Symptom assessment in elderly cancer patients receiving palliative care

Exploring unmet concerns in home hospice cancer care: Perspectives of patients, informal caregivers, palliative care providers, and family physicians

OBJECTIVES

The study examines perspectives of patients in home hospice care; their informal caregivers; palliative health-care providers (HCPs); and family physicians, all regarding patients' unmet needs and quality of life (QoL)-related concerns.

METHODS

Participants from all 4 groups were approached within 2 months after the patient's admission to the home hospice care unit. Participants completed Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself Concerns and Wellbeing (MYCAW) questionnaires, for patient's QoL-related concerns. Qualitative analysis of short narratives was conducted using ATLAS.ti software for systematic coding.

RESULTS

In total, 78 participants completed the study questionnaires: 24 patients, 22 informal caregivers, 22 palliative HCPs, and 11 family physicians. Informal caregivers gave higher scores (i.e., greater severity) than patients for fatigue on ESAS (p = 0.009); and family physicians lower scores than patients for ESAS drowsiness (p = 0.046). Compared with patients, palliative HCPs gave higher scores for patient emotional-spiritual concerns (77.2% vs. 41.7%, p = 0.02); lower scores for gastrointestinal concerns (p = 0.048); and higher scores for overall function (p = 0.049). Qualitative assessment identified a gap between how patients/informal caregivers vs. palliative HCPs/family physicians regard emotional-spiritual themes, including discussing issues related to death and dying.

SIGNIFICANCE OF RESULTS

The findings of the present study suggest that exploring a multifaceted cohort of home hospice patients, informal caregivers, palliative HCPs, and family physicians may provide insight on how to reduce communication gaps and address unmet needs of patients, particularly regarding emotional and spiritual concerns.

CONCLUSIONS

While the 4 groups were similar in their scoring of patient QoL-related concerns, there were discrepancies for some concerns (e.g., patient fatigue) and expectations regarding the need to discuss emotional and spiritual concerns, including on death and dying. Educational initiatives with programs providing training to all 4 groups may help bridge this gap, creating a more open and collaborative hospice care environment.

Symptoms in Patients Receiving Noninvasive Ventilation in the Intensive Care Unit

BACKGROUND

Although a multitude of studies have demonstrated the effectiveness of noninvasive ventilation (NIV) for treatment of respiratory insufficiency, there have been few investigations of patients' experiences while receiving this common treatment. Identification of the presence, intensity, and distress of symptoms during NIV will inform the development and testing of interventions to best manage them and improve patients' intensive care unit (ICU) experiences.

OBJECTIVE

The objectives of this study were (a) to identify the presence, intensity, and distress of symptoms in patients receiving NIV in the ICU using a modified version of the Edmonton Symptom Assessment Scale (MESAS) and (b) to describe the most common and distressing symptoms experienced by patients.

METHODS

A cross-sectional descriptive design was used with a convenience sample of 114 participants enrolled from three ICUs at one Midwestern medical center. Participants were approached if they were English-speaking, were 18 years old or older, and had an active order for NIV; exclusions included use of personal NIV equipment, severe cognitive impairment, or problems communicating. Demographic and clinical data were obtained from the electronic health record. Presence, intensity, and distress of patient-reported symptoms were obtained once using a modified, 11-item version of the MESAS.

RESULTS

The mean age of participants was 68 years old, and 54.4% were male. The primary type of NIV was bi-level positive airway pressure; a nasal/oral mask was most frequently used. The symptoms experienced by most of the participants were thirst, anxiety, tiredness, and restlessness; these symptoms were rated as moderate or severe in both intensity and distress by most participants experiencing the symptoms.

DISCUSSION

Patients in the ICU experience both intense and distressful symptoms that can be severe while undergoing treatment with NIV. Future research is warranted to determine these symptoms' interrelatedness and develop interventions to effectively manage patient-reported symptoms.

Intervention for Symptom Cluster Management of Fatigue, Loss of Appetite, and Anxiety among Patients with Lung Cancer undergoing Chemotherapy

Objective:

Patients with lung cancer can experience various distressing symptoms. The present study aims to use symptom cluster management intervention based on symptom management theory to moderate the severity of symptom clusters, including fatigue, loss of appetite, and anxiety, in patients with lung cancer undergoing chemotherapy.

Methods:

A quasi-experimental study was conducted using historical controls to assess and compare the effect of a novel symptom cluster management intervention on the severity of fatigue, loss of appetite, and anxiety in patients with lung cancer undergoing chemotherapy. Lung cancer patients were recruited from an outpatient chemotherapy unit at a university hospital in Thailand. Eighty participants were assigned equally to the experimental and control groups. The study outcomes, including fatigue, loss of appetite, and anxiety, were assessed with the Edmonton Symptom Assessment System at baseline and days 7, 14, and 28 postintervention. Repeated-measures ANOVA was analyzed to determine mean differences between groups across time.

Results:

Overall, anxiety decreased gradually on days 7, 14, and 28 (P < 0.001 for all time points) in the experimental group. Fatigue and loss of appetite also declined after days 14 (P < 0.001) and 28 (P < 0.001) compared to baseline. The significant effects of the interaction terms time × group (P < 0.001) for all symptoms within the cluster indicate the benefit of the intervention over time.

Conclusions:

The pattern of changes in the symptom cluster across the study period was significantly different between the two study groups. Patients in the experimental group reported an improvement in fatigue, loss of appetite, and anxiety over time after receiving the intervention. The results suggested that the symptom cluster management intervention provided a promising approach for the simultaneous treatment of multiple symptoms within a cluster.

Edmonton Symptom Assessment Scale Time Duration of Self-Completion Versus Assisted Completion in Patients with Advanced Cancer: A Randomized Comparison

INTRODUCTION

To compare the time duration of self-completion (SC) of the Edmonton Symptom Assessment Scale (ESAS) by patients with advanced cancer (ACPs) versus assisted completion (AC) with a health care professional.

MATERIALS AND METHODS

In this randomized comparison of ACPs seen in initial consultation at the outpatient Supportive Care Center at MD Anderson, ACPs who have never completed the ESAS at MD Anderson were allocated (1:1) to either SC of the ESAS form versus AC by a nurse. Time of completion was measured by the nurse using a stopwatch. Patients completed the Rapid Estimate of Adult Literacy in Medicine (REALM) test prior to administration of the ESAS. In the SC group, the nurse reviewed the responses to verify that the reported ESAS scores were correct.

RESULTS

A total of 126 ACPs were enrolled (69 patients to AC and 57 to SC). Seventy-one patients were female, median age was 60 years, and median REALM score was 65. Median (interquartile range) time (in seconds) of SC was significantly less than AC (73 [42.9-89.1] vs. 109 [79.5-136.7], p < .0001). With nurse review time included, median time of SC increased to 117 seconds, which was not significantly different from AC (p = .28). Lower literacy (REALM) score and shortness of breath were significantly associated with increased completion time (p = .007).

