High Symptom Burden and Low Functional Status in the Setting of Multimorbidity

Cross-cultural adaptation and validation of the caregiver self-efficacy in contributing to patient self-care scale in China

BACKGROUND

Caregiver self-efficacy is crucial in improving patient outcomes and caregiver well-being, but there is a lack of suitable scales to assess this concept within the context of Chinese culture. This study aimed to cross-culturally translate the Caregiver Self-Efficacy in Contributing to Patient Self-Care (CSE-CSC) Scale and evaluate its psychometric properties using classical test theory and item response theory.

METHODS

The CSE-CSC scale was adapted using Brislin's translation model after obtaining authorization from the original author. A multicenter, cross-sectional study was conducted to assess the psychometric properties of this scale. Classical test theory was used to evaluate reliability (internal consistency, test-retest reliability), validity (content validity, structural validity, convergent validity), and floor and ceiling effects. Item response theory was employed to assess the fit of the rating scale model, reliability, item difficulties, and measurement invariance.

RESULTS

The translation and cultural adaptation process was completed. Classical test theory demonstrated good internal consistency (Cronbach's α = 0.935) and test-retest reliability (ICC from 0.784 to 0.829, p<0.001). The I-CVI and K* of each item ranged from 0.875 to 1.00 and 0.871 to 1.00. The first-order 2-factor model fit well (χ2/df = 3.71, RMSEA = 0.082, SRMR = 0.032, CFI = 0.973, TLI = 0.60). Convergent validity showed that the CSE-CSC scores had a strong positive correlation with three separate scales of the CC-SC-CII. There was no floor and ceiling effect in this scale. Rasch analysis showed that the CSE-CSC scale demonstrated a good fit to the rating scale model and exhibited excellent reliability (person/item separation index>2, person/item reliability coefficients>0.8). The Wright map showed that item difficulty matched the respondents' measured abilities. The analysis of differential item functioning (DIF) showed that all items were comparable in gender.

CONCLUSIONS

This study indicated that the CSE-CSC scale had good reliability, validity, difficulty degree, and measurement invariance. The CSE-CSC scale can be used to measure caregiver self-efficacy of Chinese patients with multiple chronic conditions.

Interventions Addressing Symptoms in Older Adults with Multimorbidity: An Umbrella Review

This umbrella review was to synthesize the summarized evidence-based research regarding interventions addressing symptoms in older populations with multimorbidity. Three databases including PsycINFO, MEDLINE, and CINAHL were searched systematically. The JBI Methodology for Umbrella Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements were used to report this review. Six reviews published between 2016 and 2010 were included for analysis. Interventions were mixed and included components on health-related behaviors, body systems or functions, activities and participation domains, and the environment. Outcomes concerning physiological/clinical functioning were most reported. The evidence regarding the symptoms-related interventions was mixed, but all showed promising outcomes compared with usual care or not. To sum up, this umbrella review reveals the lack of strong empirical evidence for the effectiveness of intervention addressing symptoms in older adults with multimorbidity. It highlights the need to evaluate the established approach of interventions further to support this population.

Association of Functional Status and Symptom Severity Among Patients Who Received Palliative Care Consultations

Background: The relationship between functional status and the severity of different symptoms in patients with serious illnesses has not been explored in detail. Methods: We retrospectively evaluated registry data of hospitalized patients who received inpatient palliative care consults at the Mount Sinai Health System between January 01, 2020, and December 31, 2022. The registry was approved by the local institutional review board. During the initial consult, palliative care clinicians administered the Australia-modified Karnofsky Performance Status (KPS) and the Edmonton Symptom Assessment System (ESAS). We extracted these measures and other variables of interest from electronic health records and billing data, and assessed the association of functional status and symptom severity for different symptoms using ordinal logistic regression models. Results: The study included 9800 patients who received a palliative care consult. When modeling the association of functional status and the severity of different symptoms, two distinct groups of symptoms emerged: Nausea, physical discomfort, anxiety, depression, and constipation were more prevalent and severe among patients with higher functional status. Conversely, drowsiness, inactivity, dyspnea, anorexia, and agitation were more prevalent and severe among patients with lower functional status. These findings remained statistically significant after adjusting for possible confounders. Conclusion: Among patients who received inpatient palliative care consults, lower functional status was associated with a higher symptom burden. Furthermore, symptom profiles differed between patients with reduced functional status and those with preserved functional status.

Living with multimorbidity: A qualitative exploration of shared experiences of patients, family caregivers, and healthcare professionals in managing symptoms in the United States

AIMS

To elicit experiences of patients, family caregivers, and healthcare professionals in intermediate care units (IMCUs) in an academic medical centre in Baltimore, MD related to the challenges and intricacies of multimorbidity management to inform development of a multimorbidity symptom management toolkit.

DESIGN

Experience-based co-design.

METHODS

Between July and October 2021, patients aged 55 years and older with multimorbidity admitted to IMCUs at an academic medical centre in Baltimore, Maryland, USA were recruited and interviewed in person. Interdisciplinary healthcare professionals working in the IMCU were interviewed virtually. Participants were asked questions about their role in recognizing and treating symptoms, factors affecting the quality of life, symptom burden and trajectory over time, and strategies that have and have not worked for managing symptoms. An inductive thematic analysis approach was used for analysis.

RESULTS

Twenty-three interviews were conducted: 9 patients, 2 family caregivers, and 12 healthcare professionals. Patients' mean age was 67.5 (±6.5) years, over half (n = 5) were Black or Hispanic, and the average number of comorbidities was 3.67. Five major themes that affect symptom management emerged: (1) the patient-provider relationship; (2) open and honest communication; (3) accessibility of resources during hospitalization and at discharge; (4) caregiver support, training, and education; and (5) care coordination and follow-up care.

CONCLUSION

Patients, caregivers, and healthcare professionals often have similar goals but different priorities for multimorbidity management. It is imperative to identify shared priorities and target holistic interventions that consider patient and caregiver experiences to improve outcomes.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE AND IMPACT

This paper addresses the paucity of research related to the shared experience of disease trajectory and symptom management for people living with multimorbidity. We found that patients, caregivers, and healthcare professionals often have similar goals but different care and communication priorities. Understanding differing priorities will help better design interventions to support symptom management so people with multimorbidity can have the best possible quality of life.

REPORTING METHOD

We have adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines in our reporting.

PATIENT OR PUBLIC CONTRIBUTION

This study has been designed and implemented with patient and public involvement throughout the process, including community advisory board engagement in the project proposal phase and interview guide development, and member checking in the data collection and analysis phases. The method we chose, experience-based co-design, emphasizes the importance of engaging members of a community to act as experts in their own life challenges. In the coming phases of the study, the public will be involved in developing and testing a new intervention, informed by these qualitative interviews and co-design events, to support symptom management for people with multimorbidity.

Optimizing geriatric palliative care in Egypt: Comprehensive patient and family perspectives

OBJECTIVES

In Egypt, palliative care for geriatric patients is understudied, necessitating exploration for service optimization. Amidst rising chronic illnesses and aging, understanding perspectives of geriatric patients and families is crucial for targeted improvements. This study aims to explore geriatric patients' and their families' perspectives on palliative care in Egypt, seeking opportunities to optimize service delivery for the elderly.

METHODS

Employing a cross-sectional design with 110 geriatric patients and an equal number of family caregivers from the Damietta Oncology Institute and the pain treatment clinics for cancer patients at Zagazig University Hospital, the study focuses on a specialized pain clinic. Validated tools (Palliative Care Outcome Scale, Family Satisfaction with End-of-Life Care [FAMCARE] Scale, Edmonton Symptom Assessment System [ESAS], Caregiver Strain Index [CSI]) assess quality of life, family satisfaction, symptom severity, and caregiver strain.

