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Elderly Cancer Survivorship
Elderly And Aging Cancer Patients
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Elderly And Aging Cancer Patients
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There is about an 11 times increased risk of developing cancer in persons over age 65 and a 15 times increased risk of dying from cancer. Two-thirds of all cancer patients are over 65. By 2030, the population over 65 will reach 70 million, which will cause a marked increase in the number of persons with cancer.
The majority of the elderly and aging cancer patients are the largest recipients of chemotherapy. The largest segment of the USA population is becoming 65 years or older with a life expectation of another 15 years and should will remain functionally independent during this time. A 75-85 year old has an average life expectancy of 10 and 6 years, respectively. About 65% of new cancers diagnosed occur in the elderly --over age 65.
Older patients with cancer often require functional assistance. The need increases as cancer survivors age. Performance Status is of help in the assessment The use of the Karnofsky or ECOG (Eastern Cooperative Oncology Group) for functional grading.
An assessment of the activities of daily living and the aids necessary to improve self-care are important. Use of exercise rehabilitation physical therapy programs can help improve function. There is often need for assistance at home or the need for institutional care. Treatment toxicity and recovery time are also important factors in the functional status.
Current and projected comorbid conditions play a major role in geriatric care. Control of hypertension, diabetes, heart and lung disease are vital components of both psychological and functional status. With age and with cancer patients, any deficit can make a major difference in daily living. For example, it is known that diabetes decreases the eight-year disease-free survival of stage three colon cancer equal to the beneficial effects of adjuvant chemotherapy. Hyperinsulinemia decreases the survival in prostate, colon and breast cancer patients. Obesity projects a worse prognosis for ovarian and other cancers. Thus, comorbidity affects survival, as well as functional life.
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There is a need for special assessment for geriatric oncology patients. It should include:
- 1. Whether the patients needs assistance with activities of daily living (ADLs).
2. Whether there is a need for increased home care use or nursing home placement due to dependency and frailty.
3. A general assessment that asks the following questions:
- Can you get out of a chair without assistance, walk ten feet, return and sit down?
- Are you able to dress yourself?
- Are you able to cook and prepare your meals?
- Are you able to shop independently?
- Are you able to get out of bed without assistance?
-Are you able to go to the bathroom without assistance?
-Are you able to bathe without assistance?
4. List of comorbidities and their treatments - heart disease, hypertension, arthritis, osteoporosis, obesity, gastrointestinal problems and diabetes.
5. Weight loss -- if greater than 10% of the body weight is lost, this could indicate poor nutrition along with decreased exercise and mobility (compare weight now to six months ago and one year ago).
6. Cognitive problems - decreased cognitive function or Alzheimer's disease predicts a decrease in survival rate. Patients must be evaluated to ascertain if they correctly can take their medications on an appropriate schedule, appreciate toxicities, or if they need help in preparing and taking medications? Older patients take about three times the number of medications as younger patients. This opens up the potential for medication errors, which are not uncommon. 30 percent of outpatients have a history of adverse drug reactions, often requiring hospitalization.
7. Psychosocial problems with difficulties in coping with daily needs, as well as support from family members, friends and caregivers.
8. Preparation for potential home emergencies with a plan, -- such as having the phone numbers of the physicians in an accessible location or having friends and family learn CPR and first aid.
9. Assessment for anxiety, depression and the need for psychosocial support. - Knowing a patient's frailty, debility, cognition, ability to follow instructions and do self-care are areas requiring careful assessment and providing aid to help maintain both function and control of life.1
Depression In The Elderly Patient
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Depression is common in probably 20-30% of cancer patients. It is principally related to several factors:
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1. Concerns about the future after a cancer diagnosis, future treatments and survival after a cancer diagnosis.
2. Loss of a spouse, lack of psychosocial emotional support, stress of everyday life, stress from loss of physical function, and debility.
3. Distress and depression from personal and family problems.
4. Depression secondary to certain medications.
5. Depression secondary to physical symptoms from fatigue, pain, sleep problems, loss of appetite, inadequate food and eating intake, cognitive problems, feelings of hopelessness, feelings of guilt, and side effects from therapy.
6. Depression from lack of psychosocial support and confronting mortality and religious and spiritual issues.
7. Depression from lack of quality of life.
8. Isolation due to physical factors and emotional reasons.
9. Depression from lack of financial resources and/or financial support. This is especially true in the current economic conditions. - The treatment of depression requires psychological supportive therapy, drug therapy, and supportive care from family, friends, and caregivers. These issues are magnified when the patient is facing end-of-life considerations, or when the patient has no family and/or limited financial resources. Additionally, the specific side effects of cancer and its treatments also frequently lead to depression.
