Dispelling Myths About Palliative Care and Older Adults

Depressive symptoms and all-cause mortality among middle-aged and older people in China and associations with chronic diseases

Introduction

It remains unclear whether depressive symptoms are associated with increased all-cause mortality and to what extent depressive symptoms are associated with chronic disease and all-cause mortality. The study aims to explore the relationship between depressive symptoms and all-cause mortality, and how depressive symptoms may, in turn, affect all-cause mortality among Chinese middle-aged and older people through chronic diseases.

Methods

Data were collected from the China Health and Retirement Longitudinal Study (CHARLS). This cohort study involved 13,855 individuals from Wave 1 (2011) to Wave 6 (2020) of the CHARLS, which is a nationally representative survey that collects information from Chinese residents ages 45 and older to explore intrinsic mechanisms between depressive symptoms and all-cause mortality. The Center for Epidemiological Studies Depression Scale (CES-D-10) was validated through the CHARLS. Covariates included socioeconomic variables, living habits, and self-reported history of chronic diseases. Kaplan-Meier curves depicted mortality rates by depressive symptom levels, with Cox proportional hazards regression models estimating the hazard ratios (HRs) of all-cause mortality.

Results

Out of the total 13,855 participants included, the median (Q1, Q3) age was 58.00 (51.00, 63.00) years. Adjusted for all covariates, middle-aged and older adults with depressive symptoms had a higher all-cause mortality rate (HR = 1.20 [95% CI, 1.09-1.33]). An increased rate was observed for 55-64 years old (HR = 1.23 [95% CI, 1.03-1.47]) and more than 65 years old (HR = 1.32 [95% CI, 1.18-1.49]), agricultural Hukou (HR = 1.44, [95% CI, 1.30-1.59]), and nonagricultural workload (HR = 1.81 [95% CI, 1.61-2.03]). Depressive symptoms increased the risks of all-cause mortality among patients with hypertension (HR = 1.19 [95% CI, 1.00-1.40]), diabetes (HR = 1.41[95% CI, 1.02-1.95]), and arthritis (HR = 1.29 [95% CI, 1.09-1.51]).

Conclusion

Depressive symptoms raise all-cause mortality risk, particularly in those aged 55 and above, rural household registration (agricultural Hukou), nonagricultural workers, and middle-aged and older people with hypertension, diabetes, and arthritis. Our findings through the longitudinal data collected in this study offer valuable insights for interventions targeting depression, such as early detection, integrated chronic disease care management, and healthy lifestyles; and community support for depressive symptoms may help to reduce mortality in middle-aged and older people.

Older persons' perceptions and experiences of community palliative care: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to critically appraise and synthesize qualitative evidence of older persons' perceptions and experiences of community palliative care.

INTRODUCTION

Palliative care focuses on the relief of symptoms and suffering at the end of life and is needed by approximately 56.8 million people globally each year. An increase in aging populations coupled with the desire to die at home highlights the growing demand for community palliative care. This review provides an understanding of the unique experiences and perceptions of older adults receiving community palliative care.

INCLUSION CRITERIA

This review appraised qualitative studies examining the perceptions and experiences of older adults (65 years or older) receiving community palliative care. Eligible research designs included, but were not limited to, ethnography, grounded theory, and phenomenology.

METHODS

A search of the literature across CINAHL (EBSCOhost), MEDLINE (Ovid), Embase (Ovid SP), Web of Science Core Collection, and Scopus databases was undertaken in July 2021 and updated November 1, 2022. Included studies were published in English between 2000 and 2022. The search for unpublished studies included ProQuest Dissertations and Theses. Study selection, quality appraisal, and data extraction were performed by 2 independent reviewers. Findings from the included studies were pooled using the JBI meta-aggregation method.

