GERIATRIC ONCOLOGY

A Practical Guide to Geriatric Syndromes in Older

Adults With Cancer: A Focus on Falls, Cognition,
Polypharmacy, and Depression
Allison Magnuson, DO1; Schroder Sattar, RN, PhD2; Ginah Nightingale, PharmD, BCOP3; Rebecca Saracino, PhD4;
Emily Skonecki, PharmD5; and Kelly M. Trevino, PhD4
overview

Geriatric syndromes are multifactorial conditions that are prevalent in older adults. Geriatric syndromes are
believed to develop when an individual experiences accumulated impairments in multiple systems that
compromise their compensatory ability. In older adults with cancer, the presence of a geriatric syndrome is
common and may increase the complexity of cancer treatment. In addition, the physiologic stress of cancer
and cancer treatment may precipitate or exacerbate geriatric syndromes. Common geriatric syndromes include
falls, cognitive syndromes and delirium, depression, and polypharmacy. In the oncology setting, the presence
of geriatric syndromes is relevant; falls and cognitive problems have been shown to be predictive of che-
motherapy toxicity and overall survival. Polypharmacy and depression are more common in older adults with
cancer compared with the general geriatric population. Multiple screening tools exist to identify falls, cognitive
problems, polypharmacy, and depression in older adults and can be applied to the oncology setting to identify
patients at risk. When recognized, several interventions exist that could be considered for this vulnerable
population. We review the available evidence of four geriatric syndromes in the oncology setting, including
clinical implications, validated screening tools, potential supportive care, and therapeutic interventions.

INTRODUCTION geriatric syndrome frequently does not represent the

Geriatric syndromes are clinical conditions identified
more commonly in older adults, particularly in frail
older adults; these conditions are not necessarily at-
tributed to a specific, isolated underlying disease. The
presenting “symptom” of a geriatric syndrome is re-
lated to an accumulation of impairments in multiple
systems and the inability of the individual to com-
pensate for impairments. The etiology underlying the
development of geriatric syndromes is believed to be
multifactorial in nature. Conceptually, individuals have
a limited amount of “reserve” to tolerate physiologic
stressors. During the aging process, there is a decline
in the homeostatic reserve capacity of all organ sys-
tems, thus rendering individuals more susceptible to
Author affiliations stressors. When stressors overwhelm an individual’s
and support reserve capacity, the development of geriatric syn-
information (if dromes may be representative of the lack of com-
applicable) appear
at the end of this
pensatory ability to manage a particular stressor. In the
oncology setting, this is highly relevant, because
article.
cancer and cancer therapies are potential physiologic
Accepted on May 17,
2019 and published stressors and may exacerbate or precipitate geriatric
at ascopubs.org on syndromes. Common geriatric syndromes include falls,
May 17, 2019:
cognitive syndromes and delirium, depression, poly-
DOI https://doi.org/
10.1200/EDBK_ pharmacy, and urinary incontinence. As described
237641 previously by Fried et al, the clinical presentation of the
specific physiologic stressor that incites the develop-
ment of the geriatric syndrome on an organ system
level (e.g., development of delirium in the setting of
pneumonia or urinary tract infection).1 Thus, this re-
inforces the multifactorial etiology of geriatric syndromes.
In the general geriatric population, geriatric syndromes
predict greater likelihood of hospitalization, increased
health care use and cost, and increased overall mor-
tality.2,3 Previous studies demonstrated that older adult
patients with cancer experience a higher prevalence of
geriatric syndromes than those without cancer. Mohile
et al evaluated 12,480 Medicare beneficiaries, 18% of
whom reported a history of cancer, and found that,
among patients with cancer, 60.3% reported one or
more geriatric syndromes compared with 53% of those
without cancer.4 In a more fit population of patients
who underwent allogeneic stem cell transplantation
and were older than age 60, Lin et al noted that, in the
100 days post-transplantation, new geriatric syn-
dromes occurred in 21% of patients.5 In addition, the
occurrence of falls or delirium during this time were
associated with increased nonrelapse mortality, and
falls were also associated with reduced overall survival.
In the setting of cancer, geriatric syndromes may be
precipitated by the stressors of cancer or cancer

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Copyright © 2021 American Society of Clinical Oncology. All rights reserved.
 Practical Guide to Geriatric Syndromes in Older Adults With Cancer
PRACTICAL APPLICATIONS
• Clinicians will learn potential screening tools to
identify geriatric syndromes in older adults with
cancer.
• Clinicians will appreciate the relevance of falls in
older adults with cancer.
