Frailty is a hot topic in myeloma, with a subsequent push to implement tools and strategies which ensure that patients defined as frail receive appropriate treatment for their age and physiological condition. In response to this, the team at Leicester hospital, headed up by Dr Mamta Garg, have introduced a frailty assessment for all their new myeloma patients. This initiative was led by the Myeloma and MGUS Clinical Nurse Specialist (CNS) Cath Morrow.
Here, Cath takes us through the background of the project, its implementation, and how frailty assessment has become embedded in clinical practice and treatment decision-making.
Quality improvement methodology
Myeloma diagnosis is more prevalent in people over the age of 65, and over the past 20 years, improvements in treatments and outcomes have been beneficial in extending survival for patients. Older myeloma patients are living not only with their myeloma, its complications, and treatment side effects but are also dealing with the concurrent problems of ageing. These factors can compound and potentiate each other.
Frailty assessment in people 65 years and older can pinpoint people with more complicated needs due to the problems, comorbidities and social issues associated with ageing. It aligns with government guidance and recommendations for more individualised care and improving outcomes in both cancer care and the care of older people.
This CNS-led initiative was introduced using quality improvement methodology. We introduced a consistent assessment method for evaluating frailty in newly diagnosed myeloma patients, primarily to aid and inform decision-making within the MDT (multidisciplinary team) process. We used the IMWG (International Myeloma Working Group) tool and the Clinical Frailty Score to document a readily understandable assessment of patient function and frailty.
The IMWG tool (Palumbo et al., 2015) is recommended and validated for treatment decision-making, specifically in myeloma. Whilst it does score patients on age, it is useful in that it incorporates a clear and detailed assessment of their function. This is done by assessing a patient’s ability to self-care and perform instrumental activities of daily living alongside a full evaluation of co-morbidities using the Charlson co-morbidity index.
The Rockwood (2005) Clinical Frailty Score allows a quick visual appraisement of a person’s frailty and, given that it is used widely in primary, acute and older persons’ care, it allows commonality of language between professionals when communicating with older patients’ problems and requirements.
Introducing frailty assessment at diagnosis
Initially, the CNS team undertook the frailty assessments on the first consultation with the patient and carers. These results were discussed within the new patient MDT as part of the treatment decision process. Frailty scores were documented within the MDT outcome document, shared with the patient’s GP and used in communication with primary and secondary care services. After the initial frailty project, all team members now take responsibility for the frailty assessment of patients at diagnosis.
What is the impact of the introduction of frailty assessment?
Our use of frailty tools within the clinic has provided a framework for a more in-depth assessment of our older myeloma patient population at diagnosis. It has allowed us, as an MDT, to make more informed treatment decisions and give documented rationales for the decisions made. The move away from subjective assessments of frailty and the age-based focus on decision-making has negated issues concerning age discrimination as a basis for treatment decisions. The myeloma team also have a clear common language and understanding of frailty assessment and an improved ability to communicate with primary care in the patient’s best interests. In addition, the quality improvement project findings indicated that CNS consultation time was not increased by undertaking the frailty assessments.
Potential pitfalls – is frailty due to disease or ageing?
We found the occasional difficulty in assessing frailty in older people with newly diagnosed myeloma. The presenting symptoms of myeloma can impact frailty or seemingly worsen, or even mimic, frailty. When using frailty scores, assessing the patient at baseline, i.e. before they became unwell with myeloma, is important. This can be more difficult in a chronic, insidious presentation of cancer such as myeloma and can present a dilemma when using frailty to dose attenuate treatment. There is a risk of undertreating the myeloma and thus losing the benefit that more intensive treatment may offer in reversing disease complications and improving quality of life.
Impact of assessing frailty
Through this initiative, our team is now in a position whereby patients have an improved assessment of frailty and function, with little cost to the service in terms of time. There is an improved knowledge of individuals’ support systems from information gathered at the first patient assessment, which means the MDT is better positioned to identify and advise on support needs and pre-emptively undertake referrals to help patients, and their families, cope with myeloma and its treatment.
Next steps
Following the successful integration of frailty assessment for newly diagnosed myeloma patients, we are keen to extend frailty assessment to the time of relapse to ensure patients continue to have appropriate and effective treatment. We will also be keen to see the Myeloma XIV FiTNEss trial results when this completes and how the results impact our current practice. This trial is evaluating whether a clinical score can identify vulnerable non-transplant eligible myeloma patients at risk of treatment-related toxicity and whether adapting treatment based on frailty can keep patients on medication for longer and improve outcomes.
If you want to learn more about this service improvement at Leicester Royal Infirmary, please contact the CSEP team at csep@myeloma.org.uk.
Written by Cath Morrow
Myeloma and MGUS Clinical Nurse Specialist
Leicester Royal Infirmary