RESULTS

Geriatric patients (mean age: 65.0 ± 8.1 years; 45.5% male, 55.5% female) have diverse diagnoses (e.g., breast cancer 22%). Palliative care outcomes reveal challenges: low emotional well-being (2.6 ± 0.0) and alarming overall quality of life (1.8 ± 0.0). Family dissatisfaction (FAMCARE) is pervasive (total mean score 2.6 ± 0.5). Symptom severity (ESAS) is high, and caregiver strain (CSI) is notable (8.5 ± 2.2).

SIGNIFICANCE OF THE RESULTS

The findings underscore the significance of the challenges faced by geriatric patients and caregivers in palliative care. Patients confront considerable symptom burdens and emotional distress, while caregivers experience notable strain. Urgently needed are targeted interventions designed to enhance patient well-being, alleviate caregiver burden, and elevate satisfaction. The critical importance of implementing these interventions promptly is highlighted, as they are instrumental in improving the overall care experience for geriatric patients and their caregivers. Moreover, the results underscore the imperative of developing comprehensive support mechanisms to address the intricate dimensions of palliative care, ultimately contributing to a more compassionate and effective care continuum.

Common and distinct risk factors that influence more severe and distressing shortness of breath profiles in oncology outpatients

BACKGROUND

Shortness of breath occurs in 10%-70% of oncology patients. Very little is known about interindividual variability in its severity and distress and associated risk factors. Using latent profile analyses (LPAs), purpose was to identify subgroups of patients with distinct severity and distress profiles for shortness of breath as single symptom dimensions. In addition, a joint LPA was done using patients' severity AND distress ratings. For each of the three LPAs, differences among the shortness of breath classes in demographic, clinical, symptom, stress, and resilience characteristics were evaluated.

METHODS

Patients completed ratings of severity and distress from shortness of breath a total of six times over two cycles of chemotherapy. All of the other measures were completed at enrollment (i.e., prior to the second or third cycle of chemotherapy). Separate LPAs were done using ratings of severity and distress, as well as a joint analysis using severity AND distress ratings. Differences among the latent classes were evaluated using parametric and nonparametric tests.

RESULTS

For severity, two classes were identified (Slight to Moderate [91.6%] and Moderate to Severe [8.4%]). For distress, two classes were identified (A Little Bit to Somewhat [83.9%] and Somewhat to Quite a Bit [16.1%]). For the joint LPA, two classes were identified (Lower Severity and Distress [79.9%] and Higher Severity and Distress [20.1%]). While distinct risk factors were associated with each of the LPAs, across the three LPAs, the common risk factors associated with membership in the worse class included: a past or current history of smoking, poorer functional status, and higher comorbidity burden. In addition, these patients had a higher symptom burden and higher levels of cancer-specific stress.

CONCLUSIONS

Clinicians can use the information provided in this study to identify high-risk patients and develop individualized interventions.

Perceptions and experiences of living with and providing care for multimorbidity: A qualitative interview study

Background

Experiences of living with and seeking care for multimorbidity is a relatively under-researched field. By analysing experiences of people with multimorbidity, caregivers and care professionals, we can better understand the complex care needs of those with multimorbidity and identify improvements to care management. This paper reports findings from research that elicited the views of key stakeholders to inform future care practice and policy.

Aim

To elicit care recipient and care provider views to understand the care needs of those living with and seeking care for multimorbidity.

Method

A qualitative interview study using purposive sampling of those living with and providing care in multimorbidity.

Results

Increased support to those with multimorbidity and caregivers to navigate care systems was advocated. Establishing trusting care relationships featured prominently in participants accounts. Fragmented care, inadequate coordination and poor communication between care providers, were identified as system-wide challenges. There was agreement that integrated care models were needed, which delivered personalised care, such as shared decision-making, choice in care options and accessing services, and individualised care plans.

Conclusion

We found significant agreement among stakeholders on care need and management in multimorbidity. Understanding the experiences of those with multimorbidity, caregivers and care professionals, can inform future improvements in care management.

Could an optimally fitted categorization of difference between multi-disease score and multi-symptom score be a practical indicator aiding in improving the cost-effectiveness of healthcare delivery for older adults in developing countries?

BACKGROUND

Physio-psycho-socioeconomical health comprehensively declines during aging, the complexity of which is challenging to measure. Among the complexity, multiple chronic disorders continuously cumulated during aging, further aggravating the challenge.

METHODS

A population-based survey on Comprehensive Ageing Health Assessment was conducted in older adults (age >  = 60) enrolled from hospital settings and community settings in 13 working centers in six subnational regions in China. Cross-sectional datasets of 8,093 older participants with approximately complete assessment results were collected for the present analysis. Individual's multi-disease or multi-symptom was respectively scored by summing coexistent multiple diseases or multiple symptoms by respective weighting efficient for Self-Rated Health (SRH). Individual's age-dependent health decline was further summed of four SRH-weighted scores for daily function (activity of daily life, ADL), physical mobility (an average of three metrics), cognitive function (mini mental state examination, MMSE) and mental being (geriatric depression scale, GDS) plus multi-disease score (MDS) and multi-symptom score (MSS).Multi-disease patten among 18 diseases or multi-symptom pattern among 15 symptoms was latent-clustered in the older adults, the optimal outcome of which was categorized into high, moderate or low aging-associated clusters, respectively. Percentage distribution was compared between overall health decline score and multi-disease pattern cluster or multi-symptom patten cluster. A new variable of difference between MDS and MSS (hereinafter terming DMM) that displayed linear variation with socioeconomic factors was further fitted using multilevel regression analyses by substantial adjustments on individual confounders (level-1) and subnational region variation (level-2).

RESULTS

Consistent gradient distribution was shown between health decline and multimorbidity pattern cluster in the older adults. DMM was found linearly varied with personal education attainment and regional socioeconomic status. Using optimally fitted stratification of DMM (DMM interval = 0.02), an independent U-shaped interrelated tendency was shown between health decline, multi-disease and multi-symptom, which could be well explained by regional disparities in socioeconomic status.

CONCLUSION

Newly developed metrics for age-dependent health decline and aging-associated multimorbidity patten were preliminarily validated from within. The new variable of optimally fitted categorization of DMM might function as a practical indicator aiding in improving the cost-effectiveness and reduce inequity of healthcare delivery for older adults in developing countries.

A Novel Approach to Measurement-Based Care: Integrating Palliative Care Tools Into Geriatric Mental Health

Background: Older adults cared for in a geriatric mental health program often have medical co-morbidities causing physical symptoms which may be under-recognized. We explore the utility of palliative care tools in this patient population to identify the burden of symptoms and impact on patient dignity. Methods: Participants were recruited from a geriatric mental health inpatient unit and outpatient day hospital. Mood and somatic symptoms were tracked with self-report rating scales, including the Geriatric Depression Scale (GDS) and the Geriatric Anxiety Inventory (GAI) used in psychiatry, as well as the Edmonton Symptom Assessment Scale (ESAS) and Patient Dignity Inventory (PDI) used in palliative care. Demographic characteristics were collected from a retrospective chart review. Exploratory longitudinal models were developed for the GDS and GAI outcomes to assess change over time after adjusting for ESAS and PDI item scores. Results: Data were obtained for 33 English speaking patients (inpatients N = 17, outpatients N = 16) with a mean age of 76.5 (SD = 6.1). At baseline, several ESAS symptom burdens were rated as moderate and the PDI often captured physically distressing symptoms. GDS scores declined over time but at a slower rate for those reporting higher levels of pain on the ESAS (P = .04). GAI scores declined over time but at a slower rate for those identifying physically distressing symptoms on the PDI (P = .04). Conclusions: This study demonstrates how using the ESAS and PDI in a mental health population can be helpful in tracking symptoms and how these symptoms are related to psychiatric outcomes.

