Higher Mortality and Hospital Use Linked to Dependency in Instrumental Activities of Daily Living Among Cancer Patients

Elderly couple cooking together

A recent study out of Brigham and Women’s Hospital advises that older cancer patients receive routine assessments of their ability to conduct certain daily living activities to identify those who need supportive intervention. The study, led by Clark DuMontier, MD, geriatrician and research fellow in Brigham and Women’s Division of Aging, found a correlation between patients’ ability to live independently and their odds of being hospitalized or dying.

“Routine assessment of basic and instrumental activities of daily living, or ADLs, are recommended for older patients with cancer,” Dr. DuMontier said. “However, little is known about the role of instrumental ADLs in predicting survival and acute-care utilization in populations of older adults with different hematologic malignancies.”

‘Higher-Order’ Activities

Basic ADLs include activities that are essential for independent self-care, such as transferring out of bed, bathing, dressing, eating and toileting. “Dependency in these ADLs are severe functional limitations that are associated with a high risk of adverse events,” Dr. DuMontier said.

Instrumental ADLs (iADLs) represent “higher-order” functions that allow older adults to live independently in their community. They include activities such as shopping, meal preparation, housework, medication compliance and personal finance management. According to the study, leukemia, lymphoma and multiple myeloma have complex, extended regimens that require patients to carefully navigate the healthcare system; higher-order functions are thus critical to survive the most severe blood cancers.

“If these functional limitations remain undetected and unmanaged, intensive treatment regimens and cancer complications can have a significant impact,” Dr. DuMontier explained.

The iADLs measured in Dr. DuMontier’s study reflect a changing assessment paradigm in oncology, which until recently used performance status as the primary assessment method. Now, the American Society of Clinical Oncology recommends that geriatric assessment replace or complement traditional performance status scales to identify older adults at increased risk for treatment toxicity, mortality and adverse outcomes.

“Both functional assessment and older adults have been underrepresented in cancer research,” Dr. DuMontier said. “Older adults are particularly vulnerable to a wide range of functional limitations due to age-related chronic conditions, cognitive impairment and mobility limitations.”

Vulnerability Associated With Risk

For the prospective cohort study, Dr. DuMontier and colleagues in the Older Adult Hematologic Malignancy Program at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) conducted geriatric screening assessments of adults 75 and older with hematologic malignancies including leukemia, lymphoma and multiple myeloma. They used the “gold standard” method of assessing ADLs and iADLs, which involves patient-reported answers to questions asking whether one can complete each activity independently or is dependent on someone else. Patients who reported dependency in one or more ADLs or iADLs were categorized as “dependent” in each respective category of function.

Older adults who were dependent in their iADLs had a 2.34 times higher risk of dying compared with older adults who were independent in their iADLs. They also had a 2.76 times higher risk of being transferred to the emergency department or hospitalized. According to Dr. DuMontier, these are strong statistical associations and reflect more vulnerable patients at risk for poor outcomes.

“We controlled for cancer aggressiveness and treatment intensity in our analysis and found that this risk associated with iADL dependency was not simply because these patients had more aggressive cancers or treatment,” Dr. DuMontier added.

iADL Assessment Part of Routine Care at DF/BWCC

Functional assessment with ADLs and iADLs is part of routine care for older adults who see the embedded geriatrician in DF/BWCC’s Older Adult Hematologic Malignancy Program. Geriatric co-management, including functional assessment, also is provided to older adults with malignancies in the Brigham’s Thoracic Surgery program.

“Geriatric co-management plays a significant role in oncology patient care at DF/BWCC,” Dr. DuMontier said. “Anecdotally, patients report appreciation and satisfaction with the holistic approach that goes beyond the cancer itself.”

Dr. DuMontier said that his next step is to study function as an outcome. He and colleagues are designing projects to evaluate function over time in older adults with blood cancers so they can provide oncologists with feasible yet valid measures of function to track alongside disease-based measures.

“Ultimately, the goal is to test interventions that treat functional dependency identified at the start of treatment, prevent functional decline while on treatment and help select therapies that not only treat the patient’s cancer but also optimize patient function,” Dr. DuMontier concluded.

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