• Clinicians will appreciate the relevance of
cognitive impairment in older adults with
cancer.
• Clinicians will appreciate the relevance of
polypharmacy in older adults with cancer.
• Clinicians will appreciate the relevance of de-
pression in older adults with cancer.
therapy. Also, geriatric syndromes may reflect the limited
capacity of older adults to tolerate additional stressors.
Assessing older adults with cancer for geriatric syndromes
may help oncologists better understand the physiologic
reserve of their patients and help them develop supportive
care interventions to improve quality of life and function.
This review will discuss the relevance of four geriatric
syndromes—falls, cognitive impairment and delirium, de-
pression, and polypharmacy—related to the oncology set-
ting and discuss validated screening tools and potential
interventions for each condition.
FALLS
Falls are a major health issue for older patients, because
cancer and its treatments can increase their risk of falls or
fall-related injuries.4 For instance, older patients are es-
pecially at risk for falls and fall injuries because of bone loss
and disruption of bone-cell homeostasis related to bone
malignancies or bone metastases6,7; interference in bone
blood supply (e.g., pelvic hip region) related to radiation
therapy8,9; increased falls and osteoporosis resulting from
androgen deprivation therapy and osteoporosis from use
of aromatase inhibitors10-12; treatment-related anemia and
thrombocytopenia13,14; mucositis resulting from chemo-
therapy and radiation therapy15,16; fatigue17; treatment-
related sarcopenia 18,19 ; and chemotherapy-induced
peripheral neuropathy.20,21 Fall rates for community-dwelling
older patients can be as high as 75% over 3 months.22
Recent evidence shows that the injurious rate in this
population is 45%, of which nearly 25% involve bone
fracture.23 Cancer is a disease of aging, with 60% of all new
cancer diagnoses and 70% of all cancer deaths occurring in
persons older than age 65.24 By 2030, older adults will
account for 70% of all cancer diagnoses.25 Hence, oncology
care teams will soon be providing care for many more older
patients, with issues such as falls and their sequelae rep-
resenting increasingly important issues.
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Why It Is Important to Assess for Falls
Falls are associated with an increased risk of chemotherapy
toxicity and poorer survival in older patients with cancer.26,27
Falls may signal underlying issues related to the patient’s
ability to tolerate chemotherapy treatment, so fall assess-
ment may add to physicians’ understanding of patient
vulnerability when considering cancer treatment.28 More
importantly, at least one in 20 community-dwelling older
patients experiences changes to the treatment regimen
because of falls and related injuries.23 However, falls in
community-dwelling older patients with cancer are often
under-reported23 and under-recognized.29 Older patients
often do not mention falls during oncology clinic appoint-
ments23 or when visiting their family physicians once they
have begun receiving cancer treatment.23 This is particu-
larly problematic, because previous falls are strongly pre-
dictive of future falls.30,31 Older adults with a history of falls in
the past year are 2.5 times more likely to fall again,30 in part
because functional impairment from a fall often does not
resolve.32 Many falls are potentially preventable by imple-
menting interventions, especially those that target patients
at higher risk.33 Fall assessment may help unearth oppor-
tunities for an intervention (e.g., dizziness, inappropriate
medications, depressed mood, impaired gait and balance,
weakness in lower extremity) and can help gauge the
functional status of a patient.29 Of note, the commonly used
Eastern Cooperative Oncology Group assessment often
misses subtle impairment in instrumental activities of daily
living,34 a known predictor for falls in this population.35
Research suggests that one in five older adults develops
a new impairment of activities of daily living between their
first and second cycles of chemotherapy treatment.36 As
such, fall risk in this population is not static and should be
assessed on an ongoing basis,37 ideally at every clinic ap-
pointment.23 Identifying those at risk for falls, instead of
waiting for falls to happen, is beneficial and contributes to
proactive decision-making for preventive interventions.38
Screening for Falls in Older Adults With Cancer
Oncologists are under increasing pressure to take geriatric
principles into consideration during cancer care and also
often function as the interim primary care provider for older
patients during active treatment.39 As such, oncologists can
play a vital role in assessing falls, documenting them in
medical records and even initiating interventions.29 Simply
asking about any recent falls or falls since the last ap-
pointment is a good start.23 Oncology clinic nurses are well-
positioned to assess fall risks and alleviate the pressure on
oncologists by asking “did you have any falls since the last
time we saw you?” They can also administer simple gait and
balance tests, using tools such as the Timed Up and Go
test40 or Gait Speed,41 which take less than 2 minutes to
complete and can be administered while walking patients
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 Magnuson et al
from the waiting area to the examination room or during
check-in procedures.42,43 Reported falls and/or abnormal
findings can then be communicated to the treating
physician, triggering further assessments, referrals, or
interventions.
