Multidisciplinary palliative care of the older adult: a narrative review

Introduction

With the aging of society largely due to the baby boomer generation, older adults make up the fastest growing segment of the population and thus hold the distinction of being the group of individuals most common to have cancer. By 2030, 70% of all individuals diagnosed with cancer will be over the age of 65 years (1,2). Older adults are a heterogenous population who differ in their functional status, co-morbidities, physical reserve and experience changes in physiology that can affect the pharmacokinetics and pharmacodynamics of medications (3). The complexity that this presents when looking at the diagnosis and treatment of cancer from a “geriatric perspective” is difficult. A patient’s functional age may be greatly different than their chronological age and thus this needs to be incorporated into decision-making processes. Oncology providers are not well-versed in dealing with the heterogeneity of the aging population nor the unique changes that occur in the body’s physiological functioning that are important to consider when treatment decisions for cancer are being made. Thus, this places the older adult at risk for over-treatment or undertreatment of their cancer lending, placing them at higher risk for adversity with their treatment outcomes compared to younger patients (4).

Consider an older adult that may be fit, another who has suffered only a marginal decline and a third who may be deemed frail all the same chronological age. The fit individual who has few co-morbidities, no functional deficit and suffers with few if any geriatric syndromes may have resiliency and be more likely to benefit from treatment successfully. On the other hand, the frail individual with multiple co-morbidities, dependency on others for their activities of daily living and possibly have geriatric syndromes such as cognitive impairment would be susceptible to adversity and toxicities from treatment. This would result in less substantial response to treatment benefits and increase the individual’s risk for morbidity and mortality (5). Optimally, embedding geriatricians in the practice of oncology to cooperatively manage the individual’s care is most ideal. Geriatricians, using their expertise of the older adult, can complement the oncologist’s care, by providing consultative care that is geriatric focused. Further incorporating other health care providers such as geriatric nurse practitioners, social work, and pharmacy can create a “village” that is more than prepared to see that the care of the older adult is effective and efficient, maintain quality of life.

The purpose of this unsystematic narrative review is to initially demonstrate the importance that the geriatrician can have, when participating on a multidisciplinary team (MDT) with oncology, in the administration of holistic cancer care including palliative care to the older adult; secondly, to present geriatric specific issues that are imperative to consider when managing the older adult with cancer; and lastly to consider other members of the MDT inclusive of social work and pharmacy as well as nursing and their potential impact on the holistic care of the older adult with cancer. We present this article in accordance with the Narrative Review reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-23-541/rc).

Methods

For this unsystematic narrative review, data were identified by searching PubMed (January 2005 to July 2023) using the following search terms: multidisciplinary care, older adults, and cancer care. The search was repeated using geriatrics, multidisciplinary teams, chronic diseases, elderly. Excluded articles included non-English articles and observational studies. An additional review of literature was undertaken using relevant references for identified articles (see Table 1).

With improvements over the years in surgical, pharmacological and public health advances, life expectancy in the United States has increased (6). Life expectancy brings with it, individuals who are living with more chronic disease often leading to a complex course of illness and care (7). Combine this with the fact that people are living longer, and the result is a high prevalence of chronic disease. Six in ten adults in the United States have at least one chronic disease while four in ten adults have two or more chronic diseases (8). The presence of chronic diseases in older adults leads to decreased function, quality of life as well as increased cost and utilization of healthcare services. Ninety percent of the leading causes of death in 2021 can be attributable to illnesses that are chronic in nature which are defined as a physical or mental condition lasting for more than one year and require ongoing monitoring or treatment (9). Unfortunately, increased care associated with these chronic illnesses does not necessarily correlate with improved life expectancy nor quality of life. Further, the great burden this places on caregivers in the care of this population living with chronic illnesses is significant. According to AARP and the National Alliance on Caregiving [2020], 21.3% of Americans were providing care to an adult with serious illness over the year prior and 19% of this caregiving was not being compensated. Thus, it is imperative in this population to provide effective, efficient and appropriate care to the older adult, considering the older adult with chronic illnesses and their caregivers.