The Vulnerability Of Elderly Cancer Survivors
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People generally become more vulnerable as they age. In 2004, the Adult Protective Service agencies across the USA had over 600,000 reports of elders requiring protection. This is a potential problem for many cancer survivors, who become frail as a consequence of their advancing illness. Unfortunately, some elderly live in squalid conditions without electricity or utilities. Often their homes are contaminated with animal feces and roaches.
- There are many types of vulnerability in the elderly population:
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1. Physical abuse
2. Caregiver neglect
3. Financial exploitation
4. Self-neglect, which afflicts many older people unable to meet basic functional and living needs.
Personal neglect, in part, could be due to mental deterioration or Alzheimer's and often the inability to maintain the home or otherwise live independently.
Unsafe environments have many causes, such as living in poor housing, inadequate nursing home facilities, or if the principal caregiver is not physically or emotionally capable of providing appropriate care. Sometimes elder abuse and mistreatment can also be the cause.
There are certain situations where direct intervention by health industry professionals is mandated by law. For example, the health industry has the obligation to test the elderly for medical conditions, such as hypothyroidism, diabetes, and vitamin B12 deficiency. They must also check living conditions in which these people exist, although nurses or medical social workers may be assigned the task. They often have the obligation to help provide health care to those neglecting themselves or deferring or declining treatment. In some cases hospitalization is necessary and may be covered if needed.
The clues as to whether or not an elderly patient is at risk are not obvious. It takes a very knowledgeable physician to observe these clues. Once the condition is discovered, it requires a special skill set to provide necessary supportive care and treatments, as indicated.
The problem is growing, as the elderly population of the United States is aging dramatically. The problems are often neuropsychiatric with dementia, depression or even psychosis. Self-neglect is both a consequence and a symptom of these conditions. There have been two national studies showing that between 39 -50% of adults over 60 showed signs of self-neglect.2,3 As awareness of this condition increases, it is hoped that the needs of these patients can be better managed.
In the past, many erroneously considered the symptoms of self-neglect a lifestyle choice. However, the symptoms should be treated as a problem associated with aging. This requires the help of family, friends and caregivers who deal with the vulnerable adults. Unfortunately, many of these resources are not locally available and, if so, are often not helpful.
There is little evidence-based data on how best to approach the problem of self-neglect of the elderly population. The research, clinical, nursing, social work, legal and public health communities are needed to implemented new strategies to identify and treat patients who are neglectful. It is important to know when the elderly are in jeopardy, and research is a vital component in helping solve this problem and finding better ways of treating our frail, elderly, impaired growing adult population. This problem has enormous financial implications. It was estimated that in 2004, the cost of caring for the entire elderly community in the USA was under $500 million. Self-neglect in the elderly must be checked and corrected. As the Baby Boomer's population ages, there is an imminent risk of many elders living and dying in unsafe situations.
The sex life of elderly adults is another facet of their lives that is vulnerable to neglect. There is emerging evidence that older adults continue to have sex despite an age-related increase in the sexual dysfunction of both genders. It is important to note that the elderly are still at risk for contracting sexually transmitted infections.4 There are also specific legal statutes addressing the sex lives of the elderly in care homes that must be studied. Despite this risk, many physicians omit discussions with seniors about their sex life and many family members shy away from what can be an uncomfortable topic.5
- References
- 1
- Hybels CF, Pieper CF, Blazer DG, Fillenbaum GG, Steffens DC, Trajectories of mobility and IADL function in older patients diagnosed with major depression.Int J Geriatr Psychiatry. 2009 Jun 22.
- 2
- Choi NG, Kim J, Asseff J.Self-neglect and neglect of vulnerable older adults: reexamination of etiology., J Gerontol Soc Work. 2009 Feb-Mar;52(2):171-87.
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- Marijke A. Bremmera, Dorly J.H. Deega, Aartjan T.F. Beekmana, Brenda W.J.H. Penninxa, Paul Lipsc and Witte J.G. Hoogendijk, Major Depression in Late Life Is Associated with Both Hypo- and Hypercortisolemia, Biological Psychiatry, Volume 62, Issue 5, 1 September 2007, Pages 479-486
- 4
- Mary Ann E. Zagaria, PharmD, MS, RPh, CGP, Sexual Activity and STDs Among Seniors, US Pharm. 2008;33(8):28-30
- 5
- Bridget M. Kuehn Time for the Talk Again. Seniors need information on sexual health from the Medical News and Perspectives, JAMA, Sept. 17, 2008; 300(11):1285-86.
First appeared December 27, 2009