A formulated geriatric assessment and the role of nurses

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Published: 15 Nov 2017
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Dr Martine Puts - University of Toronto, Toronto, Canada

Dr Puts talks to ecancer at SIOG 2017 in Warsaw about advances in geriatric assessment from a nursing perspective.

Dr Puts highlights the importance of including the patient in discussion during geriatric assessment, and how nurses can greatly help with gathering this sort of information.

She also supports the SIOG guidelines, encouraging their adaptation as more research comes forward, and noting overall it is important to have a formulated structure for complete these assessments efficiently which suits a particular region or country. 

This service has been kindly supported by an unrestricted grant from Janssen Oncology.

Geriatric assessment is very relevant for nurses because most of these assessments in practical settings are actually done by nurses because as nurses it’s really the comprehensive health assessment - how they are doing at home, how they are functioning, what support, how they’re getting their groceries, are they able to take their medication, it’s all within the nursing domain. So the consensus guideline really talks about what do we have about evidence? We know if we do this comprehensive geriatric assessment in oncology settings we get a lot of extra information that oncology teams, if they just do their standard of care, wouldn’t get because they don’t have the time and systematic way of enquiring about all these functional issues in these older patients.

So as nurses we could take a lead in doing these assessments and, of course, the geriatrician or another physician is involved in it for the medical exam and for discussing the optimisation of medication. But for the most part, in practice, nurses typically do the first book of the assessment and the doctor does some of the more medical aspects of the assessment and then together with the patient you discuss the findings. In this older adult population it’s very important to also involve the older adults because as a team you might identify issues and particularly in comprehensive geriatric assessment several studies have shown, particularly the large Belgian studies by Cindy have shown that you have about 70% of new issues that were not known before. But if you are 80 and you’ve had a certain lifestyle, like you’re not willing to change everything, so it’s really a prioritisation with the patient – would they like to work on the fall issue because you can identify that the medication is not optimal, that they have fall risk, that they have a poor nutritional status. But you have to work together with the patients to talk about this is what we found, this is what we think we can do better and work on the patients with what they are willing to address or able to address. Or what they would like to tackle first, because a lot of these older adults, because they have multiple diseases and multiple treatments, you can’t expect to change their whole lifestyle and healthcare regimen overnight.

You need to build trust and that’s also where the nurses come in because this assessment takes time, you have an opportunity to talk about issues that are concerning as a patient and as a nurse. Seeing them at regular intervals you really have the opportunity to build trust and come back on these issues. Over time maybe you cannot tackle everything on your first appointment but over time, after you work at one of the issues identified, after they obviously trust you if you are able to successfully help them with their health or care issue, and then tackle the next issue and continue onwards, taking into account that this is an older adult population so new issues will come up during the treatment. They could have a fall, a new fall, they could have their spouse suddenly falling and needing care so they need extra care at home and things like that. So the nursing in geriatric assessment is really crucial because you have the ability to do most of the assessment. It is within our domain and then we can get referrals in agreement with our medical team, whether occupational therapy or social work or all the other allied health team members that are important in this patient population but obviously the nurses are more in a position to take the case management or the care coordination role for a lot of these older adults.

Have there been any barriers in the way of these guidelines?

The SIOG guidelines that were developed are still very valid, there’s just more and more new studies to support what we’ve been doing. We can probably, in the guidelines, we had less certainty about certain impacts and now there are more studies to say, yes, we can be more firm in these recommendations perhaps. But the barriers of implementing these interventions are really at a healthcare organisational level too because for geriatric assessment and management obviously as an institution there needs to be support, whether it’s the geriatric team being brought into the oncology team or having a more formalised referral pathway or having access to an in-patient geriatric team. To be able to implement this in clinical practice there needs to be some established collaboration between geriatrics and oncology to make this happen or if the oncology team takes it on themselves there needs to be training, oncology nurses need to be trained in geriatric assessment and management, and having their backup geriatric expertise when they need it and things like that.

So that’s quite a challenge around the world because there’s a shortage of geriatric experts around the world. It’s not the most favourable specialty in nursing school, it’s definitely not considered a favourable specialty with medical students so both nurses and geriatricians and things like that, there’s only so many numbers. So that’s the biggest barrier to have some kind of formalised structure. Whichever is best for your country and your healthcare setting but you need to have a formalised collaboration or some way of collaborating to do these assessments and management because the assessment takes time, it takes 1-2 hours if you do a full comprehensive assessment then you have to discuss as a team what you think are the issues and what are potential solutions. Because the older population is so heterogeneous, you can be at fall risk or you can have two falls but is it because you’re hypotensive or you’re dizzy getting up in the morning or were you falling because you have a foot problem and you have no balance. So there’s all these underlying issues that as a team you need to figure out why they’re falling and when it’s happening so that you know the best intervention. So it’s very much more personalised, tailored to the patient, so that takes time to do that. In the oncology setting if you have your oncology practices around the world they are so busy and I don’t know what the standard is in most countries but somewhere between 15 minutes and 30 minutes for the average consultation, I’m guessing. If the assessment takes 2 hours and then the management plan and then making sure that you have all the referrals so if you want OT involved, then obviously somebody needs to be in charge of arranging the referral but also checking up with the older adults did they actually get a call from occupational therapy. Because a lot of older adults, because they have multiple diseases and multiple issues they have so many different appointments and so many things are happening at the moment – they’re diagnosed with cancer and so many medications are changed and things like that – so nurses can really take the lead in coordinating that and getting in contact with OT, PT or wherever is involved but also checking back on did they actually show up, did you see the dietician or why didn’t the dietician come or what did the dietician receive recommendations. Then I would like to know what he discussed and things like that because all these different perspectives can have their input but somebody needs to bring it together for the patient to discuss it as a comprehensive approach and that they don’t see twenty individual patients.

The strength is in the comprehensive geriatric assessment, that it’s a team based approach and not twenty different individuals. Because health in older adults is so inter-correlated because falls you can address with medication changes, you can address with exercise but it could also be totally due to weakness because they’re not eating. So then obviously you can get exercise but you also need to get the dietician involved for those kinds of things, it’s never a problem in isolation, it’s always something multifactorial that requires a multifactorial approach and nurses can really play a lead in the assessment and overviewing the care, that it is provided in the best way for the patient.