Results

Palliative care and the older adult with chronic illness

Historically, palliative care has changed through the years conceptually and strategically. The World Health Organization initially defined palliative care more narrowly however subsequently expanded the definition to include “an approach that improves quality of life of patients and families facing life-threatening diseases, preventing and mitigating suffering through early identification, pain assessment and treatment and other physical, psychosocial and spiritual problems” (10). In their scoping review, Llop-Medina and colleagues aimed to identify the needs influencing palliative care in older adults with multiple co-morbidities, their relatives/caregivers and the health care professionals that provide them care. Eighty-one studies were included in the review, and it was determined that there were many unmet needs for palliative care among the older adults due to the complexity of the needs of the individual patients and their relatives/caregivers. This review also suggested that patients and their caregivers/families felt that their physical needs were being met, however there was a lack of support for psychosocial and spiritual needs. Thus, suggesting that changes need to occur in our health care system to adequately meet the needs of the palliative care older adult (11).

Kawashima and Evans (12) suggest in their systematic review that older persons with non-cancer conditions are less likely to be referred to palliative care services. They aimed in their review to identify needs-based triggers to help enhance timely referrals to palliative care. They reviewed 27 randomized control trials in palliative care and identified six major domains of trial eligibility: needs-based, time-based and medical-history based. They found that the potential needs-based triggers were best delineated by symptoms, functional status and quality of life. Using one of these triggers to determine eligibility proved to be most successful. They recommended further research to be done to determine however best to operationalize these needs-based triggers in order to enhance the referral process.

Multidisciplinary approach to palliative care and the older adult with cancer

Consider the older adult who historically has been diagnosed with chronic illnesses and who has been diagnosed with cancer. It is projected that with the aging of the population cancer will continue to grow as a leading cause of health and economic burden (13). Biologically, aging results from accumulation of changes that occur at the molecular and cellular level, which places the older adult at risk of cancer as well as other chronic diseases. The number of older adults with cancer will increase to 18.6 million per year in 2040, up from 9.95 million per year in 2020 (14). The challenges that this will bring to the care of the older adult with cancer who suffers with other chronic illnesses will be immense. Further this challenge is complicated by many factors including the heterogeneity of this older adult population, polypharmacy, frailty, dementia and functional impairment (15). These individuals are best served by a multidisciplinary approach with geriatrics acting as the “quarterback” while palliative care plays an integral role with regards to symptom control and quality of life (14). These individuals would benefit from palliative care in that the goals of the individual are central, and the maintenance of the individual’s independence and physical, emotional and spiritual health is the focus (11,15). Collaboration between primary care, oncology and palliative care is crucial to ensure ideal care for the older adult with cancer. This would utilize the strengths from each discipline, geriatrics, palliative care and oncology, to provide holistic care to the older adult with unique socio-demographic needs as well as the challenges that the older adult presents with regards to their chronic illnesses, functional status and overall well-being (16).

Geriatricians will need to provide for geriatric assessment, inclusive of an evaluation of the individual’s medical, functional and psychosocial status. This assessment will help to identify aging associated challenges as well as frailty and other vulnerabilities that will help to successfully guide cancer treatment. For example, an 80-year-old male recently diagnosed with lung cancer who has minimal co-morbidities, rides his bike daily and takes few medications would fare much better with regards to treatment than a similarly aged 80-year-old male who has many co-morbid conditions, is not able to ambulate across the room without getting short of breath and is on many medications. For this reason, a growing body of evidence has shown that geriatric assessment along with other interventions can provide for improved outcomes for the older person with cancer including treatment tolerance, quality of life and functional status as well as advanced care planning (14,17).

Geriatric assessment is a complex interdisciplinary assessment for the evaluation of the older adult from a biopsychosocial perspective. Central to the assessment is to note previously unknown and potentially reversible issues and then to develop a management plan for the treatment, amelioration of dysfunction and establish long-term follow-up care. In other words, it is a comprehensive and complex process utilizing multidisciplinary care partners and is thought to be far superior to conventional care in decreasing the morbidity and mortality of the older adult while improving functional status (18). Comprehensive geriatric assessment (CGA) trialists by way of a Cochrane review, asked the question what elements of CGA were essential. Thirteen trialists (of the 29 included) were included in the study and all ranked the MDT and the CGA process as most important. Other essential aspects included tailoring plans to meet the patient’s needs, importance of using specialists and clinical leadership. Furthermore, the importance of having a coordinated team was a critical difference and one that the trialists felt made a difference for the care of the patient (19).