CONCLUSION

Regular use of ESAS will have minimal impact on clinical time, as it can be completed in about 1 minute and provides a concise yet comprehensive and multidimensional perspective of symptoms that affect quality of life of patients with cancer.

IMPLICATIONS FOR PRACTICE

Because the Edmonton Symptom Assessment Scale can be completed in less than 2 minutes, hopefully the routine use of this simple yet comprehensive and multidimensional symptom assessment tool will be used at all medical visits in all patients with cancer so that the timely management of symptoms affecting patients' lives and treatment courses can occur, further enhancing personalized cancer care.

Comparing Symptom Ratings by Staff and Family Carers in Residents Dying in Long-Term Care Facilities in Three European Countries, Results From a PACE Survey

CONTEXT

Symptom management is essential in the end-of-life care of long-term care facility residents.

OBJECTIVES

To study discrepancies and possible associated factors in staff and family carers' symptom assessment scores for residents in the last week of life.

METHODS

A postmortem survey in Belgium, The Netherlands, and Finland: staff and family carers completed the End-of-Life in Dementia-Comfort Assessment in Dying scale, rating 14 symptoms on a one-point to three-point scale. Higher scores reflect better comfort. We calculated mean paired differences in symptom, subscale, and total scores at a group level and inter-rater agreement and percentage of perfect agreement at a resident level.

RESULTS

Mean staff scores significantly reflected better comfort than those of family carers for the total End-of-Life in Dementia-Comfort Assessment in Dying (31.61 vs. 29.81; P < 0.001) and the physical distress (8.64 vs. 7.62; P < 0.001) and dying symptoms (8.95 vs. 8.25; P < 0.001) subscales. No significant differences were found for emotional distress and well-being. The largest discrepancies were found for gurgling, discomfort, restlessness, and choking for which staff answered not at all, whereas the family carer answered a lot, in respectively, 9.5%, 7.3%, 6.7%, and 6.1% of cases. Inter-rater agreement κ ranged from 0.106 to 0.204, the extent of perfect agreement from 40.8 for lack of serenity to 68.7% for crying.

CONCLUSION

There is a need for improved communication between staff and family and discussion about symptom burden in the dying phase in long-term care facilities.

Associations between baseline symptom burden as assessed by patient-reported outcomes and overall survival of patients with metastatic cancer

BACKGROUND

Serial symptom assessments using patient-reported outcomes may be challenging to implement in routine clinical practices. We aimed to determine if a single measurement of symptom burden at the time of metastatic diagnosis is associated with survival.

METHODS

We examined baseline patient-reported outcomes (within 90 days of diagnosis) of patients newly diagnosed with metastatic breast, lung, colorectal, or prostate cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire. The ESASr was categorized into physical, psychological, and total symptom domains whereby scores were classified as none to mild (0-3) or moderate to severe (4-10). Multivariable Cox proportional hazards models were constructed to evaluate the effect of baseline symptom scores on overall survival.

RESULTS

We identified 1316 patients eligible for analysis. There were 181, 601, 240, and 294 patients with breast, lung, colorectal, and prostate cancer, respectively. Approximately one-quarter of all patients reported moderate to severe physical, psychological, and total symptom subscores. On multivariable Cox regression analysis, older age (P < 0.001), male sex (P = 0.002), primary lung cancer (P < 0.001), and smoking in the previous month (P = 0.007) were predictive of inferior overall survival as were baseline moderate to severe physical (hazard ratio, 1.49; 95% confidence interval, 1.16-1.90; P = 0.002) and total symptom subscores (hazard ratio, 1.38; 95% confidence interval, 1.06-1.81; P = 0.017).

CONCLUSIONS

A single assessment of baseline symptom burden using the ESASr in patients with metastatic cancer has significant prognostic value. This may represent a feasible first step towards routine collection of patient-reported outcomes in real-world settings where serial symptom measurements can be challenging to implement.

The role of geriatric palliative care in hospitalized older adults

Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.

An Open-Label, Analgesic Efficacy and Safety of Pituitary Radiosurgery for Patients With Opioid-Refractory Pain: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Hypophysectomy performed by craniotomy or percutaneous techniques leads to complete pain relief in more than 70% to 80% of cases for opioid refractory cancer pain. Radiosurgery could be an interesting alternative approach to reduce complications.

OBJECTIVE

To assess the analgesic efficacy compared with standard of care is the primary goal. The secondary objectives are to assess ophthalmic and endocrine tolerance, drug consumption, quality of life, and mechanisms of analgesic action.

METHODS

The trial is multicenter, randomized, prospective, and open-label with 2 parallel groups. This concerns patients in palliative care suffering from nociceptive or mixed cancer pain, refractory to standard opioid therapy. Participants will be randomly assigned to the control group receiving standards of care for pain according to recommendations, or to the experimental group receiving a pituitary GammaKnife (Elekta, Stockholm, Sweden) radiosurgery (160 Gy delivered in pituitary gland) associated with standards of care. Evaluation assessments will be taken at baseline, day0, day4, day7, day14, day28, day45, month3, and month6.

EXPECTED OUTCOMES

We could expect pain improvement in 70% to 90% of cases at day4. In addition we will assess the safety of pituitary radiosurgery in a vulnerable population. The secondary endpoints could show decay of opioid consumption, good patient satisfaction, and improvement of the quality of life.

DISCUSSION

The design of this study is potentially the most appropriate to demonstrate the efficacy and safety of radiosurgery for this new indication. New recommendations could be obtained in order to improve pain relief and quality of life.

Transcultural Validation of the French Version of the Modified Edmonton Symptom Assessment Scale: The ESAS12-F

Background: Cancer-related physical symptoms can decrease patients' overall quality of life and are often underdiagnosed. The Edmonton Symptom Assessment Scale (ESAS) is widely used in palliative care for cancer patients to easily assess cancer patients' symptoms. It has been often modified, adding symptoms and explanations, and translated into many languages. The European Association of Palliative Care research team developed a database, which included the modified 12-item ESAS-r as the symptom assessment tool. Objectives: The purpose of this study was to achieve the translation and cross-cultural validation in French of the 12-item ESAS-r, the ESAS12-F. Design: A French version of the ESAS-r was developed using a standardized forward and backward translation method. Patients completed the ESAS12-F and provided feedback on the translation. Setting/Subjects: Forty-five patients with advanced cancer, followed by the palliative care team from the Lyon Sud University Hospital in France, were recruited. Results: Eighty-nine percent of patients considered the ESAS easy to understand. They highlighted some concerns more about the tool itself than the translation: the time line "now," the difficulty to quantify a symptom in a numerical evaluation. Some items (sleep and appetite) needed to be reread and for some others (digestive and psychological symptoms, and well-being) to be reordered in the questionnaire. Conclusion: The ESAS12-F is well accepted and easy to use for the cancer patients. The next step is to carry out a psychometric validation of the definitive version of the ESAS12-F.

