Janine Overcash
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. Recognize the incidence and prevalence of U.S. statistics of malignancy in the older adult
2. Identify three common malignancies in the older adult
3. Recognize three common comorbidities in the older adult with cancer
4. Identify three common cancer-related emergencies in the older adult
5. Identify three assessment instruments useful in the assessment of the older person
6. Identify three important elements of a health history specific to the older cancer patient
7. Identify three important elements of a physical examination specific to the older cancer patient
8. Define clinical parameters of frailty of an older adult with cancer
OVERVIEW
The probability of developing a malignancy increases with age. In the years between 2007 and 2011, the National Cancer Institute Surveillance, Epidemiology, and End Results Program (SEER) found that the mean age of a cancer diagnosis is 66 years (Surveillance, Epidemiology, and End Results Program [SEER], 2014). Cancer of any site is most often diagnosed among people aged 65 to 74 years (SEER, 2014). According to the Centers for Disease Control and Prevention, the age-adjusted risk of dying dropped 60% from the years between 1935 and 2010; however, heart disease and cancer are the leading causes of death in the United States and have been for 75 years (Hoyert, 2012).
Older people diagnosed with cancer are often resilient; however, problems associated with comorbid conditions and poor general health status can result in less aggressive cancer treatment options (Williams et al., 2015). Treatment decisions of older cancer patients depend on life expectancy, comorbidity, and health status and not on chronological age (Hurria, 2013). Many older people tolerate chemotherapy as compared with younger people depending on their level of fitness and general health status (Sastre, Puente, García-Saenz, & Díaz-Rubio, 2008). The same is true for surgery (Wildiers et al., 2007) and radiation therapy (Gomez-Millan, 2009).
Acute care nurses must appreciate that cancer is common in older adult patients and be aware of management strategies and potential emergencies associated with the diagnosis and treatment of a malignancy. This chapter presents aspects of health that should be considered when caring for a hospitalized older cancer patient. Geriatric assessment instruments that can be used in an acute care setting and potential medical emergencies associated with the cancer disease process are addressed.
ASSESSMENT OF THE OLDER HOSPITALIZED PATIENT
Comorbid Conditions
A diagnosis of cancer may be one of several diagnoses and it is important to understand how the malignant and nonmalignant conditions affect the health of the older person. Often, nonmalignant conditions can present more risk of mortality as compared with a cancer diagnosis. Breast cancer patients undergoing treatment with chemotherapy or radiation are likely to die of nonmalignant diagnoses (Ording et al., 2015). In early-stage breast cancer, rates of noncancer-related disease death in patients aged 80 years and above are higher compared with people aged 65 to 69 years (Sakurai et al., 2015). In patients with lung cancer, cardiovascular comorbidities have a considerable impact on survival (Kravchenko et al., 2015).
The timing of a nonmalignant diagnosis between 18 and 6 months before a diagnosis of colorectal cancer has been associated with lower 1-year survival (Shack, Rachet, Williams, Northover, & Coleman, 2010). The more severe the degree of comorbidity, the less probability of survival at 1 year and 5 years after a diagnosis of cancer (Iversen, Nørgaard, Jacobsen, Laurberg, & Sørensen, 2009). For patients who are diagnosed with diabetes, there is a twofold risk of recurrence or development of a new breast cancer as compared with people who do not have diabetes (Patterson et al., 2010). Recognition, management, and severity of comorbid conditions are the principal aspects of the acute nursing assessment. Unmanaged or uncontrolled comorbid conditions have the potential to modify cancer treatment and outcomes.
Comprehensive Geriatric Assessment
The comprehensive geriatric assessment (CGA) has been used to predict various risk factors (Klepin et al., 2011), postoperative complications (Fukuse, Satoda, Hijiya, & Fujinaga, 2005), toxicity to cancer chemotherapy treatment (Aaldriks et al., 2011; Freyer et al., 2005; Hurria & Lichtman, 2007), and frailty (Kristjansson et al., 2010), and to identify people who are at risk of falls (Overcash & Beckstead, 2008). The CGA is also helpful in identifying older cancer patients who are most likely to benefit from more aggressive chemotherapy (Tucci et al., 2009) and from various surgical oncology procedures. Postsurgical cognitive changes can be predicted using CGA (Liang et al., 2015). CGA used in oncology has been found to influence cancer treatment decisions in terms of dosing, delaying treatment, and other management considerations (Chaïbi et al., 2011; Wildiers et al., 2014).
The CGA can be a predictor of 2-year mortality (Pilotto et al., 2007) and a 3-year predictor of survival (Stotter, Reed, Gray, Moore, & Robinson, 2015) in older patients. Impairment on various components of the CGA, such as nutrition, functional status, and cognition, is predictive of in-hospital mortality (Avelino-Silva et al., 2014). The American Geriatrics Society recommendations suggest that CGA is an important component of care for older persons who have or are at risk for functional limitations (American Geriatrics Society, 2008). Older patients receiving acute care can benefit from the CGA by revealing health concerns and potential readmissions to an acute care setting (Lee, Chou, et al., 2014).