Interventions to Prevent or Address Falls
Older patients should be asked at each oncology clinic
appointment about falls35 and if they experience difficulties
with walking and balance.44 As mentioned previously,
simple gait and balance tests can be done while patients are
waiting.23 Those identified as at risk for falls, such as those
who report falls or have abnormal gait and balance findings
(e.g., gait speed , 1 m/second, which signifies fall risk45),
should be offered a multifactorial assessment and in-
tervention. This includes an assessment of falls history
(frequency, circumstances, symptoms, injuries, etc.),
muscle strength, cardiovascular status, medications, visual
acuity, positional blood pressure, feet and footwear, home
environment,44,46 and mobility aids.46 Subsequent steps
include a referral to primary care provider, geriatric team, or
falls clinic46 as well as promotion of moderate physical
activity or an exercise program that incorporates gait, bal-
ance, and strength training44,47,48 to improve mobility, bal-
ance, and reaction time.49 Patients may also need specific
advice concerning environmental or activity modifications,50
such as extra vigilance while negotiating sidewalk curbs,
steps, and stairs,51 in particular for those at risk for
treatment-related peripheral neuropathy. In-home safety
evaluations should also be arranged for older patients with
neurotoxicities.46 However, education alone is not sufficient
for preventing falls,52 and older patients must be encour-
aged to report issues related to gait and/or balance and falls
during both routine family physician and oncology clinic
appointments. In addition, physicians should closely
monitor those who are on active treatment. Strategies with
respect to how to fall safely once a fall is already underway
are also beneficial.53
COGNITIVE IMPAIRMENT AND DELIRIUM
The prevalence of cognitive issues increases with age; the
prevalence of dementia in patients older than age 70 is
13.9%,54 and an estimated 22.2% of patients in this age
range have cognitive impairment without overt dementia.55
Dementia is typically diagnosed when cognitive impairments
interfere with a patient’s independence and social func-
tioning. Within the context of oncology, Surveillance, Epi-
demiology, and End Results–Medicare analyses suggest an
estimated prevalence of dementia in 3.8% to 7% of patients,
although this may be an underestimate, because cognitive
screening is not typically performed in the oncology setting.
Delirium is a common neurocognitive condition defined as
an acute change in attention, alertness, cognition, and/or
behavior. Pre-existing cognitive impairment and older age
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are recognized risk factors for the development of delirium.
Within the context of oncology, most studies that evaluate
delirium focus on the inpatient setting and include patients
of all ages, with an estimated prevalence of delirium
ranging from 33% to 58%, depending on the population
evaluated.56-61
Clinical Implications of Cognitive Impairment in Older
Adults With Cancer
When considering cognition in older adults with cancer, two
broad groups can be considered. The first includes older
adults with normal cognition at diagnosis, in whom the
potential effects of cancer and cancer therapies on cognitive
functioning can be considered. The second group includes
older adults with pre-existing cognitive impairments or
dementia, who are then faced with a cancer diagnosis.
There is increasing evidence regarding the effects of cancer
treatment on cognition in older adults; however, most pa-
tients included in these studies did not have a pre-existing
cognitive issue. Older adults with dementia or significant
cognitive problems are under-represented in oncology
research.