Instruments for the functional assessment of elderly persons in palliative care: an integrative review

Abstract Objective: to identify validated instruments that can be used for the functional assessment of elderly persons in Palliative Care. Method: an integrative review focused on identifying instruments for the functional assessment of elderly persons in palliative care was carried out by searching publications in periodicals indexed in seven electronic databases. Descriptors, keywords and Boolean operators were used for a cross-database search in November 2017. A total of 357 abstracts were identified, from which 53 articles were selected for reading, of which 21 met the inclusion criteria. Results: this strategy allowed the identification of eight scales and one test for the functional assessment of elderly persons in palliative care. Conclusion: eight scales and a functional test which also provide guidelines for improving the quality of life of elderly people in palliative care were identified, demonstrating that it is practically impossible to disassociate physical functional performance from social and psychological aspects.

The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments

CONTEXT

Routine symptom assessment represents the cornerstone of symptom management. Edmonton Symptom Assessment System (ESAS) is one of the first quantitative symptom assessment batteries that allows for simple and rapid documentation of multiple patient-reported symptoms at the same time.

OBJECTIVES

To discuss the historical development of ESAS, its current uses in different settings, and future developments.

METHODS

Narrative review.

RESULTS

Since its development in 1991, ESAS has been psychometrically validated and translated into over 20 languages. We will discuss the variations, advantages, and limitations with ESAS. From the clinical perspective, ESAS is now commonly used for symptom screening and longitudinal monitoring in patients seen by palliative care, oncology, nephrology, and other disciplines in both inpatient and outpatient settings. From the research perspective, ESAS has offered important insights into the nature of symptom trajectory, symptom clusters, and symptom modulators. Furthermore, multiple clinical studies have incorporated ESAS as a study outcome and documented the impact of various interventions on symptom burden. On the horizon, multiple groups are actively investigating further refinements to ESAS, such as incorporating it in electronic health records, using ESAS as a trigger for palliative care referral, and coupling ESAS with personalized symptom goals to optimize symptom response assessment.

CONCLUSION

ESAS has evolved over the past 25 years to become an important symptom assessment instrument in both clinical practice and research. Future efforts are needed to standardize this tool and explore its full potential to support symptom management.

The Psychometric Properties and Factor Structure of Persian Version of Edmonton Symptom Assessment Scale in Cancer Patients

Context:

Edmonton Symptom Assessment Scale (ESAS) was developed to assess objective and subjective symptoms in patients with cancer in all stages of their disease.

Aim:

The aim of the study was to translate and determine the psychometric properties of ESAS in an Iranian population.

Materials and Methods:

The current study was carried out to determine reliability and validity of ESAS using 246 patients with cancer in Imam Khomeini Hospital, Ardabil, Iran. After translating the instrument to Persian, content and face validity, discriminant validity, internal consistency, and test-retest were done to determine psychometric properties of ESAS. Furthermore, the construct validity was determined using confirmatory factor analysis to evaluate factor structure of the tool in two models: single factor and three factor.

Results:

With regard to goodness of fit indices including comparative fit index, incremental fit index, and normed fit index, factor structure of ESAS was confirmed with one factor and nine items. Because the values of average variance extracted of each dimension were less than the square of correlation coefficients between the three dimensions of ESAS, three-factor model was not confirmed. Discriminant validity was confirmed by finding significant differences between the two groups, patients with good general and critically ill conditions. Cronbach's alpha for the overall ESAS was 0.88, and correlation between test-retest with 4–6 h interval was 0.86 (r = 0.86 P < 0001).

Conclusions:

This study showed that Persian version of ESAS with same factor structure mentioned in the original version is an applicable tool for assessing objective and subjective symptoms in Iranian patients with cancer.

Stability and Repeatability of the Distress Thermometer (DT) and the Edmonton Symptom Assessment System-Revised (ESAS-r) with Parents of Childhood Cancer Survivors

OBJECTIVE

Parents report psychological distress in association with their child's cancer. Reliable tools are needed to screen parental distress over the cancer trajectory. This study aimed to estimate the stability and repeatability of the Distress Thermometer (DT) and the Depression and Anxiety items of the Edmonton Symptom Assessment System-revised (ESAS-r-D; -A) in parents of children diagnosed with cancer.

METHODS

Fifty parents (28 mothers, median age = 44) of clinically stable survivors of childhood solid and brain tumours completed questionnaires about their own distress (DT, ESAS-r-D; -A, Brief Symptom Inventory-18: BSI-18, Patient Health Questionnaire-9: PHQ-9, Generalized Anxiety Disorder-7: GAD-7) and their children's quality of life (QoL; Peds Quality of Life: PedsQL) twice, with a month interval between the two assessments. At retest, parents also evaluated life events that occurred between the two time points. Hierarchical regressions explored moderators for the temporal stability of test measures.

RESULTS

Stability estimates were ICC = .78 for the DT, .55 for the ESAS-r-D, and .47 for the ESAS-r-A. Caseness agreement between test and retest was substantial for the DT, fair for the ESAS-r-D, and slight for the ESAS-r-A. Repeatability analyses indicated that the error range for the DT was more than 2 pts below/above actual measurement, whereas it was more than 3 pts for the ESAS-r-A, and 2.5 for the ESAS-r-D. Instability of the DT could be explained by changes in children's physical QoL, but not by other components of QoL or life events. No moderators of stability could be identified for the ESAS-r items.

CONCLUSIONS

The DT appears to be a fairly stable measure when the respondent's condition is stable yet with a relatively wide error range. Fluctuations in distress-related constructs may affect the temporal stability of the DT. The lower stability of ESAS-r items may result from shorter time-lapse instructions resulting in a greater sensitivity to change. Findings support future research on the DT as a reliable instrument in caregivers.

Pain Assessment--Can it be Done with a Computerised System? A Systematic Review and Meta-Analysis

Background: Mobile and web technologies are becoming increasingly used to support the treatment of chronic pain conditions. However, the subjectivity of pain perception makes its management and evaluation very difficult. Pain treatment requires a multi-dimensional approach (e.g., sensory, affective, cognitive) whence the evidence of technology effects across dimensions is lacking. This study aims to describe computerised monitoring systems and to suggest a methodology, based on statistical analysis, to evaluate their effects on pain assessment. Methods: We conducted a review of the English-language literature about computerised systems related to chronic pain complaints that included data collected via mobile devices or Internet, published since 2000 in three relevant bibliographical databases such as BioMed Central, PubMed Central and ScienceDirect. The extracted data include: objective and duration of the study, age and condition of the participants, and type of collected information (e.g., questionnaires, scales). Results: Sixty-two studies were included, encompassing 13,338 participants. A total of 50 (81%) studies related to mobile systems, and 12 (19%) related to web-based systems. Technology and pen-and-paper approaches presented equivalent outcomes related with pain intensity. Conclusions: The adoption of technology was revealed as accurate and feasible as pen-and-paper methods. The proposed assessment model based on data fusion combined with a qualitative assessment method was revealed to be suitable. Data integration raises several concerns and challenges to the design, development and application of monitoring systems applied to pain.

An instrument to collect data on frequency and intensity of symptoms in older palliative cancer patients: A development and validation study

PURPOSE

To develop and validate an instrument to collect data on symptoms (frequency/intensity) in older palliative cancer patients.

