Management of terminal cancer in elderly patients

The effect of underweight on female and male reproduction

Chronic energy deficiency can impair the hypothalamic-pituitary-gonadal (HPG) axis and lead to hypothalamic anovulation in underweight women. This review presents the syndromes related to underweight status that are associated with infertility, summarizes the underlying mechanisms, and reviews the available treatment options. Eating disorders, such as anorexia nervosa (AN), constitute the most common cause of infertility in underweight women, who, in addition, experience miscarriages, and sexual dysfunction. The relative energy deficiency in sports (RED-S; former terminology: athlete's triad) involves menstrual dysfunction due to low energy availability, which results in anovulation. Moreover, lipodystrophies, malnutrition, starvation, systematic illnesses (malignancies, endocrinopathies, infectious diseases, advanced chronic diseases, neurologic illnesses), and the utilization of drugs can cause excessive weight loss. They may result in fertility problems due to the loss of adipose tissue and the subsequent hormonal disturbances. Each of these conditions requires multidisciplinary management. Nutritional counseling should target the restoration of energy balance by increasing intake and reducing output. Medical treatment, recommended only for patients who did not respond to standard treatment, may include antipsychotics, antidepressants, or leptin administration. Finally, psychiatric treatment is considered an integral part of the standard treatment.

Cannabinoids in the Older Person: A Literature Review

INTRODUCTION

Medical cannabinoids have received significant mainstream media attention in recent times due to an evolving political and clinical landscape. Whilst the efficacy of cannabinoids in the treatment of some childhood epilepsy syndromes is increasingly recognized, medical cannabinoids may also have potential clinical roles in the treatment of older adults. Prescribing restrictions for medical cannabinoids in certain jurisdictions (including the UK) has recently been relaxed. However, few geriatricians have the detailed knowledge or awareness of the potential risks or rewards of utilizing cannabinoids in the older person; even fewer geriatricians have direct experience of using these drugs in their own clinical practice. Older persons are more likely to suffer from medical illness representing potential indications for medical cannabinoids (e.g., pain); equally they may be more vulnerable to any adverse effects.

AIM

This narrative literature review aims to provide a brief introduction for the geriatrician to the potential indications, evidence-base, contra-indications and side effects of medical cannabinoids in older people.

METHODS

A search was conducted of CENTRAL, Medline, Embase, CINAHL and psycINFO, Cochrane and Web of Science databases. Reference lists were hand searched. Abstracts and titles were screened, followed by a full text reading of relevant articles.

RESULTS

35 studies were identified as relevant for this narrative review.

CONCLUSIONS

Cannabinoids demonstrate some efficacy in the treatment of pain and chemotherapy-related nausea; limited data suggest potential benefits in the treatment of spasticity and anxiety. Risks of cannabinoids in older patients appear to be moderate, and their frequency comparable to other analgesic drug classes. However, the quality of research is weak, and few older patients have been enrolled in cannabinoid studies. Dedicated research is needed to determine the efficiency and safety of cannabinoids in older patients.

An overview of end-of-life issues in the intensive care unit

The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.

The comparison of common cancer types and the coincidence of concomitant chronic diseases between palliative home care patients in Lodz Voivodeship and the general Polish population

INTRODUCTION

The continued growth in the number of elderly with cancer and age-related chronic diseases will cause in Poland an increase in demand for palliative care. The aim of the study was to identify chronic comorbidities and cancer types in palliative home care patients and to compare their incidence with the general Polish population.

MATERIAL AND METHODS

The data was obtained from 543 patients who received palliative home care between 2005-2009. The occurrence of the most common chronic conditions such as arterial hypertension, ischemic heart disease, diabetes, chronic pulmonary diseases and central nervous system diseases were analysed together with the cancer types.

