specific module for the elderly has been proposed to address potential deficiencies of the QLQ system for cancer patients who are elderly (Wheelwright 2013).

Reference paper:

Link to tool: QLQ-C30; ELD14

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