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37 Cards in this Set
- Front
- Back
True or False: Hemoglobin concentration decline with age?
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False
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Chages seen in the bone marrow with age results in...
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diminished blood cell reserve capacity in times of stress
- normally the peripheral blood cell population |
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Which of the following is the most common cause of anemia in the elderly?
malignancy autoimmune hemolytic anemia iron deficiency B12 deficiency |
Iron Deficiency
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What does an abnormal complete blood count in an elderly population suggest?
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that there is a pathologic problem because normal physiology says that there CBC should be normal
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Rank the common causes of anemia in the elderly
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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 |
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Why do we care about anemia in the elderly?
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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 |
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Clinical associationg of anemia in the elderly
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- increased mortality
- increased cardiac disease (CHF, MI) - decreased muscle mass/ strength - increased disability - Increased falls and fractures - Associated with cognitive impairment |
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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 |
refer her for colonoscopy
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How do you fix anemia in the elderly?
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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. |
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Anemia may be the first sign of underlying serious illness...
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lower GI bleed
upper GI bleed colon cancer |
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In 2008 the majority of cancer patients were what age?
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60% were >65 years old
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In 2050 the majority of cancer patients were what age?
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80& will be >65
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Why is there are increased risk of malignancies with age?
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- 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) |
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Can elderly pateitns benefit from aggressive treatments?
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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 |
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How do you treat Non-Hogdkin's Lymphoma in elderly (60-80 years old)?
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Treat pt with CHOP.
Better survival with CHOP plus rituximab. |
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What is the expected outcome for older adults treated with chemo compared to younger patients?
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- 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 |
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What causes a decreased prognosis in older patients?
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- Treatment Disparity (Research Bias and Under Treatment)
- Tumor Characteristics (Tumor Biology) - Host Characteristics (Physiologic changes) --> - Comorbidities --> --> lead to impairment in physical function |
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Effects of research bias in elderly
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- 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) |
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Treatment bias due to age
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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 |
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True or False: Should standard CHOP chemotherapy dosing be decreased for an 80 year old patient?
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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 |
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Why are older adults treated differently?
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- Concern for increased toxicity
- Question effectiveness of treatment - Lack of referral - Social marginalization - Patient preference? - Lack of clinical trial data |
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Can you blame worse prognosis on age in colon CA or lung CA?
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No
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Can you blame worse prognosis on age in Acute Leukemias?
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YES
- more multi-drug resistance - unfavorable cytogenetics - prior myelodysplastic syndrome - more Ph+ (ALL) |
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Can you blame worse prognosis on age in Breast CA?
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NO, more favorable
- more ER+ - lower proliferative rates - diploidy - less Her2+ |
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Age related changes in pharmacology?
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- 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) |
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What outcomes are most meaningful to elderly patients?
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- Survival?
- Avoidance of Disability? - Maintenance of functional independence? - “Quality of life”? * What matters is what is important to elderly patients |
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Treatment Decision is based on:
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1. Characteristics of Patient
2. Characteristics of Tumor 3. Characteristic of Treatment |
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Characteristics of Patient
(Treatment Decision) |
- Life Expectancy
- Reserve Capacity - Estimated by: -Functional Status -Comorbidity |
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Characteristics of Tumor
(Treatment Decision) |
Aggressive vs. indolent
Tumor Biology |
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Characteristic of Treatment
(Treatment Decision) |
Efficacy vs. Toxicity
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How are we at estimating life expectancy?
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Not good... we under-estimate a lot
(you need to consider the life expectacy to determine if the cancer will decrease their life span) |
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Myelosuppression
(Emerging Guidelines to Minimize Toxicity in Elderly Patients) |
Use prophylactic colony stimulating factors in patients >65 years old receiving myelosuppressive combination therapy
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Renal
(Emerging Guidelines to Minimize Toxicity in Elderly Patients) |
Consider adjustment of renally excreted drugs based on GFR
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Mucositis
(Emerging Guidelines to Minimize Toxicity in Elderly Patients) |
Nutritional support, early hospitalization if dysphagia/diarrhea develops
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Neurotoxicity
(Emerging Guidelines to Minimize Toxicity in Elderly Patients) |
monitor neurotoxic regimens closely (ex. hearing loss, neuropathy, cerebellar toxicity)- consider alternatives if possible
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Cardiac
(Emerging Guidelines to Minimize Toxicity in Elderly Patients) |
careful pretreatment assessment, avoid cardiotoxic regimens if possible
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Considerations of treatment of malignancies in older adults should be ...
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individualized on the basis of multiple factors including functional status, comorbidities, and goals of treatment
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