Decision-making in cancer care for people living with dementia

End of life care for people with dementia and comorbid cancer: recent studies and research gaps

PURPOSE OF REVIEW

This narrative review examines recent research on end of life (EOL) care for people with dementia and comorbid cancer, highlighting the complexity and challenge of providing effective EOL care for this group and areas of interest for future research.

RECENT FINDINGS

People with cancer and dementia and their family/supporters have more complex care and support needs at EOL that are less well met than those of older adults with cancer alone, including questionable use of aggressive EOL care interventions, poorer access to specialist palliative care teams and poor pain management. Those diagnosed with dementia at the same time as, or after their cancer diagnosis, are at greater risk of aggressive EOL care and EOL cancer treatment and care plans that are not able to meet their care needs as dementia progresses.

SUMMARY

There is a lack of research on EOL care for people with cancer and dementia. There is little understanding of what good care for this population looks like and if and how EOL care can best meet the needs of people with cancer and dementia or their carers/supporters. More research is needed to inform improved care for this population.

Nurses' perspectives on shared decision-making in the daily care of hospitalized patients with dementia: An exploratory qualitative study

AIM

Gain insight into the process of shared decision-making (SDM) in daily hospital care for patients with dementia from nurses' perspectives.

DESIGN

Explorative qualitative design.

METHODS

In-depth digital interviews were conducted with 14 registered nurses between June and November 2022. A phenomenological approach was applied using Colaizzi's seven-step method.

RESULTS

Five themes were identified in the data: (1) SDM in daily care: How shared decision-making is applied; (2) Nurses' perceptions and competence: How nurses perceive and manage SDM; (3) Nurses' roles and advocacy: The evolving roles of nurses and their advocacy efforts, (4) Recognition of dementia and its impact: How nurses recognize and manage dementia; and (5) Interventions to support SDM: Strategies and interventions to facilitate SDM.

CONCLUSION

This study highlights the complexity of SDM in patients with dementia. It demonstrates the importance of the involvement of relatives, omission of patient goals in discussions and perceived deficiencies of nurses. The early identification of dementia, evaluation of nuanced capacity and targeted communication are essential. Further research and enhanced training are required to improve care in this context.

IMPACT

Potential areas for further research on SDM in nurses involving patients with dementia include investigating the effects of integrating goal discussions into SDM training for nurses, overcoming barriers to SDM competence, and challenging the idea that SDM is solely the responsibility of physicians. These findings highlight the need for policies that encourage interdisciplinary collaboration, address misconceptions and recommend training programmes that focus on applying SDM to the daily care of patients with dementia, thereby improving the overall quality of patient care.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Integrating Shared Decision-Making into Undergraduate Oncology Education: A Pedagogical Framework

The integration of shared decision-making (SDM) into undergraduate oncology education represents a critical evolution in medical pedagogy, reflecting the growing complexity and patient-centric focus of contemporary healthcare. This paper introduces a comprehensive pedagogical framework designed to embed SDM within the undergraduate medical curriculum, particularly in oncology, where the multiplicity of treatment options and their profound impact on patient life underscore the necessity of this approach. Grounded in a systematic literature review and aligned with established educational theories, this framework proposes twelve strategic approaches to cultivate future physicians proficient in both clinical acumen and patient-collaborative decision-making. The framework emphasizes real-world clinical experience, role-playing, case studies, and decision aids to deepen students' understanding of SDM. It advocates for the development of communication skills, ethical deliberation, and cultural competence, recognizing the multifaceted nature of patient care. The inclusion of patient narratives and evidence-based decision-making further enriches the curriculum, offering a holistic view of patient care. Additionally, the integration of digital tools within the SDM process acknowledges the evolving technological landscape in healthcare. The paper also addresses challenges in implementing this framework, such as curricular constraints and the need for educator training. It underscores the importance of continual evaluation and adaptation of these strategies to the dynamic field of medical education and practice. Overall, this comprehensive approach aims not only to enhance the quality of oncological care but also to prepare medical students for the complexities of modern medicine, where patient involvement in decision-making is both a necessity and an expectation.

Factors Related to Person-Centered Care for Older Patients With Cancer and Dementia in Designated Cancer Hospitals

BACKGROUND

Person-centered care (PCC) should be promoted for patients with cancer and dementia who are likely to be hindered from pursuing a meaningful life owing to their will not being reflected in the cancer treatment process.

OBJECTIVE

This study aimed to clarify the factors related to nurses' practice of PCC for older patients with cancer and dementia in designated cancer hospitals.