Functional Status Changes in Patients Receiving Palliative Care Consult During COVID-19 Pandemic

CONTEXT

Hospitalized patients with functional impairment have higher symptom burden and mortality. Little is known about how increased patient volume and acuity during the coronavirus disease 2019 (COVID-19) pandemic affected access to palliative care among patients with functional impairment.

OBJECTIVES

To examine changes in functional status and hospital outcomes among patients receiving inpatient palliative care consultation before, during and after the COVID-19 pandemic.

METHODS

We conducted a retrospective, multisite cohort study of all adult patients (≥ 18 years) admitted to four hospitals in New York City, USA, who received inpatient palliative care consultation between March 1, 2019 and February 28, 2022 with documented functional status at the time of consultation measured by Karnofsky Performance Status scale.

RESULTS

Among 13,180 eligible patients identified, patients' functional status at the time of consultation decreased as palliative care consult volume increased with the onset of the pandemic. Compared to pre-pandemic, there was a statistically significant trend of lower functional status (P < 0.001) and higher in-hospital mortality (P < 0.001) among patients with noncancer and non-COVID-19 diagnoses two years after the pandemic. In contrast, patients with cancer had a statistically significant trend of higher functional status (P < 0.001) and no significant changes in in-hospital mortality over time.

CONCLUSION

As the healthcare system was stressed with high demand and limited resources, palliative care consultation prioritized highest acuity patients by shifting towards those with lower functional status and higher in-hospital mortality. This shift disproportionately affected noncancer patients. Innovative approaches to ensure upstream palliative care consultation during increased resource constraints are needed.

Identification of distinct symptom profiles in patients with gynecologic cancers using a pre-specified symptom cluster

PURPOSE

Pain, fatigue, sleep disturbance, and depression are four of the most common symptoms in patients with gynecologic cancer. The purposes were to identify subgroups of patients with distinct co-occurring pain, fatigue, sleep disturbance, and depression profiles (i.e., pre-specified symptom cluster) in a sample of patients with gynecologic cancer receiving chemotherapy and assess for differences in demographic and clinical characteristics, as well as the severity of other common symptoms and QOL outcomes among these subgroups.

METHODS

Patients completed symptom questionnaires prior to their second or third cycle of chemotherapy. Latent profile analysis was used to identify subgroups of patients using the pre-specified symptom cluster. Parametric and nonparametric tests were used to evaluate for differences between the subgroups.

RESULTS

In the sample of 233 patients, two distinct latent classes were identified (i.e., low (64.8%) and high (35.2%)) indicating lower and higher levels of symptom burden. Patients in high class were younger, had child care responsibilities, were unemployed, and had a lower annual income. In addition, these women had a higher body mass index, a higher comorbidity burden, and a lower functional status. Patients in the high class reported higher levels of anxiety, as well as lower levels of energy and cognitive function and poorer quality of life scores.

CONCLUSIONS

This study identified a number of modifiable and non-modifiable risk factors associated with membership in the high class. Clinicians can use this information to refer patients to dieticians and physical therapists for tailored interventions.

Simultaneous exercise stress cardiac magnetic resonance and cardiopulmonary exercise testing to elucidate the Fick components of aerobic exercise capacity: a feasibility and reproducibility study and pilot study in hematologic cancer survivors

BACKGROUND

Patients treated for hematologic malignancy often experience reduced exercise capacity and increased fatigue; however whether this reduction is related to cardiac dysfunction or impairment of skeletal muscle oxygen extraction during activity is unknown. Cardiopulmonary exercise testing (CPET) coupled with stress cardiac magnetic resonance (ExeCMR), may provide a noninvasive method to identify the abnormalities of cardiac function or skeletal muscle oxygen extraction. This study was performed to determine the feasibility and reproducibility of a ExeCMR + CPET technique to measure the Fick components of peak oxygen consumption (VO2) and pilot its discriminatory potential in hematologic cancer patients experiencing fatigue.

METHODS

We studied 16 individuals undergoing ExeCMR to determine exercise cardiac reserve with simultaneous measures of VO2. The arteriovenous oxygen content difference (a-vO2diff) was calculated as the quotient of VO2/cardiac index (CI). Repeatability in measurements of peak VO2, CI, and a-vO2diff was assessed in seven healthy controls. Finally, we measured the Fick determinants of peak VO2 in hematologic cancer survivors with fatigue (n = 6) and compared them to age/gender-matched healthy controls (n = 6).

RESULTS

Study procedures were successfully completed without any adverse events in all subjects (N = 16, 100%). The protocol demonstrated good-excellent test-retest reproducibility for peak VO2 (intraclass correlation coefficient [ICC] = 0.992 [95%CI:0.955-0.999]; P < 0.001), peak CI (ICC = 0.970 [95%CI:0.838-0.995]; P < 0.001), and a-vO2diff (ICC = 0.953 [95%CI:0.744-0.992]; P < 0.001). Hematologic cancer survivors with fatigue demonstrated a significantly lower peak VO2 (17.1 [13.5-23.5] vs. 26.0 [19.7-29.5] mL·kg-1·min-1, P = 0.026) and lower peak CI (5.0 [4.7-6.3] vs. 7.4 [7.0-8.8] L·min-1/m2, P = 0.004) without a significant difference in a-vO2diff (14.4 [11.8-16.9] vs. 13.6 [10.9-15.4] mLO2/dL, P = 0.589).

CONCLUSIONS

Noninvasive measurement of peak VO2 Fick determinants is feasible and reliable with an ExeCMR + CPET protocol in those treated for a hematologic malignancy and may offer insight into the mechanisms of exercise intolerance in those experiencing fatigue.

Multiple Chronic Conditions among Seriously Ill Adults Receiving Palliative Care

The objective of this study was to characterize multiple chronic conditions (MCCs) among seriously ill adults receiving palliative care at the end of life. A latent class analysis was conducted to identify latent subgroups of seriously ill older adults based on a baseline Charlson comorbidity index (CCI) measurement, a measure of comorbidity burden, and mortality risk. The three latent subgroups were: (1) low to moderate CCI with MCC, (2) high CCI with MCC, and (3) high CCI and metastatic cancer. The "low to moderate CCI and MCC" subgroup included older adults with chronic obstructive pulmonary disease (COPD), cardiovascular disease, congestive heart failure, myocardial infarction, dementia, diabetes, and lymphoma. A "high CCI and MCC" subgroup included individuals with severe illness including liver or renal disease among other MCCs. A "high CCI and metastatic cancer" included all participants with metastatic cancer. This study sheds light on the MCC profile of seriously ill adults receiving palliative care.

The Experiences and Views on Palliative Care of Older People with Multimorbidities, Their Family Caregivers and Professionals in a Spanish Hospital

The increasing prevalence of complex chronic diseases in the population over 65 years of age is causing a major impact on health systems. This study aims to explore the needs and preferences of the multimorbid patient and carers to improve the palliative care received. The perspective of professionals who work with this profile of patients was also taken into account. A qualitative study was conducted using semi-structured interviews with open-ended questions. Separate topic guides were developed for patients, careers and health professionals. We included 12 patients, 11 caregivers and 16 health professionals in Spain. The results showed multiple unmet needs of patients and families/caregivers, including feelings of uncertainty, a sense of fear, low awareness and knowledge about palliative care in non-malignant settings, and a desire to improve physical, psychosocial and financial status. A consistent lack of specialized psychosocial care for both patients and caregivers was expressed and professionals highlighted the need for holistic needs assessment and effective and early referral pathways to palliative care. There is a lack of institutional support for multimorbid older patients in need of palliative care and important barriers need to be addressed by health systems to face the significant increase in these patients.

Self-reported symptom causes of mobility difficulty contributing to fear of falling in older adults

BACKGROUND

Self-reported symptom causes of mobility difficulty that contribute to  fear of falling (FOF) in older adults has not been fully explored as an area for intervention.

