Falls in older patients with cancer: Nursing and Allied Health Group of International Society of Geriatric Oncology review paper

Dizziness and impaired walking balance in aging patients during chemotherapy

INTRODUCTION

Older adults are at risk of adverse effects during chemotherapy including nausea and fatigue, but many also suffer from dizziness and peripheral neuropathy. This may lead to balance and walking impairments and increased risk of falls and affect health-related quality of life. Moreover, these symptoms are often underreported with inadequate awareness among health professionals leading to deficient focus on the need for targeted assessment and rehabilitation. We aimed to examine the prevalence of dizziness, impaired walking balance, and neuropathy and falls in older adults ≥65 years with gastrointestinal cancer receiving chemotherapy and the associations between these symptoms. Further, we aimed to examine the quantity of patients reporting these symptoms to the oncologist.

MATERIALS AND METHODS

This is a cross-sectional study among patients ≥65 years with gastrointestinal cancers who have completed three or more series of chemotherapy. The prevalence of dizziness, impaired walking balance, neuropathy, and reporting of these adverse effects was examined through structured questionnaires.

RESULTS

Of two hundred patients (57 % male, mean age 74.4 years) the prevalence of dizziness was 54 % and the prevalence of patients experiencing impaired walking balance was 48 %. Symptoms of neuropathy was present in 32 % of patients and 11 % experienced falls during chemotherapy. Symptoms of neuropathy was associated with experiencing dizziness: odds ratio (OR) 1.98 (95 % confidence interval [CI]: 1.06; 3.71) and impaired balance: OR 3.61 (95 % CI: 1.87; 6.96). Less than half the patients (48 %) told the oncologist about these symptoms.

DISCUSSION

Dizziness and impaired walking balance during chemotherapy are underreported yet profound symptoms among older patients with cancer. Dizziness and impaired balance should be systematically assessed during chemotherapy among older patients.

Assessment Tools of Biopsychosocial Frailty Dimensions in Community-Dwelling Older Adults: A Narrative Review

Frailty is a complex interplay between several factors, including physiological changes in ageing, multimorbidities, malnutrition, living environment, genetics, and lifestyle. Early screening for frailty risk factors in community-dwelling older people allows for preventive interventions on the clinical and social determinants of frailty, which allows adverse events to be avoided. By conducting a narrative review of the literature employing the International Narrative Systematic Assessment tool, the authors aimed to develop an updated framework for the main measurement tools to assess frailty risks in older adults, paying attention to use in the community and primary care settings. This search focused on the biopsychosocial domains of frailty that are covered in the SUNFRAIL tool. The study selected 178 reviews (polypharmacy: 20; nutrition: 13; physical activity: 74; medical visits: 0; falls: 39; cognitive decline: 12; loneliness: 15; social support: 5; economic constraints: 0) published between January 2010 and December 2021. Within the selected reviews, 123 assessment tools were identified (polypharmacy: 15; nutrition: 15; physical activity: 25; medical visits: 0; falls: 26; cognitive decline: 18; loneliness: 9; social support: 15; economic constraints: 0). The narrative review allowed us to evaluate assessment tools of frailty domains to be adopted for multidimensional health promotion and prevention interventions in community and primary care.

Communication About Fall Risk in Community Oncology Practice: The Role of Geriatric Assessment

PURPOSE

Falls are a modifiable source of morbidity for older adults with cancer, yet are underassessed in oncology practice. In this secondary analysis of a nationwide cluster-randomized controlled trial, we examined characteristics associated with patient-oncologist conversations about falls, and whether oncologist knowledge of geriatric assessment (GA) resulted in more conversations.

METHODS

Eligible patients (ClinicalTrials.gov identifier: NCT02107443) were age ≥ 70 years, had stage III/IV solid tumor or lymphoma, were being treated with noncurative treatment intent, and ≥ 1 GA domain impairment. Patients in both arms underwent GA. At practices randomly assigned to the intervention arm, oncologists were provided a GA summary with management recommendations. In both arms, patients had one clinical encounter audio-recorded, transcribed, and coded to categorize whether a conversation about falls occurred. Generalized linear mixed models adjusted for arm, practice site, and other important covariates were used to generate proportions and odds ratios (ORs) from the full sample.