RESULTS

Nine qualitative studies involving 98 participants were included in this review. A total of 100 findings were extracted and grouped into 14 categories. Four synthesized findings evolved from these categories: i) Older persons receiving palliative care in the community recognize that their life is changed and come to terms with their situation, redefining what is normal, appreciating life lived, and celebrating the life they still have by living one day at a time; ii) Older persons receiving palliative care in the community experience isolation and loneliness exacerbated by their detachment and withdrawal from and by others; iii) Older persons receiving palliative care in the community face major challenges managing prevailing symptoms, medication management difficulties, and costs of medical care and equipment; and iv) Older persons want to receive palliative care and to die at home; however, this requires both informal and formal supports, including continuity of care, good communication, and positive relationships with health care providers.

CONCLUSIONS

Experiences and perceptions of community palliative care vary among older adults. These are influenced by the individual's expectations and needs, available services, and cost. Older adults' input into decision-making about their care is fundamental to their needs being met and is contingent on effective communication between the patient, family, and staff across services. Policy that advocates for trained palliative care staff to provide care is necessary to optimize care outcomes, while collaboration between staff and services is critical to enabling holistic care, managing symptoms, and providing compassionate care and support.

Living and dying with incurable cancer: a qualitative study on older patients' life values and healthcare professionals' responsivity

BACKGROUND

In ageing Western societies, many older persons live with and die from cancer. Despite that present-day healthcare aims to be patient-centered, scientific literature has little knowledge to offer about how cancer and its treatment impact older persons' various outlooks on life and underlying life values. Therefore, the aims of this paper are to: 1) describe outlooks on life and life values of older people (≥ 70) living with incurable cancer; 2) elicit how healthcare professionals react and respond to these.

METHODS

Semi-structured qualitative interviews with 12 older persons with advanced cancer and two group interviews with healthcare professionals were held and followed by an analysis with a grounded theory approach.

RESULTS

Several themes and subthemes emerged from the patient interview study: a) handling incurable cancer (the anticipatory outlook on "a reduced life", hope and, coping with an unpredictable disease) b) being supported by others ("being there", leaving a legacy, and having reliable healthcare professionals) and; c) making end-of-life choices (anticipatory fears, and place of death). The group interviews explained how healthcare professionals respond to the abovementioned themes in palliative care practice. Some barriers for (open) communication were expressed too by the latter, e.g., lack of continuity of care and advance care planning, and patients' humble attitudes.

CONCLUSIONS

Older adults living with incurable cancer showed particular outlooks on life and life values regarding advanced cancer and the accompanying last phase of life. This paper could support healthcare professionals and patients in jointly exploring and formulating these outlooks and values in the light of treatment plans.

Older persons' perceptions and experiences of community palliative care: a systematic review of qualitative evidence protocol

The objective of this systematic review is to identify and synthesize the best available qualitative evidence on how older persons perceive and experience community palliative care.The specific question is: What are older persons' perceptions and experiences of community palliative care?

Discursive meaning of hope for older persons with advanced cancer and their caregivers

This study used van Dijk's critical-discourse approach to explore the current societal discourse on hope and to explore the hope of older terminally ill cancer patients, their significant others and primary nurse. Forty-three newspaper articles dealing with hope and cancer were collected and analyzed to explore how hope is socially constructed by print media. Individual face-to-face, qualitative, open-ended interviews were conducted with three triads, each consisting of an older palliative cancer patient, a significant other, and a primary nurse. The predominant discourse of hope and cancer in the newspaper articles was considered ageist, conveying the message that only one legitimate hope existed for persons with cancer: hope for a cure. The study findings suggested that this message caused confusion and distress for the patients, significant others, and their primary nurses because their own discourses of hope were focused on comfort, peace, and maintaining relationships at the end of life.

The transition experience of rural older persons with advanced cancer and their families: a grounded theory study

BACKGROUND

Transitions often occur suddenly and can be traumatic to both patients with advanced disease and their families. The purpose of this study was to explore the transition experience of older rural persons with advanced cancer and their families from the perspective of palliative home care patients, bereaved family caregivers, and health care professionals. The specific aims were to: (1) describe the experience of significant transitions experienced by older rural persons who were receiving palliative home care and their families and (2) develop a substantive theory of transitions in this population.

METHODS

Using a grounded theory approach, 27 open-ended individual audio-taped interviews were conducted with six older rural persons with advanced cancer and 10 bereaved family caregivers. Four focus group interviews were conducted with 12 palliative care health care professionals. All interviews were transcribed verbatim, coded, and analyzed using Charmaz's constructivist grounded theory approach.

