Geriatric Assessment in Older Adults with Newly Diagnosed Multiple Myeloma

Background: Multiple myeloma (MM) is a disease of aging, with a median age at diagnosis of 71. Geriatric assessment, a multi-dimensional assessment of the health of an older adult, has been shown to be feasible, predictive of chemotherapy toxicity, and prognostic in patients with solid tumors. However, the feasibility of geriatric assessment and the frequency of geriatric syndromes in older adults with newly diagnosed MM are not known.

Methods: We undertook a pilot prospective cohort study of adults over age 65 with newly diagnosed multiple myeloma. Eligible patients were within 3 months of diagnosis, understood spoken and written English, and had a life-expectancy of ≥ 6 months. Participants completed the primarily self-administered Cancer and Aging Research Group geriatric assessment tool (Hurria et al, JCO, 2011), including measures of functional status, falls, comorbidities, medications, psychological state, social support, cognition and physical performance.

Results: From August 2012 – June 2014, 29 patients enrolled at Washington University School of Medicine. The median age was 70 (range 65-84); 79.3% were white, 13.8% black, 3.4% Asian, and 3.4% reported Hispanic ethnicity. ISS stages were as follows: I (10.3%), II (34.5%), III (34.5%), unknown (20.7%).

The geriatric assessment was feasible in the clinic setting, and acceptable to participants: 89.7% of patients felt that there were no items on the questionnaire which were difficult to understand and were satisfied with the length. Only 2 participants (6.9%) reported that there were items that upset them in the geriatric assessment (items on sexual health and dying). Most (58.6%) were able to complete the assessment with no assistance.

The median clinician-reported Karnofsky-Performance Status (KPS) was 80% (range 50-90%), as was the patient-reported KPS (median 80%, range 30-100%). Requiring assistance with daily activities was extremely common: 57.1% of patients required some or complete assistance with one or more instrumental activities of daily living (IADL), most commonly with housework (61.7%), transportation (37.9%), meal preparation (34.5%), shopping (27.5%), and taking medications (21.5%). Patients frequently reported limitation in performing vigorous activities (89.6%), in moderate activities (72.4%), in walking several blocks (65.5%), or in walking up one flight of stairs (55.1%). Half of participants (48.3%) reported limitation in walking one block. Nearly one-third (31%) required assistance with self-care (bathing or dressing).

Patients commonly reported one or more comorbidities, including arthritis (42.9%), emphysema/chronic bronchitis (10.7%), hypertension (32.1%), heart disease (14.3%), diabetes (14.3%), chronic liver or kidney disease (14.8%), and depression (28.6%). Polypharmacy was extremely common. The median number of medications taken on a scheduled and as needed basis was 10 (range 2-23). Sensory impairments were common: 31% reported their vision was fair or worse; 24% reported their hearing was fair or worse. Three patients (10.3%) screened positive for cognitive impairment on the Blessed Orientation-Memory-Concentration Test, while none reported a clinical diagnosis of dementia.

Of the 26 patients who completed the Timed Up and Go test (TUG), the median time to complete was 11.3 seconds (range 7.2-19.8 seconds); 26.9% required >13.5 seconds to complete the TUG, which is associated with an increased risk for falls. One in five (21.4%) participants reported one or more falls in the 6 months prior to assessment.

Conclusions: A brief, primarily self-administered geriatric assessment was feasible and satisfactory to the participants. Geriatric syndromes including comorbidities, functional dependence, polypharmacy, sensory impairment and falls were common in this cohort, despite most patients having a KPS which is considered “good” in clinical practice. Future study is needed to examine whether the presence of geriatric syndromes in older adult with myeloma is predictive of chemotherapy toxicity, as it is in solid tumors, and whether interventions based on impairments identified in a geriatric assessment can improve outcomes in older adults with myeloma.