AIMS

Identify the prevalence of self-reported symptoms causing mobility difficulties and to examine the difference in FOF by symptom category.

METHODS

Conduct a secondary data analysis of a population-based cohort of community-dwelling older adults, ≥ 70 years, enrolled in the MOBILIZE Boston study. The analysis included 242 older adults reported difficulty walking ¼ mile (0.4 km) and/or climbing one flight of stairs. Participants identified the main symptom cause of the mobility difficulty from a list of 32 symptoms, grouped into five categories. FOF was measured using the Tinetti Falls Efficacy Scale.

RESULTS

Pain was the primary symptom causing mobility difficulty (38%), followed by endurance (21%), weakness (13%), balance (9%), and other (3%). Although a greater proportion of participants who identified balance as the primary symptom category had significantly higher FOF compared to others, there was a greater number overall who reported pain as their main symptom who also had FOF. Therefore, pain contributed to a higher relative burden of FOF in the population than did balance symptoms.

DISCUSSION

Various symptoms affect mobility and are associated with FOF, a known fall risk factor. Many older adults identify pain as the main cause of their mobility difficulty and report FOF.

CONCLUSIONS

Improving pain symptoms for older adults may improve mobility and reduce fear of falling, potentially averting further decline in mobility and independence.

The Effect of Dual Sensory Impairment and Multimorbidity Patterns on Functional Impairment: A Longitudinal Cohort of Middle-Aged and Older Adults in China

Objective

There is an urgent need to evaluate the contribution of several co-existing diseases on health. This study aims to explore the combined effect of dual sensory impairment (DSI) and multimorbidity patterns on functional impairment among middle-aged and older adults in China.

Methods

Data were from 10,217 adults aged 45 or older from four waves of the China Health and Retirement Longitudinal Study (CHARLS). Sensory impairments were self-reported measures. Multimorbidity patterns were identified by using k-means cluster analyses. Functional impairment was defined using activities of daily living (ADL) scale and instrumental activities of daily living (IADL) scale. Generalized estimating equation models were estimated to assess the effect of co-occurring DSI and multimorbidity on functional impairment.

Results

DSI prevalence was 50.4%, and multimorbidity prevalence was 37.7% at the baseline. The simultaneous presence of DSI and multimorbidity was associated with increased odds of ADL limitations (OR = 2.27, 95% CI: 2.11–2.43) and IADL limitations (OR = 1.89, 95% CI: 1.77–2.02). Five multimorbidity patterns were identified: the cardio-cerebrovascular pattern, the stomach-arthritis pattern, the respiratory pattern, the hepatorenal pattern, and the unspecified pattern. Compared to DSI only, DSI plus the hepatorenal pattern was most strongly associated with functional impairment (for ADL: OR = 2.70, 95% CI: 2.34–3.12; for IADL: OR = 2.04, 95% CI: 1.77–2.36).

Conclusion

Middle-aged and older adults with co-occurrence of DSI and multimorbidity are at increased risk of functional impairment, especially those with multimorbidity characterized by the hepatorenal pattern. These findings imply that integrated care for DSI and multimorbidity may be a potent pathway in improving functional status.

Influência dos Cânceres Gástrico e Hematológico na Qualidade de Vida e na Funcionalidade de Pacientes Oncológicos

Introdução: O câncer é uma doença complexa, sendo a segunda maior causa de morte no Brasil e no mundo, com uma média de 9,8 milhões de óbitos ao ano. Objetivo: Verificar a influência do tipo de câncer, gástrico ou hematológico, na qualidade de vida e na funcionalidade dos indivíduos. Método: Trata-se de um estudo clínico, transversal, analítico e de abordagem quantitativa. Utilizaram-se na coleta de dados uma ficha com dados demográficos, antropométricos, habituais e da doença, o Quality of Life Questionnaire-Core30 da European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) e a Escala de Performance de Karnofsky (KPS). Resultados: Foram avaliados 29 pacientes no total; destes, 19 pacientes com câncer hematológico (Grupo A) e dez com câncer gástrico (Grupo B). A correlação entre idade, EORTC QLQ-C30 e KPS foi positiva entre a idade e os sintomas (r=,571, p=0,011) e a idade e a somatória total do EORTC QLQ-C30 (r=,548, p=0,015); e negativa entre a KPS e os sintomas (r=-,495, p=0,031) e a KPS e a somatória total do EORTC QLQ-C30 (r=,-580, p=0,009) no grupo A. No grupo B, não foi observada nenhuma correlação entre essas variáveis. Conclusão: Pacientes com câncer hematológico e câncer gástrico apresentam redução da qualidade de vida, sendo observada uma diminuição da funcionalidade nos pacientes com câncer hematológico quando comparado ao câncer gástrico. A redução da função nesses indivíduos pode estar diretamente relacionada com a idade e os sintomas físicos apresentados.

Self-Reported and Performance-Based Evaluations of Functional Status in Older Women With Breast Cancer

OBJECTIVES

To evaluate self-reported and performance-based functional status (FS) in older women with breast cancer according to stage and time of visit during treatment.

SAMPLE & SETTING

72 women with breast cancer aged 78 years or older and receiving any type of treatment at a midwestern outpatient clinic.

METHODS & VARIABLES

FS was evaluated using grip strength, the Index of Activities of Daily Living (ADLs), the instrumental ADLs (IADLs) scale, and the Timed Up and Go Test (TUGT). Mixed models were fit for grip strength and the TUGT, and generalized estimating equations were used to fit binary logistic regressions for the Index of ADLs and the IADLs scale. Continuous FS outcomes were evaluated using means and standard deviations.

RESULTS

Cancer stage and time of visit did not affect self-reported or performance-based FS scores. Most participants were considered independent on the Index of ADLs, the IADLs scale, and the TUGT, which did not change significantly between visits. Self-reported measures revealed less impairment.

IMPLICATIONS FOR NURSING

Monitoring FS using self-reported and performance-based measures can ensure that older patients receive timely support.

Latent Class Analysis of Symptom Burden Among Seriously Ill Adults at the End of Life

BACKGROUND

Serious illness is characterized by high symptom burden that negatively affects quality of life (QOL). Although palliative care research has highlighted symptom burden in seriously ill adults with cancer, symptom burden among those with noncancer serious illness and multiple chronic conditions has been understudied. Latent class analysis is a statistical method that can be used to better understand the relationship between severity of symptom burden and covariates, such as the presence of multiple chronic conditions. Although latent class analysis has been used to highlight subgroups of seriously ill adults with cancer based on symptom clusters, none have incorporated multiple chronic conditions.

OBJECTIVES

The objectives of this study were to (a) describe the demographic and baseline characteristics of seriously ill adults at the end of life in a palliative care cohort, (b) identify latent subgroups of seriously ill individuals based on severity of symptom burden, and (c) examine variables associated with latent subgroup membership, such as QOL, functional status, and the presence of multiple chronic conditions.

METHODS

A secondary data analysis of a palliative care clinical trial was conducted. The latent class analysis was based on the Edmonton Symptom Assessment System, which measures nine symptoms on a scale of 0-10 (e.g., pain, fatigue, nausea, depression, anxiousness, drowsiness, appetite, well-being, and shortness of breath). Clinically significant cut-points for symptom severity were used to categorize each symptom item in addition to a categorized total score.

RESULTS

Three latent subgroups were identified (e.g., low, moderate, and high symptom burden). Lower overall QOL was associated with membership in the moderate and high symptom burden subgroups. Multiple chronic conditions were associated with statistically significant membership in the high symptom burden latent subgroup. Older adults between 65 and 74 years had a lower likelihood of moderate or high symptom burden subgroup membership compared to the low symptom burden class.