METHODS

A four-phase instrument development and validation study was performed. A preliminary version of the instrument was developed through a literature review. Face- and content validity were assessed in a Delphi-procedure with eleven experts. Cognitive interviewing with 24 older cancer patients was performed to enhance content validity of the instrument. Test-retest was performed to assess the stability.

RESULTS

An 40-item instrument was developed. The Assessment Symptoms Palliative Elderly (ASPE) collects data on frequency and intensity of 24 physical, 10 psychological, 3 functional, 1 spiritual and 2 social symptoms. Content validity was excellent (I-CVI 81.8%-100.0% and S-CVI 92.9%). Cognitive interviewing allowed to improve the content validity. Test-retest showed substantial to almost perfect agreement for 87.5% of the items. No item had poor or fair agreement.

CONCLUSION

This study resulted in the development of the ASPE which reflects good properties for face- and content validity and reliability. Cognitive interviewing has a valuable contribution in the validation process. The instrument can be used to gain insight in symptoms in older palliative cancer patients.

Validation of the Japanese Version of the Edmonton Symptom Assessment System-Revised

CONTEXT

The Edmonton Symptom Assessment System-revised (ESAS-r) is a brief and widely used symptom measurement tool.

OBJECTIVES

To validate the Japanese version of the ESAS-r in Japanese patients with cancer.

METHODS

We assessed the internal consistency, test-retest reliability, concurrent validity, and known-group validity in 292 Japanese adult patients with cancer. They completed Japanese versions of the ESAS-r, M. D. Anderson Symptom Inventory, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30.

RESULTS

Cronbach's alpha coefficient of the Japanese version of the ESAS-r was 0.87. The intraclass correlation coefficient in the test-retest examination ranged from 0.82 to 0.91 for each symptom score and was 0.90 for the total score. Pearson correlation coefficients of each ESAS-r symptom score with corresponding M. D. Anderson Symptom Inventory and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items ranged from 0.45 to 0.80. The total score of the ESAS-r was significantly higher in patients with an Eastern Cooperative Oncology Group performance status of 2-4 than in those with a performance status of 0 and 1 (P < 0.0001).

CONCLUSION

The Japanese version of the ESAS-r is a reliable and valid tool for measuring symptoms in Japanese adult patients with cancer.

The Brazilian Version of the Edmonton Symptom Assessment System (ESAS) Is a Feasible, Valid and Reliable Instrument for the Measurement of Symptoms in Advanced Cancer Patients

Purposes

To develop and validate a Portuguese version of the Edmonton Symptom Assessment System (ESAS) in Brazilian patients with advanced cancer.

Methods

The ESAS was translated and then back translated into Portuguese in accordance with international guidelines. The final version was approved by an Expert Committee after pilot testing on 24 advanced cancer patients. Subsequently, we evaluated the time to complete the assessment, the number of unanswered items, internal consistency, convergent validity, and known-group validity in a sample of 249 advanced cancer patients who completed the ESAS along with the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), Hospital Anxiety and Depression Scale (HADS), and Epworth Sleepiness Scale (ESS). A total of 90 clinically stable patients were retested after 4 to 96 hours (test-retest reliability), and 80 patients answered the ESAS after 21 (±7) days to measure scale responsiveness using an anchor-based method.

Results

The ESAS was completed in a mean time of only 2.2 minutes. The internal consistency was good (Cronbach's alpha = 0.861), and the removal of single items did not change the overall alpha value. For convergent validity, Spearman’s correlation coefficients between the ESAS symptom scores and the corresponding EORTC QLQ-C30 and ESS symptom scores ranged between 0.520 (95% CI = 0.424–0.605) and 0.814 (95% CI = 0.760–0.856), indicating moderate to strong correlations. Test-retest reliability values were considered adequate, with intraclass correlation coefficients ranging from 0.758 (95% CI = 0.627–0.843) to 0.939 (95% CI = 0.905–0.960).

Conclusions

ESAS is a feasible, valid and reliable multi-symptom assessment instrument for use in Brazil.

Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer

CONTEXT

The Edmonton Symptom Assessment System (ESAS) measures the severity of nine symptoms. Constipation and sleep disturbance are common in patients with cancer, but are not currently included in the ESAS.

OBJECTIVES

To validate the numerical rating scale (NRS) versions of ESAS and its revised version (ESAS-r), with the additional symptoms of constipation and sleep (CS), and to assess patient preference for either version.

METHODS

Outpatients with advanced cancer (N = 202) completed three assessments during a single clinic visit: ESAS-CS, and an added time window of "past 24 hours"; ESAS-r-CS, with a time window of "now" and symptom definitions; and the Memorial Symptom Assessment Scale (MSAS). Internal consistency was calculated using Cronbach's alpha. Paired t-tests compared ESAS-CS and ESAS-r-CS scores; these were correlated with MSAS using Spearman correlation coefficients. Test-retest reliability at 24 hours was assessed in 26 patients.

RESULTS

ESAS-CS and ESAS-r-CS total scores correlated well with total MSAS (Spearman's rho 0.62 and 0.64, respectively). Correlation of individual symptoms with MSAS symptoms ranged from 0.54-0.80 for ESAS-CS and 0.52-0.74 for ESAS-r-CS. Although participants preferred the ESAS-r-CS format (42.8% vs. 18.6%) because of greater clarity and understandability, the "past 24 hours" time window (52.8%) was favored over "now" (21.3%). Shortness of breath and nausea correlated better for the "past 24 hours" time window (0.8 and 0.72 vs. 0.74 and 0.64 in ESAS-r-CS, respectively). The 24-hour test-retest of the ESAS-CS demonstrated acceptable reliability (intraclass correlation coefficient = 0.69).

CONCLUSION

The ESAS-CS and ESAS-r-CS NRS versions are valid and reliable for measuring symptoms in this population of outpatients with advanced cancer. Although the ESAS-r-CS was preferred, patients favored the 24-hour time window of the ESAS-CS, which also may best characterize fluctuating symptoms.

The psychometric properties of cancer multisymptom assessment instruments: a clinical review

PURPOSE

Various instruments are used to assess both individual and multiple cancer symptoms. We evaluated the psychometric properties of cancer multisymptom assessment instruments.

METHODS

An Ovid MEDLINE search was done. All searches were limited to adults and in English. All instruments published from 2005 to 2014 (and with at least one validity test) were included. We excluded those who only reported content validity. Instruments were categorized by the three major types of symptom measurement scales employed as follows: visual analogue (VAS), verbal rating (VRS), and numerical rating (NRS) scales. They were then examined in two areas: (1) psychometric thoroughness (number of tests) and (2) psychometric strength of evidence (validity, reliability, generalizability). We also assigned an empirical global psychometric quality score (which combined the concepts of thoroughness and strength of evidence) to rank the instruments.