METHODS

An online cross-sectional survey was administered to nurses working at designated cancer hospitals in Japan. The survey items included demographic data and factors assumed to be related to nursing practice and practice of PCC.

RESULTS

A multiple regression analysis indicated that the factors related to the practice of PCC were attitude toward patients with dementia (β = 0.264, P < .001), holding conferences (β = 0.255, P < .001), knowledge about cancer nursing (β = 0.168, P < .001), knowledge about dementia (β = 0.128, P = .003), and participation in dementia care training (β = 0.088, P = .032).

CONCLUSIONS

Nurses' practice of PCC may not be sufficient to provide personalized care tailored to patients' cognitive function. The factors related to PCC are attitude toward patients with dementia, holding conferences, knowledge about cancer and dementia, and dementia care training.

IMPLICATIONS FOR PRACTICE

To promote PCC for patients with cancer and dementia, nurses should learn about these conditions with an interest in patients and collaborate with other professionals. Future studies should use cluster sampling and focus on the extent of cancer or dementia symptoms.

Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

BACKGROUND

Multiple long-term conditions-the co-existence of two or more chronic health conditions in an individual-present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals.

METHODS

We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings.

RESULTS

Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers (n = 13) and healthcare professionals (n = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care.

CONCLUSIONS

Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care.

Shared decision-making with older adults with cancer: Adaptation of a model through literature review and expert opinion

OBJECTIVE

To provide a literature overview of characteristics of Shared Decision Making (SDM) with specific importance to the older adult population with cancer and to tailor an existing model of SDM in patients with cancer to the needs of older adults.

METHODS

A systematic search of several databases was conducted. Eligible studies described factors influencing SDM concerning cancer treatment with adults aged 65 years or above, with any type of cancer. We included qualitative or mixed-methods studies. Themes were identified and discussed in an expert panel, including a patient-representative, until consensus was reached on an adjusted model.

RESULTS

Overall 29 studies were included and nine themes were identified from the literature. The themes related to the importance of goal setting, need for tailored information provision, the role of significant others, uncertainty of evidence, the importance of time during and outside of consultations, the possible ill-informed preconceptions that health care professionals (HCPs) might have about older adults and the specific competencies they need to engage in the SDM process with older adults. No new themes emerged from discussion with expert panel. This study presents a visual model of SDM with older patients with cancer based on the identified themes.

CONCLUSIONS

Our model shows key elements that are specific to SDM with older adults. Further research needs to focus on how to educate HCPs on the competencies needed to engage in SDM with older patients, and how to implement the model into everyday practice.

Delivering Palliative and Supportive Care for Older Adults with Cancer: Interactions between Palliative Medicine and Geriatrics

The world's population is aging rapidly, with projections indicating that by 2050 one in six people will be aged ≥65 years. As a result, the number of cancer cases in older people is expected to increase significantly. Palliative care is an essential component of cancer care with a direct impact on quality of life. However, older adults with cancer often suffer from multiple comorbidities, cognitive impairment, and frailty, posing unique challenges in the delivery of palliative care. The complex healthcare needs of older patients with cancer therefore require a comprehensive assessment, including a geriatric evaluation. Collaboration between geriatrics and palliative care can offer a solution to the challenges faced by older people with cancer, since this is a population with overlapping concerns for both disciplines. This review highlights the importance of palliative care for older adults with cancer and the benefits of a multidisciplinary approach. It also addresses the coordination of palliative care and geriatrics for specific symptom management and decision making.

Patients' views on the decision to investigate cancer symptoms in older adults: a qualitative interview study in primary care

BACKGROUND

Cancer is predominantly a disease of older adults. To date there has been little research on the experiences of older adults or their views on the diagnostic pathway.

AIM

To gain an improved understanding of the views and experiences of older adults on all aspects of cancer investigation.

DESIGN AND SETTING

This was a qualitative study using semi-structured interviews with patients aged ≥70 years. Patients were recruited from primary care in West Yorkshire, UK.

METHOD

Data were analysed using a thematic framework analysis.

RESULTS

The themes identified in participants' accounts included the patients' process of decision making, the value of having a diagnosis, the patients' experience of cancer investigations, and the impact of the COVID-19 pandemic on the diagnostic pathway. Older adults in this study indicated a clear preference for having clarity on the cause of symptoms and the diagnosis, even in the face of unpleasant investigations. Patients suggested they wanted to be involved in the decision process.