The majority of data regarding the impact of cancer therapy
on cognition has been conducted in younger patients, al-
though there is increasing evidence that older adults may be
more susceptible to the effects of cancer therapy on cog-
nition. Ahles et al demonstrated that older patients (older
than age 60) with lower baseline cognitive reserve experi-
enced the most notable decline in cognition after expo-
sure to chemotherapy.62 In a population of older adults,
Mandelblatt et al demonstrated that patients exposed to che-
motherapy had greater declines on measures of attention,
processing speed, and executive function, and those who
received hormonal therapy had lower scores on learning
and memory assessment.63 Cognitive changes were shown
to influence cancer-related outcomes as well. In a model to
predict chemotherapy toxicity in older adults with cancer
(the Chemotherapy Risk Assessment Scale for High-Age
Patients score), a Mini-Mental Status Evaluation score
under 30 was predictive of nonhematologic toxicity.64 The
presence of a dementia diagnosis affected overall survival in
multiple types of solid tumor malignancies.65 In hematologic
malignancies, the presence of an abnormal cognitive screen
using a five-word delayed recall test was also shown to
influence survival.66
Screening for Cognitive Problems
Within the oncology setting, guidelines recommend
screening for cognitive impairment in older adults.67 Several
screening tools exist, including the Mini-Cog or the Blessed
Orientation-Memory-Concentration test. The Mini-Cog is
a brief assessment that takes approximately 2 minutes to
perform and has been shown to have good sensitivity and
specificity for identifying dementia compared with tools that
 Practical Guide to Geriatric Syndromes in Older Adults With Cancer
take longer.68 The Mini-Cog has a three-word delayed recall
component and a clock-drawing test, and it is generally
scored as a normal screen versus an abnormal screen. The
Blessed Orientation-Memory-Concentration scale is also
a brief screening tool and has been shown to be feasible
when incorporated into a geriatric assessment within the
context of a clinical trial for older adults with cancer.69,70
Other longer options for screening tools include the Mini-
Mental Status Evaluation71,72 and the Montreal Cognitive
Assessment. The most commonly used screening tool for
delirium is the Confusion Assessment Method.73
Interventions for Older Adults With Cognitive Problems
For older adults who experience chemotherapy-related
cognitive impairment, several studies have demonstrated
the benefit of interventions in the survivorship setting to
improve cognition, although these studies preferentially
included younger patients. Most of these studies evaluated
behavioral therapies, such as cognitive rehabilitation or
exercise.74-80 Additional studies are needed to develop
targeted interventions for older adults specifically.
For older adults with pre-existing cognitive impairment or
an abnormal cognitive screening evaluation, expert con-
sensus and guidelines suggest assessment of decision-
making capacity, delirium risk counseling, medication
review, and potential referral for more extensive cognitive
assessment for older adults with cancer who have an
abnormal cognitive screening test.67,81 To date, no studies
have evaluated therapeutic or supportive care in-
terventions for older adults with cancer and pre-existing
cognitive impairment who are receiving cancer therapy
specifically. Extrapolating from the general geriatrics lit-
erature, several supportive care interventions could be
considered, although they are not evidence based in the
oncology population in particular.82 Counseling patients
and caregivers about the potential cognitive-related effects
of cancer therapy and subsequent impact on inde-
pendence is important. If an older adult with pre-existing
cognitive issues is living independently in the community,
the stressors of cancer treatment may compromise his or
her ability to maintain instrumental activities of daily living
(e.g., driving, finance, and medication management) and
thus potentially compromise independence. Completion of
advanced directives, particularly designating a health care
proxy who can make medical decisions if the patient’s
cognitive status makes them unable to, is also suggested.
Older adults may be living alone, and enhancing social
support to aide in monitoring of medication compliance
and toxicity should also be considered. Depending on the
degree of cognitive impairment, more enhanced super-
vision, such as 24-hour care or increased level of support
(e.g., skilled nursing facility), may be beneficial for safety.
This should be considered if there is concern that patients
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may not be able to reliably recognize side effects or
manage oral cancer therapies.
POLYPHARMACY
Polypharmacy is a major public health problem that par-
ticularly affects older adults, who are the largest consumers
of medications. Although older adults comprise 14.9% of
the U.S. population, they account for 34% of prescription
and 30% of nonprescription medication use.83 A systematic
review identified 138 definitions of polypharmacy and found
that 80% of these definitions used the numerical definition
of five or more daily medications; only 6.4% of articles
classified the distinction between appropriate and in-
appropriate polypharmacy.84 Inappropriate polypharmacy
largely refers to medications lacking evidence-based in-