RESULTS

We analyzed 57 instruments (17 original, 40 modifications). They varied in types of scales used, symptom dimensions measured, and time frames evaluated. Of the 57, 10 used VAS, 28 VRS, and 19 NRS. The Edmonton Symptom Assessment System (ESAS), ESAS-Spanish, Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Symptom Distress Scale (SDS), M.D. Anderson Symptom Inventory (MDASI)-Russian, and MDASI-Taiwanese were the most comprehensively tested for validity and reliability. The ESAS, ESAS-Spanish, ASDS-2, Memorial Symptom Assessment Scale (MSAS)-SF, POMS, SDS, MDASI (and some translations), and MDASI-Heart Failure all showed good validity and reliability.

CONCLUSIONS

The MDASI appeared to be the best overall from a psychometric perspective. This was followed by the ESAS, ESAS-Spanish, POMS, SDS, and some MDASI translations. VRS-based instruments were most common. There was a wide range of psychometric rigor in validation. Consequently, meta-analysis was not possible. Most cancer multisymptom assessment instruments need further extensive validation to establish the excellent reliability and validity required for clinical utility and meaningful research.

Screening for distress in patients with cancer: methodologic considerations

Distress has been declared the 6th vital sign in Canadian cancer care. Accordingly, health care professionals in Canada are expected to screen for distress in patients with cancer, for which a toolkit has been developed. Identifying patients who may be in need of further resources has the potential to improve quality of care because those patients are more likely to have their existing distress identified and to be referred for appropriate follow-up services. The present article briefly reviews the background literature and the validation of the measures in the toolkit, and highlights future directions for methodologic validation of the toolkit for use according to the protocol.

[Depression and advanced cancer: agreement between different screening strategies]

Depression is a frequent problem in advanced cancer patients. However, there is no systematic screening for depression in the majority of cancer center resulting in underdiagnosed depression among cancer patients. The main objective of this study was to assess the level of agreement between self-reported depression by the patient and the physician and nurse assessment using the same tools. One of the secondary objectives was to estimate the possibility of a systematic and repeated (at one month) assessment. We used two scales for depression screening: the Brief Edinburg Depression Scale (BEDS) and the depression item of the Edmonton Symptom Assessment System (ESAS). Twenty-nine patients were included and eight of them (28%) had a BEDS score >6 and benefited from the initiation or modification of their antidepressant treatment. At visit 2, 15 patients were seen again and BEDS score was found ≤6 for all of them. A moderate concordance was found between assessment using the BEDS by patient and physician's (κ=0.519) and low agreement was found between physician and nurse regardless of the tool used (κ from 0.071 to 0.313). Researches with larger cohorts are now needed to confirm the benefits of depression's screening in this frail population and also to assess available strategies.

A critical analysis of test-retest reliability in instrument validation studies of cancer patients under palliative care: a systematic review

BACKGROUND

Patient-reported outcome validation needs to achieve validity and reliability standards. Among reliability analysis parameters, test-retest reliability is an important psychometric property. Retested patients must be in a clinically stable condition. This is particularly problematic in palliative care (PC) settings because advanced cancer patients are prone to a faster rate of clinical deterioration. The aim of this study was to evaluate the methods by which multi-symptom and health-related qualities of life (HRQoL) based on patient-reported outcomes (PROs) have been validated in oncological PC settings with regards to test-retest reliability.

METHODS

A systematic search of PubMed (1966 to June 2013), EMBASE (1980 to June 2013), PsychInfo (1806 to June 2013), CINAHL (1980 to June 2013), and SCIELO (1998 to June 2013), and specific PRO databases was performed. Studies were included if they described a set of validation studies. Studies were included if they described a set of validation studies for an instrument developed to measure multi-symptom or multidimensional HRQoL in advanced cancer patients under PC. The COSMIN checklist was used to rate the methodological quality of the study designs.

RESULTS

We identified 89 validation studies from 746 potentially relevant articles. From those 89 articles, 31 measured test-retest reliability and were included in this review. Upon critical analysis of the overall quality of the criteria used to determine the test-retest reliability, 6 (19.4%), 17 (54.8%), and 8 (25.8%) of these articles were rated as good, fair, or poor, respectively, and no article was classified as excellent. Multi-symptom instruments were retested over a shortened interval when compared to the HRQoL instruments (median values 24 hours and 168 hours, respectively; p = 0.001). Validation studies that included objective confirmation of clinical stability in their design yielded better results for the test-retest analysis with regard to both pain and global HRQoL scores (p < 0.05). The quality of the statistical analysis and its description were of great concern.

CONCLUSION

Test-retest reliability has been infrequently and poorly evaluated. The confirmation of clinical stability was an important factor in our analysis, and we suggest that special attention be focused on clinical stability when designing a PRO validation study that includes advanced cancer patients under PC.

Validation of the Edmonton Symptom Assessment System in Korean patients with cancer

CONTEXT

The Edmonton Symptom Assessment System (ESAS) is a brief, widely adopted, multidimensional questionnaire to evaluate patient-reported symptoms.

OBJECTIVES

To develop a Korean version of the ESAS (K-ESAS) and to perform a psychometric analysis in Korean patients with advanced cancer.

METHODS

We tested the K-ESAS in two pilot studies with 15 patients each. We assessed internal consistency, test-retest reliability, and concurrent validity in 163 Korean patients, who completed the K-ESAS along with the Korean versions of the M. D. Anderson Symptom Inventory (K-MDASI) and the Hospital Anxiety and Depression Scale (K-HADS) twice. A total of 38 patients completed the questionnaires again seven days later to assess responsiveness.

RESULTS

The K-ESAS scores had good internal consistency, with a Cronbach's alpha coefficient of 0.88, indicating that no questions had undue influence on the score. Pearson correlation coefficients for K-ESAS symptom scores between baseline and after two to four hours ranged from 0.72 (95% CI 0.64-0.79) to 0.87 (95% CI 0.82-0.90), indicating strong test-retest reliability. For concurrent validity, Pearson correlation coefficients between K-ESAS symptom scores and corresponding K-MDASI symptom scores ranged from 0.70 (95% CI 0.62-0.77) to 0.83 (95% CI 0.77-0.87), indicating good concurrent validity. For the K-HADS, concurrent validity was good for anxiety (r=0.73, 95% CI 0.65-0.79) but moderate for depression (r=0.4, 95% CI 0.26-0.52). For responsiveness, changes in K-ESAS scores after seven days were moderately correlated with changes in K-MDASI scores but weakly correlated with changes in K-HADS scores.

CONCLUSION

The K-ESAS is a valid and reliable tool for measuring multidimensional symptoms in Korean patients with cancer.

[Translation and cross-cultural adaptation of the Edmonton Symptom Assessment System for use in Palliative Care]

The objective of the study was translation and cross-cultural adaptation into Brazilian Portuguese of the instrument Edmonton Symptom Assessment System (ESAS-r). The ESAS-r is a revised version of the instrument ESAS that assesses nine symptoms in Palliative Care. This is a methodological study based on a benchmark composed of six steps: translation, synthesis, backtranslation, expert committee, pre-test and submission of translated version for consideration of the authors. As a result changes were made to the title, statements and certain terms to ensure adequacy of grammar and vocabulary. In the pre-test the term 'nausea' raised doubts, and an additional explanation on this word was suggested. Standardization of instrument columns and the replacement of the term 'depression' for 'sadness' was also recommended. In this study, the ESAS-r instrument was translated and adapted to Brazilian Portuguese, and the next step will be testing the psychometric properties.