DISCUSSION

Lower QOL was associated with high symptom burden. Multiple chronic conditions were associated with high symptom burden, which underlines the clinical complexity of serious illness. Palliative care at the end of life for seriously ill adults with high symptom burden must account for the presence of multiple chronic conditions.

Symptom experience of older oncology patients with low versus high levels of multimorbidity prior to chemotherapy

PURPOSE

Evaluate for differences in demographic and clinical characteristics between older oncology patients with low multimorbidity (<2 multimorbidities) and high multimorbidity (≥2 multimorbidities) and evaluate for differences in symptom occurrence, severity, and distress ratings between the two groups.

METHODS

Symptoms of older oncology patients (n = 125) were assessed using the Memorial Symptom Assessment Scale prior to chemotherapy administration. Data were analyzed using t-tests for continuous variables and Chi-square or Fisher's exact tests for categorical variables.

RESULTS

For the total sample, lack of energy and pain were the two most common symptoms. Compared to the low multimorbidity group, the high multimorbidity group had a higher number of symptoms and significantly higher occurrence rates for feeling nervous, difficulty sleeping, dry mouth, and pain. Compared to the low multimorbidity group, the high multimorbidity group had significantly higher severity ratings for pain, feeling sad, lack of energy, feeling drowsy, and worrying. For distress, the high multimorbidity group reported significantly higher ratings for pain, worrying, feeling sad, feeling nervous, and "I don't look like myself". No differences were found in any demographic or clinical characteristics between the two multimorbidity groups.

CONCLUSIONS

Multimorbidity is associated with higher symptom occurrence, severity, and distress in older oncology patients. Our findings suggest that the symptoms with the highest severity ratings were not the most distressing. Clinicians should identify multimorbidities and assess symptoms prior to chemotherapy to identify patients at increased risk and initiate referrals for interventions.

Moral Distress: Its Manifestations in Healthy Donors during Peripheral Blood Hematopoietic Stem Cell Harvesting

Hematopoietic stem cell donors (HSCDs) may have ambivalent feelings about donation. These feelings are related to moral obligation to help a sick relative and/or fear about the donation procedure. This ambivalence can produce moral distress (MD) and anxiety, which are usually unnoticed by the treating physician. The aim of this study was to evaluate the incidence of MD and anxiety in a group of related HSCDs for allogeneic transplantation. In this prospective observational study, to assess MD and anxiety, we applied 3 self-answered questionnaires-a questionnaire developed to assess MD (MDQ), State Trait Anxiety Index (STAI), and Edmonton Symptom Assessment System (ESAS)-before, during, and after hematopoietic stem cell donation. A total of 60 consecutive related HSCDs with a mean age of 38.2 years were included. Thirty-six were male. Hematopoietic stem cell collections were done by apheresis, performed as an outpatient process in all cases. The incidence of MD during the donation process was 56%. The proportion of HSCDs with moderate to high state anxiety decreased significantly from before donation (63%) to after donation (30%). Higher scores for MD correlated with higher scores on the STAI questionnaire (r = 0.448; P < .005). Thirty-seven donors (62%) had at least 1 physical symptom even before the stem cell mobilization process started, mainly anxiety (33%), difficulty sleeping (33%), and fatigue (30%). The number of symptomatic donors increased during donation (100%) and decreased after the procedure (80%). We conclude that MD and anxiety symptoms experienced by HSCDs are very common and can be explained by mixed feelings about the donation process. Providing comprehensive psychological support before starting the donation process and guaranteeing respect for the donor's autonomy are needed to decrease the negative impact of the donation experience.

SymTrak-8 as a Brief Measure for Assessing Symptoms in Older Adults

BACKGROUND

Patient- and caregiver-reported 23-item SymTrak scales were validated for monitoring clinically actionable symptoms and impairments associated with multiple chronic conditions (MCCs) in older adults. Items capture physical and emotional symptoms and impairments in physical and cognitive functioning. An abbreviated SymTrak is desirable when response burden is a concern.

OBJECTIVE

Develop and validate the 8-item SymTrak.

DESIGN AND PARTICIPANTS

Secondary analysis of SymTrak validation study; 600 participants (200 patient-caregiver dyads; 200 patients without an identified caregiver).

MAIN MEASURES

Demographic questions, SymTrak, and Health Utility Index Mark 3 (HUI3).

KEY RESULTS

SymTrak-8 demonstrated good fit to a one-factor model using confirmatory factor analysis (CFA). Concurrent criterion validity was supported by high standardized linear regression coefficients (STB) between baseline SymTrak-8 total score (independent variable) and baseline HUI3 preference-based overall HRQOL utility score (dependent variable; 0 = death, 1 = perfect health), after adjusting for demographics, comorbid conditions, and medications, with strength comparable to SymTrak-23 (STB = - 0.81 and - 0.84, respectively, for SymTrak-8 and SymTrak-23, when patient-reported; and - 0.60 and - 0.62, respectively, when caregiver-reported). Coefficient alpha (0.74; 0.76) and 24-h test-retest reliability (0.83; 0.87) were high for SymTrak-8 for patients and caregivers, respectively. The convergent correlation between brief and parent SymTrak scales was high (0.94). SymTrak-8 demonstrated approximate normality and a linear relationship with SymTrak-23 and HUI3. Importantly, a 3-month change in SymTrak-8 was sensitive to detecting the criterion (3-month reliable change categories; improved, stable, declined in HUI3 overall utility), with results comparable to SymTrak-23.

CONCLUSIONS

SymTrak-8 total score demonstrates internal reliably, test-retest reliability, criterion validity, and sensitivity to change that are comparable to SymTrak-23. Thus, patient- or caregiver-reported SymTrak-8 is a viable option for identifying and monitoring the aggregate effect of symptoms and functional impairments in patients with multimorbidity when response burden is a concern.

Occurrence and timely management of problems requiring prompt intervention among Indigenous compared with non-Indigenous Australian palliative care patients: a multijurisdictional cohort study

OBJECTIVES

Anticipation and prompt relief of symptoms among patients with a life-limiting illness is a core element of palliative care. Indigenous Australians commonly encounter cultural barriers in healthcare that may impair outcomes. The Palliative Care Outcomes Collaboration collects patient care data for the purposes of continuous quality improvement and benchmarking, with each recorded care episode divided into phases that reflect a patient's condition. We aimed to investigate differences between Indigenous and non-Indigenous patients in the occurrence and duration of 'unstable' phases (which indicate unanticipated deterioration in a patient's condition or circumstances), and determine attainment of the relevant benchmark (resolution of unstable phases in ≤3 days in 90% of cases) for both groups.

DESIGN

Cohort study.

SETTING

Australia-wide hospital-based and community-based specialist palliative care (1 January 2010 to 30 June 2015).

PARTICIPANTS

139 556 (1502 Indigenous and 138 054 non-Indigenous) adult patients.

OUTCOME MEASURES

Indigenous and non-Indigenous patients were compared on (1) the risk of a phase being categorised as unstable, (2) the duration of unstable phases, and (3) the risk of unstable phases being prolonged (>3 days). Crude and adjusted estimates were produced from three-level robust Poisson regression and complementary log-log discrete time survival models.

RESULTS

Unstable phases occurred with similar frequency overall among Indigenous and non-Indigenous patients (adjusted relative risks 1.06; 95% CI 1.00 to 1.11; not significant after correction for multiple comparisons). The duration and risk of prolongation of unstable phases were similar in both patient groups, with no significant differences evident among subgroups. The benchmark was not met for either Indigenous or non-Indigenous patients (unstable phase duration >3 days in 24.3% vs 25.5%; p=0.398).

CONCLUSIONS

Despite well-documented shortcomings of healthcare for Indigenous Australians, there is no clear evidence of greater occurrence or prolongation of unanticipated problems among Indigenous patients accessing specialist palliative care services in hospital or the community.

