When Lorraine Griggs’ 86-year-old father was diagnosed with prostate cancer, he was treated with 35 rounds of radiation, though he had a long list of other serious medical issues, including diabetes, kidney disease and high blood pressure. The treatment left him frailer, Griggs recalls.

A few years later, when his prostate cancer reoccurred, Griggs’ father received a different kind of cancer care. Before his doctor devised a treatment plan, she ordered what’s known as a geriatric assessment. It included a complete physical and medical history, an evaluation by a physical therapist, a psychological assessment and a cognitive exam. The doctor also asked her father about his social activities, which included driving to lunch with friends and grocery shopping with some assistance.

“When the doctor saw how physically active and mentally sharp my father was at 89 years of age, but that he had several chronic, serious medical problems, including end stage kidney disease, she didn’t advise him to have aggressive treatment like the first time around,” says Griggs, who lives in Rochester, N.Y.

Instead, his oncologist placed her dad on one pill a day that just slowed down his cancer. Griggs’ father was able to enjoy his activities for another three years until he died at the age of 92.

Geriatric assessment is an approach that clinicians use to evaluate their elderly patients’ overall health status and to help them choose treatment appropriate to their age and condition. The assessment includes questionnaires and tests to gauge the patients’ physical, mental and functional capacity, taking into account their social lives, daily activities and goals.

The tool can play an important role in cancer care, according to clinicians who work with the elderly. It can be tricky to predict who will be cured, who will relapse and who will die from cancer treatment. Geriatric assessments can help physicians better estimate who will likely develop chemotherapy toxicities and other serious potential complications of cancer treatment, including death.

Geriatric assessment includes an evaluation by a physical therapist, a psychological assessment, a cognitive exam and a complete physical and medical history. The doctor takes all these factors into account and tallies a score for their patient to help guide their decision-making about the patient’s treatment.

Although the geriatric assessment is not 100% accurate, “it’s better than the clinician eyeball test,” says Supriya Gupta Mohile, a geriatric oncologist and professor of medicine at the University of Rochester. “If I didn’t do a geriatric assessment and just looked at a patient I wouldn’t have the same information,” she says.

A vulnerable population

More than 60% of cancers in the U.S. occur in people older than 65. As the population grows older, so will the rate of cancer among seniors. The cancer incidence in the elderly is expected to rise 67% from 2010 to 2030, according to a 2017 study in the Journal of Clinical Oncology. Yet many oncologists don’t have geriatric training.

Mohile, who treated Griggs’ father during his cancer relapse, explains that geriatric oncologists take a different approach than many other oncologists.

“We want to help older adults successfully undergo cancer treatment without significant toxicities, so it leads to a survival benefit,” she says. “What we don’t want to do is treat patients who will be harmed.”

Mohile says when she saw that Griggs’ dad was frail because of his other health issues, she explained that the standard treatment of care would be difficult for him.

“We went through the decision-making together and I was able to explain how it could cause harm and it would have no risk benefit. He wanted to live and not suffer toxicities,” she says.

A growing body of evidence supports the notion that cancer care for older adults can be improved with geriatric assessments.

A study published in the Journal of Geriatric Oncology in November found that in 197 cancer patients 70 years and older, 27% of the treatment recommendations patients received from the tumor board were different from those received after completing a geriatric assessment. Patients who received a geriatric assessment were recommended to have less intensive treatment or palliative care.

Overall, geriatric assessments have been found valuable for helping older adults with health conditions achieve higher quality of life. A 2017 Cochrane review of 29 studies of geriatric assessments on patients who’d been hospitalized found that patients were more likely to be alive and at home a year later compared to those who had standard care.

One of the reasons geriatric assessments can be so useful to clinicians treating cancer is that doctors don’t have enough information at their fingertips about how older patients respond to the drugs commonly used for chemotherapy. This is partly because there’s less research on this age group.

“You’re playing a guessing game most of the time. Older patients on chemo can get in more trouble than younger patients. The real issue is the patient’s capacity to tolerate care. I think geriatric assessments can improve how we tailor therapy,” says Efrat Dotan, associate professor of hematology/oncology at Fox Chase Cancer Center in Philadelphia and chair of the National Comprehensive Cancer Network, NCCN.

But other experts caution that geriatric assessments can backfire because of a dominant culture in medicine that tends to try to cure patients at all costs, even when treatments may be dangerous.

“Sometimes you don’t want to ask questions because you’re afraid you may have to deal with the answers,” says Otis Brawley, Bloomberg distinguished professor of oncology and epidemiology at Johns Hopkins University in Baltimore.

“The test tends to give us answers that scare us from treatment, and we are supposed to treat patients,” he says.

