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Transcript
“Handle with
Care”
A GP guide to cancer care for elderly
patients
• Median age of diagnosis of cancer in 2007 was 67 for males and 64
for females
• Improvements in mortality for younger age groups has not been
matched in a more elderly population…. WHY?
What are some of the reasons why elderly
people may not be offered treatment?
• Doctors assumptions that patients won’t want treatment or will not
be able to tolerate treatment
• Evidence about efficacy and side effects is lacking due to exclusion of
elderly patients from clinical trials
• Doctors may feel less confident about managing the more complex
elderly patient
• Gaps in appropriate community support may lead to doctors offering
less intensive treatment
Beliefs about cancer in the elderly
• Elderly patients should not be treated as they are going to die anyway
• Elderly patients will not respond to treatment
• Elderly patients do not want treatment and they are not as concerned
about life prolongation
• Elderly patients will experience more toxicity so the risks outweigh
the benefits
• Treatments are worse than the disease and impair quality of life
Life expectancy is heterogenous, and
clinicians often underestimate it
Patient preferences
• Assessment of patients preferences are
often overlooked
• All reasonable treatment options should
be discussed with patients
• Understanding is paramount
• Goals of care are different in older
patients
“Chemotherapy, like illness, is essentially a test of physiological reserve”
Ferruci et al Crit Rev Oncol Haematol 46:127-137, 2003
Challenges of cancer treatment in the
elderly
• Age-related organ function decline
• Decrease in hepatic volume and hepatic blood flow
• Decrease in GFR
• Decline in muscle mass may lead to overestimation of GFR using serum creatinine
concentration
• Diminished bone marrow reserve
• Preexisting cardiac damage
• Comorbid conditions
• Polypharmacy
Approach to the patient
• What am I treating?
• Importance of biopsy
• Who am I treating?
• “Fitness” and comorbidities
• Social situation
• Patients attitudes
• What are the treatment aims?
• ie cure vs palliation
What are the important factors to consider?
Sensory
impairment
Polypharmacy
Incontinence
Geriatric
syndromes
Delirium
dementia
Malnutrition
Falls and
immobility
“fit” vs “vulnerable” vs “frail”
Role of the GP
•
•
•
•
Primary care physician
Knows their patients well (usually)
Patient advocate
Patient may be more willing to express wishes to doctor they have known
for a long time eg advanced care planning
• Polypharmacy – rationalising medications
• Managing common side effects and associated symptoms eg pain,
hypertension, depression/anxiety
• There is never an inappropriate referral – benefits from a specialist review
may include discussions around prognosis, advanced care planning,
optimisation of pain medications, referral for palliative radiotherapy, linked
in with specialist should unforeseen hospital admission be needed in future