dications, medications with treatment risks that outweigh
benefits, medications that are frequently associated with
adverse drug reactions, or medications that may potentially
interact with other medications and/or disease states.85
Older adults with cancer are purportedly at a higher risk
of polypharmacy, because many patients meet the criteria
for polypharmacy before initiation of cancer therapy. In
cohorts of older adults with cancer, polypharmacy preva-
lence ranges from 8% to 84%,86-94 and inappropriate poly-
pharmacy prevalence ranges from 11% to 63%.86-88,90,91,95
This research is limited by study confounders, inconsistent
definitions and evaluation methods, and heterogeneous
cancer types and stages. Despite the prevalence of poly-
pharmacy in these studies, there is no consensus on its
definition or the optimal polypharmacy cutoff point for
predicting clinically important adverse events.96 Clinical
consequences of polypharmacy in older adults with cancer
have been linked to adverse drug reactions, depression,
disability, falls, frailty, health care use, postoperative com-
plications, mortality, and caregiver burden.90,93,97-102
Polypharmacy Challenges and Considerations
Age-related physiologic changes can affect the pharma-
cokinetics and pharmacodynamics of cancer- and non-
cancer medications, intensifying the prescribing challenges
in older adults.103 Pharmacokinetics is the study of the
absorption, distribution, metabolism, and excretion of
medications, all of which are directly influenced by normal
changes of aging and by physical changes associated with
disease states. Pharmacodynamics is the study of what a
medication does to the body or how the body responds to
the medication (e.g., concentration of drug at the receptor
and/or drug–receptor interactions). Declining cell function
in advanced age influences pharmacodynamics of medi-
cations and causes older adults to be more sensitive to
medications. Other reasons for complexity of medication
management in this population include organ impairment,
high pill burdens, and complex medication regimens. The
large number of specialists, primary care providers, and
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 Magnuson et al
allied health professionals involved in the delivery of care
gives way to communication failures that result in medi-
cation duplications, unnecessary medications, and medi-
cation omission and/or undertreatment. 88 In addition,
prescribing cascades can occur when, in a cyclic man-
ner, the effects of a medication are mistaken for and/or
interpreted as a new medical symptom, leading to
a new medication that itself causes additional adverse
reactions.104
An increased risk of drug–drug interactions (DDIs) can
result from these prescribing cascades as well as from
fragmented care coordination, age-related physiologic
changes, multimorbidity, and single disease state guide-
lines. Drug interactions can lead to adverse drug reactions in
which the intended therapeutic effect or safety of a medi-
cation is altered by the administration of another substance
(e.g., drug, herb, food). Studies specific to older adults with
cancer have reported DDI prevalence ranging from 2% to
77%, with broad sweeping variability linked to inconsistent
design methodology; definitions for DDIs; DDI screening
assessments and/or approaches; and heterogeneity of
cancer types, stages, and treatments.91,95,105,106 In a recent
population-based study in older adults with cancer taking
tyrosine kinase inhibitors and proton pump inhibitors, DDIs
were high (22.7%) and were associated with an increased
risk of death (at 90 days and 1 year). Polypharmacy also
affects medication adherence, which is particularly con-
cerning because of the accelerated expansion of oral
chemotherapy agents. The International Society of Geriatric
Oncology taskforce published recommendations on ad-
herence to oral cancer therapy in older adults.107 The
Morisky Medication Adherence Scale could be useful as an
adherence screening tool, but it has not yet been validated
for use in oncology.108
Screening for Polypharmacy
A high rate of inappropriate polypharmacy persists among
older adults with cancer despite nearly three decades of
published guidelines, including the Beers criteria,109 the
Medication Appropriate Index,110 the Screening tool of older
persons' potentially inappropriate prescriptions (STOPP),
and the Screening tool to alert doctors to right treatment
(START) criteria,111 in addition to broad availability of
medication alternatives.112 Each tool can be used in a
complementary manner because of some of the variances
between tools. The Beers criteria, first published in 1991
and most recently updated in the 2019, are the most fre-
quently used in the United States. Supported and endorsed
by the American Geriatric Society, Beers criteria classify
more than 40 potentially problematic medications or
medication classes across five criteria.109 The STOPP/
START criteria were developed and validated by expert
consensus in Europe, and the criteria are organized
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according to physiologic systems.111 The Medication Ap-
propriate Index uses 10 criteria for each medication to
determine if it is appropriate, marginally appropriate, or
inappropriate.110 None of these tools are all inclusive of
every high-risk medication that has been linked with ad-
verse drug events, emergency department visits, and
hospitalization.