Cassarino and her colleagues (20) looked at the impact of care that older adults presenting to an emergency department (ED) received from an MDT as compared to standard care. Utilizing a randomized control trial, they looked at 353 patients 65 years of age and older who presented with low urgency complaints to an ED. Their intervention was early assessment and intervention of the patient by the MDT vs. standard care. Primary outcome of interest was the length of stay while secondary outcomes of interest were many: rates of hospital admission from the ED, hospital length of stay for those admitted, patient satisfaction, revisits to the ED, mortality and nursing home admission, patient functional status and quality of life both initially and at follow up. What they found was that patients in the experimental group experienced significantly shorter ED stays when compared to the control group. Other significant differences of interest when comparing the intervention group to the control group included: lower rates of hospitalization, higher levels of satisfaction, improved functioning with 30 days (about 4 and a half weeks) of discharge from the hospital as well as at 6 months. Thus, using an MDT early in the process was beneficial. Furthermore, they did note that their findings mirrored earlier results found in the literature.

Models of multidisciplinary care

The literature purports over the last 20 years, four different geriatric oncology models of care have been developed and described. The first being a screen and referral model. This model is utilized when an older adult is screened and deemed that they would benefit from a referral to geriatric oncology. This model tends to take time to complete and is resource-intensive due to the coordination of a group of team members needed to complete the assessment. While this type of model is used primarily in an inpatient setting, some researchers are looking to utilize it in a community setting. Using prepopulated self-assessments that are answered by the patient as a form of screening would be helpful in decreasing the time needed to complete the assessment and thus the commitment of professional time is decreased. Once individuals are screened in to receive CGA based on pre-populated self-assessment, it was shown that the elements of CGA could be implemented in the outpatient or community setting with limited resources however the cost effectiveness of this model is not known (21,22).

The second model is the primary provider model. The primary provider model benefits from a formally trained geriatric oncologist, geriatrician and palliative medicine provider as the team that works with the older adult with cancer. These teams have the unique ability to provide CGA, overall treatment planning and manage the older adults care from the time of diagnosis to the end of their life. Advantages of this care model include care continuity, comprehensive care for the older adult with complex care needs and a concentration on resources for the most vulnerable of patients with cancer (23,24). The disadvantages include limited numbers of those trained in geriatric oncology to participate on the team placing limits on the number of patients that can be included; increase use of specialized resources needed to provide this care inclusive of intensive training of team members. Due to these constraints, it is often difficult to develop this care model outside of a large organization that could invest resources into it (23). However, this care model delivers the highest value of care for frail older adults with cancer.

A third model is the multidisciplinary consultive model. This model is consultative in nature and is used typically for the frail older adult at the request of other oncologists. Typically, CGA is performed on these older adults in the outpatient setting using a team of professionals inclusive of but not limited to advanced practice nurses, pharmacists, social work, nutritionists, physical therapists, occupational therapists and patient navigators (23). Advantages of this model include: the evaluation of older adults can include a larger magnitude of individuals; older adults are provided with advice while still maintaining continuity of care with their primary oncologist. However, the ability to provide continued care in this model is more limited as it has at its core a consultative model. Longitudinal care of the older adult is not provided for in this model.

The final model is a geriatrics driven and embedded consultative model. This is using geriatricians within the oncology clinic or at a separate location to perform CGA. This model is like the multidisciplinary consultative model in that geriatrics is infused into an on-going care plan specific to oncology (23). This model would work best in institutions where geriatrics has a great presence but where geriatric oncologists are not readily available. This geriatric led team would be available to help with non-oncology related concerns as they arise during the patient’s oncology care. This care model is a partnership between geriatrics and oncology where geriatric expertise can be infused into the care of the oncology patient thus providing more comprehensive care to older adults with very complex health issues.

No matter what the model of care is, what is apparent and very important is the active involvement of an MDT in the palliative care of the older adult with cancer. The positives that can be gained to support and augment the older adult’s plan of care is immeasurable and should be instituted wherever possible. These care models are important in providing individualized geriatric care specific to the older adult’s functional level and their cancer-specific care. These models also provide a multidisciplinary approach to everyone’s medical, support and social service needs. Furthermore, these programs can help shape future health care policies and procedures.

Discussion

The MDT: who to include?

The core function of an MDT is to bring together different disciplines to augment an individual’s plan of care. Initially using a geriatric nurse practitioner who has specialty training in geriatric oncology to support the patient during the entire diagnosis and treatment process would be most ideal. This will include doing nursing interventions such as assessing disease toxicities and wound care management but also doing a case management role including facilitating and coordinating the patient’s care plans (25). The geriatric nurse practitioner can be involved in education, prevention, supportive care and symptom management. The natural focus of the geriatric nurse practitioner is early assessment of symptoms with interventions that are timely. They can also provide for consistency needed follow-up as well as coordination of care (5).