What is the methodological rigour of palliative care research in long-term care facilities in Europe? A systematic review

BACKGROUND

The European population is rapidly ageing, resulting in increasing numbers of older people dying in long-term care facilities. There is an urgent need for palliative care in long-term care facilities.

AIM

The aim of this study was to systematically review the literature on palliative care research in long-term care facilities in Europe with respect to how the palliative care populations were described, and to determine the study designs and patient outcome measures utilized.

METHODS

We used a systematic literature review. The search strategy included searches of PubMed, Embase and PsychINFO databases from 2000 up to May 2010, using search terms related to 'palliative care' and 'end-of-life care' combined with search terms related to 'long-term care'. We selected articles that reported studies on patient outcome data of palliative care populations residing in a long-term care facility in Europe.

RESULTS

This review demonstrated that there are few, and mainly descriptive, European studies on palliative care research in long-term care facilities. Fourteen studies were retained in the review, of which eight were conducted in the Netherlands. None of these studies described their study population specifically as a palliative care or end-of-life care population. Retrospective and prospective designs were applied using many different measurement instruments. Most instruments were proxy ratings. Symptom (management) was the most frequently measured outcome.

CONCLUSION

To improve future research on palliative care in long-term care facilities, agreement on what can be considered as palliative care in long-term care facilities and, the availability of well-developed and tested measurement instruments is needed to provide more evidence, and to make future research more comparable.

The disparity between patient and nurse symptom rating in a hospice population

BACKGROUND

Meticulous assessment, monitoring, and treatment of symptoms are key components of palliative care. The Symptom Assessment Scale (SAS) is a 0-10 numerical rating scale (NRS) used for self-report of sleep, appetite, nausea, bowels, breathing, fatigue, and pain. Ideally, symptom rating should be by self-report; however, the ratings are often completed by nurses. The aim of this study was to examine the relationship between simultaneous symptom ratings of patients and nurses in an Australian inpatient palliative care unit.

METHODS

All inpatients and their treating nurse (blinded to the patient's report) scored the SAS weekly. Nurse symptom rating was considered accurate if the score for an individual symptom differed by ≤1. The relationship for each dyad was examined by comparing absolute values, mean differences, and Pearson correlations.

RESULTS

Sixty-four pairs of symptom ratings were obtained from 29 patients (mean 65 years, male 55%, malignancy 90%, mean Karnofsky 50). The absolute differences were closest for nausea, bowels, and breathing domains, and worst for appetite. Mean differences and Pearson correlations did not adequately reflect the disparity between patient and nurse symptom rating, and nurses systematically underreported symptoms. The total difference for the seven items ranged from nurses overreporting the patients' symptoms by 39 points to underreporting by 31 out of a possible 70 points.

DISCUSSION

Proxy symptom assessment only modestly correlates with patient symptom rating, can significantly misrepresent the patient's actual symptom burden, and should only be used when the patient is absolutely unable to contribute his or her own view.

The Edmonton Symptom Assessment System, a proposed tool for distress screening in cancer patients: development and refinement

OBJECTIVE

The Edmonton Symptom Assessment System (ESAS) has been proposed as one element of a distress screening strategy in cancer patients. It consists of 11-point numerical rating scales for self-report of nine common symptoms of cancer, with a 10th scale for a patient-specific symptom. The ESAS has undergone widespread adoption internationally for clinical, research and administrative purposes. Despite its rapid uptake, validity evidence has lagged behind, and concerns have been raised about feasibility and usefulness. The objective of this paper is to provide a synthesis of a program of research focusing on the psychometric properties of the ESAS.

METHODS

We describe and discuss a series of three ESAS studies undertaken by our group: (i) a review of ESAS validation studies (1991-2006); (ii) a think-aloud study conducted in 20 advanced cancer patients; and (iii) a prospective multicenter study conducted in 160 patients in different palliative care settings, comparing the ESAS with a revised version (ESAS-r).

RESULTS

The review identified 13 articles focusing on gathering reliability and/or validity evidence; the need to standardize the ESAS and conduct further validation research was apparent. The think-aloud study elucidated the complex cognitive processes by which patients arrive at symptom ratings and areas of potential difficulty in understanding and completing the ESAS. The multicenter study demonstrated that the ESAS-r was significantly easier for patients to understand.

CONCLUSIONS

Overall, our findings support consideration of the ESAS and its successor, the ESAS-r, for use in distress screening in cancer patients. Areas for future research will be presented. Copyright © 2011 John Wiley & Sons, Ltd.

A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients

CONTEXT

The Edmonton Symptom Assessment System (ESAS) is a widely used, self-report symptom intensity tool for assessing nine common symptoms in palliative care, with ratings ranging from 0 (none, best) to 10 (worst). Based on a "think-aloud" study of 20 advanced cancer patients, the ESAS was revised (ESAS-r).

OBJECTIVES

To compare the consistency of patients' symptom ratings and obtain patient perspectives regarding ease of understanding and completion between the ESAS and ESAS-r.

METHODS

Cognitively intact patients (n=160) were recruited from eight palliative care sites in Canada and Switzerland, using cross-sectional sampling (20 per site). Consenting patients completed the ESAS, ESAS-r, and a structured interview. Intraclass correlation coefficients (ICCs) were calculated to assess rating consistency.

RESULTS

In total, 1046 patients were screened. One hundred sixty were enrolled and evaluable (female 51%, median age 61 [range 34-92], lung cancer 26%, gastrointestinal cancer 22%). Mean ESAS scores ranged from 1.2 (nausea, standard deviation [SD] 2.1) to 4.3 (appetite, SD 3.3). ICCs ranged from 0.65 to 0.83, with lowest scores (<0.8) for drowsiness, appetite, and well-being. Although most patients rated both versions as very easy or easy to understand and complete, the ESAS-r was significantly easier to understand than the ESAS (P=0.008). Significantly, more patients preferred the ESAS-r (39%) than the ESAS (14%, P<0.001) because of its definitions, clarity, and format.

CONCLUSION

The ESAS-r retains core elements of the ESAS, with improved interpretation and clarity of symptom intensity assessment. It represents the next generation of ESAS development, with further validation recommended for drowsiness, appetite, and well-being.