RESULTS

Of 541 patients (intervention N = 293 and usual care N = 248, mean age: 77 years, standard deviation: 5.3), 528 had evaluable audio recordings. More patients had conversations about falls in the intervention versus usual care arm (61.3% v 10.3%, P < .001). Controlling for the intervention and practice site, history of falls (OR, 2.1; 95% CI, 1.3 to 3.6; P = .005) and impaired physical performance (OR, 4.7; 95% CI, 1.7 to 12.8; P = .002) were significantly associated with patient-oncologist conversations about falls.

CONCLUSION

GA intervention increased conversations about falls. History of falls and impaired physical performance were associated with patient-oncologist conversations about falls in community oncology practice.

Falls in older ambulatory care patients with cancer in Iran: Implications for clinical practice

RATIONALE/AIM

Falls can have severe consequences particularly for older patients with cancer undergoing ambulatory care. The aim of the study is to identify the predictors of falls in older patients receiving cancer ambulatory care and evaluate the accuracy of the final multivariable model in detecting older patients with falls.

METHOD

A retrospective study was conducted on 300 older patients aged 60 years and above that were referred for ambulatory care in three oncology clinics based at hospitals in Tehran, Iran. Participants completed a questionnaire comprising demographic, history of falls, and cancer-related factors. Logistic regression was used to determine risk factors associated with falls.

RESULTS

A total of 35.3% of the older patients with cancer had experienced a fall in the 6 months following the start of their ambulatory care. The most important predictors of falls include the fourth stage of cancer (odds ratio [OR]: 6.47, 95% confidence interval [CI]: 3.20-13.08, p < 0.001), fear of falling (OR: 5.64, 95% CI: 2.58-12.33, p < 0.001), use of hearing (OR: 2.38, 95% CI: 1.07-5.29, p = 0.033) and visual aids (OR: 2.36, 95% CI: 1.12-5.01, p = 0.025), and the number of visits to the doctor (OR: 1.10, 95% CI: 1.01-1.21, p = 0.035).

CONCLUSIONS

The results indicate that a reduction in falls is possible by introducing strategies to improve care for older patients in the advanced stage of cancer, eliminating the causes of fear of falling, examining and improving vision and hearing, and identifying and addressing the underlying causes of visits to the doctor.

Fall predictors in hospitalized patients living with cancer: a case-control study

PURPOSE

To identify fall predictors and develop an assessment tool to be used for screening hospitalized cancer patients at risk for fall.

METHODS

A retrospective case-control study was conducted in 2018 at a cancer center in Northern Italy. The study participants were 448 adult cancer patients admitted to the oncology ward from 2009 to 2013. The case group consisted of 112 patients presenting at least one fall, while controls were randomly chosen by matching each case for age, sex, and admission period with three patients who did not fall. Data for the fall predictors were extracted from the electronic medical records. Conditional logistic regression was used to evaluate the association between patient's characteristics and fall risk.

RESULTS

The overall prevalence of patients having at least one candidate fall predictor was high (98%). Seven of the studied variables showed an independent association with fall risk at multivariate analysis. These were tumor site, the presence of neurologic diseases, gait imbalance disorders, fatigue, and the assumption of certain medications such as diuretics, hypnotics, and opioids (odds ratios and 95% confidence intervals in brackets were 3.78 (1.78-8.13), 2.26 (1.08-4.77), 4.22 (1.87-9.52), 2.76 (1.45-5.26), 2.66 (1.52-4.66), 2.41 (1.20-4.85), and 3.03 (1.68-5.45), respectively).

CONCLUSIONS

In this study, we identified falling risk factors in an Italian population of hospitalized cancer patients and developed a new risk assessment tool. An external validation is necessary before implementing our screening tool in clinical practice.

The Role of Family Caregivers in the Care of Older Adults with Cancer

OBJECTIVES

To provide an overview on the role of family caregivers (FCGs) in the care of older adults with cancer and review quality of life needs for FCGs.