RESULTS

The study group included 259 women (47.7%) and 284 men (52.3%) aged 25-91 years old. The most common primary neoplasm locations for men were lung (28.2% vs. 21.4% in general population) and colorectal cancer (18.7% vs. 11.4% in general population), and in women breast (19.7% vs. 22.8% in general population) and colorectal cancer (17.4% vs. 9.2% in general population). The incidence of ischemic heart disease, diabetes, and chronic pulmonary diseases was significantly different in comparison to the general populations (47.0% vs. 11.3%; 20.3% vs. 6.8%; 16.6% vs. 27.5%, respectively). The mean number of concomitant diseases was 1.6 for women and 1.8 for men vs. 1.7 and 1.2 in the general Polish population respectively.

CONCLUSIONS

The majority of the patients had concomitant disease, with cardiovascular diseases being most common. The most common primary neoplasm diagnoses in palliative home care patients were lung and colorectal cancer, which corresponds to the cancer prevalence in the general population.

Quality of life and perceived educational needs among older cancer survivors

The purpose of this study was to evaluate perceived educational needs regarding nutrition and exercise in older cancer survivors. One hundred ninety survivors, age 70.7 (7.5), completed a Survey of Needs developed from the City of Hope Quality of Life model. Fifty percent reported distress related to poor appetite, 60% reported distress related to weight change, 64% reported distress related to balance/walking/mobility difficulty, and 79% reported distress related to fatigue. Weight change, poor appetite, balance/walking/mobility difficulty, and fatigue were significantly associated with distress related to (a) managing household activities, (b) caring for family, (c) maintaining a sense of well-being, (d) coping with grief and loss, and (e) managing stress. Despite distress associated with weight change, poor appetite, mobility difficulty, and fatigue, respondents did not recognize a need for education regarding nutrition and exercise. Findings suggest that evaluating older survivors' perceptions of needs may be necessary prior to designing interventions for care.

Effects of an Individualized Caregiver Training Intervention on Self-Efficacy of Cancer Caregivers

Caring for older cancer patients after hospital discharge is challenging and many of their caregivers lack confidence to do so. This study investigated the effects of an individualized caregiver training program on self-efficacy in home care and symptom management. A total of 120 patient–caregiver dyads were randomly assigned to either the treatment ( n = 60) or control group ( n = 60). The training focused on prevention of infection, pain control, maintenance of nutrition and adequate elimination, and specific care issues identified by the caregiver. Control group received information about community-based resources. Results revealed a significant increase in self-efficacy after the training in the treatment group but not in the control group. No intervention effect was seen on caregiver’s psychological well-being (depression, anxiety, and quality of life) and patient’s physical symptoms.

Treating nausea and vomiting in palliative care: a review

Nausea and vomiting are portrayed in the specialist palliative care literature as common and distressing symptoms affecting the majority of patients with advanced cancer and other life-limiting illnesses. However, recent surveys indicate that these symptoms may be less common and bothersome than has previously been reported. The standard palliative care approach to the assessment and treatment of nausea and vomiting is based on determining the cause and then relating this back to the "emetic pathway" before prescribing drugs such as dopamine antagonists, antihistamines, and anticholinergic agents which block neurotransmitters at different sites along the pathway. However, the evidence base for the effectiveness of this approach is meager, and may be in part because relevance of the neuropharmacology of the emetic pathway to palliative care patients is limited. Many palliative care patients are over the age of 65 years, making these agents difficult to use. Greater awareness of drug interactions and QT(c) prolongation are emerging concerns for all age groups. The selective serotonin receptor antagonists are the safest antiemetics, but are not used first-line in many countries because there is very little scientific rationale or clinical evidence to support their use outside the licensed indications. Cannabinoids may have an increasing role. Advances in interventional gastroenterology are increasing the options for nonpharmacological management. Despite these emerging issues, the approach to nausea and vomiting developed within palliative medicine over the past 40 years remains relevant. It advocates careful clinical evaluation of the symptom and the person suffering it, and an understanding of the clinical pharmacology of medicines that are available for palliating them.

Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment

Pain is highly prevalent in frail older people who often have multiple co-morbidities and multiple medicines. Rational prescribing of analgesics in frail older people is complex due to heterogeneity in drug disposition, comorbid medical conditions, polypharmacy and variability in analgesic response in this population. A critical issue in managing older people with pain is the need for judicious choice of analgesics based on a comprehensive medical and medication history. Care is needed in the selection of analgesic medicine to avoid drug-drug or drug-disease interactions. People living with dementia and cognitive impairment have suboptimal pain relief which in part may be related to altered pharmacodynamics of analgesics and challenges in the systematic assessment of pain intensity in this patient group. In the absence of rigorously controlled trials in frail older people and those with cognitive impairment a pharmacologically-guided approach can be used to optimize pain management which requires a systematic understanding of the pharmacokinetics and pharmacodynamics of analgesics in frail older people with or without changes in cognition.

End-of-life care in the oldest old

Objective:

The aim of this study was to describe the last year of life of a sample of the oldest old, focusing on care trajectories, health, social networks, and function in daily life activities.

Method:

Data originated from the NONA study, a longitudinal study of 193 individuals among the oldest old living in a Swedish municipality. During this longitudinal study, 109 participants died. Approximately one month after their death, a relative was asked to participate in a telephone interview concerning their relative's last year of life. One hundred two relatives agreed to participate.

Results:

Most of the elderly in this sample of the oldest old (74.5%) died at an institution and the relatives were mostly satisfied with the end-of-life care. The oldest old relatives estimated that the health steadily declined during the last year of life, and that there was a decline in performing of daily life activities. They also estimated that those dying in institutions had fewer social contacts than those dying in a hospital or at home.

Significance of results:

Care at end of life for the oldest old is challenged by problems with progressive declines in ability to perform activities of daily living and health. The findings also highlight the need to support social networks at eldercare institutions.

A pilot study on the influence of an individualized and experiential training on cancer caregiver's self-efficacy in home care and symptom management

The aim of this pilot study was to investigate if an individualized and experiential training can promote family caregiver's confidence (self-efficacy) in home care and symptom management. The study was conducted in a hematology/oncology unit in a southeastern regional medical center. Twenty informal cancer caregivers participated in the study. The individualized and experiential training was conducted at the bedside prior to patient's hospital discharge. Self-efficacy in home care and cancer symptom management was measured using the Cancer Caregiver Self-Efficacy Measure before and after training, and at 1 week after hospital discharge of cancer patients. Results of the study showed mean Cancer Caregiver Self-Efficacy Measure increased by 41.1 points immediately after the training (z = 4.49, p < 0.001) and was 31.7 points higher at 1-week follow-up (z = 3.22, p < 0.01). The findings of this study suggest that individualized and experiential training may be another avenue for nurses, including home care nurses, to support family home caregiving. By helping family members in home care, favorable patient outcomes may be achieved, enabling older patients with cancer to stay longer in the comfort of their homes.

End-of-life issues in the acute and critically ill patient

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.

The driving brain: the CNS in the pathogenesis and treatment of anorexia-cachexia syndrome

Over the past few years, medical care has dramatically improved knowledge of the pathogenic mechanisms of diseases, leading to more effective therapies as well as improved technologies, yielded to enhance survival for diseases that, just a few decades ago, would have been considered lethal. Unfortunately, not all diseases can be completely defeated. In many circumstances, therapies may delay the progression of the disease, leading to improved survival but bringing new issues to light. Of particular interest are nutritional and metabolic alterations due to both prolonged clinical course of disease and long-term therapies. Anorexia-cachexia syndrome often complicates the course of chronic illnesses. Anorexia (i.e., loss of appetite) and cachexia (i.e., loss of weight due to lean body mass and fat-mass wasting) are both associated with a number of diseases. The aim of this article is to highlight the clinical impact of the anorexia-cachexia syndrome and to review current and future etiologic therapeutic approaches.