CONCLUSION

Older adults who present to primary care with symptoms suggestive of cancer may accept diagnostic testing solely for the benefit of knowing the diagnosis. There was a clear patient preference that referrals and investigations for cancer symptoms should not be deferred or delayed based on age or subjective assessments of frailty. Shared decision making and being involved in the decision-making process are important to patients, regardless of age.

The Role of Nurse on the Treatment Decision Support for Older People with Cancer: A Systematic Review

Background: The number of older adults with cancer is increasing worldwide. The role of nurses in supporting patients' decision-making is expanding, as this process is fraught with complexity and uncertainty due to comorbidities, frailty, cognitive decline, etc., in older adults with cancer. The aim of this review was to examine the contemporary roles of oncology nurses in the treatment decision-making process in older adults with cancer. Methods: A systematic review of PubMed, CINAHL, and PsycINFO databases was conducted in accordance with PRISMA guidelines. Results: Of the 3029 articles screened, 56 full texts were assessed for eligibility, and 13 were included in the review. We identified three themes regarding nurses' roles in the decision-making process for older adults with cancer: accurate geriatric assessments, provision of available information, and advocacy. Nurses conduct geriatric assessments to identify geriatric syndromes, provide appropriate information, elicit patient preferences, and communicate efficiently with patients and caregivers, promoting physicians. Time constraints were cited as a barrier to fulfilling nurses' roles. Conclusions: The role of nurses is to elicit patients' broader health and social care needs to facilitate patient-centered decision-making, respecting their preferences and values. Further research focusing on the role of nurses that considers diverse cancer types and healthcare systems is needed.

Understanding the experiences and psychosocial support needs of caregivers of people with comorbid dementia and cancer

BACKGROUND

Family carers of people living with comorbid dementia and cancer (CDC) play a vital supportive role, but this may be particularly burdensome and adversely impact their own health and wellbeing.

OBJECTIVE

To examine the experiences and psychosocial support needs of caregivers of people with CDC.

METHODS

A flyer advertising the study was distributed to relevant UK voluntary sector organisations and shared across social media. 13 carers of people with CDC were recruited. In-depth semi-structured interviews were conducted and transcripts were analysed using reflexive thematic analysis, underpinned by an inductive phenomenological approach.

RESULTS

Complex interactions of dementia and cancer resulted in heightened responsibility for carers, who played a crucial role in recognition/management of symptoms, performing difficult cancer-related care, and treatment decision-making that posed difficult ethical challenges. Care-recipients had reduced insight into their cancer diagnosis and prognosis, so carers often carried the emotional burden alone. Responsibilities faced by carers were compounded by a lack of targeted, accessible information/support for CDC. Carers expressed a desire to talk to and learn from others who understand the unique challenges of navigating cancer-related decision-making, treatment and care for people who are also living with dementia.

CONCLUSIONS

Cancer alongside dementia presents complex challenges for carers, who desire more cancer-related information and support which is tailored to people living with dementia and their family caregivers.

Cancer care for people with dementia: Literature overview and recommendations for practice and research

As many countries experience population aging, patients with cancer are becoming older and have more preexisting comorbidities, which include prevalent, age-related, chronic conditions such as dementia. People living with dementia (PLWD) are vulnerable to health disparities, and dementia has high potential to complicate and adversely affect care and outcomes across the cancer trajectory. This report offers an overview of dementia and its prevalence among patients with cancer and a summary of the research literature examining cancer care for PLWD. The reviewed research indicates that PLWD are more likely to have cancer diagnosed at an advanced stage, receive no or less extensive cancer treatment, and have poorer survival after a cancer diagnosis. These cancer disparities do not necessarily signify inappropriately later diagnosis or lower treatment of people with dementia as a group, and they are arguably less feasible and appropriate targets for care optimization. The reviewed research indicates that PLWD also have an increased risk of cancer-related emergency presentations, lower quality processes of cancer-related decision making, accessibility-related barriers to cancer investigations and treatment, higher experienced treatment burden and higher caregiver burden for families, and undertreated cancer-related pain. The authors propose that optimal cancer care for PLWD should focus on proactively minimizing these risk areas and thus must be highly person-centered, with holistic decision making, individualized reasonable adjustments to practice, and strong inclusion and support of family carers. Comprehensive recommendations are made for clinical practice and future research to help clinicians and providers deliver best and equitable cancer care for PLWD and their families.

Is there evidence of age bias in breast cancer health care professionals' treatment of older patients?