Guidelines from the International Society of Geriatric On-
cology, the American Society of Clinical Oncology, and the
National Comprehensive Cancer Network all recommend
performing a geriatric assessment (GA) as part of the initial
screening and/or workup for older adults with cancer.67,113,114
However, polypharmacy has not consistently been included
as part of the GA because of conflicting study results that
demonstrated causality between polypharmacy and patient
outcomes.115
Polypharmacy Interventions
The brown bag medication review method is highly rec-
ommended, because it involves the patient bringing in all
medicines and supplements from home to the visit. If
polypharmacy is identified as part of the GA, the provider
should evaluate each medication indication (e.g., medi-
cation and disease matching), dosage, duration of use,
duplications, DDIs, drug–disease interactions, and adverse
drug reactions. The provider should also evaluate the pa-
tient’s ability to read medication instructions and safely
manage medications. According to one study, such GA-
driven polypharmacy discussions helped ameliorate poly-
pharmacy concerns.116 If unnecessary and/or inappropriate
polypharmacy is identified, de-prescribing should occur for
those medications that are discontinued in the context of
the patient’s goals, functional status, life expectancy, values,
and preferences. 117,118 Progress note documentation
should indicate that a comprehensive medication evalua-
tion was conducted and that medication-related problems
were identified and resolved. Geriatrician-led polypharmacy
interventions made through a GA have been effective at
identifying medication-related problems, reducing the
number of medications, and improving chemotherapy
tolerance. 119-121
Another approach to managing polypharmacy is through
integration of pharmacists as part of the health care de-
livery model for patient-centered care. The Institute of
Medicine recognizes the important role played by phar-
macists in the areas of medication therapy management
and medication safety, and it recognizes the value of the
pharmacist–physician collaboration in patient care.122,123 A
pilot study found that a pharmacist-led polypharmacy and
de-prescribing intervention in a geriatric oncology clinic
resulted in reduced symptoms among two-thirds of pa-
tients and avoidance of $4,282 in potential health care
expenditures per patient.124 Another pilot study found that
 Practical Guide to Geriatric Syndromes in Older Adults With Cancer
a pharmacist-led polypharmacy intervention in 41 patients
identified 123 medication-related problems in 95% of pa-
tients and resulted in a 45.5% reduction in number of
medication-related problems.125 A similar pharmacist-led
intervention in 294 patients identified 1,091 medication-
related problems in 90.1% of patients (mean age 71.8
years) and reported that the most common drug-related
problems were potential DDIs, adverse drug events, and
patient nonadherence.126 A study on the impact of a phar-
macist-led comprehensive medication review for hospital-
ized geriatric patients with cancer significantly reduced
inappropriate polypharmacy at discharge versus admission.127
Last, a randomized pilot intervention that used pharmacists
to enhance medication management and vaccination ad-
ministration found fewer discrepant medications and in-
creased vaccination rates.128
In summary, the literature consistently reflects a high
prevalence of polypharmacy in the older adult oncology
population despite widespread availability of published
screening tools. Preliminary evidence shows that relation-
ships exist between polypharmacy and health outcomes,
including adverse drug reactions, depression, disability,
falls, frailty, health care use, postoperative complications,
mortality, and caregiver burden. Pilot studies have proven
effective at reducing polypharmacy, yet a critical need re-
mains for randomized, controlled trials that not only reduce
polypharmacy but also demonstrate successful and scal-
able interventions that affect functional status, quality of life,
and health care resource use in this vulnerable population.
DEPRESSION
Depression is characterized by a combination of depressed
mood, loss of interest or pleasure, changes in weight and
sleep, psychomotor agitation or retardation, fatigue, feelings
of worthlessness or guilt, difficulty concentrating, and re-
current thoughts of suicide or death.129 The prevalence of
depressive disorders in older adults with cancer ranges from
1.8% to 10.0%130,131 whereas up to 28% have clinically
notable depressive symptoms.98,132-134 These rates are
much higher than the 1%–5% prevalence in community
samples of older adults.135,136 Although older adults with
cancer report lower levels of137 and less severe depression
than younger patients,138 rates of depression may increase
with age in older adults.139,140
Depression in patients with cancer is associated with worse
physical symptoms141-145; poor quality of life146,147; longer
hospitalizations148,149; increased risk of emergency de-
partment visits, overnight hospitalization, and 30-day
readmission150,151 ; and shorter survival. 152-154 Further-
more, older adults with cancer are at increased risk for
suicide relative to peers in the general population155 and
those with other medical illnesses.156 Depression is a major
risk factor for suicide in older adults.157,158 Therefore, older
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adults with cancer and depression are likely at heightened
risk for suicide.
Screening for Depression in Older Adults With Cancer
Accurate assessment and effective treatment are needed to
mitigate depression and its adverse effects. However, as-
sessment of depression in older adults with cancer is complex
because of unique characteristics of older adults and overlap
between somatic symptoms of depression, cancer, and
cancer treatment.159 The diagnostic criteria for major de-
pressive disorder stipulate that a patient must endorse de-
pressed mood or loss of interest or pleasure, referred to as the
“gateway” symptoms of depression.159 Older adults are less
likely than younger adults to endorse these gateway symp-
toms.160,161 They are also less likely to endorse self-criticism,
guilt, and sense of failure.161-163 However, older adults are
more likely to endorse somatic symptoms, such as sleep and
stomach problems.161-163 This pattern of symptom reporting
makes diagnosing depression in older adults with cancer
particularly difficult, because the somatic symptoms of de-
pression can also be due to cancer and its treatment.