Often, if a cancer patient is turned away from treatment, they try to find a doctor that will offer it anyway.

“This happens all the time. The irony is that by going away from a doctor really doing the appropriate thing and then going to another doctor who doesn’t do the appropriate thing, sometimes that second doctor is actually hastening death,” says Brawley, former chief medical and scientific officer at the American Cancer Society.

An underutilized tool

Though geriatric assessments were developed about two decades ago and hailed as one of the clinical cancer advances of 2012 by the American Society of Clinical Oncology, they are still not widely used by oncologists.

The Surgical Task Force at the International Society of Geriatric Oncology found that only 6.4% of surgeons use comprehensive geriatric assessments in daily practice, and only 36.3% collaborate with geriatricians, according to a 2016 study in the European Journal of Surgical Oncology.

Many major academic centers have adopted the use of geriatric assessments. However, they’re still fairly scarce in community practices where staffing shortages, financial constraints, lack of institutional support and technology are major barriers to use. They are also time-consuming to complete — taking about two hours.

But these days, “the geriatric assessment is a tool anyone can print out and use,” Mohile says. It’s recently been streamlined and will soon be built into the online health record, EPIC, she says.

Still, lack of training among oncologists is an issue, Mohile says.

“Geriatric assessments have been around for a long time, but they have not been traditionally used by oncologists because they haven’t been trained how to do it or use it,” she says.

Finding treatment options for frail patients

Matthew LoBiondo Sr. from Conesus, N.Y., was being treated with chemotherapy for a gastrointestinal tumor when Mohile first met him as an inpatient. The 89-year-old was hospitalized because he was weak, dehydrated and not eating. Mohile says the dose of the medication he was on was too toxic for him.

Once she took over his care, she weaned him off that treatment, did a geriatric assessment with him and tailored a less toxic treatment plan.

One of the tenets of geriatric assessments is to help physicians select treatments that are best suited for a patient by getting to the core of their physical and mental capacity, regardless of their chronological age.

That’s ultimately the best way to treat older cancer patients, says Armin Shahrokni, a geriatrician and medical oncologist at Memorial Sloan Kettering Cancer Center in New York.

“The data are clear that the fitness of an older cancer patient, rather than age per se, should be the factor considered” when it comes to cancer treatment, he wrote in an editorial in the Annals of Surgical Oncology.

“Age is a meaningless number. I can see a very active 85-year-old very healthy cancer patient who runs marathons. I can also see a 65-year-old with a lot of other comorbid illnesses who is not as functional. How I treat them for cancer would be different,” Shahrokni says.

When he assesses a patient to be too frail for cancer surgery, he says it doesn’t mean that a patient would automatically go on palliative care.

“You would be amazed at how many other options open,” he says.

A frail patient with lung cancer, for instance, can be redirected from surgery to radiation, which is less toxic than chemotherapy and less invasive than surgery.

Geriatric assessments are a way to guide better cancer decision-making, he says.

As more studies about the value of geriatric assessments come out, Shahrokni says he hopes more people will become aware of their importance and find a way to implement them in their practice.

Health problems are less obvious among older adults because of atypical presentations, or because of communication problems due to hearing loss or cognitive impairment. Problems such as psychosocial status, or the environment, increase in importance in older patients because they frequently coexist with health problems and can interfere with their management.

“I think things are moving forward very nicely. In the next 10 years my hope is that not only surgeons and oncologists will do these types of assessments, but patients and their families will demand the health care system to provide a more comprehensive assessment of their functional status before cancer treatment. I think this is going to lead to better outcomes for patients,” Shahrokni says.

Cheryl Platzman Weinstock is an award-winning health and science journalist. This article was written with the support of a fellowship from the Gerontological Society of America, Journalists Network on Generations and the Retirement Research Foundation.

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Babies born to mothers who used opioids during pregnancy represent one of the most distressing legacies of an opioid epidemic that has claimed almost 400,000 lives and ravaged communities.

In fact, many of the ongoing lawsuits filed against drug companies make reference to these babies, fighting through withdrawal in hospital nurseries.

The cluster of symptoms they experience, which include tremors, seizures and respiratory distress, is known as neonatal abstinence syndrome, or NAS. Until recently, doctors rarely looked for the condition. Then case numbers quadrupled over a decade. Hospital care for newborns with NAS has cost Medicaid billions of dollars.

Studies indicate more than 30,000 babies with the condition are born every year in the U.S. — about one every 15 minutes. Although their plight is mentioned in opioids-related litigation, there are growing concerns that those same children will be left out of financial settlements being negotiated right now.

Robbie Nicholson, a mother in Eagleville, Tenn., tried to comfort her second child while the baby slowly underwent withdrawal from drugs Nicholson had taken during pregnancy.