OBJECTIVES

Despite NICE (2009; 2018) guidelines to treat breast cancer patients 'irrespective of age', older women experience differential treatment and worse outcomes beyond that which can be explained by patient health or patient choice. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and perhaps perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients.

METHODS

This mixed methods study explored age bias amongst breast cancer HCPs through four components: 1) An implicit associations test (31 HCPs) 2) A treatment recommendations questionnaire (46 HCPs). 3) An attitudes about older patients questionnaire (31 HCPs). 4) A treatment recommendations interview (20 HCPs).

RESULTS

This study showed that breast cancer HCPs held negative implicit associations towards older women; HCPs were less likely to recommend surgery for older patients; some HCPs held assumptions that older patients are more afraid, less willing and able to be involved in decision-making, and are less willing and able to cope with being informed of a poor treatment prognosis; and conditions which disproportionately affect older patients, such as dementia, are not always well understood by breast cancer HCPs.

CONCLUSIONS

These results indicate that there are elements of age bias present amongst breast cancer HCPs. The study's findings of age-based assumptions and a poorer understanding of conditions which disproportionately affect older patients align with patterns of differential treatment towards older breast cancer patients suggesting that age bias may be, at least in part, driving differential treatment.

Experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to critically analyze and synthesize the experiences and perceptions of health care professionals making decisions that result in treatment recommendations for older adults living with memory loss who are experiencing health problems.

INTRODUCTION

Health care professionals provide care to older adults living with memory loss and other coexisting health conditions across all clinical settings. Older adults living with memory loss most commonly experience impaired independent decision-making, which can challenge health care professionals when decisions about treatment need to be made. These challenges contribute to older adults with memory loss receiving inappropriate treatment and experiencing higher morbidity than those without memory loss. To date, existing reviews have not focused on the experiences and perceptions of health care professionals who are making treatment decisions when older adults living with memory loss experience health problems. A deeper exploration of this evidence is needed to understand health care professionals' experiences and perceptions of treatment decision-making to support the goal of improving care for older adults.

INCLUSION CRITERIA

This systematic review will consider studies across all clinical settings focused on the experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss who are experiencing health problems.

METHODS

We will conduct a comprehensive systematic search using CINAHL, MEDLINE, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Two reviewers will independently appraise the selected studies and extract qualitative data using the recommended JBI method for study selection, critical appraisal, data extraction, and data synthesis. The ConQual approach will be applied to provide a level of confidence for the review findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021271485.

A comparison of end-of-life care patterns between older patients with both cancer and Alzheimer's disease and related dementias versus those with only cancer

INTRODUCTION

Aggressive end-of-life (EOL) care that is not aligned with the preferences of persons with cancer has negative impacts on their quality of life. Alzheimer's disease and related dementias (ADRD) could potentially complicate EOL care planning among persons with cancer. Little is known about the aggressive EOL care patterns among Medicare beneficiaries with both cancer and ADRD.

MATERIALS AND METHODS

A matched retrospective cohort was created using the 2004 to 2016 Surveillance, Epidemiology, End Results-Medicare (SEER-Medicare) data differentiated by beneficiaries' ADRD status. Beneficiaries with breast, lung, colorectal, or prostate cancer who died between January 1, 2005 and December 31, 2016, were included. Six existing domains of aggressive EOL care and one overall indicator were derived. The major predictor was having ADRD comorbidity; other covariates included sex, marital status, census tract poverty indicator, race/ethnicity, metro status, geographic location, Charlson Comorbidity Index (CCI), survival time, cancer site, and histology stage. Multivariable logistic regression models were deployed to estimate the odds of receiving aggressive EOL care.

RESULTS

The study sample was 135,380 people after the one-to-one propensity score matching. The prevalence of aggressive EOL care utilization was slightly lower in beneficiaries with both cancer and ADRD when compared to beneficiaries with cancer only (54% vs. 58%, p < 0.0001). Beneficiaries with both cancer and ADRD were less likely to receive aggressive EOL care (AOR: 0.88, 95% CI: 0.86, 0.90) versus beneficiaries with cancer only. From the multivariable logistic regression model, certain beneficiaries' characteristics were associated with higher odds of receiving aggressive EOL care, such as: beneficiaries belonging to a racial/ethnic minority, a shorter survival time, and a higher CCI score.

DISCUSSION

The combined presence of ADRD and cancer was associated with lower odds of receiving aggressive EOL care compared to the presence of only cancer; however, the prevalence difference between the cohorts was not huge. Future studies could conduct in-depth evaluations of the ADRD's influence on the EOL care utilization.