No one definition of a CGA exists. A CGA can be developed to include screening instruments necessary to meet the needs of a particular older patient population (American Geriatrics Society and the British Geriatrics Society, 2010). The instruments that commonly make up the CGA and that guide screening practices in many health care domains are all found on www.consultgerirn.org and chapters in this text. Although a CGA may be relevant to primary care settings, understanding such issues as medication history and polypharmacy, caregiver situation, and emotional condition is also important to an acute assessment.
A CGA can include various laboratory tests in addition to self-report and performance evaluations. Laboratory data, such as C-reactive protein, are able to predict morbidity or mortality and help identify individual risk factors (Chundadze et al., 2010; Pal, Katheria, & Hurria, 2010). Serum 25-hydroxyvitamin D (25OHD) will assess vitamin D levels to determine whether falls or muscle weakness can be a risk factor. People with lower concentrations of 25OHD have a high probably of falling (Annweiler & Beauchet, 2015). In patients with colorectal cancer, higher levels of 25OHD are related to better survival (Wesa et al., 2015). Serum albumin levels at 3.3 mg/dL on admission, serum creatinine levels at 1.3 mg/dL or higher, history of heart failure, immobility, and advanced age are all predictors of inpatient mortality (Silva, Jerussalmy, Farfel, Curiati, & Jacob-Filho, 2009). Other mortality risk factors in older hospitalized patients are red blood cell and platelet transfusions, which increase the opportunity for venous and arterial thrombotic events (Khorana et al., 2008).
Determining caregiver availability in the home following hospital discharge is another important element of the CGA. For many older cancer patients, lack of a caregiver can be a problem and can impact health and medical treatment. Breast cancer patients who live alone or are unmarried have an increased risk of mortality (Osborne, Ostir, Du, Peek, & Goodwin, 2005). Conversely, older cancer patients who are married tend to live longer than those who are not married (Patel et al., 2010). In general, people who are married report higher perceived health status (Joutsenniemi et al., 2006). It is important for the nurse to determine whether the patient lives with someone and the extent to which that person is able to assist. Of note, often the patient is the caregiver to the spouse or others (Overcash, 2004) and it is important to discuss the caregiver situation before discharge.
Assessment of the older patient should occur on admission to the hospital and before discharge to understand trends in health, as well as in functional and behavioral ability. Discharge planning should include interventions based on the CGA findings and communication is vital with outpatient providers to continue to address the limitations that may affect the health, quality of life, and independence of the older person with cancer.
DEVELOPING A COMPREHENSIVE GERIATRIC ASSESSMENT FOR HOSPITALIZED PATIENTS
The following are instruments that can identify functional, physical, emotional, and medication history and cognitive impairment in the acute care patient and are generally included in a CGA (see Chapters 6, 14, 15, 16, and 19):
A. Assess for depression and/or emotional distress
1. The Geriatric Depression Scale (Yesavage et al., 1982)
2. The SF-12 Tool (Ware, Kosinski, & Keller, 1996): The SF-12 is a general health-related quality-of-life instrument that is widely used in research and clinical assessment. Two summary scores are the culmination of the measures from the mental health aspect and the physical health domain. The SF-12 is simple to administer and provides the clinician with a measure of emotional health and physical health.
B. Assessment for cognitive limitations
1. The Mini-Cog is used in the assessment of cognition (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000; Borson, Scanlan, Chen, & Ganguli, 2003). The instrument comprises the Clock Draw test and recall.
2. Assess the number and indications of medications. Look for medications with the same indications, potential harmful interactions and consider any difficulty with cancer treatment, agents. (For more information on polypharmacy screening, visit www.consultgeriRN.org and select “Try This: The Beers Medication Screen, Criteria for Potentially Inappropriate Medication Use in the Elderly.”)
C. Assess for geriatric syndromes (such as urinary incontinence, falls, or depression; for more information, visit www.consultgerirn.org/resources and select “Try This: Urinary Incontinence Assessment, Fall Risk Assessment or the Geriatric Depression Scale”)
D. Assess functional status and potential for falls
1. Ask the patient whether a fall had been experienced within the past year.
2. The Physical Performance Test battery (Simmonds, 2002) has age-related norms and is a valid and reliable tool used with cancer patients.
3. The 6-minute walk that assesses the speed and ability to ambulate for the entire time (Enright et al., 2003)
a. The Timed Get Up & Go Test considers rising from a chair, walking 3 m and returning to the chair in a sitting position (Podsiadlo & Richardson, 1991).
b. Assessment of physical status can take place on observation of gait using the Gait Assessment Scale (Tinetti, 1986; Tinetti, Mendes de Leon, Doucette, & Baker, 1994).
c. Berg Balance Scale (BBS) is a 14-item scale developed for use in a clinical setting (Berg, Wood-Dauphinee, Williams, & Maki, 1992). The BBS can be helpful in predicting falls and functional-status problems.