Symptom Profiles, Health-Related Quality of Life, and Clinical Blood Markers among Korean Community-Dwelling Older Adults Living with Chronic Conditions

Older adults suffer from multiple symptoms, which negatively affects their health-related quality of life. The single-symptom management approach has been less than effective. The data of 2362 Korean community-dwelling older adults aged 70 and above were analyzed in the Korean Frailty and Aging Cohort Study (KFACS) study. A cluster analysis, correlation analysis, and logistic regression were used to analyze the data. We found three symptom clusters: high symptom burden (HSB, n = 1032); pain and fatigue group (PAF, n = 566); and the sleep deprivation group (SDP, n = 764). Participants in the HSB group are more likely to be of old age (OR = 1.1), be female (OR = 2.4), live in a rural area (OR = 1.4), have low physical activity (OR = 0.9), and have multiple chronic conditions (OR = 1.5). The clinical blood markers analysis showed a negative relationship among the physical health, free T4 (r = -0.083, p < 0.01) and insulin (r = -0.084, p < 0.01). The sex-specific blood markers analysis showed differences among three clusters. While free testosterone (male: r = 0.124, female: r = 0.110, p < 0.05) and dehydroepiandrosterone (DHEA) (male: r = 0.352 and female: r = 0.134, p < 0.05) were associated with physical health in the HSB group, only free testosterone was associated with mental health (male: r = -0.093, and female: r = -0.116, p < 0.05) in the SDP group. These findings suggest the potential role of the patient's sex and sex hormones in symptoms of Korean community-dwelling older adults. Understanding the symptom profiles and impact of biopsychosocial factors may enhance precision symptom management.

Examination of individual and multiple comorbid conditions and health-related quality of life in older cancer survivors

PURPOSE

Older cancer survivors (≥ 65 years at diagnosis) are at high-risk for multimorbidity (2 + comorbid conditions). However, few studies have utilized a generalizable sample of older cancer survivors to understand how individual comorbid conditions, as opposed to total comorbidity burden, are associated with health-related quality of life (HRQOL). We examined associations between HRQOL outcomes (pain, fatigue, physical function), individual comorbidities (cardiovascular disease [CVD], lung disease, diabetes, arthritis) and total comorbidity (cancer-only, cancer + 1 condition, cancer + 2 or more conditions).

METHODS

Utilizing a population-based sample of 2019 older cancer survivors, we tested associations between comorbid conditions and the HRQOL outcomes using generalized linear models. HRQOL domains were assessed using Patient-Reported Outcome Measurement Information System^® (PROMIS^®) measures. Comorbidity was assessed via self-report.

RESULTS

Cancer survivors with lung disease reported significantly worse physical functioning (β = - 4.96, p < 0.001), survivors with arthritis reported significantly higher pain (β = 4.37, p < 0.001), and survivors with CVD reported significantly higher fatigue (β = 3.45, p < 0.001) compared to survivors without each condition. Having cancer + 1 condition was not as strongly associated with all outcomes as when individual conditions were tested (e.g. pain: β = 3.09, p < 0.001). Having 2+ comorbidities had a stronger association with all outcomes (e.g. physical function: β = - 7.51, p < 0.001) than examining conditions individually.

CONCLUSIONS

Knowing the specific comorbid condition profile of an older cancer survivor provides insight into specific HRQOL outcomes that may be impaired in cancer survivorship, but understanding total comorbidity burden, regardless of the specific conditions, sheds light on survivors at-risk for multiple impairments in HRQOL. This information, taken together, can inform risk-stratified survivorship care.

An Adapted Conceptual Model Integrating Palliative Care in Serious Illness and Multiple Chronic Conditions

OBJECTIVE

Seriously ill adults with multiple chronic conditions (MCC) who receive palliative care may benefit from improved symptom burden, health care utilization and cost, caregiver stress, and quality of life. To guide research involving serious illness and MCC, palliative care can be integrated into a conceptual model to develop future research studies to improve care strategies and outcomes in this population.

METHODS

The adapted conceptual model was developed based on a thorough review of the literature, in which current evidence and conceptual models related to serious illness, MCC, and palliative care were appraised. Factors contributing to patients' needs, services received, and service-related variables were identified. Relevant patient outcomes and evidence gaps are also highlighted.

RESULTS

Fifty-eight articles were synthesized to inform the development of an adapted conceptual model including serious illness, MCC, and palliative care. Concepts were organized into 4 main conceptual groups, including Factors Affecting Needs (sociodemographic and social determinants of health), Factors Affecting Services Received (health system; research, evidence base, dissemination, and health policy; community resources), Service-Related Variables (patient visits, service mix, quality of care, patient information, experience), and Outcomes (symptom burden, quality of life, function, advance care planning, goal-concordant care, utilization, cost, death, site of death, satisfaction).

DISCUSSION

The adapted conceptual model integrates palliative care with serious illness and multiple chronic conditions. The model is intended to guide the development of research studies involving seriously ill adults with MCC and aid researchers in addressing relevant evidence gaps.

Validating a Patient-Reported Outcomes-Derived Algorithm for Classifying Symptom Complexity Levels Among Patients With Cancer

BACKGROUND

The patient-reported outcomes (PROs) symptom complexity algorithm, derived from self-reported symptom scores using the Edmonton Symptom Assessment System and concerns indicated on the Canadian Problem Checklist, has not been validated extensively.

METHODS

This is a retrospective chart review study using data from the Alberta Cancer Registry and electronic medical records from Alberta Health Services. The sample includes patients with cancer who visited a cancer facility in Alberta, Canada, from February 2016 through November 2017 (n=1,466).

RESULTS

The effect size (d=1.2) indicates that the magnitude of difference in health status between the severe- and low-complexity groups is large. The symptom complexity algorithm effectively classified subgroups of patients with cancer with distinct health status. Using Karnofsky performance status, the algorithm shows a sensitivity of 70.3%, specificity of 84.1%, positive predictive value of 79.1%, negative predictive value of 76.7%, and accuracy of 77.7%. An area under the receiver operating characteristic of 0.824 was found for the complexity algorithm, which is generally regarded as good, This same finding was also regarded as superior to the alternative algorithm generated by 2-step cluster analysis (area under the curve, 0.721).

CONCLUSIONS

The validity of the PRO-derived symptom complexity algorithm is established in this study. The algorithm demonstrated satisfactory accuracy against a clinician-driven complexity assessment and a strong correlation with the known group analysis. Furthermore, the algorithm showed a higher screening capacity compared with the algorithm generated from 2-step cluster analysis, reinforcing the importance of contextualization when classifying patients' symptoms, rather than purely relying on statistical outcomes. The algorithm carries importance in clinical settings, acting as a symptom complexity flag, helping healthcare teams identify which patients may need more timely, targeted, and individualized patient symptom management.

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.

General practitioner strategies for managing patients with multimorbidity: a systematic review and thematic synthesis of qualitative research

Background

General practitioners (GPs) increasingly manage patients with multimorbidity but report challenges in doing so. Patients describe poor experiences with health care systems that treat each of their health conditions separately, resulting in fragmented, uncoordinated care. For GPs to provide the patient-centred, coordinated care patients need and want, research agendas and health system structures and policies will need to adapt to address this epidemiologic transition. This systematic review seeks to understand if and how multimorbidity impacts on the work of GPs, the strategies they employ to manage challenges, and what they believe still needs addressing to ensure quality patient care.

Methods

Systematic review and thematic synthesis of qualitative studies reporting GP experiences of managing patients with multimorbidity. The search included nine major databases, grey literature sources, Google and Google Scholar, a hand search of Journal of Comorbidity, and the reference lists of included studies.