DATA SOURCES

Journal articles, research reports, state of the science papers, position papers, and clinical guidelines from professional organizations were used.

CONCLUSION

The high prevalence of multiple comorbidities and the associated burden of geriatric events in older adults have a substantial impact on the quality of life of their FCGs. Practical and efficient models of comprehensive assessment, interventions, and caregiving preparedness support are needed to improve outcomes for both older adults with cancer and their FCGs.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses practicing in clinical and research settings have a responsibility to prepare themselves with evidence-based knowledge and resources to include the needs of FCGs in the care provided to older adults with cancer.

Oncology clinic nurses' attitudes and perceptions regarding implementation of routine fall assessment and fall risk screening: A survey study

Falls in older adults with cancer are often under-recognized and under-reported. The objective of this study was to explore oncology clinic nurses' willingness and perceived barriers to implement routine falls assessment and falls screening in their practice. Nurses working in outpatient oncology clinics were invited to complete an online survey. Data were analyzed using descriptive statistics and sorted into thematic categories. The majority of respondents indicated willingness to routinely ask older patients about falls (85.7%) and screen for fall risks (73.5%). The main reasons for unwillingness included: belief that patients report falls on their own, lack of time, and lack of support staff. Findings from this study show many oncology nurses believe in the importance of routine fall assessment and screening and are willing to implement them routinely, although falls are not routinely asked about or assessed. Future work should explore strategies to address barriers nurses face given the implications of falls amongst this vulnerable population.

Évaluation systématique des chutes et du risque de chutes : Sondage sur l’attitude et les perceptions des infirmières cliniques en oncologie

Chez les personnes âgées atteintes de cancer, les chutes sont un problème souvent sous-estimé et peu rapporté. La présente étude visait à explorer la volonté des infirmières cliniques en oncologie à évaluer et à dépister systématiquement les chutes dans leur pratique; l’étude examinait également les obstacles perçus à l’évaluation et au dépistage systématique. Les infirmières ont donc été invitées à remplir un sondage en ligne. Les données ont été analysées à l’aide de statistiques descriptives. La majorité des infirmières ayant répondu ont dit qu’elles accepteraient de poser systématiquement des questions sur les chutes (85,7 %) et de dépister les risques de chutes (73,5 %) chez les personnes âgées. Voici les principales raisons des réticences : conviction que les patients signalent les chutes d’euxmêmes, manque de temps, pénurie de personnel de soutien. Selon les résultats de l’étude, beaucoup d’infirmières en oncologie trouvent important d’évaluer et de dépister systématiquement les chutes, et sont d’accord pour l’intégrer à leur pratique bien que, d’habitude, les chutes ne fassent pas automatiquement l’objet de questions ou d’une évaluation. Étant donné les conséquences des chutes sur ces patients vulnérables, la recherche à venir devra explorer les stratégies permettant de surmonter les obstacles auxquels se butent les infirmières.

An update on cancer-related fatigue in older adults: A narrative review

Up to 70% of older adults report fatigue after a cancer diagnosis. For many of these patients, cancer-related fatigue (CRF) persists for years after cancer treatment and is associated with significant disability. Despite this, little has been written on the diagnosis and management of CRF in older adults. To address this gap, we performed a narrative review of the literature on CRF in older adults and used literature from the general population when evidence was lacking to provide guidance to clinical providers on how to tailor care to this population. We recommend evidence-based options for evaluating CRF and address their limitations in the assessment of older adults. We also provide guidance and a treatment algorithm on evaluating CRF using the Comprehensive Geriatrics Assessment. Lastly, we present evidence for the use of non-pharmacologic and pharmacologic therapies in the management of CRF in older adults.

