Assessment and management of cancer pain in the cognitively impaired elderly

Emotional and neurobehavioural status in chronic pain patients

OBJECTIVE

To investigate the emotional and neurobehavioural status of patients suffering from chronic pain.

METHODS

Fifteen male patients with chronic lower back pain and 15 healthy control subjects were studied for approximately six months. Pain was measured using a visual analogue scale. The WHO Neurobehavioral Core Test Battery (NCTB) was used to assess neurobehavioural effects of environmental and occupational exposures.

RESULTS

Visual analogue scale results demonstrated a modest range of reported pain (mean [± SD] 62.0 ± 10.8) in chronic pain patients, whereas control subjects reported no measurable pain. With the NCTB, it was found that scores of negative mood state, including anger-hostility, depression-dejection, fatigue-inertia and tension-anxiety in pain patients were significantly higher than scores in the control subjects. By contrast, scores of positive mood state (vigour-activity) in chronic pain patients were lower than those in the control group. The NCTB scores of the Santa Ana Dexterity and Pursuit Aiming II tests in chronic lower back pain patients were lower than those of the control group. Scores for other NCTB subtests, including the Digit Span, Benton Visual Retention and Digit Symbol tests, were not significantly different compared with controls. <span style="font-weight:

CONCLUSIONS

Chronic lower back pain patients had more negative mood and less positive mood than controls. These patients also demonstrated neuromotor deficits in coordination and reaction time. Further studies are required to examine possible neurological mechanisms and research potential intervention strategies for patients suffering from chronic pain.

Gero-Oncology Nursing Research

PURPOSE/OBJECTIVES

To analyze the development of gero-oncology research through a critical review of nursing and other relevant research as well as the present state of practice.

DATA SOURCES

Journal articles, book chapters, and personal experience.

DATA SYNTHESIS

Cancer in older adults is viewed through two investigative perspectives. The assumptions, questions, theoretical frames, and research design that follow from these investigative perspectives do not adequately meet the need to examine the interplay of responses to aging, cancer, and nursing practice. The mismatch of need, knowledge, and resources marks older adults with cancer as a special population in need of far more sophisticated research. With the synthesis of a new perspective, gero-oncology nursing research becomes age focused, more precisely shaping theoretical, methodologic, and analytic approaches.

CONCLUSIONS

Uniform attachment of chronologic age or other simple age-related variables to investigations, which is the primary consideration of age-related research, is irrelevant for older adults who are diagnosed with, treated for, live with, survive, and die from cancer. Shaping the next phase of gero-oncology research with a focus on age precisely integrates theoretical, methodologic, and analytic approaches through language specific to older adults and cancer.

IMPLICATIONS FOR NURSING

Shifting perspectives in gero-oncology nursing research will better inform future practice.

Delirium in Older Adults With Cancer: Implications for Practice and Research

PURPOSE/OBJECTIVES

To provide a comprehensive review of the literature and existing evidence-based findings on delirium in older adults with cancer.

DATA SOURCES

Published articles, guidelines, and textbooks.

DATA SYNTHESIS

Although delirium generally is recognized as a common geriatric syndrome, a paucity of empirical evidence exists to guide early recognition and treatment of this sequelae of cancer and its treatment in older adults. Delirium probably is more prevalent than citations note because the phenomenon is under-recognized in clinical practice across varied settings of cancer care.

CONCLUSIONS

Extensive research is needed to formulate clinical guidelines to manage delirium. A focus on delirium in acute care and at the end of life precludes identification of this symptom in ambulatory care, where most cancer therapies are used. Particular emphasis should address the early recognition of prodromal signs of delirium to reduce symptom severity.

IMPLICATIONS FOR NURSING

Ongoing assessment opportunities and close proximity to patients' treatment experiences foster oncology nurses' mastery of this common exemplar of altered cognition in older adults with cancer. Increasing awareness of and knowledge delineating characteristics of delirium in older patients with cancer can promote early recognition, optimum treatment, and minimization of untoward consequences associated with the historically ignored example of symptom distress.

Nursing staff members' assessments of pain in cognitively impaired nursing home residents

Our aim was to assess the reliability and validity of nursing staff members' assessments of pain in cognitively impaired nursing home residents. Participants were 57 cognitively impaired nursing home residents and 52 nursing staff members. Twenty-eight residents had mild/moderate cognitive impairment and 29 were severely impaired. Nursing staff members were asked to evaluate their patients' pain using 2 scales: the Nurse Global Scale of pain (NGS) and the Present Pain Inventory (PPI). Independent measures of pain were obtained from patient interviews, physician assessments, and from the Minimum Data Set (MDS) items; these were used to measure validity of the nursing staff's perception of pain. Test-retest and inter-rater reliabilities were also computed. Significant correlations were obtained between most of the physician-derived measures and the PPI for the moderately impaired group, but not for the severely impaired group. Both measures of nursing assistants' pain assessments correlated significantly with MDS-based measures; these correlations were higher for the less cognitively impaired group. Finally, the PPI correlated significantly and positively with resident-derived measures for those with moderate rather than severe cognitive impairment. Nursing staff members' ratings of pain were correlated with residents' level of cognitive functioning and with intake of pain medication. The results underscore the difficulty in assessing pain in those with severe cognitive impairment.

Assessing pain in cognitively impaired older adults with cancer

Assessing pain in cognitively impaired older adults with cancer presents a challenge to healthcare providers. As the age and number of older adults with cancer and cognitive impairments increase, so does the need for appropriate methods and instruments to adequately assess pain in this population. Oncology nurses report pain control to be one of the more challenging aspects of caring for patients with cancer. This article discusses methods and tools used by healthcare providers to accurately assess pain in cognitively impaired older adults with cancer, specific behavioral indicators that healthcare providers should recognize to assess pain accurately among this population, and the most appropriate pain scales to use when assessing pain in this population.

Supportive therapy of elderly cancer patients

Elderly cancer patients often require supportive care due to the physiologic decline of organs and apparatus linked with the aging process per se, and for the effects of tumor or of anticancer treatments. Pain and nutritional deficits are some clinical aspects requiring supportive care. Lack of studies on these latter topics does not allow an in depth analysis of the problem. The present review deals with literature concerning pain and nutritional problems in the general cancer population with emphasis on aspects typical for elderly cancer subjects. Physiologic and cancer-related changes in body composition, physical function and cognitive capacity of the elderly are presented and, when appropriate, linked with pathogenetic factors of pain and malnutrition, as well as their treatment. Pain demographic data, pain intensity evaluation and currently available techniques to provide pain relief such as etiologic treatment, analgesic pharmacotherapy and invasive analgesic procedures, are extensively discussed. Causes and assessment of malnutrition as well as available nutritional approaches such as oral, enteral and parenteral nutrition are also debated.