The older cancer patient

Providing effective and tolerable cancer treatment for the growing number of older adult patients who have cancer requires an understanding of the role of aging, comorbidity, functional status, and frailty on treatment outcomes. The incorporation of comprehensive geriatric assessment (CGA) into the care of older patients who have cancer ensures that the cognitive, physical, and psychosocial strengths and limitations of individual patients are considered in the development of treatment plans. CGA also may improve outcomes by identifying and optimally treating comorbid conditions and functional impairments. Optimal treatment of the older adult patient who has cancer starts with careful delineation of goals through conversation. The treatment plan should be comprehensive and address cancer-specific treatment, symptom-specific treatment, supportive treatment modalities, and end-of-life care.

Death, dying, and last wishes

Issues regarding patient care near the end of life can be challenging and rewarding for emergency physicians. Knowledge of the patient's wishes is essential, and may be accomplished by advance directives or communication with patients and surrogates. Resuscitative efforts are appropriate for many patients, but inappropriate for others. The goals of medicine remain the following: providing optimal health care, provision of the best possible symptom control, communication, empathy, and caring. As death approaches, provision of the best possible medical care, in accordance with the patient's wishes, can be rewarding for patients, families, and health care providers.

The older cancer survivor

Cancer is an age-related disease, and has increased in prevalence as the population has grown older. Improvements in screening and the availability of better therapeutic options contribute to burgeoning numbers of cancer survivors, who number more than 24 million worldwide. Sixty-one percent of these survivors are at least 65 years old. This review is an attempt to consolidate some of the data available in the area of cancer survivorship, with emphasis on the elderly. Our aim is to provide a better description of the population, elucidate specific physical and psychosocial sequelae secondary to cancer and it's treatment, and better understand how comorbid conditions, functional status, body-weight, and other issues contribute to quality of life, and overall health. This paper also suggests some surveillance guidelines for following elderly cancer survivors and identifies areas that require further research.

The older cancer patient

Providing effective and tolerable cancer treatment for the growing number of older adult patients who have cancer will require an understanding of the role of aging, comorbidity, functional status, and frailty on treatment outcomes. The incorporation of CGA into the care of older patients who have cancer will ensure that the heterogeneity of this population is considered in the development of treatment plans. It also may improve outcomes by identifying and optimally treating comorbid conditions and functional impairments. Optimal treatment of the older adult patient who has cancer starts with careful delineation of goals through conversation. The treatment plan should be comprehensive and address cancer-specific treatment, symptom-specific treatment, supportive treatment modalities, and end-of-life care.

Informal caregiver training on home care and cancer symptom management prior to hospital discharge: a feasibility study

PURPOSE/OBJECTIVES

To determine the feasibility of individualized caregiver training for home care and symptom management conducted at the bedside of older patients with cancer prior to hospital discharge.

DESIGN

Pilot study.

SETTING

The Extended Care Rehabilitation Center at the Durham Veterans Affairs Medical Center in North Carolina.

SAMPLE

7 female informal caregivers with a mean age of 56 (range = 26-76). More than half were African American. Most commonly, caregivers were spouses of the patients with cancer.

METHODS

Individualized and experiential training on home care and cancer symptom management was conducted at the bedside of patients before hospital discharge. Caregiver demographic data were collected. An informal interview at the end of the training asked about the usefulness of the training in preparing for home caregiving.

MAIN RESEARCH VARIABLES

Feasibility of the training.

FINDINGS

Individualized bedside training to caregivers prior to hospital discharge is feasible. All caregivers noted the relevance of the content as well as the approach to the training.

CONCLUSIONS

When given an opportunity for training on symptom management and home care, informal caregivers were very interested in participating. The individualized approach gave caregivers an opportunity to have their particular needs met. The flexibility of when to conduct the training proved to be crucial when soliciting attendance. The biggest challenge was in recruiting caregiver subjects through patients with cancer.

IMPLICATIONS FOR NURSING

The impetus now is to look at the effects of the training on caregiver-patient variables as well as the cost-effectiveness and sustainability of such an approach to caregiver training.

