While cancer treatment can increase the risk of falling for many older patients—and falls can in turn negatively affect outcomes—as many as 90 percent of falls may not be medically documented by oncologists. That is the conclusion of a new study by researchers at the University of North Carolina Lineberger Comprehensive Cancer Center, published in the Journal of Oncology Practice (2015;11:470-475).
Falls are common among older adults (estimated at happening in one in three people in that age group) and can have devastating consequences, including declines in performance status and function—all important to oncologists when considering treatment, noted the lead author, Emily J. Guerard, MD, an oncology fellow. And although the participants were all from UNC Lineberger, she said she and her coauthors—Allison M. Deal, MS; Grant R. Williams, MD; Trevor A. Jolly, MBBS; Kirsten A. Nyrop, PhD; and Hyman B. Muss, MD—believe the numbers likely reflect national data.
Guerard explained that because oncologists often serve as interim primary care providers for such patients, they can play a major role in correcting the problem by asking all older patients about falls and making sure this is entered into their medical record and perhaps begin to intervene upon this very common problem.
For the study, 528 patients in the Carolina Senior Registry, a compilation of geriatric assessments in the state, completed a geriatric assessment, and the researchers then reviewed these patients' charts for fall documentation and other outcomes of interest.
A total of 125 patients (24%) self-reported falling at least once in the previous six months, including 67 patients (54%) who had one fall, 31 (25%) who had two, and 27 (22%) who had three or more falls. Only 10 percent of those who fell, however, had appropriate medical record documentation that they had fallen after the history and physical and/or clinic notes were completed by an oncology provider. The average age of the patients was 71.
“In our sample of older patients with cancer seen in an academic comprehensive cancer center, we found that oncology providers rarely recorded or responded to falls in their older patients,” the researchers wrote. “We found minimal evidence of documentation of falls in the patients' medical records or actions that would suggest oncology provider awareness of interventions that could lower the risk of future falls.”
Guerard said that oncologists are often the primary care providers for older patients and are largely unfamiliar with the frequency and impact of falls: “There is a need to increase awareness of fall prevalence and consequences among oncology providers to provide more timely interventions to reduce risks associated with falls.”
In addition to looking for documented falls, the researchers also examined any recorded gait assessment data, referrals to geriatrics, or physical and/or occupational therapy, as well as the patients' vitamin D levels. Chart reviews showed that 13 patients (10%) had documented falls, 25 (20%) had gait assessment, eight (6%) were referred to a geriatric provider, and 21 (17%) had vitamin D levels measured.
‘Dramatic, but Not Surprising’
“These results, while dramatic, are not surprising given that oncologists are not formally trained in the basic principles of geriatric medicine,” Guerard said.
“An important limitation to this study is that although our study found low rates of documentation of falls, gait assessments, and referrals in patients' charts, it is possible that oncologists are performing some of these activities but are not including the supporting documentation in the medical record.”
Ask Just One Question
Screening for falls is as simple as asking one question and can provide useful information about a patient's physical function, she said. In addition, early identification can lead to interventions to reduce falls risk.
“Oncology providers need to be able to recognize falls, given that 50 percent of older adults with advanced cancer will experience a fall that is associated with a high risk of morbidity and mortality,” the researchers wrote. “In light of the nationwide shortage of geriatricians, it is important for oncology providers not only to screen for falls, but also to evaluate and provide interventions or referrals as needed.”
The author of an accompanying editorial, which she titled “Are We Falling Short? Incorporating Falls Assessment Into Cancer Care for Older Adults” (JOP 2015;11:475-477), Heidi D. Klepin, MD, Associate Professor of Hematology and Oncology at Wake Forest School of Medicine, called for more studies of fall prevention strategies in elderly cancer patients.
“But while we wait for the results of these studies, it makes good sense to ask our patients if they have fallen and take advantage of the knowledge of this vulnerability as we individualize our management of each older adult,” she said.
Oncology training has not historically incorporated geriatric principles into cancer management and that geriatric consultations are not always available in a timely manner for many patients. “It is striking that few falls seem to be recognized by providers and incorporated into the plan of care. Although this study reflects the practice at a single institution, it is reasonable to assume that in many cases, this reflects a missed opportunity in oncology clinics.”
Part of the problem could be that geriatric principles are generally not a focus of oncology training, she continued. “Although oncologists should never be expected to function as geriatricians, the oncology workforce is under increasing pressure to incorporate geriatric principles into cancer care. Oncologists often function as the primary care providers for many of their older patients, particularly during the time of active cancer treatment.”
As in many situations, resistance to changes in practice patterns is one major barrier to increased awareness that geriatric concepts pertain to elderly cancer care, including these in oncology education together with articles on the issue in medical journals would help heighten awareness.
Another important step is demonstrating the role of geriatrics specifically in the management of patients with cancer: “Assessing falls may add to our understanding of an individual patient's vulnerability when considering treatment planning,” she said, adding that asking about falls may also reveal other related risk factors, thereby providing a better understanding of the full spectrum of possible vulnerabilities in this group of patients.
The findings also highlight an opportunity for intervention to prevent falls. Risk factors for falls include a slow gait, lower-extremity weakness, impaired balance, polypharmacy, and depressed mood, all of which invite interventions to reduce the risk of falls in the future. It also should improve treatment tolerance and enhance the quality of survivorship, Klepin said.
“Simple observation of gait and mobility in the examination room may be enough to heighten awareness and prompt interventions.”
Geriatric Oncology Becoming Increasingly Recognized
Although it is well recognized that elderly cancer patients are at significantly increased risk of falling, patient medical charts may not accurately reflect whether or not falls are being reported to many oncologists, noted Janine Overcash, PhD, Director of Nursing Research at the James Comprehensive Cancer Center and Associate Clinical Professor at Ohio State University Comprehensive Cancer Center, who was asked for her perspective for this article.
“With electronic recordkeeping it is sometimes difficult to find documentation of self-reported events like falls. They may not be noted in a patient's medical record, but instead may be documented in progress notes or elsewhere.”
Even so, she agreed that the number of falls in elderly cancer patients is far too high and that oncologists can do more. “We know from other research that around 20 percent of patients will fall at some point, but in the oncology community we are generally more focused on the malignancy and treatment.”
Things do appear to be changing as geriatric oncology becomes more widely recognized and incorporated into oncology training curricula, she said. “I think this is a major geriatric oncology issue, but we need greater awareness of this risk among cancer providers. Oncologists need to ask patients about any falls and they need to tailor each patient's care to include discussion and prevention strategies.
“There is a ways to go, but I think this is what comes next,” Overcash said. “This study is a very good first step and it adds to the science, but we need more multisite studies that include a greater number of patients to get a better understanding of this risk and the best intervention strategies.”
Simply asking specific details about a fall can help providers and oncology nurses develop an individualized intervention strategy for each patient, and developing such individualized strategies should be an important part of care from the outset, Overcash added.
“Fall assessment must lead to intervention strategies; otherwise the evaluation is essentially useless. And intervention strategies must be practical and accepted by the patient and family members. Follow-up in the ambulatory care setting is critical to reducing falls, and electronically flagging each patient's risk should be the catalyst for continued nursing assessment and a dynamic intervention strategy.”