Validation

of G-8 screening tool for Comprehensive Geriatric Assessment & Post-operative

Delirium in Gynecological Cancer Patients undergoing Robotic Surgery
Haibin Yin* 1, 2, Johanne Monette1, 2, Doreen Wan-Chow-Wah1, 2, 3, Walter Gotlieb4, 5
1Division of Geriatric Medicine, McGill University. 2Division of Geriatric Medicine, Jewish General Hospital. 3Division of Geriatric Medicine, McGill University Health Centre.

SOLIDAGE Research Group

McGill University Universit de
Montral Research Group on Frailty
and Aging

4Department of Obstetrics and Gynecology, McGill University. 5Department of Obstetrics and Gynecology, Jewish General Hospital, Montreal, Canada

Introduction
Several studies have suggested that comprehensive geriatric assessments (CGA) in geriatric oncology paBents are
useful to predict morbidity and survival [1]. At the same Bme, the systemaBc applicaBon of CGA is debatable, as there
is growing evidence that it may be of limited value in healthy elderly paBents[2, 3]. Furthermore, specialized geriatric
oncology services are relaBvely rare, therefore, an increasing number of screening tests for CGA [4, 5] have been
developed to beWer triage paBents in order to idenBfy elderly oncology paBents who would benet the most from
CGA. Bellera et al. (2011) [6] developed G-8, which comprises the Mini-NutriBon Assessment (MNA-SF) plus an age
item. It is a test that could be administered by health care professionals. The score ranges from 0 (most impaired) to
17 (Not at all impaired). Bellera et al. demonstrated that G-8 has good sensiBvity (85%) and acceptable specicity
(65%) to screen for idenBcaBon of abnormality in at least one CGA reference test (ADL, IADL, MNA, MMSE, GDS,
CIRS-G, TUG) [1].
Table 1 - G-8 tool

A

Items
Has food intake declined over the past 3 months
due to loss of appeBte, digesBve probllems, or
chewing or swallowing diculBes?
Weight loss during the last 3 months

Mobility

Neuropsychological problems

Body mass index

Takes more than 3 prescripBon drugs per day

In comparison with other people of the same

age, how do they consider their health status?

Age

Total Score

Possible answers
Score
0: severe decrease in food intake
1: moderate decrease in food intake

2: no decrease in food intake
0: weight loss > 3 kg
1: does not know

2: weight loss between 1 and 3 kg
3: no weight loss
0: bed or chair bound
1: able to get out of bed/chair but does

not go out
2: goes out
0: severe demenBa or depression
1: mild demenBa or depression

2: no psychological problems
0: BMI < 18.5

1: 19 BMI 21

2: 21 BMI 23

3: BMI 23

0: yes

1: no
0: not as good
0.5: does not know

1: as good
2: beWer
0: > 85 yr
1: 80-85 yr

2: < 85 yr

0 - 17

The measured outcomes were:

Part 1: G8 vs. Comprehensive Geriatric Assessments
Gold standard 1: Any posiBve score in a reference test in CGA
Gold standard 2: GIC > 2 is posiBve
Part 2: G8 vs. Delirium
Gold standard: Presence of Delirium
The data extracBon was performed from the database from the consultaBon services for senior oncology paBents of
the geriatric oncology clinic at the Jewish General Hospital. A chart review was performed to collect data on hospital
stay, past history of demenBa and depression prior to CGA and for diagnosis of post-operaBve delirium. The G-8 scores
are calculated from the available data in the database retrospecBvely.

IBM SPSS v. 21 was used for data analysis. SensiBviBes, speciciBes, Receiver operaBng curve and Area under the
Receiver operaBng curve (AUC) are used to assess the G-8 screening tool. Condence interval (95%) was used. We have
decided to favour sensiBvity over specicity in determining the opBmal cut-o point in order to try to prevent paBents
who are more impaired from being missed by this screening tool.

Results: G-8 as a screening tool for CGA

A total of 138 paBents who were referred between January 2007 and July 2013 were included in the study. Only rst
geriatric oncology visits were taken into account. 113 (72.8%) had endometrial cancer as primary cancer. A majority
(51.4%) of the paBents are over 80 years old. In terms of G-8 scores, 35 paBents (25.4%) had a score of 14 or more, 38
(27.5%) had a score between 12 and 13.5, and 27 (19.6%) of the paBents had a score of 11.5 or less. There was
insucient data to calculate G-8 scores in 38 (27.5%) paBents. In terms of GIC categories, 92% of paBents had at least
one Medical recommendaBon, 57% had at least one cogniBve recommendaBon, 38% had at least one pharmacological
recommendaBon and 12% at least one mobility recommendaBon. The majority (76.2%) of the paBents received
recommendaBons in 2 GIC categories or less (i.e. GIC score 2), and therefore 23.8% of the paBents has a GIC score