Embedding cancer care within pre-registration nurse education programmes: Policy, practice and opportunities for change

This paper discusses policy and professional drivers which outline the need for, and inclusion of cancer education within pre-registration nursing curricula within the UK. It also evaluates arguments in favour of the development of separate and distinctive cancer modules within nurse training programmes against those advocating a more integrated or thematic approach. The authors suggest that there are advantages and disadvantages to each strategy, and argue that the most important factor irrespective of the approach taken, is that cancer learning outcomes are clearly enunciated within all pre-registration nursing curricula and constructively aligned against teaching, learning and assessment strategies which may encompass a single module or entire programme. The authors then discuss their personal experience of teaching cancer care using both approaches and posit one suggestion for an embedded pre-registration cancer-care curriculum developed as the catalyst for a broader debate on the scope and content of cancer-care education within pre-registration nursing curricula.

Preparation of the Patient for Palliative Procedures

The primary intent of surgical procedures traditionally has been the achievement of cure. Palliative surgery is emerging as an equally legitimate strategy of care; its goals are symptom relief and enhanced quality of life based on the patient's preferences. The key to successful palliative surgery is understanding patient and family dynamics, interdisciplinary team approaches, and producing a consistent and rational treatment plan. Far from condemning a patient, palliative surgery has a potential place in many treatment plans for enhanced quality of life and longevity.

Therapy Insight: cancer anorexia–cachexia syndrome—when all you can eat is yourself

Tumor growth is associated with profound metabolic and neurochemical alterations, which can lead to the onset of anorexia-cachexia syndrome. Anorexia is defined as the loss of the desire to eat, while cachexia results from progressive wasting of skeletal muscle mass--and to a lesser extent adipose tissue--occurring even before weight loss becomes apparent. Cancer anorexia-cachexia syndrome is highly prevalent among cancer patients, has a large impact on morbidity and mortality, and impinges on patient quality of life. However, its clinical relevance is frequently overlooked, and treatments are usually only attempted during advanced stages of the disease. The pathogenic mechanisms of cachexia and anorexia are multifactorial, but cytokines and tumor-derived factors have a significant role, thereby representing a suitable therapeutic target. Energy expenditure in anorexia is frequently increased while energy intake is decreased, which further exacerbates the progressive deterioration of nutritional status. The optimal therapeutic approach to anorectic-cachectic cancer patients should be based on both changes in dietary habits, achieved via nutritional counseling; and drug therapy, aimed at interfering with cytokine expression or activity. Our improved understanding of the influence a tumor has on the host's metabolism is advancing new therapeutic approaches, which are likely to result in better preservation of nutritional status if started concurrently with specific antineoplastic treatment.

Cancer anorexia: clinical implications, pathogenesis, and therapeutic strategies

Anorexia and reduced food intake are important issues in the management of patients with cancer because they contribute to the development of malnutrition, increase morbidity and mortality, and impinge on quality of life. Accumulating evidence indicates that cancer anorexia is multifactorial in its pathogenesis, and most of the hypothalamic neuronal signalling pathways modulating energy intake are likely to be involved. Several factors are considered to be putative mediators of cancer anorexia, including hormones (eg, leptin), neuropeptides (eg, neuropeptide Y), cytokines (eg, interleukin 1 and 6, and tumour necrosis factor), and neurotransmitters (eg, serotonin and dopamine). These pathways are not isolated and distinct pathogenic mechanisms but are closely inter-related. However, convincing evidence suggests that cytokines have a vital role, triggering the complex neurochemical cascade which leads to the onset of cancer anorexia. Increased expression of cytokines during tumour growth prevents the hypothalamus from responding appropriately to peripheral signals, by persistently activating anorexigenic systems and inhibiting prophagic pathways. Hypothalamic monoaminergic neurotransmission may contribute to these effects. Thus, the optimum therapeutic approach to anorectic cancer patients should include changes in dietary habits, achieved via nutritional counselling, and drug therapy, aimed at interfering with cytokine expression or hypothalamic monoaminergic neurotransmission.