RESULTS

Within a rural context of isolation, lack of information and limited accessibility to services, and values of individuality and community connectedness, older rural palliative patients and their families experienced multiple complex transitions in environment, roles/relationships, activities of daily living, and physical and mental health. Transitions disrupted the lives of palliative patients and their caregivers, resulting in distress and uncertainty. Rural palliative patients and their families adapted to transitions through the processes of "Navigating Unknown Waters". This tentative theory includes processes of coming to terms with their situation, connecting, and redefining normal. Timely communication, provision of information and support networks facilitated the processes.

CONCLUSION

The emerging theory provides a foundation for future research. Significant transitions identified in this study may serve as a focus for improving delivery of palliative and end of life care in rural areas. Improved understanding of the transitions experienced by advanced cancer palliative care patients and their families, as well as the psychological processes involved in adapting to the transitions, will help health care providers address the unique needs of this vulnerable population.

Reducing the potential for suffering in older adults with advanced cancer

Objective:

To deliver quality care at the end of life, understanding the impact of various changes and life transitions that occur in older age is essential. This review seeks to uncover potential sources of distress in an elder's physical, psychological, social, and spiritual well-being to shed light on the unique challenges and needs facing this age group.

Methods:

Papers relating to older adults (aged 65 years and older or a mean age of 65 years and older) with advanced/terminal cancer receiving palliative, hospice, or end-of-life care published after 1998 were reviewed.

Results:

Older adults with advanced cancer have unique needs related to changes in their physical, psychological, social, and spirituals well-being. Changes in each of these domains offer not only the risk of causing distress but also the potential for growth and development during the final stages of advanced cancer.

Significance of results:

Being aware of the various changes that occur with aging will help health care professionals tailor interventions to promote dignity-conserving care and greatly reduce the potential for suffering at the end of life.

The hope experience of older bereaved women who cared for a spouse with terminal cancer

In this study we explore the experience and processes of hope of older women who were bereaved after caring for a spouse with terminal cancer, and we develop a tentative, emerging theory of their hope experience. We used constructivist grounded theory methods. We conducted 30 open-ended, in-depth, audiotaped interviews with 13 western Canadian women, aged 60 to 79 years, within the 1st year of bereavement, and collected 12 hope diaries. Data were analyzed using constant comparative analysis. Participants defined hope as a gradual process of regaining inner strength and building self-confidence to make sense of their completely changed situations. They were learning to stay positive and move ahead with their lives. The participants' main concern was losing hope, which they dealt with by searching for new hope through finding balance, new perspectives, and new meaning and purpose. The emerging theory is conceptualized as a spiral within the complex social context of bereavement after caregiving.

Living with hope: initial evaluation of a psychosocial hope intervention for older palliative home care patients

The overall purpose of this study was to evaluate the effectiveness of a psychosocial supportive intervention called the "Living with Hope Program" (LWHP) in increasing hope and quality of life for older adult, community-living, terminally ill cancer patients. Using a mixed method concurrent nested experimental design, 60 terminally ill cancer patients over the age of 60 years were randomly assigned to a treatment group and a control group. Baseline hope (Herth Hope Index [HHI]) and quality-of-life scores (McGill Quality of Life Questionnaire [MQOL]) were collected at the first visit in the patients' homes by trained research assistants. Those in the treatment group received the LWHP, which consisted of viewing an international award-winning video on hope and a choice of one of three hope activities to work on over a one-week period. The control group received standard care. Hope and quality-of-life data were collected one week later from both groups. Qualitative data using open-ended hope questions were collected from the treatment group. Patients receiving the LWHP had statistically significant higher hope (U=255, P=0.005) and quality-of-life scores at Visit 2 (U=294.5, P=0.027) than those in the control group. Qualitative data confirmed this finding, with the majority (61.5%) of patients in the treatment group reporting the LWHP increased their hope. This preliminary evaluation of the effectiveness of the LWHP suggests that it may increase hope and quality of life for older terminally ill cancer patients at home.