The critical unmet needs in the management of geriatric patients with MM, emphasizes the challenges in identification, referral, and follow-up care (Table 1). As identified by the steering committee, these challenges highlight the necessity for standardized practices and multidisciplinary approaches to improve patient outcomes.

The identification of older adults with MM who would benefit from a referral to geriatric oncology requires careful evaluation of key factors, tools, and challenges (Table 2). GA serves as a cornerstone for this process, enabling healthcare providers to assess frailty, comorbidities, and other vulnerabilities that may affect treatment outcomes. Below are the essential criteria and characteristics for referral, as well as a discussion on the tools and methods used for frailty detection, along with their advantages and limitations.

Key factors for patient identification for referral include age, cognitive abilities, frailty, and the presence of significant comorbidities. A specific threshold for these criteria needs to be established in clinical settings to ensure consistent and effective patient identification. For example, older adults with measurable frailty or cognitive impairments, as well as those exhibiting continuous clinical deterioration or lack of improvement despite treatment, should be prioritized for referral to geriatric oncology (1, 30).

Comorbidities play a significant role in influencing treatment decisions. (5, 41). In addition to managing comorbidities, MM presents a wide range of disease manifestations and complications, which are exacerbated by the patient’s advanced age and significantly impair quality of life. These complications require targeted management strategies to mitigate their impact (5). The CMRG Consensus Guideline Consortium emphasizes the need for a national consensus on the prevention, detection, and management of MM-related manifestations and complications. These guidelines provide evidence-based recommendations that consider the older median age of patients with MM and are aimed at improving and maintaining patient care across Canada (5).

The IMWG frailty score is an additive scoring system (0–5 points) that combines geriatric evaluation (functional status in activities of daily living (ADL), instrumental activities of daily living(IADL)), and age to classify patients into three groups: “fit” (score = 0), “intermediate fitness” (score = 1), and “frail” (score ≥2), with a score ≥2 being considered the gold standard to signify frailty (15, 30, 41). On the other hand, simplified myeloma frailty scale is designed to categorize patients based on fewer parameters, enhancing its feasibility using only two categories: nonfrail (score = 0–1) and frail (score ≥2) (14). The IMWG and simplified myeloma frailty scores are MM-specific (14, 41). Complementing this, CGA is a multidimensional, evidence-based tool that evaluates social status, comorbidities, functional and mental states, polypharmacy, nutritional status, and geriatric syndromes. This approach identifies deficits that may not be detected through routine clinical examinations, guiding treatment decisions in older oncology patients. While rarely performed, CGA has been shown to be successfully used in patients with MM (43). However, GA is preferred, carried out without the multidisciplinary team (13).

Frailty assessment tools offer significant advantages in managing older patients with MM, particularly in tailoring treatment approaches. By integrating factors such as age, functional status, and comorbidities, these tools effectively predict survival rates and treatment-related toxicity (12). GA facilitate treatment personalization, minimizing toxicity and improving clinical outcomes. Moreover, GA implementation has been shown to reduce the risk of severe AEs by approximately one-third, enhancing patient safety during treatment (12). These assessments also improve therapeutic decision-making, ensuring that frail patients receive care aligned with their functional and clinical needs. Additionally, including frail patients in clinical trials generates more applicable data for this vulnerable population, contributing to the broader relevance of research findings.

However, frailty assessments are not without challenges (44). The time-intensive and resource-demanding nature of these evaluations further hampers their routine use in clinical practice. Additionally, standard performance status tools, such as Eastern Cooperative Oncology Group (ECOG) scores, often fall short, necessitating more advanced methods for comprehensive frailty evaluation.

Post-diagnosis follow-up is crucial for the ongoing management of a patient’s health conditions, ensuring continuous care for chronic or comorbid issues alongside their treatment journey. Moreover, MM treatment is typically continuous as most patients will relapse and undergo several lines of treatment throughout their journey. This necessitates the ongoing evaluation of frailty due to its dynamic nature. Due to the dynamic state of increased vulnerability to stressors, frailty is not static or inevitable but can evolve over time. The dynamic nature of frailty highlights its potential for progression, stability, or improvement, depending on interventions and health management strategies (42, 45). As frailty changes over time, it also affects treatment options, tolerance, and overall patient outcomes (43, 46).

Geriatricians play a vital role in monitoring patients after referral, often collaborating with oncologists to deliver integrated care (47). GA contributes to developing personalized treatment plans that address individual needs, enhancing the overall quality of care and improving outcomes for elderly patients with complex health conditions (41).

As a solution to the aforementioned challenges, we propose a pathway designed to ensure that geriatric patients with MM receive appropriate, individualized assessments and interventions, according to the challenges unveiled in the Quebec healthcare system. This structured approach we have developed (Figure 1) helps identify patients who may benefit from adjustment of treatment or from geriatric consultation, ensuring that their complex needs are managed in a way that optimizes their quality of life and treatment outcomes. The pathway begins with age-based patient triage, segmenting patients by age group to determine the level of GA required:

For patients in the 75–85 age group, specific criteria are used to guide the decision for referral to a geriatric consultation. This assessment includes— Geriatric screening: Indicators like gait speed (less than 0.8 m/s), recent weight loss (5% or more in the last two months), and a Simplified IMWG Frailty Score (≥2, or, if the patient is over 80 years old, >2) help determine physical frailty levels. Cognitive Assessment: Cognitive ability is evaluated using the Mini-Cog test, selected based on expert opinion, with a score of 0–2 suggesting potential cognitive challenges (48). The chosen assessments provide a plethora of information on the functional and cognitive status of the patient more so than the standard tools currently used, allowing clinicians to identify patients who may benefit from a comprehensive geriatric assessment and support. While the criteria are structured, physicians retain the flexibility to use clinical judgment in special cases such as patients with acute medical conditions that temporarily affect cognitive function, or those with exceptional resilience despite advanced age (Figure 1). This allows them to make tailored decisions for patients who may not meet the exact criteria but still require geriatric consultation.

