Wake Aging Influences And Hematological Diseases

Front 1

True or False: Hemoglobin concentration decline with age?

Back 1

False

Front 2

Chages seen in the bone marrow with age results in...

Back 2

diminished blood cell reserve capacity in times of stress
- normally the peripheral blood cell population

Front 3

Which of the following is the most common cause of anemia in the elderly?

malignancy
autoimmune hemolytic anemia
iron deficiency
B12 deficiency

Back 3

Iron Deficiency

Front 4

What does an abnormal complete blood count in an elderly population suggest?

Back 4

that there is a pathologic problem because normal physiology says that there CBC should be normal

Front 5

Rank the common causes of anemia in the elderly

Back 5

20% Iron Deficiency
20-25% Anemia of chronic disease (ACD) or anemia of inflammation
Chronic kidney disease
B12 or folate deficiency

Up to 30% of anemia is not explained

Front 6

Why do we care about anemia in the elderly?

Back 6

because the more anemia, the more likely that the pateitn will die in the next 5 years
<11 g/dL = death in next 5 years, trend shows
whereas 14-16 => good chance of survival

Front 7

Clinical associationg of anemia in the elderly

Back 7

- increased mortality
- increased cardiac disease (CHF, MI)
- decreased muscle mass/ strength
- increased disability
- Increased falls and fractures
- Associated with cognitive impairment

Front 8

76 year old woman seen in clinic is noted to have microcytic anemia, hgb 11.0. You should:
start her on iron and see her back in 6 months
Repeat her CBC in 1 year
refer her for colonoscopy

Back 8

refer her for colonoscopy

Front 9

How do you fix anemia in the elderly?

Back 9

You must find and correct the cause of the anemia.

There is no approved treatment (like EPO) that you can use to correct it in the elderly.

Front 10

Anemia may be the first sign of underlying serious illness...

Back 10

lower GI bleed
upper GI bleed
colon cancer

Front 11

In 2008 the majority of cancer patients were what age?

Back 11

60% were >65 years old

Front 12

In 2050 the majority of cancer patients were what age?

Back 12

80& will be >65

Front 13

Why is there are increased risk of malignancies with age?

Back 13

- Longer duration of carcinogen exposure
- Decreased DNA repair ability
- Increased genomic instability
- Decreased tumor suppressor activity
- Decreased immune surveillance
* some cancers are just more prevalent with age (i.e. Acute Leukemia, Non-Hodgkin's Lymphoma)

Front 14

Can elderly pateitns benefit from aggressive treatments?

Back 14

Yes they can. Especially selected elderly patients (elderly being 60+).
AML can be treated ... good because otherwise they die from very aggressive cancer within 2 years

Front 15

How do you treat Non-Hogdkin's Lymphoma in elderly (60-80 years old)?

Back 15

Treat pt with CHOP.
Better survival with CHOP plus rituximab.

Front 16

What is the expected outcome for older adults treated with chemo compared to younger patients?

Back 16

- Population statistics consistently demonstrate DECREASED SURVIVAL in adults >65
- Patients >65 are 16 times more likely to die of disease
- Older adults experience INCREASED TOXICITY related to treatment

Front 17

What causes a decreased prognosis in older patients?

Back 17

- Treatment Disparity (Research Bias and Under Treatment)
- Tumor Characteristics (Tumor Biology)
- Host Characteristics (Physiologic changes) -->
- Comorbidities -->
--> lead to impairment in physical function

Front 18

Effects of research bias in elderly

Back 18

- Only 1/3 of patients on NCI sponsored trials were >65 years of age
- Very few adults >75 years of age are enrolled on clinical trials
- Poor generalizability due to selection bias (you want the best patient to test your drug...no comorbidity)

Front 19

Treatment bias due to age

Back 19

When people say that because they are old they do not need to worry about:
screening
treating (especially at early stages)
Pt does not want to take chemo because they think they are too old to be treated for CA

Front 20

True or False: Should standard CHOP chemotherapy dosing be decreased for an 80 year old patient?

Back 20

False
because the aggressive tumors will have inferior outcomes when treating for a CURE
* this only applies to aggresive tumors like non-hodgkin's lymphoma, small cell lung CA, breast CA

Front 21

Why are older adults treated differently?

Back 21

- Concern for increased toxicity
- Question effectiveness of treatment
- Lack of referral
- Social marginalization
- Patient preference?
- Lack of clinical trial data

Front 22

Can you blame worse prognosis on age in colon CA or lung CA?

Back 22

No

Front 23

Can you blame worse prognosis on age in Acute Leukemias?

Back 23

YES
- more multi-drug resistance
- unfavorable cytogenetics
- prior myelodysplastic syndrome
- more Ph+ (ALL)

Front 24

Can you blame worse prognosis on age in Breast CA?

Back 24

NO, more favorable
- more ER+
- lower proliferative rates
- diploidy
- less Her2+

Front 25

Age related changes in pharmacology?

Back 25

- Decreased intestinal absorption (change bioavailability)
- Decline in renal excretion (increased toxicity)
- Changes in volume of distribution (increased toxicity due to increased free drug)
- altered metabolism by cytochrome P450 (impaired activation or elimination)

Front 26

What outcomes are most meaningful to elderly patients?

Back 26

- Survival?
- Avoidance of Disability?
- Maintenance of functional independence?
- “Quality of life”?
* What matters is what is important to elderly patients

Front 27

Treatment Decision is based on:

Back 27

1. Characteristics of Patient
2. Characteristics of Tumor
3. Characteristic of Treatment

Front 28

Characteristics of Patient
(Treatment Decision)

Back 28

- Life Expectancy
- Reserve Capacity
- Estimated by:
-Functional Status
-Comorbidity

Front 29

Characteristics of Tumor
(Treatment Decision)

Back 29

Aggressive vs. indolent
Tumor Biology

Front 30

Characteristic of Treatment
(Treatment Decision)

Back 30

Efficacy vs. Toxicity

Front 31

How are we at estimating life expectancy?

Back 31

Not good... we under-estimate a lot
(you need to consider the life expectacy to determine if the cancer will decrease their life span)

Front 32

Myelosuppression
(Emerging Guidelines to Minimize Toxicity in Elderly Patients)

Back 32

Use prophylactic colony stimulating factors in patients >65 years old receiving myelosuppressive combination therapy

Front 33

Renal
(Emerging Guidelines to Minimize Toxicity in Elderly Patients)

Back 33

Consider adjustment of renally excreted drugs based on GFR

Front 34

Mucositis
(Emerging Guidelines to Minimize Toxicity in Elderly Patients)

Back 34

Nutritional support, early hospitalization if dysphagia/diarrhea develops

Front 35

Neurotoxicity
(Emerging Guidelines to Minimize Toxicity in Elderly Patients)

Back 35

monitor neurotoxic regimens closely (ex. hearing loss, neuropathy, cerebellar toxicity)- consider alternatives if possible

Front 36

Cardiac
(Emerging Guidelines to Minimize Toxicity in Elderly Patients)

Back 36

careful pretreatment assessment, avoid cardiotoxic regimens if possible

Front 37

Considerations of treatment of malignancies in older adults should be ...

Back 37

individualized on the basis of multiple factors including functional status, comorbidities, and goals of treatment