What are the special challenges in the elderly?
In general, elderly tolerate targeted therapies better than cytotoxic therapy. But, elderly have in general more accompanying comorbidities and other age related conditions. Therefore, elderly may need special attention to support adherence with taking the medication on time and as prescribed.
Geriatric screening as per NCCN guidelines, every 70+ patient should receive a brief screening of function, gait speed, or grip strength before treatment. Only those patients identified as high risk patients during screening, need a comprehensive geriatric assessment before treatment. Geriatric assessment can allow the classification of patient as “fit”, “compromised”, and “frail” groups. Fit patients mostly can be treated comparably to younger patients, but compromised and frail patients need special attention. A focused geriatric assessment may facilitate best practices and enhance overall patient care.
Mucocutaneous adverse events
Mucocutaneous adverse events appear often during treatment with targeted agents. Due to ageing, elderly patients may have dry and atrophic skin and mucosa at initiation of therapy. Dry skin can easily develop into fissures. Older people have an increased risk of skin trauma because they are more likely to slip, and this risk is increased further with hand-foot skin reaction. Furthermore, aging and topical steroids can cause skin atrophy, both of which lead to thinning of the upper layers of the skin over time, causing them to be more fragile and prone to tears and ulcerations. The face is often the first place people notice this condition, because the skin there is more sensitive and also more visible. Because of the thin texture, the skin can tear easily increasing the risk of infection, which increases the risk of more severe dermatological adverse events, and more ocular and oral complaints. Oral complaints are generally underappreciated, underreported, undertreated and under studied, especially in the elderly population. Oral hygiene which reduces oral microbial load and consuming an atraumatic diet are general recommendations.
Neuropathy is another problem more common in older people; potentially due to multifactorial risk and reduced tolerance. It can lead to worsening of fissures because it lowers awareness of skin cracking. Furthermore it can increase the chance of falls due to the lower limb awareness and balance/mobility issues.
Cardiac conditions are highly prevalent in older adult populations. This raises the question of whether they can be safely treated with targeted agents. Treatment-related cardiac dysfunction can be classified as type I agents (e.g. anthracyclines), which can cause cellular death and as type II agents (e.g. trastuzumab), which cause predominantly reversible cellular dysfunction. The smaller the cardiac reserves are, the more likely it is that the type II agent will augment the type I injury. Lack of reserves is a key issue. With type II agents, the cells don’t die, but function affected, with potential reversibility. Type II cardiac dysfunction is temporary; however they interfere with recovery from anthracycline damage. The timing of administration of these agents is crucial.