Results

Thirty-three studies from fourteen countries were included. Three major challenges were identified: practising without supportive evidence; working within a fragmented health care system whose policies and structures remain organised around single condition care and specialisation; and the clinical uncertainty associated with multimorbidity complexity and general practitioner perceptions of decisional risk. GPs revealed three approaches to mitigating these challenges: prioritising patient-centredness and relational continuity; relying on knowledge of patient preferences and unique circumstances to individualise care; and structuring the consultation to create a sense of time and minimise patient risk.

Conclusions

GPs described an ongoing tension between applying single condition guidelines to patients with multimorbidity as security against uncertainty or penalty, and potentially causing patients harm. Above all, they chose to prioritise their long-term relationships for the numerous gains this brought such as mutual trust, deeper insight into a patient’s unique circumstances, and useable knowledge of each individual’s capacity for the work of illness and goals for life. GPs described a need for better multimorbidity management guidance. Perhaps more than this, they require policies and models of practice that provide remunerated time and space for nurturing trustful therapeutic partnerships.

Role of nurses in medication management at the end of life: a qualitative interview study

Background

Patients in the last phase of their lives often use many medications. Physicians tend to lack awareness that reviewing the usefulness of medication at the end of patients’ lives is important. The aim of this study is to gain insight into the perspectives of patients, informal caregivers, nurses and physicians on the role of nurses in medication management at the end of life.

Methods

Semi-structured interviews were conducted with patients in the last phase of their lives, in hospitals, hospices and at home; and with their informal caregivers, nurses and physicians. Data were qualitatively analyzed using the constant comparative method.

Results

Seventy-six interviews were conducted, with 17 patients, 12 informal caregivers, 15 nurses, 20 (trainee) medical specialists and 12 family physicians. Participants agreed that the role of the nurse in medication management includes: 1) informing, 2) supporting, 3) representing and 4) involving the patient, their informal caregivers and physicians in medication management. Nurses have a particular role in continuity of care and proximity to the patient. They are expected to contribute to a multidimensional assessment and approach, which is important for promoting patients’ interest in medication management at the end of life.

Conclusions

We found that nurses can and should play an important role in medication management at the end of life by informing, supporting, representing and involving all relevant parties. Physicians should appreciate nurses’ input to optimize medication management in patients at the end of life. Health care professionals should recognize the role the nurses can have in promoting patients’ interest in medication management at the end of life. Nurses should be reinforced by education and training to take up this role.

Reliability and Validity of the Korean Language Version of the U.S. National Cancer Institute's Patient-Reported Outcomes Common Terminology Criteria for Adverse Events

CONTEXT

To improve precision and accuracy in the capture of symptomatic adverse events (AEs) by self-report, the U.S. National Cancer Institute has developed a library of 124 patient-reported outcome (PRO) items reflecting 78 symptomatic AEs drawn from the Common Terminology Criteria for Adverse Events (CTCAE). The PRO-CTCAE™ item library has been translated and linguistically validated in the Korean language.

OBJECTIVES

The aim of this study was to examine the psychometric properties of PRO-CTCAE-Korean.

METHODS

PRO-CTCAE-Korean and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire Core 30 (QLQ-C30) were administered to 1358 Korean-speaking individuals receiving treatment for cancer at two medical centers in Korea (mean age 55.1 years; SD ±11.9; 60% females; and 61% high school education or less). A subset of 82 study participants completed the same two measures on a second occasion approximately three days later.

RESULTS

Correlations between PRO-CTCAE-Korean and conceptually relevant QLQ-C30 items were all greater than r = 0.30 except for headache severity. Most PRO-CTCAE-Korean items correlated at least moderately with QLQ-C30 summary scores. Monotonically decreasing total QLQ-C30 scores were observed across worsening levels of symptom frequency, severity, and interference (all P < 0.01), indicating that PRO-CTCAE-Korean response choices are well comprehended, and that PRO-CTCAE-Korean discriminates respondents with different levels of symptom burden. PRO-CTCAE-Korean also demonstrated generally acceptable to good reliability (88% of items intraclass correlation coefficient >0.50).

CONCLUSION

PRO-CTCAE-Korean is a reliable and valid instrument to capture symptomatic AEs by self-report in patients on cancer clinical trials.

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.

Symptom burden among older breast cancer survivors: The Thinking and Living With Cancer (TLC) study

BACKGROUND

Little is known about longitudinal symptom burden, its consequences for well-being, and whether lifestyle moderates the burden in older survivors.

METHODS

The authors report on 36-month data from survivors aged ≥60 years with newly diagnosed, nonmetastatic breast cancer and noncancer controls recruited from August 2010 through June 2016. Symptom burden was measured as the sum of self-reported symptoms/diseases as follows: pain (yes or no), fatigue (on the Functional Assessment of Cancer Therapy [FACT]-Fatigue scale), cognitive (on the FACT-Cognitive scale), sleep problems (yes or no), depression (on the Center for Epidemiologic Studies Depression scale), anxiety (on the State-Trait Anxiety Inventory), and cardiac problems and neuropathy (yes or no). Well-being was measured using the FACT-General scale, with scores from 0 to 100. Lifestyle included smoking, alcohol use, body mass index, physical activity, and leisure activities. Mixed models assessed relations between treatment group (chemotherapy with or without hormone therapy, hormone therapy only, and controls) and symptom burden, lifestyle, and covariates. Separate models tested the effects of fluctuations in symptom burden and lifestyle on function.

RESULTS

All groups reported high baseline symptoms, and levels remained high over time; differences between survivors and controls were most notable for cognitive and sleep problems, anxiety, and neuropathy. The adjusted burden score was highest among chemotherapy-exposed survivors, followed by hormone therapy-exposed survivors versus controls (P < .001). The burden score was related to physical, emotional, and functional well-being (eg, survivors with lower vs higher burden scores had 12.4-point higher physical well-being scores). The composite lifestyle score was not related to symptom burden or well-being, but physical activity was significantly associated with each outcome (P < .005).

CONCLUSIONS

Cancer and its treatments are associated with a higher level of actionable symptoms and greater loss of well-being over time in older breast cancer survivors than in comparable noncancer populations, suggesting the need for surveillance and opportunities for intervention.

Perceived stress is associated with a higher symptom burden in cancer survivors

BACKGROUND

Although multiple co-occurring symptoms are a significant problem for cancer survivors, to the authors' knowledge little is known regarding the phenotypic characteristics associated with a higher symptom burden. The objectives of the current study were to evaluate the occurrence, severity, and distress associated with 32 symptoms and examine the phenotypic and stress characteristics associated with a higher symptom burden.

METHODS

A total of 623 cancer survivors completed a demographic questionnaire, as well as measures of functional status, comorbidity, and global (Perceived Stress Scale) and cancer-related (Impact of Event Scale-Revised) stress. The Memorial Symptom Assessment Scale was used to evaluate symptom burden. Multiple linear regression analysis was used to determine the phenotypic characteristics associated with a higher symptom burden.

RESULTS

The mean number of symptoms was 9.1 (±5.2). The most common, severe, and distressing symptoms were lack of energy, problems with sexual interest/activity, and hair loss, respectively. Poorer functional status, a higher level of comorbidity, and a history of smoking as well as higher Perceived Stress Scale and Impact of Event Scale-Revised scores were associated with a higher symptom burden. The overall model explained approximately 45.6% of the variance in symptom burden.

CONCLUSIONS

Although cancer survivors report a high number of co-occurring symptoms of moderate severity and distress, in the current study, no disease or treatment characteristics were found to be associated with a higher symptom burden. Clinicians need to assess for general and disease-specific stressors and provide referrals for stress management interventions. Future studies need to examine the longitudinal relationships among symptom burden, functional status, and level of comorbidity, as well as the mechanisms that underlie the associations between stress and symptom burden.