Another integral member of the MDT is the pharmacist. Pharmacists are excellent team members to have to look at all medications and the patient’s adherence to their medications for their chronic conditions as well as their oncology/palliative care. It is known that about half of all Medicare beneficiaries stop taking their antihypertensive medications within one year of the initial prescription (26). Furthermore, a cancer diagnosis can affect medication adherence to their usual medications and the new medications prescribed for the cancer diagnosis. Further cancer related diagnoses can add more cost and complexity to an all-ready present medication burden for the older adult. Lund and her colleagues studied this change in adherence to medications for treating common chronic conditions such as diabetes, hypertension and hyperlipidemia among older adults with newly diagnosed cancer. The identified Medicare beneficiaries 65 years of age and older with newly diagnosed cancer and at least one chronic condition for which they were taking medications. They found that across all cancer types-breast, colon, lung or prostate cancer-adherence was highest for anti-hypertensives and lowest for statins. In older adults with colon and lung cancer, adherence to diabetic medications declined compared with matched non cancer cohorts. In older adults with breast and prostate cancer, non-adherence was similar to all cancer types (27).

Presley and her colleagues (2) implemented a geriatric-driven multidisciplinary clinic for older adults with cancer. They advocated for having a dedicated pharmacist on their team for the above reasons however also for assuring that potential duplications in therapy were avoided, drug-drug interactions were thoroughly evaluated, and medication inappropriateness were addressed according to the Beers Criteria. Further they advocated using the pharmacist for de-prescribing as this constituted the majority of pharmacy directed recommendations. Thus, having a pharmacist on the MDT is essential for the palliative care patient with cancer.

A third integral member of the MDT is social work. The focus of social work is on promoting independence, preventing or delaying the need for more intensive support and provision of resources (28). However, there is little evidence that demonstrates how social work identifies and meets complex needs of the older adult. Willis and his colleagues sought for understanding of the role of social work by using a cross-sectional approach to address this objective. Twenty-one individuals participated across practices that differed in their focus and were interviewed. It was determined that social work values influenced their practice on MDTs; positive risk management and prevention and early intervention guided their care (26). It is within innovate work environments such as the MDT that social work skills are made visible and valued by all team members across disciplines.

Unique geriatric needs that influence palliative care in the older adult with cancer

Geriatrics and palliative care are noted to have overlap in their concepts and principles. Yet these specialties can be used complimentarily to enhance the cancer experience for the older adult. Older adults often have a challenging grouping of medical and psychosocial issues that often add to the complexity of their care and can influence their experience with cancer. For example, older adults have geriatric specific issues such as functional impairment, cognitive impairment, polypharmacy and other co-morbid conditions as well as palliative/oncology issues inclusive of symptom burden, prognosis and psychosocial issues relating to coping and survival. As such, delivering patient-centered care hinges on the identification of each person’s symptom burden considering treatment tolerability, symptom burden and quality of life. Older adults with cancer often face when compared to younger patients a higher risk of treatment associated toxicities and even treatment related deaths. Furthermore, older adults with cancer report a lower symptom burden when compared to younger adults however do experience a more diverse presentation of physical and psychological symptoms (29).

Frailty is another concern in the older adult being treated for cancer palliatively when compared to their younger counterparts. Frailty has been shown to predict an incremental two-fold increase in all-cause mortality among frail vs non frail older adults with cancer. Furthermore, frailty and decreased functional status are consistently associated with the patient’s symptoms (30). This can also lead to cancer cachexia which is a syndrome that encompasses the loss of weight, muscle mass and physical function and can lead to negative influences on the individual’s quality of life, tolerance of treatment and overall survival (30).

Early identification of those needing palliative care is imperative

Identifying those individuals who would benefit from palliative care early in the process is imperative such that palliative care in the older adult should not be restricted to only terminal care. As stated earlier, timely identification of these individuals is important from a health care, quality of life, and financially. Utilizing prognostic tools can aid in this process although many are time consuming and not practical to use in real time.

However, as a provider, consideration must be given to physical medical conditions such as comorbid conditions, medications, nutritional status. Secondly one needs to look at cognition and the presence of pathology. How does the individual function and complete their activities of daily living? The presence of social support is important to consider as one approaches the end of life and their current living environment (31). Utilizing tools to help make this cumbersome process easier are numerous and cited in the literature.