Can the global uptake of palliative care innovations be improved? Insights from a bibliometric analysis of the Edmonton Symptom Assessment System

Clinical research is undertaken to improve care for palliative patients, but little is known about how to support the broad uptake of resultant innovations. The objectives of this paper are to: (1) explore the uptake of the Edmonton Symptom Assessment System throughout the global palliative care community through the lens of a bibliometric review - a research method that maps out the journey of new knowledge uptake by evaluating where key articles are cited in published literature; (2) construct hypotheses on attributes of the global community of palliative care learners; and (3) make inferences on approaches that could improve knowledge transfer. While preliminary, results of the study suggest several specific approaches that could support widespread uptake of innovations in palliative care: targeting publication in high impact, international journals; explicitly focusing on how the innovation is applied to best practice; encouraging additional research to expand on early studies; consciously targeting key professional groups and organizations to promote discussion in the grey literature; and early translation and promotion within multiple languages.

Constipation in persons receiving hospice care

CONTEXT

Symptom burden at the end of life is incompletely understood.

OBJECTIVES

To estimate the natural history of constipation and the relation of clinical and demographic characteristics to moderate or severe constipation among persons who received hospice care in the United States starting in 2005.

METHODS

Data were obtained from a national provider of hospice pharmacy services and included information about the hospice organization, patient demographics and clinical characteristics, constipation intensity, and drugs prescribed. Hospice nurses assessed patients' constipation during the previous 24 hours periodically, using a 0-10 numeric rating scale (NRS; 0=no intensity and 10=worst imaginable; none [NRS 0], mild [NRS 1-3], moderate [NRS 4-6], or severe [NRS 7-10]). Regression models were constructed to identify factors associated with last reported constipation severity scores.

RESULTS

Fifty thousand six hundred forty-one persons received hospice services, had at least two constipation assessments, and had complete clinical and demographic information; 55.3% of these individuals were female, 87.1% were Caucasian, and mean age was 75.9 years. Constipation was assessed a mean of four times per person; 12% of persons had moderate or severe constipation at their first or last assessment, and 19% of persons who reported moderate or severe constipation at the first assessment also had moderate or severe constipation at the last assessment. First constipation and last pain scores, having cancer, and prescription of a laxative were associated with increased likelihood of moderate or severe constipation at the last assessment.

CONCLUSIONS

These data provide insight into a common and potentially distressing symptom and also may be useful as process indicators of the quality of hospice care.

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.

Depression assessment and classification in palliative cancer patients: a systematic literature review

The objective of this study was to review the literature on depression in palliative cancer care in order to identify which assessment methods and classification systems have been used in studies of depression. Extensive electronic database searches in PubMed, CancerLit, CINAHL, PsychINFO, EMBASE and AgeLine as well as hand search were carried out. In the 202 included papers, 106 different assessment methods were used. Sixty-five of these were only used once. All together, the Hospital Anxiety and Depression Scale (HADS) was the most commonly used assessment method. However, there were regional differences and while the HADS dominated in Europe it was quite seldom used in Canada or in the USA. Few prevalence and intervention studies used assessment methods with an explicit reference to a diagnostic system. There were in total few case definitions of depression. Among these, the classifications were in general based on cut-off scores (77%) and not according to diagnostic systems. The full range of the DSM-IV diagnostic criteria was seldom assessed, i.e. less than one-third of the assessments in the review took into account the duration of symptoms and 18% assessed consequences and impact upon patient functioning. A diversity of assessment methods had been used. Few studies classified depression by referring to a diagnostic system or by using cut-off scores. Evidently, there is a need for a consensus on how to assess and conceptualize depression and related conditions in palliative care.

Older adults and cancer treatment

Approximately 60% of cancer incidence occurs in adults aged > or =65 years, yet older patients often are not accorded access to treatment trials. Therefore, providers remain uninformed about clinical and behavioral responses of older patients with cancer to cancer treatment. The objectives of this article were to provide a broad overview of some of the dimensions of cancer treatment in the elderly and to raise issues for behavioral research. The literature was reviewed in general for cancer treatment and specifically to address areas such as comorbidity, function, adverse events, palliation, side effects, social and psychological factors, cognition, and provider behavior. The authors address the importance of behavioral research and discuss issues for behavioral researchers in the context of cancer treatment. Few studies were identified that were specific to behavioral research. The results indicated that chronological age alone is an inadequate indicator to determine responses among older patients to cancer treatment. When they are selected carefully, older patients can benefit from treatment or palliation. More research is needed to define clinical and behavioral criteria for the inclusion of older patients in treatment trials.

A review of the reliability and validity of the Edmonton Symptom Assessment System

BACKGROUND

Systematic symptom reporting by patients and the use of questionnaires such as the Edmonton Symptom Assessment System (ESAS) have potential to improve clinical encounters and patient satisfaction. We review findings from published studies of the ESAS to guide use of the system and to focus research.

METHODS

A systematic search for articles from 1991 through 2007 found thirty-nine peer-reviewed papers from 25 different institutions, thirty-three of which focused on patients with cancer. Observations, data, and statistics were collated according to relevance, reliability, validity, and responsiveness.

RESULTS

Findings apply predominantly to symptomatic palliative patients with advanced cancer who were no longer receiving active oncologic therapies. Uncertainty about summarizing findings arises from frequent modification of the ESAS (altered items, scales, and time periods). Overall, reliability is established for daily administration. Scores are skewed, with a floor effect, but the relative order of symptoms by mean scores is similar across studies. Emotional symptoms are poorly captured by the depression and anxiety items. An equally weighted summation of scores may estimate a construct of "physical symptom distress," which in turn is related to performance status, palliative goals, quality of life, and well-being.

CONCLUSIONS

The ESAS is reliable, but it has restricted validity, and its use requires a sound clinical process to help interpret scores and to give them an appropriate level of attention. Research priorities are to further develop the ESAS for assessing a greater number of important physical symptoms (and to target "physical symptom distress"), and to develop a similar instrument for emotional symptoms.

The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991--2006)

INTRODUCTION

The purpose of this review was to identify and critique validation studies focusing on the Edmonton Symptom Assessment System (ESAS), a commonly used symptom assessment tool for advanced cancer and palliative patients.

METHODS

Using a comprehensive literature search, the authors identified and screened 87 publications. Thirteen articles were selected for in-depth review, based on the following inclusion criteria: psychometric studies with a primary focus on the ESAS, 1991--2006 publication dates and peer-reviewed English language publications.

RESULTS

Most studies involved cancer patients (n = 11). The ESAS format varied across studies, in terms of scale format, item number, item selection and language. Studies focused on gathering reliability estimates (n = 8), content validity evidence (n = 1), concurrent validity evidence (n = 5), predictive validity evidence (n = 1), and sensitivity and/or specificity (n = 3). None of these studies involved patients' perspectives as a source of validity evidence.

DISCUSSION

The use of varying instrument formats and limited psychometric evidence support the need for further ESAS validation studies, including the involvement of patients.

Perceptual consistency of pain and quality of life between hospice cancer patients and family caregivers: a pilot study

AIMS

Clinicians usually adjust medical management based on caregivers' observation when caring for seriously ill or cognitive-impaired patients. The purpose of this study is to research the differences in perceptual congruence of patients and caregivers when assessing patients' global pain (GP) and quality of life (QOL) in a hospice ward.