Table 2 - CGA reference test, reference values, cuto values, numbers of subjects with abnormal scores and
proporKon of paKents with abnormal scores (adapted to facilitate comparison with Ballera et al.)
CGA reference test

Total score
range

PosiBve if

Number of subjects
% of paBents with
with abnormal score/
abnormal scores
Total paBents with data

MMSE
Grip Strength (kg)
Gait Speed (m/s)
TUG (seconds)
ADL-Katz
IADL-OARS
GDS-15
Charlson Comorbidity Index

0-30
0-innite
0-innite
0-innite
0-6
0-14
0-15
0-innite

MMSE < 24
Grip strength < 20kg
Gait speed < 1m/s
TUG > 20 sec
Katz < 6
OARS < 14
GDS > 5
CCI >= 6

22/131
49/131
94/124
16/74
26/132
82/133
12/79
17/137

17%
37%
76%
22%
20%
62%
15%
12%

Total

0-innite

Total > 0

113/139

81%

Figure 1 -

RoboBc surgeries for gynecological cancers have been performed at the Jewish General Hospital (a McGill
University-aliated teaching hospital) since December 2007 [8]. Elderly paBents undergoing roboBc TAH-BSOs for
endometrial and ovarian CAs have been systemaBcally referred to the Geriatric Oncology Clinic for comprehensive
geriatric assessments. We have noBced that G-8 scores are calculable with the collected data in our geriatric oncology
database. We have also came to the realizaBon that data on Geriatricians intervenBons were also available for every
referred paBent. It was therefore interesBng to study whether or not a correlaBon exists between G-8 and the number
of Geriatric intervenBons, which could conrm the fact that G-8 might be a good screening test for CGAs.

SensiKvity and specicity at

dierent G-8 cutos in G8 vs.
CGA reference exam
abnormaliKes (at least one
abnormal)

In our literature review, we have also realized that comprehensive geriatric assessments are shown to be useful in
prevenBon of post-operaBve complicaBons [8, 9]. Several studies have demonstrated the capacity of CGA to predict
post-operaBve adverse events [10]. Due to the fact that the lowest-score answers to several items on the G-8 are
known risk factors of delirium, we have also decided to verify the possible uBlity of using G-8 as a predicBon tool for
post-operaBve delirium.

SensiBvity Specicity G-8 score

31.7%
94.4%
12
45.1%
88.9%
12.5
51.2%
88.9%
13
64.6%
77.8%
13.5
73.2%
72.2%
14
85.4%
50.0%
14.5

Objectives
Previous studies had important limitaBons. First of all, the external validity was quesBonable as most paBents
included in the studies were candidates for chemotherapy. Another issue was that the reference tests (CGA domains)
did not directly measure clinical suggested made by the Geriatricians. Thirdly, there were limited studies on using G-8
as a screening tool for the comprehensive geriatric assessment and as a predicBon tool for post-operaBve
complicaBons, especially post-operaBve delirium.

between 3 and 6. Table 2 tries to demonstrate the number paBents having at least one abnormal score on a CGA
reference test. It is noted that this allows comparison with Bellera et al., who used the same reference tests.

Figure 5 -

In order to test the validity of G-8 as a screening tool for CGA (using the above-menBoned criteria of at least one
abnormality reference test as the gold standard), a receiver operaBng curve (Figure 1) was obtained aRer sensiBviBes
and speciciBes are calculated for each G-8 score cuto. We have concluded that with a G-8 cuto of 14.5, there is
good sensiKvity (85%) and acceptable specicity (50%) to idenBfy the presence of at least one abnormal reference test
in the CGA.

We have also tested the validity of G-8 as a screening tool for a GIC of more than 2 as a gold standard (Figure 2). We
have discovered that using a G-8 cuto of 13.5, there is good sensiKvity (80%) and acceptable specicity (50%) to
idenBfy paBents requiring more than 2 geriatric intervenBon categories. Therefore, G-8 could be used as a triage tool to
idenBfy paBents presenBng with more CGA abnormaliBes and requiring more geriatric intervenBons.