Research priorities to address polypharmacy in older adults with cancer

Polypharmacy poses a significant public health problem that disproportionately affects older adults (≥65 years) since this population represents the largest consumers of medications. Clinicians caring for older adults with cancer must rely on evidence to understand polypharmacy and its implications, not only to communicate with patients and other healthcare providers, but also because of the significant interplay between polypharmacy, cancer, cancer-related treatment, and clinical outcomes. Interest in polypharmacy is rising because of its prevalence, the origins and facilitating factors behind it, and the direct and indirect clinical outcomes associated with it. The growing body of publications focused on polypharmacy in older adults with cancer demonstrates that this is a significant area of research; however, limited evidence exists to guide medication use (e.g., prescribing, administration) in this population. Currently, research priorities aimed at polypharmacy in the field of geriatric oncology lack clarity. We identified current gaps in the literature in order to establish research priorities for polypharmacy in older adults with cancer. The five research priorities-Polypharmacy Methodology and Definitions, Suboptimal Medication Use, Comorbidities and Geriatric Syndromes, Underrepresented Groups, and Polypharmacy Interventions-highlight critical areas for future research to improve outcomes for older adults with cancer.

Systematic review of self-management interventions for older adults with cancer

AIM

The purpose of this systematic review was to determine the effectiveness of self-management interventions for older adults with cancer and to determine the effective components of said interventions.

METHODS

We conducted a systematic review of self-management interventions for older adults (65+) with cancer guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. We conducted an exhaustive search of the following databases: Ageline, AMED, ASSIA, CINAHL, Cochrane, Embase, Medline, PsychINFO, and Sociological Abstracts. We assessed for quality using the Cochrane Risk of Bias tool and Down & Black for quasi-experimental studies, with data synthesized in a narrative and tabular format.

RESULTS

Sixteen thousand nine hundred and eight-five titles and abstracts were screened, subsequently 452 full-text papers were reviewed by two independent reviewers, of which 13 full-text papers were included in the final review. All self-management interventions included in this review measured Quality of Life; other outcomes included mood, self-care activity, supportive care needs, self-advocacy, pain intensity, and analgesic intake; only one intervention measured frailty. Effective interventions were delivered by a multidisciplinary teams (n = 4), nurses (n = 3), and mental health professionals (n = 1). Self-management core skills most commonly targeted included: problem solving; behavioural self-monitoring and tailoring; and settings goals and action planning.

CONCLUSIONS

Global calls to action argue for increased emphasize on self-management but presently, few interventions exist that explicitly target the self-management needs of older adults with cancer. Future work should focus on explicit pathways to support older adults and their caregivers to prepare for and engage in cancer self-management processes and behaviours.

Falls in older adults with cancer: an updated systematic review of prevalence, injurious falls, and impact on cancer treatment

PURPOSE

This update of our 2016 systematic review answers the following questions: (1) How often do older adults with cancer fall? (2) What are the predictors for falls? (3) What are the rates and predictors of injurious falls? (4) What are the circumstances and outcomes of falls? (5) How do falls in older patients affect subsequent cancer treatment? and a new research question, (6) Which fall reduction interventions are efficacious in this population?

METHODS

MEDLINE, PubMed, CINAHL, and Embase were searched (September 2015-January 25, 2019). Eligible studies included clinical trials and cohort, case-control, and cross-sectional studies published in English in which the sample (or subgroup) included adults aged ≥ 60, with cancer, in whom falls were examined as an outcome.

RESULTS

A total of 2521 titles were reviewed, 67 full-text articles were screened for eligibility, and 30 new studies were identified. The majority involved the outpatient setting (n = 19) utilizing cross-sectional method (n = 18). Sample size ranged from 21 to 17,958. Fall rates ranged from 1.52 to 3.41% per 1000 patient days (inpatient setting) and from 39%/24 months to 64%/12 months (outpatient setting). One out of the 6 research questions contributed to a new finding: one study reported that 1 in 20 older patients experienced impact on cancer treatment due to falls. No consistent predictors for falls/fall injuries and no studies on fall reduction interventions in the geriatric oncology setting were identified.

CONCLUSION

This updated review highlights a new gap in knowledge pertaining to interventions to prevent falls. Additionally, new knowledge also emerged in terms of impact of falls on cancer treatment; however, further research may increase generalizability. Falls and fall-related injuries are common in older adults with cancer and may affect subsequent cancer treatment. Further studies on predictors of falls, subsequent impacts, and fall reduction in the oncology setting are warranted.