Multiple strategies for overcoming these assessment chal-
lenges have been proposed. One strategy is to remove or
replace questions about somatic symptoms when assessing
depression.130 Assessments that remove somatic symptoms
classify fewer older adults with cancer as depressed than
assessments that retain these symptoms. Strategies that
replace somatic symptoms with affective and/or behavioral
symptoms vary more widely in the percentage of older adults
with cancer identified as depressed.130 Research has not
yet established the sensitivity and specificity of these
approaches relative to a criterion measure. However,
a three-step process for assessing depression symptoms
and isolating them from the effects of cancer has been
proposed.159,164 First, conduct a thorough evaluation of the
gateway symptoms (depressed mood and loss of plea-
sure). Second, assess remaining depressive symptoms
(i.e., changes in weight and sleep, psychomotor agitation or
retardation, fatigue, feelings of worthlessness or guilt, dif-
ficulty concentrating, and thoughts of death or suicide).
However, many of these symptoms can be caused by
cancer and its treatment. The purpose of the third step is to
assess depressive symptoms commonly endorsed by older
adults that are not attributable to cancer. These symptoms
include general malaise or dissatisfaction, general aches
or diffuse somatic complaints, hopelessness, late insomnia
(waking during the night and being unable to return to
sleep), mood variation during the day, and change in sexual
interest.159,164 Endorsement of these symptoms in addition
to those assessed in steps one and two suggest that an older
adult with cancer has depression.
A second strategy for assessing depression in older adults
with cancer relies on previously established screening tools,
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TABLE 1. Summary of Potential Screening Tools and Interventions for Select Geriatric Syndromes
Geriatric Syndrome Potential Screening Tool
Falls • Fall history
• Timed Up and Go test
• Gait speed assessment
Cognitive impairment • BOMC test
• Mini-Cog
Polypharmacy • Beers criteria
• STOPP and START criteria
Depression • GDS
• HADS
• CESD-R
Abbreviations: BOMC, Blessed Orientation-Memory-Concentration; STOPP, screening tool of older persons’ potentially inappropriate prescriptions; START,
screening tool to alert doctors to right treatment; GDS, Geriatric Depression Scale; HADS, Hospital Anxiety and Depression Scale; CESD-R, Center for
Epidemiology Studies Depression Scale-Revised.
such as the Geriatric Depression Scale–Short Form, the
Hospital Anxiety and Depression Scale, and the Center for
Epidemiologic Studies Depression Scale–Revised. These
measures have cutoff scores validated in geriatric and
medical populations.165 However, recent work comparing
these assessments with a structured clinical interview for
identification of depressive disorders found that these
cutoffs failed to identify 33%–83% of depressed older adults
with cancer.166 Lower cutoff scores that maximize the
sensitivity and specificity of these measures in older adults
with cancer may be more appropriate. However, additional
research is needed before modified cutoff scores are
implemented in clinical care.
Interventions for Depression
Depression screening alone without appropriate treatment
does not reduce depression.167-169 However, when paired
with referral to psychosocial services, screening is associ-
ated with improved patient outcomes. Treatment options
for depression in older adults with cancer include psy-
chopharmacology and psychotherapy approaches. Psy-
chopharmacologic treatments generally target serotonin,
norepinephrine, and dopamine.170 Common side effects
include headache, sedation or insomnia, feeling “groggy,”
gastric distress, sexual dysfunction, weight changes, high or
low blood pressure, and dry mouth.171 More serious but less
common adverse reactions include suicidal thoughts or
behaviors, medication-induced mania, restlessness or ag-
itation, and serotonin syndrome.171 When initiating an an-
tidepressant in an older adult, start with a low dose and
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Copyright © 2021 American Society of Clinical Oncology. All rights reserved.
Magnuson et al
Potential Interventions for Consideration
• Evaluation of additional risk factors for falls, such as medication review, visual
acuity, positional blood pressure, footwear, etc.
• Home safety evaluation
• Physical therapy and/or occupational therapy referral for strength and balance
training
• Home exercise program
• Fall counseling education
• Medication review
• Referral for more comprehensive cognitive assessment (e.g., neurology or
neuropsychology)
• Delirium risk counseling for patients and caregivers
• Assess decision-making capacity
• Brown bag medication review
• Pharmacist involvement in oncology care
• Deprescribing potentially inappropriate medications
• Referral for psychosocial services
• Pharmacologic therapy
• Cognitive-behavioral therapy or problem-solving therapy
increase slowly.170 Similarly, evaluate patients’ liver and
renal functions, cognitive function, other medications and
possible interactions, alcohol use, and electrocardiographic
results.170 Psychiatrists, particularly those with geriatric
expertise, can assist with the dosage and titration of anti-
depressants in the context of cancer, treatment, and age-
related comorbidities.170
Cognitive-behavior therapy and problem-solving therapy are
psychotherapy approaches that have been extensively ex-
amined in older adults and patients with cancer.172-176
Cognitive-behavior therapy and problem-solving therapy
are brief goal-oriented and present-focused treatments.
