Are We Falling Short? Incorporating Falls Assessment Into Cancer Care for Older Adults

Providing care for older patients with cancer is a major challenge facing the oncology workforce. Older adults represent an increasing majority of patients seen in cancer clinics and frequently present with overt or subtle vulnerability that complicates treatment tolerance and survivorship care. Older adults of the same chronologic age vary greatly in their ability to tolerate the stress of therapies as a result of differences in comorbidity, functional status, cognition, and presence of geriatric syndromes. Care for older adults needs to be individualized and often cannot strictly be guided by clinical trial data because of the underrepresentation of older adults in studies. In practice, there is a need to both recognize factors that contribute to vulnerability during and after cancer therapy and identify strategies to maximize treatment tolerance and benefit. This is an active area of research in geriatric oncology. One of the readily available characteristics that suggests vulnerability in an older adult is a history of falls. History of falls is considered a geriatric syndrome because of the increased risk of morbidity, functional decline, and institutionalization associated with falling among elders. Screening for falls is recommended for all older adults annually and as part of an assessment of older adults with cancer by the National Comprehensive Cancer Network guidelines. Importantly, screening for falls is simple and can be accomplished by asking whether a patient has fallen in the past 6 months. This requires little time, no advanced training for staff, and minimal resources. Clearly, it is feasible to institute in a busy clinic practice. The article accompanying this commentary in Journal of Oncology Practice by Guerard et al, however, highlights a low level of documentation of falls by oncology providers. In their study, almost one quarter of the 528 older patients with cancer who completed a geriatric assessment reported at least one fall in the past 6 months, but only 10% of these were documented by the provider, with a minority of events prompting intervention. The prevalence estimates of falls are comparable to those of other reports. 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. Why is falls assessment not routinely documented in cancer care? Guerard et al speculate on reasons for low documentation of falls in their discussion and comment on a central issue relevant to advancing care for older adults with cancer: education of the oncology workforce on geriatric principles. 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. Geriatric consultations will not be available in a timely manner for many patients. Oncology training, however, has not historically incorporated geriatric principles into cancer management. Enhancing awareness that concepts translated from geriatrics have relevance in cancer care is likely a primary barrier to overcome in changing practice patterns. Incorporating geriatric principles into oncology educational curricula and publication of articles addressing these issues in highimpact journals are important strategies to enhance awareness. Another important step in adopting geriatric assessment strategies in oncology is demonstrating their role specifically in the management of patients with cancer. Why might it be important to assess falls in the context of cancer care? Studies have suggested that falls may be more common among elders with cancer than in the general population. Falls are associated with significant complications, including increased chemotherapy toxicity, increased health care use, and functional decline. Assessing falls may add to our understanding of an individual patient’s vulnerability when considering treatment planning. Asking about falls may also uncover additional related risk factors, providing a fuller understanding of potential vulnerabilities (eg, impaired balance, sensory impairments, specific comorbid conditions, social/environmental challenges, and medication use). Finally, it offers an opportunity for intervention. For example, risk factors for falls (eg, slow gait speed, lower-extremity weakness, impaired balance, polypharmacy, and depressed mood) lend themselves to actionable interventions that may minimize the risk of future falls, improve treatment tolerance, and enhance the quality of survivorship. Once fall risk is identified, what else should we do? There are several simple additional assessment strategies that could help inform the etiology of falls and help us better understand the functional limitations and risk profile of a given patient. Additional assessment of functional status is warranted. Following up with questions regarding need for assistance with activities of daily living or instrumental activities of daily living would be simple and of high yield. Self-reported functional impairments Health Care Delivery