Once a referral is made using on the proposed screening of patient characteristics, geriatricians and geriatric oncologists conduct a thorough geriatric assessment, evaluating domains such as physical function, cognitive status, nutrition, and social support (Table 2). This comprehensive assessment informs personalized geriatric management strategies, ensuring that care plans are tailored to address the patient’s specific life goals, needs and vulnerabilities. Their responsibilities would include making treatment recommendations based on the patient’s overall health and age-related conditions. The geriatric oncology team will also put interventions in place to optimize functioning and psychosocial support to facilitate treatment experience. They advise on adjusting MM treatment regimens to improve safety and effectiveness. Comorbidity management where, geriatricians help identify and manage comorbid conditions that may interfere with MM treatment or exacerbate health risks and neuropathy detection. As an example, neuropathy is a common side effect of MM treatments, geriatricians monitor and address this condition, especially for patients who are more susceptible to treatment-related complications.

Steroid tapering in elderly MM patients requires individualized strategies to balance efficacy and minimize toxicity and highlights the roles that various healthcare professionals play in the effective management of elderly MM patients (8). Alternatively, steroid-free approaches have been successfully implemented in elderly patients with MM and should be considered (49).

Geriatricians and geriatric oncologists play vital roles in frailty assessment, treatment personalization, and managing toxicities, including steroid-related side effects. Their multidisciplinary approach ensures optimized care, focusing on quality of life and effective therapy, while fostering coordination among care teams to address the unique needs of this vulnerable patient population. Following the geriatric consultation, patients may benefit from a multidisciplinary care approach (Figure 1), where various specialists collaborate to provide holistic and comprehensive support. It is important to note that access to multidisciplinary care may vary across clinics. Social workers can assess the patient’s home environment, identify available resources, and provide guidance on accessing community or institutional support systems to address psychosocial and practical challenges. They also assist in coordinating care plans and ensuring patients and caregivers have the tools needed to navigate their treatment journey. Occupational therapists may be asked to evaluate the patient’s functional abilities, mobility, and overall well-being, working to maintain or improve their independence and quality of life. Pharmacists collaborate with other healthcare providers to ensure the safe, effective, and appropriate use of medications, carefully managing polypharmacy by addressing potential interactions, side effects, and the overall medication burden on patients. Hematologists oversee MM-specific treatment, monitoring the patient’s response to therapy and managing treatment-related toxicities, especially for patients with age-related vulnerabilities. Nutritionists track dietary intake, nutritional status, and any signs of malnutrition or treatment intolerance, offering tailored nutritional plans to support the patient’s overall health. Hematological nurses provide direct care, focusing on disease management, symptom control, and patient education, helping patients effectively manage MM and related symptoms. Geriatric oncology nurses also provide direct care. They help assess specific needs for older adults and implement interventions to improve their cancer experience. Geriatric oncology nurses also aid in maintaining communication between the geriatric and hematology teams. Through this coordinated, patient-centered approach, the multidisciplinary team aims to enhance the patient’s quality of life and treatment outcomes.

The proposed algorithm identifies key factors influencing patient referral and follow-up in geriatric MM care. However, certain components require further elaboration such as:

In addition, the algorithm refers to an ideal scenario, where multiple disciplines are available. While multidisciplinary care should be standardized, there are socio-economic and local disparities that may hinder access to care and resources.

A critical feature of the algorithm is its emphasis on conducting baseline assessments for all patients with MM. Establishing a comprehensive baseline assessment at diagnosis provides a reference point for evaluating changes in health over time.

This approach offers multiple benefits such as:

Addressing Unmet Needs

The algorithm addresses several longstanding unmet needs in geriatric MM care by providing a structured and individualized framework for patient management. The key strengths of the algorithm include:

Embedding GA into oncology workflows ensures seamless integration and accessibility for elderly patients, minimizing disruption to existing processes. Training programs for nurses and physicians equip HCPs with the skills to conduct initial screenings, identify frailty, and refer patients effectively. Standardized tools, such as the Mini-Cog and gait speed tests, bring consistency across practices, ensuring uniformity in assessments. This structured approach not only facilitates the early identification of high-risk patients but also streamlines the coordination between oncology and geriatric services.

The implementation of this algorithm (Figure 1) is expected to yield benefits. By tailoring treatment intensity for old and frail patients, adverse effects can be minimized, improving treatment tolerance and overall quality of life. Comprehensive care plans address broader health needs, enhancing functional status and social support. Moreover, targeted referrals optimize resource allocation, preventing overburdening of geriatric services while improving survival outcomes through balanced, personalized interventions that prioritize patient well-being.

Although the algorithm represents a significant advancement in geriatric MM care, further research and clinical validation are necessary to refine its components. Addressing its limitations, particularly in follow-up and multidisciplinary integration, will be essential for ensuring its widespread adoption and effectiveness.

We hope these recommendations provide clarity and actionable insights for HCPs in managing older adults with MM. By fostering a more cohesive and personalized approach to care, this framework aims to set a new standard for the management of MM in aging populations.

Given that the therapeutic landscape of MM is rapidly evolving and that geriatric MM care is an area of intensive research, we have presented recommendations based on the most up-to-date evidence and clinical experience at the time of writing. We expect best practices to advance as real-world experience with geriatric MM care accumulates and as clinical data mature.