Impact of Comorbid Dementia on Patterns of Hospice Use

Background: The evidence base for understanding hospice use among persons with dementia is almost exclusively based on individuals with a primary terminal diagnosis of dementia. Little is known about whether comorbid dementia influences hospice use patterns. Objective: To estimate the prevalence of comorbid dementia among hospice enrollees and its association with hospice use patterns. Design: Pooled cross-sectional analysis of the nationally representative Health and Retirement Study (HRS) linked to Medicare claims. Subjects: Fee-for-service Medicare beneficiaries in the United States who enrolled with hospice and died between 2004 and 2016. Measurements: Dementia was assessed using a validated survey-based algorithm. Hospice use patterns were enrollment less than or equal to three days, enrollment greater than six months, hospice disenrollment, and hospice disenrollment after six months. Results: Of 3123 decedents, 465 (14.9%) had a primary hospice diagnosis of dementia and 943 (30.2%) had comorbid dementia and died of another illness. In fully adjusted models, comorbid dementia was associated with increased odds of hospice enrollment greater than six months (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI]: 1.11-2.09) and hospice disenrollment following six months of hospice (AOR = 2.55, 95% CI: 1.43-4.553). Having a primary diagnosis of dementia was associated with increased odds of hospice enrollment greater than six months (AOR = 2.62, 95% CI: 1.86-3.68), hospice disenrollment (AOR = 1.82, 95% CI: 1.32-2.51), and hospice disenrollment following six months of hospice (AOR = 4.31, 95% CI: 2.37-7.82). Conclusion: Approximately 45% of the hospice population has primary or comorbid dementia and are at increased risk for long hospice enrollment periods and hospice disenrollment. Consideration of the high prevalence of comorbid dementia should be inherent in hospice staff training, quality metrics, and Medicare Hospice Benefit policies.

Support needs of carers making proxy healthcare decisions for people with dementia: a systematic review based on the Noblit and Hare meta-ethnographic synthesis of qualitative studies

BACKGROUND

There are 50 million dementia sufferers worldwide. Decisions about healthcare often need to be made when the person with dementia lacks capacity to do so.Understanding the support needs of carers acting as proxy healthcare decision-makers will be vital in improving the decision-making process for people with dementia and addressing the holistic needs of carers.

OBJECTIVE

The objective of this study was to review the existing literature on the support needs of carers acting as proxy healthcare decision-makers for people with dementia.

DESIGN

A qualitative systematic review protocol was published on PROSPERO. The Critical Appraisal Skills Programme checklist was used to appraise study quality. A meta-ethnographic synthesis was performed to develop third-order constructs.

DATA SOURCES

A search was conducted using three online databases (MEDLINE, CINAHL and PsycINFO).

ELIGIBILITY CRITERIA

Fifteen studies met the inclusion criteria: primary qualitative research involving carers of people with dementia who had been involved in making proxy healthcare decisions.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers conducted validity assessments for each paper selected for inclusion, and discrepancies were resolved by discussions with a third reviewer. Nvivo software was used and conceptual findings from study papers lead to interpretations of findings by the team.

RESULTS

From the 15 papers included in the study, three main domains arose from the meta-ethnography; informational, practical and emotional. Informational support needs included information about dementia itself and the anticipated disease trajectory. Practical needs included continuity of care, person-centred care and the use of legal frameworks.Emotional support included recognising the guilt that healthcare decisions can provoke and the importance of providing guidance in an empathic manner.

CONCLUSIONS

This meta-ethnography highlights opportunities for healthcare professionals and policymakers to improve experiences of carers making proxy healthcare decisions for people with dementia.

PROSPERO REGISTRATION NUMBER

CRD42020124485.

Treatment and prognosis of patients with both cancer and impaired decision-patient with both cancer and dementia making as a symptom of dementia

AIM

In our aging society, the number of patients with both cancer and dementia has recently been increasing. One of the major clinical questions is whether patients with dementia could receive appropriate cancer treatment. The purpose of this study is to know the prognosis of patients with both cancer and impaired decision-making as a symptom of dementia, and to discuss the proper cancer treatment of the patients with dementia.

METHODS

Patients newly diagnosed with both cancer and impaired decision-making as a symptom of dementia at Ehime University Hospital between January 2010 and December 2016 were reviewed. The data of patients with cancer were retrospectively analyzed using an electronic medical record system.

