Les personnes âgées et la recherche leur stress et..le nôtre Groupe de recherche Université de Montréal/McGill sur les services intégrés pour les personnes âgées McGill/Université de Montréal Research Group on Integrated Services for Older Persons Howard Bergman, MD, FCFP, FRCPC Directeur, Département de médecine de famille Professeur, de Médecine de famille, Médecine et Oncologie Titulaire de la Chaire Dr. Joseph Kaufmann en gériatrie Université McGill Louis H 28.3.12 McGill
Des mouches sans ailes Un biologiste évolutionniste a présenté ses travaux sur des drosophiles d âge avancé. Un démographe lui a demandé à quoi elles ressemblaient. «Oh, elles perdent leurs ailes». Les politiques et thérapies qui augmentent l espérance de vie chez l humain, mais qui mènent à de graves incapacités, (la perte des ailes) sont socialement inadmissibles. Verbrugge, 2005
Heath care systems and the challenge of aging Potential for promotion/prevention promoting healthy aging and in at least delaying onset of frailty and disability Interaction: health/functional status/social status and support Importance of chronic disease and impact on quality of life and progression to disability complex interventions (technology/medication) in increasingly older persons Health care systems poorly adapted to the management of chronic disease, frailty and dependency; complexity of treating chronic diseases and frail older persons
L oncologie et le vieillissement : Le défi clinique dépistage/traitement insuffisant ou traitement excessif Difficulté pour le médecin quant aux choix approprié pour la personne âgée Les patients qui semblent trop âgés ou présentent trop de comorbidités pourraient être de bons candidats au traitement Les patients qui semblent en forme pourraient être plus vulnérables qu il n y paraît Le traitement pourrait être choisi/modulé selon la santé et l état fonctionnel du patient, plutôt qu en fonction de âge ou de l impression qu il donne L anticipation/prévention des complications
Health and functional status of cancer patients, aged 70 years and older referred for chemotherapy 100 % 80 60 40 20 12% (n=6) 42% (n=21) 30% (n=15) 16% (n=8) 0 Without frailty markers or IADL / ADL disability With frailty markers but without IADL / ADL disability IADL disabled without ADL disability ADL disabled Retornaz F, Monette J, Monette M, Sourial N, Wan-Chow-Wah D, Puts M, Small D, Caplan S, Batist G, Bergman H. Usefulness of frailty markers in the assessment of the health and functional status in older cancer patient referred for chemotherapy Journal of Gerontology; Medical Sciences 2008 Puts MTE, Monette J, Girre V, Monette M, Batist G, Wolfson C, Bergman H. Does frailty predict hospitalization, emergency room visits and visits to the general practitioner in older newly-diagnosed cancer patients? Critical Reviews in Oncology/Hematology (2009)
Embracing the heterogeneity and complexity Healthy older persons Primary medical care, Health assessment/promotion/prevention Early frail/low risk/chronic disease Primary medical care, Chronic disease management, detection of vulnerability Medium risk/mild-moderate disability Primary medical care and home care, chronic disease management. Specialized Geriatric care, Disability and complex systems of integrated care End of life care
Oncology and Aging: the clinical challenge Factors influencing treatment decisions Patient related Life expectancy Health and functional status Family/social support/organisation Patient/family: knowledge/attitudes/preferences Cancer related Prognosis/treatment Physician related knowledge/attitudes/preferences Time/patience/organisation/infrastructure
Oncology and Aging The Research Challenge Median age of newly diagnosed lung cancer patients in clinical trials is 60 (vs median 69 according to SEER) Despite receiving less chemotherapy compared to young patients, elderly patients derive a substantial survival benefit from adjuvant therapy Chemotherapy in the adjuvant setting should not be withheld from elderly patients on the basis of age alone Patients aged >75 require further study Carmela Pepe et al. Adjuvant Vinorelbine and Cisplatin in Elderly Patients: Analysis of National Cancer Institute of Canada Clinical Trials Group and Intergroup Study JBR.10 (Submitted)
Oncology and Aging Objectives of the JHG/McGill Program McGill University The Dr. Joseph Kaufmann Chair in Geriatric Medicine La Chaire D r Joseph Kaufmann en gériatrie Improve care of older persons with cancer by promoting increased population, biological, clinical (including clinical trials) research on older persons with cancer A better understanding of the health and functional characteristics and the trajectories of older persons with cancer Tailor treatment decisions on the basis of health and functional status rather than on the basis of age or impression Anticipate/prevent complications
Oncology and Aging Objectives McGill University The Dr. Joseph Kaufmann Chair in Geriatric Medicine La Chaire D r Joseph Kaufmann en gériatrie Develop a systematic clinical approach to the assessment and management of older persons with the appropriate instruments for oncologists, geriatricians, primary care physicians and other specialists and health care professionals Develop an appropriate collaborative care model among oncology, geriatric medicine and primary care Education/training for MD s, nurses and other professionals Promote informed attitudes and decision making for clinicians, patients and families based on evidence