SensiKvity and specicity at

dierent G-8 cutos in G8 vs.
Post-operaKve delirium

Results: G-8 as a prediction tool for post-operative delirium

Figure 3 - Flow chart of paKents on roboKc hysterectomy paKents who underwent comprehensive geriatric oncology
assessments
PaBents underwent CGA
(138)

sensiBvity specicity G-8 score

Pa?ents who did not undergo

surgery
(46)

Our research objecBve would be to see in gynecology-oncology paBents undergoing roboBc surgeries, whether or
not we can validate G-8 as a screening tool with both CGA reference test abnormality (dened as one abnormality in
any one of the CGA reference test, as dened in Ballera et al.) and Geriatric intervenKon Categories (GIC) as the gold
standards as well as to validate G-8 as a screening tool for post-operaKve delirium.

Methodology
We have decided to conduct a retrospecBve cross-secBonal analyBcal study. Our study populaBon were elderly
paBents with primary gynecological cancer who were systemaBcally referred by the gynecology-oncology service at a
terBary care university hospital. The inclusion and exclusion criteria are as follows:
Inclusion criteria: over 70 years-old, primary gynecological cancer
Exclusion criteria: paBents already assessed at the geriatrics assessment clinic prior to referral to the geriatric
oncology clinic. For G-8 and post-operaBve delirium, paBents who did not undergo surgery are excluded
TEMPLATE DESIGN 2008

www.PosterPresentations.com

81.0%

11.5

71.4%

12

100.0%

68.3%

12.5

PaBents underwent surgery

(92)
Pa?ents with insucient
informa?on to calculate G-8 score
(23)

Discussion
The present study conrms the ndings of previous studies on the G-8 tool, which demonstrated that a cut-o in the
14.5 provided excellent sensiBvity in terms of screening for any abnormal value on a CGA reference test. AddiBonally,
with this study, we have possibly established the correlaBon between the G-8 and Geriatricians recommendaBons
(GICs) in a CGA, with 13.5 as an opBmal cut-o point. GICs might be another possible gold standard test to measure
CGA. Further studies are needed to validate this possibility.

PaBents with G-8 score available (69)

PaBent who developed delirium

(6)

PaBent at low risk of

delirium in CGA
(1)

PaBent at high risk of

delirium in CGA
(5)

PaBent who did not develop delirium

(63)

PaBent at low risk of

delirium in CGA
(42)

However, there are several limitaBons in this study. First of all, the low specicity means that there was a large
number of false posiBves with G-8. Despite this fact, the use of this tool could sBll potenBally decrease the referral to
geriatric oncology clinics for CGAs by at least 38%. Secondly, in this study, G-8 scores were calculated retrospecBvely,
and therefore its accuracy may potenBally be aected. A prospecBve study to validate the G-8 score is under
consideraBon. A prominent issue was that we have calculated the G-8 data based on informaBon collected before a
CGA was performed, in order to maximize its applicability in a screening seQng, i.e. before the gold-standard was
performed. This might have overesBmated the paBents G-8 score. This signies that should G-8 were performed aRer
CGA assessment, its accuracy would probably increase. Thirdly, gynecology-oncology paBents capacity to represent the
enBre geriatric oncology paBents is quesBonable. A meta-analysis on G-8s screening power for all elderly cancer
paBents should be considered so that it could be more widely adopted. Fourthly, the use of geriatric intervenBon
categories (GICs) as a measurement of CGA might not reect the vulnerability and complexity of the paBents, because
we did not account for the number of intervenBons in each category. This fact is further reected by the fact that the
Area Under the Curve (AUC) of G-8 vs. GIC is smaller than that of G-8 vs CGA reference test, meaning that G-8 is less
accurate in predicBng GIC. Nevertheless, GICs were one of the rst measurement tests to assess the direct impact of
CGAs, and a beWer GIC model (i.e. dierenBal scoring system based on the impact value of each intervenBon) could be
developed.

PaBent at high risk of

delirium in CGA
(21)

A total of 92 paBents underwent roboBc gynecological surgery. The main reasons for paBents not undergoing
surgery were: paBents undergoing chemotherapy instead, paBents already post-operaBve (referred for post-operaBve
geriatric and cogniBve assessment), paBents were unt for surgery or paBents had previous complicated surgeries.

Among 69 paBents who had G-8 score available, 6 (9.8%) developed post-operaBve delirium (Figure 3). We also
further divided delirious and non-delirious groups by the delirium risk as esBmated by the Geriatrician during the CGA.
It is noted that the majority of the paBents 21 of 26 paBents who were deemed at high risk for delirium did not develop
delirium.

Figure 4 shows the average G-8 scores as well as 95% condence intervals of the subgroups of paBents with high and
low delirium risks as well as delirium outcomes. It is noted that the mean G-8 score dierence was 3 points between
the delirious and non-delirious group. Even though this dierence is not staKsKcally signicant, but might be clinically
signicant.

