Pharmacotherapy of the elderly is very complex due to age-related physiologic changes, multiple comorbidities, multiple medications (prescription, over-the counter, and herbal), and multiple providers (prescribers and pharmacies). Age-related physiologic changes and disease-related changes in organ function affect drug handling (pharmacokinetics) and response (pharmacodynamics). In addition, patients' cognitive impairment, functional difficulties, as well as caregiver issues play a large role in errors and compliance. Many older adults have several chronic conditions, and they stand to benefit the most from best practice guidelines. However, they are also at risk of toxicity given our increasingly complex pharmacopoeia and potential adverse effects that can cause morbidity and mortality. It is imperative that physicians learn how to minimize side effects and interactions. Potentially inappropriate medications (medications that pose more risk than benefit to the patient) are among the most important causes of adverse drug reactions, independent of the number of medications and other confounding factors. Many of these adverse drug reactions could be predicted from the known pharmacology of the drug and therefore could be potentially avoidable. To prescribe appropriately, we need to consider not only the pharmacological properties of the drugs, but also clinical, epidemiological, social, cultural, and economic factors. Elders' adherence to prescribed medications is also complex and depends on medical, personal, and economic factors; cognitive status; and relationship with the physician. Detection of nonadherence is a necessary prerequisite for adequate treatment, and patient education is a cornerstone in achieving medication adherence. Finally, appropriate prescribing should include a consideration of life expectancy and goals of care.
Background The American College of Surgeons and American Geriatrics Society recommend performing a geriatric assessment (GA) in the preoperative evaluation of older patients. To address this, we developed an electronic GA; the Electronic Rapid Fitness Assessment (eRFA). We reviewed the feasibility and clinical utility of the eRFA in the preoperative evaluation of geriatric patients. Methods We performed a retrospective review of our experience using the eRFA in the preoperative assessment of geriatric patients. The rate of and time to completion of the eRFA were recorded. The first 50 patients who completed the assessment were asked additional questions to assess their satisfaction. Descriptive statistics of patient-reported geriatric-related data were used for analysis. Results In 2015, 636 older cancer patients (median age, 80 years) completed the eRFA during preoperative evaluation. The median time to completion was 11 minutes (95% CI, 11 to 12 minutes). Only 13% of patients needed someone else to complete the assessment for them. Of the first 50 patients, 90% (95% CI, 75% to 98%) responded that answering questions by using eRFA was easy. Geriatric syndromes were commonly identified through the performance of the GA: 16% of patients had a positive screening for cognitive impairment, 22% (95% CI, 19% to 26%) needed a cane to ambulate, and 26% (95% CI, 23% to 30%) had fallen at least once during the previous year. Conclusion Implementation of the eRFA was feasible. The eRFA identified relevant geriatric syndromes in the preoperative setting that, if addressed, could lead to improved outcomes.
Purpose With the rapid spread of COVID-19 in New York City since early March 2020, innovative measures were needed for clinical pharmacy specialists to provide direct clinical care safely to cancer patients. Allocating the workforce was necessary to meet the surging needs of the inpatient services due to the COVID-19 outbreak, which had the potential to compromise outpatient services. We present here our approach of restructuring clinical pharmacy services and providing direct patient care in outpatient clinics during the pandemic. Data sources We conducted a retrospective review of electronic clinical documentation involving clinical pharmacy specialist patient encounters in 9 outpatient clinics from March 1, 2020 to May 31, 2020. The analysis of the clinical pharmacy specialist interventions and the impact of the interventions was descriptive. Data summary As hospital services were modified to handle the surge due to COVID-19, select clinical pharmacy specialists were redeployed from the outpatient clinics or research blocks to COVID-19 inpatient teams. During these 3 months, clinical pharmacy specialists were involved in 2535 patient visits from 9 outpatient clinics and contributed a total of 4022 interventions, the majority of which utilized telemedicine. The interventions provided critical clinical pharmacy care during the pandemic and omitted 199 in-person visits for medical care. Conclusion The swift transition to telemedicine allowed the provision of direct clinical pharmacy services to patients with cancer during the COVID-19 pandemic.
Older patients currently are the largest group of oncology patients and their numbers will continue to expand. There has been minimal participation of older patients in clinical trials. This has resulted in a lack of data to make high-level evidence-based decisions with regard to chemotherapy. There has now been a number of clinical trials which have given information with regard to age-related changes and the spectrum of toxicity that occurs with older patients. There is also an expanding literature on organ dysfunction. The overall data seem to indicate that there are a very few age-related changes in the pharmacokinetics of chemotherapy. The small changes that are present have not been clinically significant. It seems that the pattern of toxicity is more reflective of patient selection (functional status, performance status), comorbidity, and drug scheduling. The large number of drugs with significant renal excretion requires careful evaluation of renal function. Future clinical trial design needs to be adapted to older patients. Therefore, drugs, which will be primarily used by older patients, should be studied in older patients. These studies should involve pharmacokinetics, and oral therapies should include measurements of compliance. Phase II trials of new agents should consider prospectively dividing groups of patients by age (i.e., <75 years vs. >or=75 years). Phase I trials should consider accruing older patients. The studies can be performed in the older group by using progressive degrees of functional impairment and increasing comorbidity as a surrogate for dose limiting toxicity. Functional independence as a clinical benefit of cancer treatment in older individuals should be considered as an endpoint. Overall survival may not be an appropriate endpoint in clinical trials in the oldest group. Clinical trials should consider studying long-term functional and medical consequences of cancer treatment in long-term older cancer survivors. Journal editors should encourage the inclusion of age-related analyses in the reporting of clinical trials to provide meaningful information for clinicians caring for older patients. Ideally, the clinical trial design should prospectively incorporate age analysis to maximize clinical benefit of data generated. A careful assessment of medication used in older patients needs to be part of routine evaluation to minimize the adverse effects of polypharmacy.
Polypharmacy is prevalent in older adults with cancer and may be advantageous for the management of certain chronic disease states, but uncertainty exists regarding potential hazards and consequences. Cancer-related therapy adds to the prevalence of polypharmacy, which can lead to compromised cancer management plans (i.e., postoperative complications, treatment delays, and/or premature treatment discontinuation). Polypharmacy has been identified as one of the domains commonly included in the Comprehensive Geriatric Assessment likely because of the potential influence on health outcomes. This review summarizes existing evidence regarding health outcomes associated with polypharmacy in older adults with cancer. Preliminary evidence demonstrated that relationships exist between polypharmacy and health outcomes including adverse drug events, falls, frailty, hospitalization, postoperative complications, and mortality. This research is limited by study confounders, inconsistent definitions for polypharmacy, heterogeneous cancer types and stages, and the complex relationship between medication regimens and outcomes. Additional studies are needed to enhance the accuracy and replicability of this research.
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