RESULTS

In total, 9354 cases were diagnosed with cancer in the Ehime University Hospital over 7 years, and only 105 (1.1%) cases with impaired decision-making as a symptom of dementia were recorded by medical professionals, probably due to poor attention to the cognitive functions of patients with cancer. Analysis of the cancer prognosis of these patients showed that a better prognosis was seen in patients with any therapeutic interventions than in those with no treatment for the cancer itself. However, the prognosis of patients was not significantly different between standard and non-standard treatments.

CONCLUSIONS

This study suggests that the poor interest of medical professionals in the cognitive function of patients with cancer at the time of diagnosis of cancer and the lack of any guidelines for patients with both cancer and dementia are major problems in our aging society. Geriatr Gerontol Int 2021; 21: 1105-1110.

Balancing the needs of individuals and services in cancer treatment for people with dementia: A focused ethnographic study

BACKGROUND

Managing multiple conditions is difficult for patients and their families, increasing complexity in care. Two of the most common long-term conditions, cancer and dementia, both disproportionately affect older adults. However, little is known about the needs and experiences of those living with both conditions, which could inform practice in the area.

OBJECTIVES

This focused ethnographic study sought to understand how oncology services balance the unique and complex needs of these patients with those of the service more widely.

DESIGN

Focused ethnography.

SETTING

Two National Health Service hospital trusts.

PARTICIPANTS

Seventeen people with dementia and cancer, 22 relatives and 19 staff members participated.

METHODS

Participant observation, informal conversations, semi-structured interviews, and medical notes review.

RESULTS

Improved satisfaction and outcomes of care were reported when staff were delivering person-centred care. Staff tried to balance the need for personalised and flexible support for individuals with dementia with managing targets and processes of cancer care and treatment. The importance of continuity of people, places, and processes was consistently highlighted.

CONCLUSION

Navigating and managing the delicate balance between the needs of the individual and the needs of services more widely was difficult for both staff and patients. Improved awareness, identification and documentation of dementia would help to ensure that staff are aware of any specific patient needs. Consistency in staffing and appointment locations should develop familiarity and routine for people with dementia.

Cancer and Aging: Two Tightly Interconnected Biological Processes

Age is one of the main risk factors of cancer; several biological changes linked with the aging process can explain this. As our population is progressively aging, the proportion of older patients with cancer is increasing significantly. Due to the heterogeneity of general health and functional status amongst older persons, treatment of cancer is a major challenge in this vulnerable population. Older patients often experience more side effects of anticancer treatments. Over-treatment should be avoided to ensure an optimal quality of life. On the other hand, under-treatment due to fear of toxicity is a frequent problem and can lead to an increased risk of relapse and worse survival. There is a delicate balance between benefits of therapy and risk of toxicity. Robust biomarkers that reflect the body's biological age may aid in outlining optimal individual treatment regimens for older patients with cancer. In particular, the impact of age on systemic immunity and the tumor immune infiltrate should be considered, given the expanding role of immunotherapy in cancer treatment. In this review, we summarize current knowledge concerning the mechanistic connections between aging and cancer, as well as aging biomarkers that could be helpful in the field of geriatric oncology.

Understanding and identifying ways to improve hospital-based cancer care and treatment for people with dementia: an ethnographic study

Background

Providing cancer care and treatment for ageing populations with complicating comorbidities like dementia is a growing global challenge. This study aimed to examine the hospital-based cancer care and treatment challenges and support needs of people with dementia, and identify potential ways to address these.

Methods

A two-site ethnographic study in England involving semi-structured interviews, observations and accompanying conversations, and medical record review. Participants (N = 58) were people with dementia and comorbid cancer (n = 17), informal caregivers (n = 22) and hospital staff (n = 19). Ethnographically informed thematic analysis was conducted.

Results

There was an accumulated complexity of living with both illnesses simultaneously. People with dementia and families could feel confused and uninformed due to difficulties understanding, retaining and using cancer information, which impacted their informed treatment decision-making. Dementia increased the complexity and burden of travelling to and navigating unfamiliar hospital environments, frequent lengthy periods of waiting in hospital, and self-managing symptoms and side-effects at home. Oncology staff were often working without the full picture, due to variable documenting of dementia in medical records, dementia training was limited, and time and resource pressures impeded the highly individualised, flexible cancer care required by people with dementia. Supportive family carers were crucial in enabling people with dementia to access, navigate and undergo cancer treatment and care.

Conclusions

Dementia complicates cancer care in a range of ways accumulating across the cancer pathway. Our findings suggest there are several strategies and interventions, which we list here, with potential to improve cancer care and treatment for people with dementia and their families.