Figure 5 shows the receiver-operator curve of G-8 as a predicBon tool for post-operaBve delirium. It is noted that the
sensiKvity could reach 83% and specicity 71% at a cuto score of 12. Therefore, G-8 could possibly be used to predict
post-operaBve delirium in gynecological cancer paBents undergoing roboBc surgery.

In the current study, we have also explored the usefulness of G-8 in predicBng post-operaBve complicaBons. We
have decided to focus on delirium, as several risk factors of delirium are directly tested in the G-8: age, cogniBve
impairment, depression, medical illness, funcBonal impairment and polypharmacy. It could be deducted that the
paBents with a lower G-8 score should be at higher risk for delirium. The results demonstrated that there is a clinically
signicant dierence of 2 points between paBents who developed post-operaBve delirium and those who did not. This
result is interesBng as few tools could predict delirium risk. If this result could be reproduced in large-scale studies and
in dierent oncology populaBons, the G-8 might become an easy tool that could be used in a pre-operaBve seQng in
health care faciliBes without geriatric oncology services to screen for paBents who might benet from aggressive
measures to prevent delirium. However, another possibility is that If the study is done in a larger populaBon with more
diverse primary cancer, the accuracy of the tool might decrease. A future meta-analysis will probably be useful but
more studies in dierent populaBons must be done beforehand.

Figure 4 -

Another limitaBon of this study is selecBon bias. It is possible that the paBents whose G-8 score could not be
calculated due to insucient informaBon are more frail than those with G-8 scores, and therefore the G-8 score of all
paBents referred to the geriatric oncology clinic be globally poorer. We have compared the average and condence
intervals of CGA reference test scores of the paBents with and without G-8 scores and the conclusion was that they
were similar. A prospecBve study with systemaBc use of the G-8 score will eliminate this selecBon bias.

There has been debates in the geriatric oncology community about the best way to quanBfy CGAs. There was no
consensus over one single quanBtaBve model of CGA in the geriatric oncology community[12,13]. It has been shown
that cumulated number of impairments in CGA domain is associated with adverse outcomes, in-hospital events, and
prolonged hospital stays [10,11]. We have decided to introduce the noBon of Geriatric IntervenKon Categories (GIC),
which represents the number of categories of intervenBon made aRer each CGA. The score ranges from 0 to 6, with 1
point for each of the following categories: Medical, Pharmacological, CogniKve, Psychosocial, Dietary and Mobility.
Therefore, paBents with a GIC of 0 means that CGA generated no intervenBon. On the other hand, a GIC of 6 means
that the paBent received intervenBons in each one of the 6 categories, i.e. the paBent is more impaired. For a posiBve
associaBon between G-8 and GIC to be established, a lower G-8 score should correlate with a higher GIC score. We
have also gathered data on CGA reference tests so that comparison with previous studies could be performed.

66.7%
83.3%

Figure 2 -

Conclusion
G-8 could possibly be implemented as a pracBcal and convenient screening test in the pre-operaBve seQng, inside or
outside the geriatric oncology clinic, to idenBfy paBents requiring more intervenBons and those with higher risk for
delirium. The tools simplicity of administraBon is its main strength, as it can be easily administered by a health care
professional with minimal training. A prospecBve study could beWer validate G-8 as a candidate for a good screening
tool to nd paBents who will are in higher priority for comprehensive geriatric assessment. Another research direcBon
might be the a meta-analysis in order to validate the G-8 in elderly paBents with dierent primary cancers. Finally, an
adapted model of Geriatric IntervenBon Categories (GIC) could be a beWer potenBal candidate for outcome
measurement of comprehensive geriatric assessments.

SensiKvity and specicity at

dierent G-8 cutos in G8 vs.
Geriatric IntervenKon
categories (GIC)
Sensivity Specicity G-8 score
36.0%
76.3%
12
52.0%
65.8%
12.5
64.0%
61.8%
13
80.0%
50.0%
13.5
88.0%
42.1%
14
92.0%
25.0%
14.5

Bibliography
For bibliography and addiBonal tables / gures, please send requests to haibin.yin@mcgill.ca

Dr. Haibin Yin holds an M.D. degree from University of Montreal (2010). A<er comple?ng residency at McGill
University (2014), he joined the Division of Geriatric Medicine of Jewish General Hospital in Montreal, Canada, as
aHending sta. He was appointed assistant professor of the Faculty of Medicine of McGill University in 2014.