“The whole experience is just traumatizing, really,” Nicholson says.

Nicholson’s ordeal actually began right after her first pregnancy. To help with postpartum recovery, her doctor prescribed her a pile of Percocets. That was the norm.

“Back then, it was like I was on them for a full month. And then he was like, ‘Ok, you’re done.’ And I was like, ‘Oh my god, I’ve got a newborn, first time mom, no energy, no sleep, like that was getting me through,’ ” she says. “It just built and built and built off that.”

After developing a full-blown addiction to painkillers, Nicholson eventually found her way into recovery. In accordance with evidence-based guidelines, she took buprenorphine, a medication that helps keep her opioid cravings at bay. And then came another pregnancy.

But buprenorphine — as well as methadone, another drug used in medication-assisted addiction treatment — is a special kind of opioid. Its use during pregnancy can still result in withdrawal symptoms for the newborn, although increasingly physicians have decided that the benefits of keeping a mother on the medication, to help her stay sober and stable during pregnancy, outweighs the risk of her giving birth to a baby with neonatal abstinence syndrome.

Treatment protocols for NAS vary from hospital to hospital, but over time doctors and neonatal nurses have become better at diagnosing the condition and weaning newborns safely. Sometimes the mom and her baby can even stay together if the infant doesn’t have to be sent to the neonatal intensive care unit.

But not much is known about the long-term effects of NAS, and both parents and medical professionals worry about the future of children exposed in utero to opioids.

“I wanted her to be perfect, and she is absolutely perfect,” Nicholson says. “But in the back of my mind, it’s always going to be there.”

There are thousands of children like Nicholson’s daughter entering the education system. Dr. Stephen Patrick, a neonatologist in Nashville, says schools and early childhood programs are on the front lines now.

“You hear teachers talking about infants with a development delay,” he says. “I just got an email this morning from somebody.”

Studies haven’t proven a direct link between in utero exposure to opioids and behavior problems in kids. And it’s challenging to untangle which problems might stem from the lingering effects of maternal drug use, as opposed to the impacts of growing up with a mother who struggles with addiction, and perhaps unemployment and housing instability as well. But Patrick, who leads the Center for Child Health Policy at Vanderbilt University, says that’s what his and others’ ongoing research wants to find out.

As states, cities, counties and even hospitals go after drug companies in court, Patrick fears these children will be left out. He points to public discussion of pending settlements, and the settlement deals struck between pharmaceutical companies and the state of Oklahoma, which make little or no mention of children.

Settlement funds could be used to monitor the health of children who had NAS, to pay for treatment of any developmental problems, and to help schools serving those children, Patrick explains.

“We need to be in the mix right now, in schools, understanding how we can support teachers, how we can support students as they try to learn, even as we work out was there cause and effect of opioid use and developmental delays or issues in school,” he says.

But it’s a nuanced problem with no consensus on where money is most needed, even among those who’ve been working on the problem for years.

Justin Lanning started Nashville-based 180 Health Partners, which works with mothers at risk of delivering a baby dependent on opioids. Most are covered by Medicaid. And those Medicaid departments in each state pay for most of the NAS births in the U.S.

“We have a few departments in our country that can operate at an epidemic scale, and I think that’s where we have to focus our funds,” he says.

Lanning sees a need to extend government-funded insurance for new mothers, since in states like Tennessee that never expanded Medicaid, these moms can lose health coverage just two months after giving birth. That often derails the mother’s own drug treatment funded by Medicaid, he says.

“This consistency of care is so key to their recovery, to their productivity, to their thriving,” Lanning says of new mothers in recovery.

Robbie Nicholson now has a job at 180 Health Partners, assisting and mentoring pregnant women struggling with addiction. Nicholson says their biggest need is a stable place to live and reliable transportation.

“I just feel kind of hopeless,” she says. “I don’t know what to tell these women.”

There are many needs, Nicholson says, but no simple fix. Those who work with mothers in recovery fear any opioid settlement money may be spread so thin that it doesn’t benefit their children — the next generation of the crisis.

This story comes from NPR’s reporting partnership with Nashville Public Radio and Kaiser Health News.

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Herman Ware sits at a small, wobbly table inside a large van that’s been converted into a mobile health clinic. The van is parked on a trash-strewn, dead-end street in downtown Atlanta where homeless residents congregate.

Ware is here for a seasonal flu shot.

“It might sting,” he says, thinking back on past shots.

Ware grimaces slightly as the nurse injects his upper arm.

After filling out some paperwork, he climbs down the van’s steps and walks back to a nearby homeless encampment where he’s been living. The small cluster of tents sits below an interstate overpass, next to a busy rail line.