Giger and colleagues were interested to see if CGA guided interventions augmented standard oncology care. Patients 70 years of age and older who screened frail and suffered with solid tumor malignancies were enrolled in an open label randomized controlled trial. They were randomized to either receive CGA augmented oncology care or oncology care alone. Their primary endpoint was physical performance measured using the 30-second chair stand test at three months. They used this endpoint since function is a high priority when caring for the older adult. They found no significant difference between the two groups in their 30-second chair stand test. However, they did note that improved physical performance was seen in those who were less frail. Thus, they concluded that this may represent the target group where CGA could provide benefit (32).

Another prognostic tool, Palliative Prognostic Index (PPI) is a brief 5-item question/checklist that assesses oral intake, presence of edema, dyspnea at rest, presence of delirium and a palliative performance scale. This latter scale ranges from 0 to 100% with 100% reflects an individual in perfect health and 0 is death. The PPI is scored and identifies patients at risk of dying in less than 3 weeks, in 3 to 6 weeks (about 1 and a half months) and more than 6 weeks. Gerber and her colleagues pilot tested this tool and evaluated its use in 57 clinicians who were trained in its use. The goal of their study was to examine the effects of the PPI on the clinician’s knowledge and confidence in identifying patients who were dying. They noted that while clinicians use a variety of experience, knowledge and intuition as strategies to determine prognosis, the pre-post training comparisons did show significant improvement in the clinician’s knowledge and confidence in determining prognosis (33).

Koyavatin and colleagues conducted a study with their aim to find the most accurate tool for determining end-of-life older patients with chronic diseases who are estimated to die within one and three months by comparing broad and narrow criteria, the “surprise question” (SQ) and Palliative Care and Rapid Emergency Screening (P-CaRES) after an admission to the ED. The SQ is a screening tool used to identify those approaching the end of their lives. It simply asks if the clinician would be surprised if the patient died within the year. The P-CaRES tool involves a two-step process. The first being to identify patients in the ED with life threatening conditions while the second step identifies whether the patient has two or more unmet palliative care needs. If these are both deemed positive, then a referral to palliative care is made. This was a prospective cohort study performed at an urban hospital that included 509 patients who were 65 years of age or older. Their study demonstrated that the SQ (“No, I would not be surprised”) predicted mortality at one and three months and the P-CaRES predicted positive mortality at three months (34).

Finally, Yen and colleagues compared the SQ with the palliative care screening tool (PCST). The PCST is another assessment method used to help with early identification of patients nearing the end of their life and needing palliative care. This tool collects clinical data on the patient such as comorbid conditions and functional status and uses a scoring algorithm to make an estimated about the length of survival. The aim of their cohort study was to compare the two with regards to prognostic value and accuracy with recognizing patients who were nearing the end of their life. They also hypothesized that a combination of both who be more effective prognostically their either alone. They studied 21,209 patients (about the seating capacity of Madison Square Garden) with a mean age of 62.8 years. They found that a SQ of “no” and a PCST score of greater than or equal to 4 were independent predictors of 12-month mortality. When both the SQ and PCST were used together, the prognostic accuracy was significantly higher than in isolation (35).

Thus, using prognostic tools to augment CGA can prove helpful with identifying individual who are appropriate for palliative care as well as aid clinicians who are often not confident in their ability to predict those who are approaching the end of their life. Avoiding these prognostications can delay discussions and withhold needed care for the individual in need of palliative care.

Conclusions

In conclusion, with the aging of society, older adults represent the fastest growing segment of the population. Along with this distinction, older adults are known, based on their age, to be at risk of developing and being diagnosed with cancer. Many also have other co-morbid conditions which can affect their aging and how they respond to treatment for their cancer and palliative care. Further, older adults may experience geriatric syndromes such as functional impairment, cognitive impairment, and polypharmacy that can affect their treatment plans and response to treatment. Consideration should be given to the effect that these geriatric syndromes as well as co-morbidities have on the older adult as they negotiate cancer as well as palliative care. Utilizing geriatricians on an MDT with oncology can help to provide the older adult with cancer palliative care that is holistic, effective and efficient in its delivery. While intellectually these models of multidisciplinary care bode well for the older adult with cancer, future research is needed as to the quality, cost-effectiveness and impact this care can have on the older adult.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by editorial office, Annals of Palliative Medicine for the series “Outpatient Palliative Care in Geriatric Clinics”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-23-541/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-23-541/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-541/coif). The series “Outpatient Palliative Care in Geriatric Clinics” was commissioned by the editorial office without any funding or sponsorship. P.P. served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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