METHODS

From July 2002 to June 2004, hospice inpatients and their family caregivers were invited to participate in this study at a medical centre in Southern Taiwan. The survey was cross-sectional, incorporating patients' bio-psycho-social factors so as to understand their impacts on patients' pain perception and QOL. The bio-psycho-social factors included biological pain, physical dependence, financial difficulty, anxiety over family, existential meaning of life, uncontrolled outcome of disease and insufficient emotional support.

RESULTS

Fifty-eight patient/caregiver dyads were recruited in the study. The mean of patients' self-reported GP was higher than caregivers' rating (5.9 +/- 1.7 vs. 5.1 +/- 1.9, p < 0.05); however, the score of patients' QOL was lower in the patients than in the caregivers (6.9 +/- 1.6 vs. 7.9 +/- 1.4, p < 0.001). The result of regression analyses showed that 'biological pain', 'religion' and 'gender' were independent variables for patients' GP; however, 'biological pain' and 'gender' were factors for patients' QOL. No psychosocial factor was revealed as a factor in patient's perception of GP or QOL in this survey.

CONCLUSION

This study indicates that caregivers have the propensity to under-rate patients' pain and overvalue QOL; moreover, 'religion' and 'gender' influence patients' perception near the end-of-life. Therefore, reassessment and proper holistic approach are important in hospice care.

Multidisciplinary approach to the geriatric oncology patient

Given the dramatic demographic shift observed in developed countries, the medical community, especially oncologists, geriatricians, and primary care providers, are confronted with the expanding challenge of the management of elderly people with cancer. Ageing is associated with the accumulation of multiple and various medical and social problems. With a prevalence comparable to that of other chronic conditions in this age group, such as diabetes or dementia, cancer holds a prominent place among diseases of the elderly. The care of elderly cancer patients is fundamentally interdisciplinary. Communication and collaboration between geriatricians/primary care providers and oncologists represent key features of effective care in geriatric oncology. The combination of the disease-oriented approach of oncologists and the patient-oriented approach of geriatricians is the most powerful way to better serve this specific population. The medical approach of elderly cancer patients should ideally be under the lead of geriatricians or primary care providers sensitive to geriatric issues. Oncologists should manage the biologic consequences of the interplay between cancer and ageing. Close collaboration between clinicians will help promote active dedicated clinical research and the development of guidelines on the management of elderly people with cancer.

Errors in Symptom Intensity Self-Assessment by Patients Receiving Outpatient Palliative Care

BACKGROUND

Patient-based symptom scores are the standard method for assessment in palliative care. There has been limited research on the frequency of errors upon using this approach. The Edmonton Symptom Assessment Scale (ESAS) is a reliable and valid assessment tool routinely used for symptom intensity assessment in our cancer center.

OBJECTIVE

To determine if patients were scoring the symptoms on the ESAS in the way it was supposed to be scored.

SETTINGS

The study was carried out at the outpatient palliative care center.

DESIGN AND SUBJECTS

Retrospective review of 60 consecutive patient charts was done where the patient had initially scored the ESAS. The physician looked at this scoring on the ESAS and went back to the patient to do the scoring again to see if the patient had scored it in the way it was intended to be scored. The same physician did the assessment on all of the patients.

OUTCOME MEASURES

Level of agreement (weighted kappa) before versus after the physician visit; Screening performance of patient completed ESAS for mild and moderate symptom intensity.

RESULTS

Complete agreement ranged from 58% (sleep) to 82% (well-being); the weighted kappa ranged from 0.49 (drowsiness) to 0.78 (well-being). There was more agreement for symptoms such as dyspnea, nausea, anxiety, and depression and less agreement for symptoms such as lack of sleep and lack of appetite. The screening performance of the initial patient self assessment showed less sensitivity for nausea, drowsiness if the intensity was mild and less sensitivity for pain, nausea, anxiety, and drowsiness if the intensity was moderate.

CONCLUSIONS

Vigilance needs to be maintained about the ESAS scores done by the patients particularly for symptoms of sleep, appetite, and pain. There is a likelihood of error if doctors or nurses do not routinely check the way patients have completed the assessment form. More research is needed to determine the best way to teach patients how to minimize errors in self-reporting of symptoms.

Pain in Severe Dementia: Self-Assessment or Observational Scales?

OBJECTIVES

To assess the performance of self-assessment scales in severely demented hospitalized patients and to compare it with observational data.

DESIGN

Prospective clinical study.

SETTING

Geriatrics hospital and a geriatric psychiatry service.

PARTICIPANTS

All patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for dementia, with a Mini-Mental State Examination score less than 11 and a Clinical Dementia Rating score of 3.

MEASUREMENTS

Three self-assessment tools--the verbal, horizontal visual, and faces pain scales--were administered in randomized order. A nursing team independently completed an observational pain rating scale. Main outcomes were comprehension (ability to explain scale use and correctly indicate positions for no pain and extreme pain, on two separate occasions), inter- and intrarater reliability, and comparison of pain intensities measured by the different scales.

RESULTS

Sixty-one percent of 129 severely demented patients (mean age 83.7, 69% women) demonstrated comprehension of at least one scale. Comprehension rates were significantly better for the verbal and the faces pain scales. For patients who demonstrated good comprehension, the inter- and intrarater reliability of the three self-assessment scales was high (intraclass correlation coefficient=0.88-0.98). Correlation between the three self-assessment scales was moderate to strong (Spearman correlation coefficient (r)=0.45-0.94; P<.001). Observational rating correlated at least moderately with self-assessment (r=0.25-0.63), although for patients reporting pain, the observational rating scale underestimated severity compared with all three self-assessment scales.

CONCLUSION

Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.

Cancer symptom assessment instruments: a systematic review

PURPOSE

A variety of assessment instruments have been created to identify cancer symptoms. We reviewed systematically cancer symptom assessment instruments published in English.

METHODS

A systematic search of the MEDLINE database, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and EMBASE was performed. Non-peer-reviewed articles were identified through BIOSIS. Articles were accessed through the related article links in PubMed and references were searched by hand. Studies were included if the instrument had symptom assessment as the primary outcome. Quality-of-life instruments were excluded.

RESULTS

We identified 21 instruments; some had undergone modification or validation. An additional 28 studies examined symptom prevalence and interrelations; many involved symptom checklists. Studies varied in design, patient characteristics, symptoms, and outcome. Meta-analysis was not possible due to heterogeneity in design, study outcomes, and validation. Seventy-six articles and two conference abstracts (derived from MEDLINE, Cochrane, CINAHL, EMBASE, BIOSIS, related articles link in PubMed, and search by hand) met inclusion/exclusion criteria. The electronic search (without related links) yielded only 26% of those articles and conference abstracts that met inclusion criteria. Searches by hand of related articles identified 59% of studies.

CONCLUSION

Twenty-one instruments were identified as appropriate for clinical use. The instruments vary in symptom content and extent of psychometric validation. Both comprehensive and shorter instruments have been developed, and some instruments are intended for specific symptom assessment or symptoms related to treatment. There is no ideal instrument, and the wide variety of instruments reflects the different settings for symptom assessment. Additional research is necessary.