Ware hasn’t paid much attention to his medical needs lately, which is pretty common among people living on the street. For those trying to find a hot meal or a place to sleep, health care can take a backseat.

“Street medicine” programs, like the outfit giving Ware his flu shot, aim to change that. Mercy Care, a health care nonprofit in Atlanta, operates a number of clinics throughout the city that mainly treat poor residents, and also has been sending teams of doctors, nurses and other health care providers into the city’s streets since 2013. The idea is to treat homeless people where they live.

This public health strategy can now be found in dozens of cities in the U.S. and around the world, according to the Street Medicine Institute, which works to spread the practice.

Building relationships to give care

Giving shots and conducting exams outside the walls of a health clinic comes with unique challenges.

“When we’re coming out here to talk to people, we’re on their turf,” says nurse practitioner Joy Fernandez de Narayan, who runs Mercy Care’s Street Medicine program.

A big challenge is getting patients to accept help, whether it comes in the form of a vaccination or something simpler — like a bottle of water.

“We’ll sit down next to someone, like ‘Hey, how’s the weather treating you?’ ” she says. “And then kind of work our way into, like, ‘Oh, you mentioned you had a history of high blood pressure. Do you mind if we check your blood pressure?’ “

The outreach workers spend a lot of time forging relationships with homeless clients, and it can take several encounters to gain someone’s trust and get them to accept medical care.

Their persistent encouragement was helpful for Sopain Lawson, who caught a debilitating foot fungus while living in the encampment.

“I couldn’t walk,” Lawson says. “I had to stay off my feet. And the crew, they took good care of my foot. They got me back.”

“This is what street medicine is about — going out into these areas where people are not going to seek attention until it’s an emergency,” says Matthew Reed, who’s been doing social work with the team for two years.

“We’re trying to avoid emergencies, but we’re also trying to build relationships.”

“Go to the people”

The street medicine team uses the trust they’ve built with patients to eventually connect them to other services, such as mental health counseling or housing.

Access to those services may not be readily available for many reasons, says Dr. Stephen Hwang, who studies health care and homelessness at St. Michael’s Hospital in Toronto. Sometimes the obstacle — say, lacking enough money for a bus ticket — seems small, but is formidable.

“It may be difficult to get to a health care facility, and often there are challenges, especially in the U.S., where people don’t have health insurance,” Hwang adds.

Georgia is one of a handful of states that has not expanded Medicaid to all low-income adults, which means many of its poorest residents don’t have access to the government-sponsored health care program. But even if homeless people are able to get health coverage and make it to a hospital or clinic, they can run into other problems.

“There’s a lot of stigmatization of people who are experiencing homelessness,” Hwang says, “and so often these individuals will feel unwelcome when they do present to health care facilities.”

Street medicine programs are meant to break down those barriers, says Dr. Jim Withers. He’s medical director of the Street Medicine Institute and started making outreach visits to the homeless back in 1992, when he worked at a clinic in Pittsburgh.

“Health care likes people to come to it on its terms,” Withers says, while the central tenet of street medicine is, “Go to the people.”

Help, with respect

Mercy Care in Atlanta spends about $900,000 a year on its street medicine program. In 2018, that sum paid for direct treatment for some 300 people, many of whom got services multiple times. Having clinics on the street can help relieve the care burden of nearby hospitals, which Withers says don’t have a great track record when it comes to treating the homeless.

“We’re not dealing with them well,” Withers admits, speaking on behalf of American health care in general. In traditional health settings, homeless patients do worse compared to other patients, he says. “They stay in the hospital longer. They have more complications.”

Those extra days and clinical complications mean additional costs for hospitals. One recent estimate cited in a legislative report on homelessness suggested that more than $60 million in medical costs for Atlanta’s homeless population were passed on to taxpayers.

Mercy Care says its program makes homeless people less likely to show up in local emergency rooms and healthier when they do — which saves money.

It’s past sundown when the street medicine team rolls up to their final stop: outside a church in Atlanta where homeless people often gather. A handful of people have settled down for the night on the sidewalk. Among them is Johnny Dunson, a frequent patient of the street medicine program.

Dunson says the Mercy Care staffers have a compassionate style that makes it easy to talk to them and ask for help.

“You gotta let someone know how you’re feeling,” Dunson says. “Understand me? Sometimes it can be like behavior, mental health. It’s not just me. It’s a lot of people that need some kind of assistance to do what you’re supposed to be doing, and they do a wonderful job.”

Along with the medical assistance, the staff at Mercy Care give every patient big doses of respect and dignity. When you’re living on the street, it can be hard to find either.

This story is part of NPR’s reporting partnership with WABE and Kaiser Health News.

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