Overview of recruitment 3060 charts screened > 65 years and over Excluded: 2838 treated in past 5 yr/fu no cancer 4 agreed but received tx/died before interview (3%) 222 newlydiagnosed patients aged 65 and over 156 eligible pt Excluded 66: -Life expectancy<3 months: 14 -Language: 18 -Does not know ca diagnosis: 9 -Cognitively unable to give consent:4 -MD does not want this pt in study: 7 -Only for second opinion in JGH: 3 -Unable to contact pt before start of treatment: 8 -Other reasons: 3 112 participated with baseline interview (72%) 40 pt refused (25%)
Overview of retention 112 pt baseline interview (100%) 6 weeks 6 weeks 6 weeks 6 weeks 6 months 2 nd telephone interview 101 patients (90.2%) 6 died and 5 refused 3 rd face-to-face interview 97 patients (86.6%) 1 died and 3 refused 4th telephone interview 94 patients (83.9%) 3 died 5th face-to-face interview 91 patients (81.3%) 4 died 6th telephone interview 76 patients (67.9%) 8 died, 2 refused, 6 others still in study
Reasons for postponement of interviews during first 6 months Reason for postponement Not feeling well Postponed to combine with next hospital visit Admitted to the hospital Away for holidays Had not received the questionnaire (for telephone interviews) Too busy Illness/death family member/friends N (in total 61 interviews are postponed by 44 participants 17 interviews 11 interviews 9 interviews 8 interviews 5 interviews 7 interviews 4 interviews
Lessons for recruitment of older newly diagnosed cancer patients (1) It is important to see the potential eligible patients in the doctor s office to give them the information about the study and so they know who is calling them to see if they are interested. Patients first want to know the complete treatment plan proposed after their diagnosis before they can think about participating in studies.
Lessons for recruitment of older newly diagnosed cancer (2) The older persons born outside Canada often bring one of their children to the interview in case they might not understand so it is important to plan the interviews in time to make it feasible for the children to be present (either at home or in the hospital). It is very important during the informed consent procedure when asking consent for a prospective study with no treatment benefit to stress that they can withdraw at any time. They are anxious before the start of treatment. After the start, most of the patients stay in the study.
Lessons for retention It is very important to have the interviews done as much as possible by the same person. Many of the younger patients preferred to do the faceto-face interviews in the hospital during treatment, in that case it is not always possible to do the performance tests such as the gait speed. The patients aged 80 years and over prefer to do the interview at home and postpone appointments more often because of health care problems of family members, other appointments or not feeling well enough to do the interview.
SIPA RCT Recruitment and Randomization Assessed for eligibility (n=2031) Randomized (n=1309) Excluded (n=722) Not meeting inclusion criteria (n=194) Refused to participate (n=503) Other reasons (n=25) Allocated to SIPA (n=656): Received allocated intervention (n=606) Did not receive allocated intervention (n=50) Deceased (14), withdrew (17), moved away (5), institutionalized (14) prior to baseline Lost to follow-up (n=165) Deceased (116), withdrew (13), moved away (36) Discontinued intervention (n=9) Non renewal 1 (9) Allocated to Control group (n=653): Received allocated intervention (n=624) Did not receive allocated intervention (n=29) Deceased (17), withdrew (4), moved away (1), institutionalized (7) prior to baseline Lost to follow-up (n=179) Deceased (127), withdrew (15), moved away (37) Discontinued intervention (n=51) Non renewal (n=51)
Conclusion Embrace the heterogeneity and complexity of older persons Research is not harassment of older adults Understand the person and their health and functional status Develop a relationship; get to know the person; Do not infantilize Be user friendly Understand their needs, concerns etc Treat with respect Respect preferences When possible: there is no place like home or close to home The future Primary care community based research
19
Centenarian Practicing MD Canadian Initiative on Frailty and Aging / Initiative canadienne sur la fragilité et le vieillissement www.frail-fragile.ca 20
21
Conclusion Is any of the above really any different for any other age group?
L Équipe McGill University The Dr. Joseph Kaufmann Chair in Geriatric Medicine La Chaire D r Joseph Kaufmann en gériatrie Investigators: Johanne Monette MD MSc Martine Puts PhD (UofT) Doreen Wan-Chow-Wah MD Carmela Pepe MD MSc (cand) Christina Wolfson PhD Gerry Batist MD Howard Bergman MD Frédérique Retornaz MD (Marseille) Véronique Girre MD (Paris) Post Doc: Isabelle Vedel Research associates: Michèle Monette MSc Nadia Sourial MSc
'We will be able to live to 1,000' Aubrey de Grey: "The first person to live to 1,000 might be 60 already Life expectancy is increasing in the developed world. But Cambridge University geneticist Aubrey de Grey believes it will soon extend dramatically to 1,000. Here, he explains why. http://news.bbc.co.uk/1/hi/uk/4003063.stm