Cognitive-behavior therapy targets maladaptive thoughts
and behaviors that increase distress.177,178 Patients and
therapists work to identify these thoughts and behaviors and
replace them with more adaptive strategies for managing
stressors and difficult emotions. In problem-solving therapy,
patients learn strategies for solving difficult problems that
increase negative emotions.179 Modifications to cognitive-
behavior therapy and problem-solving therapy for older
adults with cancer include a greater emphasis on behavioral
change, particularly in the context of cognitive impairment;
consideration of physical and mobility limitations; provision
of additional time for summarization and review of in-
formation; and modification of materials and communica-
tion style to account for sensory impairment.180,181
Despite the availability of efficacious treatments for de-
pression in older adults with cancer, implementation of
these interventions into clinical care settings has been poor.
 Practical Guide to Geriatric Syndromes in Older Adults With Cancer

Approximately one-half of distressed patients with cancer do
not receive mental health care,182,183 and only 5% receive
evidence-based psychological care.184 Furthermore, older
adults with cancer who screen positive for elevated distress
are more likely than younger adults to decline a mental
health referral.185 Barriers to mental health treatment in
older adults with cancer include lack of knowledge about
mental health treatments in patients and providers, stigma
regarding receipt of mental health services, the number
of competing appointments, and physical and financial
hardships associated with aging.164,186,187 Institutional
characteristics, such as inadequate staffing, a dearth of
mental health providers, and heavy workloads of current
providers, can also reduce patient access to mental health
services.186
The cost of providing mental health services and limited
resources in health care settings are often cited as barriers
to providing psychosocial care. However, research suggests
that health care costs for patients with cancer and
depression are much higher than for patients with cancer
only.154,188,189 In a study of older adults with multiple my-
eloma, the cost of care in the first 6 months following the
diagnosis was higher in patients with depression ($19,500)
than in patients without depression ($12,300).190 Fortu-
nately, research also indicates that receipt of mental health
treatment is associated with reductions in health care costs
in patients with cancer who have depression. In a study of
patients with cancer and major depressive disorder, each
additional mental health visit was associated with a 2.7%
reduction in total health care charges. Patients with de-
pression who participated in 12 mental health visits in the
year following diagnosis accrued $27,829 less in health care
costs in that year than patients who did not receive mental
health care.191 Taken together, these studies suggest that
untreated depression in patients with cancer may increase
health care costs that can be reduced with mental health
treatment. Therefore, provision of mental health services to
older adults with cancer and depression is likely to improve
older adults’ quality of life while potentially reducing health
care costs (Table 1).
SUMMARY
In summary, geriatric syndromes are prevalent health issues
in older adults, and the presence of a geriatric syndrome
may indicate a more limited reserve to tolerate additional
stressors. Common geriatric syndromes include falls, cog-
nitive impairment and delirium, depression, and polypharmacy;
these conditions are highly relevant for older adults with
cancer. The presence of these conditions may influence
overall ability to tolerate therapy as well as quality of life and
potentially survival. Screening for geriatric syndromes can
be implemented in the oncology setting to identify potential
areas for interventions to improve quality of life and other
related outcomes.

AFFILIATIONS CORRESPONDING AUTHOR

1
Department of Medicine, Division of Hematology/Oncology, University of Allison Magnuson, DO, Department of Medicine, Division of Hematology/
Rochester Medical Center, Rochester, NY Oncology, University of Rochester Medical Center, Wilmot Cancer
2
University of Saskatchewan, Regina, Saskatchewan, Canada Institute, 601 Elmwood Ave., Box 704, Rochester, NY 14642; email:
3
Thomas Jefferson University, Philadelphia, PA allison_magnuson@urmc.rochester.edu.
4
Memorial Sloan Kettering Cancer Center, New York, NY
5
Walgreens Specialty Pharmacy, Philadelphia, PA
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
AND DATA AVAILABILITY STATEMENT
Disclosures provided by the authors and data availability statement (if
applicable) are available with this article at DOI https://doi.org/10.1200/
EDBK_237641.

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 Practical Guide to Geriatric Syndromes in Older Adults With Cancer

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