ORLANDO, Fla.—Cancer disproportionately affects older people, with a median age at diagnosis in the United States in the 70s. A working knowledge of frailty, multimorbidity, and geriatric syndromes, as well as self-awareness of and sensitivity to ageism are key skills for oncology navigators caring for these patients.1
In short, oncology navigators need geriatric competence to provide optimal cancer care for older people, explained Sarah H. Kagan, PhD, RN, of the Abramson Cancer Center at Pennsylvania Hospital and the School of Nursing University of Pennsylvania in Philadelphia, in an oral presentation at the 2nd Annual Oncology Nurse Advisor Navigation Summit.
In the literature, geriatric competence is defined as being knowledgeable about the aging process, skilled in assessment and management of chronic illness, and able to practice in an interdisciplinary milieu.
As with most of American health care, cancer care does not meet the needs of older patients. It is challenged by limited geriatric oncology science, low elder enrollment in clinical trials, and exclusion of multimorbid elders from clinical trials. Furthermore, cancer care team members are inadequately prepared to deliver fully competent care to older patients.
Frailty is an epigenetic phenomenon that manifests as declining functional reserve likely triggered by malnutrition and inactivity. It results in slowed gait speed and altered cognition. Cancer treatment may induce frailty expression that cannot be predicted by chronological age. But it may prolonge recovery. Prehabilitation is known to optimize outcomes.
Geriatric syndromes include incontinence, falls, pressure ulcers, delirium, and functional decline. Risk factors for geriatric syndromes can lead to frailty, which in turn can exacerbate symptoms of geriatric syndromes, resulting in poor outcomes (eg, disability and dependence, need for nursing home care, death).
Multimorbidity can refer to other comorbid conditions with cancer as the index condition; it can also refer to the functional issues of a patient (eg, values, function, health concerns, care, work, meaning). Multimorbidity and functional limitations can affect decision making (ie, patient preference, decisional capacity, organ function) and/or treatment (ie, sensory impairment, physical function, cognitive capacity, family function, financial resources, social support).
To overcome ageism, navigators need to avoid granny bashing, parentalism, and self-stereotyping. “Lower your pitch” rather than simplying your words when talking to older patients, advised Kagan. You need to fight the urge to push older patients to react, move, or respond faster.
Guidance navigators can give older patients include expect good cancer care, do not accept care predicated on age, ask all your questions, do not stand for age-based replies, and ask for what you need. Older patients should also be encouraged to keep a notebook or other record of their care, not be afraid to change their mind or ask “why are we doing that?” They should also be reminded not to forget their desires and goals and to bring an advocate and companion with them to their appointments.
Clinicians should cultivate an age-friendly perspective that focuses on the person and his or her capacity and is respectful of their generation. Limit your emphasis on chronological age and avoid ageist assumptions
Aim for age-friendly communications that avoid assumptions, cultivate relationships, build and return trust; be sure to underscore success and emphasize the positive. When talking to the older patient, sequence the information you give them. Allow the patient time to process the information given to them and reiterate any information they may not have understood or missed.
Age-friendly materials should be prepared for these patients that use larger, easy-to-read type (14 pt font, san serif, high contrast [black on white]) at the 5th grade reading level and avoid handwritten notes and materials, explained Kagan. In addition, diagrams and interpretable photos are good options for materials for older patients.
Family dynamics should be acknowledged and adhered to. Older people may resist help, so accepting support needs to be normalized. Adult children may overstep and older caregivers may not admit confusion. Navigators need to go with the established family dynamics, plan to revisit as changes occur, and revisit supportive care needs over time.
1. Kagan SH. Treating an aging population: guidance for older patients. Oral presentation at: Oncology Nurse Advisor Navigation Summit; April 7-9, 2016; Orlando, FL.