Supporting self-management in palliative care throughout the cancer care trajectory

PURPOSE OF REVIEW

Despite increased survivorship and the subsequent need for chronic management of cancer, the association of self-management and palliative care is still emerging within cancer care. Routine and timely use of self-management strategies in the palliative setting can help reduce self-management burden and maximize quality of life. In this review, we consider the complementary relationship of self-management and palliative care and how they support living with cancer as a chronic illness.

RECENT FINDINGS

Recent studies provide evidence of support among patients, family caregivers and healthcare professionals for integration of self-management interventions into palliative cancer care. As a guiding framework, components of the revised Self and Family Management Framework correspond to the provision of palliative care across the care trajectory, including the phases of curative care, palliative care, end-of-life care and bereavement. Additional work among self-management partners facing cancer and other life-limiting illnesses, that is patients, family caregivers and healthcare professionals, would be useful in developing interventions that incorporate self-management and palliative care to improve health outcomes.

SUMMARY

There is an increasing acceptance of the complementarity of self-management and palliative care in cancer care. Their integration can support patients with cancer and their family caregivers across the care trajectory.

The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions

Background

Serious life-threatening and life-limiting illnesses place an enormous burden on society and health systems. Understanding how this burden will evolve in the future is essential to inform policies that alleviate suffering and prevent health system weakening. We aimed to project the global burden of serious health-related suffering requiring palliative care until 2060 by world regions, age groups, and health conditions.

Methods

We projected the future burden of serious health-related suffering as defined by the Lancet Commission on Palliative Care and Pain Relief, by combining WHO mortality projections (2016–60) with estimates of physical and psychological symptom prevalence in 20 conditions most often associated with symptoms requiring palliative care. Projections were described in terms of absolute numbers and proportional change compared with the 2016 baseline data. Results were stratified by World Bank income regions and WHO geographical regions.

Findings

By 2060, an estimated 48 million people (47% of all deaths globally) will die with serious health-related suffering, which represents an 87% increase from 26 million people in 2016. 83% of these deaths will occur in low-income and middle-income countries. Serious health-related suffering will increase in all regions, with the largest proportional rise in low-income countries (155% increase between 2016 and 2060). Globally, serious health-related suffering will increase most rapidly among people aged 70 years or older (183% increase between 2016 and 2060). In absolute terms, it will be driven by rises in cancer deaths (16 million people, 109% increase between 2016 and 2060). The condition with the highest proportional increase in serious-related suffering will be dementia (6 million people, 264% increase between 2016 and 2060).

Interpretation

The burden of serious health-related suffering will almost double by 2060, with the fastest increases occurring in low-income countries, among older people, and people with dementia. Immediate global action to integrate palliative care into health systems is an ethical and economic imperative.

Funding

Research Challenge Fund, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London.

Symptom Burden and Palliative Care Needs Among High-Risk Veterans With Multimorbidity

CONTEXT

Palliative care research has focused on patients with disease-specific conditions. However, older patients with multimorbidity may have unmet palliative care needs.

OBJECTIVES

We assessed symptom burden and quality of life among veterans with multimorbidity and sought to determine if their bothersome symptoms were addressed and treated in the primary care setting. We sought to identify specific diagnoses that may account for greater symptom burden. We hypothesized that patients with a higher number of diagnoses would experience greater symptom burden and poorer quality of life.

METHODS

We identified veterans at high risk of hospitalization or death using a validated prognostic model. We administered cross-sectional surveys via telephone, The Memorial Symptom Assessment Scale-Short Form and Veterans RAND 12, to randomly selected patients in primary care in the VA Health Care System from May to December 2015. We assessed if their most bothersome symptom was addressed and treated during their most recent visit. Regression models identified specific diagnoses accounting for greater symptom burden and patient predictors of high symptom burden and poor quality of life.

RESULTS

Patients (n = 503) reported (10.6 ± 5.5) active symptoms and poor physical quality of life. Patients reported pain and dyspnea as their most bothersome symptoms (n = 145 [29%] and n = 57 [11%], respectively). Most patients acknowledged their clinicians assessed (n = 348 [74%]) and treated (n = 330 [70%]) their most bothersome symptom. Physical symptoms (78%, P < 0.0001) were more likely to be addressed than psychological symptoms (55%, P < 0.001). Patients diagnosed with obesity or depression experienced greater physical symptom burden. Younger patients reported greater symptom severity than older patients (P < 0.01). Younger patients and those with greater multimorbidities reported lower self-perceived quality of health than older patients and those with fewer multimorbidities (P = 0.01 and P < 0.01, respectively).

CONCLUSION

Outpatients with multimorbidity have high symptom burden, unaddressed symptoms, poor quality of life, and unmet palliative care needs. Our findings support standardization of comprehensive symptom assessment and management in primary care for veterans with multimorbidities, which may ameliorate symptoms and improve quality of life.

Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways

This review discusses the interplay between multimorbidity (i.e. co-occurrence of more than one chronic health condition in an individual) and functional impairment (i.e. limitations in mobility, strength or cognition that may eventually hamper a person's ability to perform everyday tasks). On the one hand, diseases belonging to common patterns of multimorbidity may interact, curtailing compensatory mechanisms and resulting in physical and cognitive decline. On the other hand, physical and cognitive impairment impact the severity and burden of multimorbidity, contributing to the establishment of a vicious circle. The circle may be further exacerbated by people's reduced ability to cope with treatment and care burden and physicians' fragmented view of health problems, which cause suboptimal use of health services and reduced quality of life and survival. Thus, the synergistic effects of medical diagnoses and functional status in adults, particularly older adults, emerge as central to assessing their health and care needs. Furthermore, common pathways seem to underlie multimorbidity, functional impairment and their interplay. For example, older age, obesity, involuntary weight loss and sedentarism can accelerate damage accumulation in organs and physiological systems by fostering inflammatory status. Inappropriate use or overuse of specific medications and drug-drug and drug-disease interactions also contribute to the bidirectional association between multimorbidity and functional impairment. Additionally, psychosocial factors such as low socioeconomic status and the direct or indirect effects of negative life events, weak social networks and an external locus of control may underlie the complex interactions between multimorbidity, functional decline and negative outcomes. Identifying modifiable risk factors and pathways common to multimorbidity and functional impairment could aid in the design of interventions to delay, prevent or alleviate age-related health deterioration; this review provides an overview of knowledge gaps and future directions.

Functional Capacity and Levels of Physical Activity in Aging: A 3-Year Follow-up

Over the last decades, the world elderly population has increased exponentially and this tendency will continue during the coming years; from 2000 to 2050, people over 60 will double and those over 80 will quadruple. Loss of independence occurs as people age due to mobility restrictions, frailty, and decreased functional fitness and cognitive abilities. Evidence has shown that appropriate programs and policies contribute to keep older adults healthy and independent over time. The purpose of this chapter is to report the results of our 3-year follow-up study designed to characterize functional physical fitness in a sample of Portuguese community-dwelling older adults to propose a set of functional parameters that decline the most. We studied a group of 43 elderly people, aged 60 and over. Variables assessed on the participants were anthropometric measurements, functional capacity with the Senior Fitness Test battery (muscle strength, aerobic endurance, flexibility, agility, and dynamic balance), handgrip strength, levels of physical activity, and balance. Three years after the first assessment, a second assessment of the same variables was conducted. We analyzed what were the variables that, for this group, were related with a healthier aging and the relation with different physical activity levels. Our study showed that the distance covered in 6-min walk test and handgrip strength seem to explain a great amount of variability on functional variables that have changed on this period (68% of balance, lower and upper functional strength, respectively) and the active participants showed less decrements with aging in anthropometric and functional variables than those inactive or insufficiently active (p < 0.05). Greater importance should be given to prescription of exercise targeting older adults and, specifically, walking and manual activities should be given more attention as components of a community exercise program.