F. Assess the ability to perform self-care activities
1. Activities of Daily Living Scale (Katz, Downs, Cash, & Grotz, 1970)
2. Instrumental Activities of Daily Living Scale (Lawton & Brody, 1969)
Health History
The subjective information obtained from the older adult is a critical factor in the development of the plan of care. Respect and confidence are not only prudent, but standard practice for the acute care nurse, and can set the stage for a productive health-centered dialogue. The nurse should assess the reason(s) for seeking care (chief complaint) and include the family and support person(s). The following are issues that should be considered when conducting a health history of the older adult with cancer:
A. Assess history of present illness in regard to cancer diagnosis, cancer stage at diagnosis, current cancer stage, and cancer treatment (surgical, chemotherapy, radiation therapy, and hormonal therapy).
B. Assess past medical history as related to a diagnosis of cancer (include dates of diagnosis and treatments and regular oncological assessment continue).
C. Assess family medical history of malignancy and ages on diagnosis (some families have strong familial histories of malignancy and perhaps younger generations should consider genetic counseling).
D. Assess regular cancer screening examinations.
E. Assess for common geriatric syndromes (issues, such as incontinence or falls, that have many motivating factors).
Physical Examination
Conducting a physical examination of an older adult must orchestrate an understanding of normative aging changes and knowledge of pathology. The physical examination is also an opportunity to teach about the importance of self-examination (breast and skin exams) and provide relevant health information. The physical exam is not only an empirical evaluation, but an opportunity to determine current health status and trends over time.
Evaluation of functional status should be performed with the physical examination of the older patient. Understanding level of fitness (healthy, vulnerable, frail, or terminally ill) can help identify appropriate cancer treatment options (Droz et al., 2014). Physical examination and functional status assessment can help reveal a clinical presentation of frailty. According to a classic study by Fried et al. (2001), frailty can, in part, be defined as:
1. Older than 85 years
2. Dependent in one or more activities of daily living (ADL)
3. The presence of one or more geriatric syndromes (Fried et al., 2001)
Determining whether a person is “frail” in the primary care setting can help make important decisions before a patient is admitted to an acute care unit (Lee, Heckman, & Molnar, 2015). When frailty is considered in the physical examination, discussions concerning advance directives, palliative versus curative treatment, and many other critical conversations can occur before an acute situation is realized (Sanchis et al., 2014).
MEDICAL EMERGENCIES ASSOCIATED WITH CANCER AND CANCER TREATMENT
A diagnosis of cancer can lead to medical emergencies, such as electrolyte imbalances, unstable fractures, and neutropenia leading to infection. It is important to obtain cancer-related history and physical information concerning the type of treatment and the exact diagnosis with metastasis (spread of the malignancy from the original site). It is also important for the acute care nurse to know the chemotherapy administration schedule, the dosage, and when it was last administered. Often chemotherapy, such as doxorubicin and cyclophosphamide, is administered four times, 3 weeks apart. As the chemotherapy proceeds, various issues, such as nausea and vomiting, low white cell counts (neutropenia), and mouth sores, may occur and be present on acute evaluation. The following are considered oncological emergencies and require acute care.
Hypercalcemia
Hypercalcemia is a reasonably common complication associated with multiple myeloma, breast, and lung cancers. A common cause of hypercalcemia is malignancy (Reagan, Pani, & Rosner, 2014) and is generally found in 3% to 5% of emergency admission patients (Lee et al., 2006). In primary hypercalcemia, hyperparathyroidism is the most common cause (Ahmad, Kuraganti, & Steenkamp, 2015). Survival can be markedly improved with early recognition in the emergency department (Royer, Maclellan, Stanley, Willingham, & Giles, 2014).
Hypercalcemia is defined as calcium concentration greater than 10.2 mg/dL (Lee et al., 2006). Signs and symptoms of hypercalcemia are often not evident in patients with mild or moderate hypercalcemia (calcium levels of 10.3–14.0 mg/dL). Gastrointestinal discomfort, changes in level of consciousness, and general nonspecific discomfort can be experienced in cases of moderate hypercalcemia (Reagan et al., 2014). Other signs and symptoms are lethargy, confusion, anorexia, nausea, constipation, polyuria, and polydipsia (Halfdanarson, Hogan, & Moynihan, 2006).
Treatment of hypercalcemia depends on the severity. Thiazide diuretics should be discontinued. Hydration must be maintained to diminish the risk of exacerbation of hypercalcemia. Severe hypercalcemia should be considered a medical emergency. Intravenous normal saline and loop diuretics should be implemented but will only last as long as the treatments are infusing. Bisphosphonates can help reduce bone reabsorption resulting in low serum calcium levels (Fallah-Rad & Morton, 2013). Calcitonin can also be administered subcutaneously or intramuscularly and can also reduce calcium levels (Halfdanarson et al., 2006). 25OHD levels and vitamin D supplementation may also reduce the risk of hypercalcemia (Fallah-Rad & Morton, 2013).
Tumor Lysis Syndrome
Tumor lysis syndrome (TLS) is caused when a tumor breaks down rapidly as a result of treatment or decompensation leading to massive cell death (Wagner & Arora, 2014). TLS is often detected in hematological malignancies (Rasool et al., 2014) and can be associated with high proliferation rate, bulky tumor (Mughal, Ejaz, Foringer, & Coiffier, 2010), high tumor burden, and sensitivity to chemotherapy (Rasool et al., 2014). TLS causes hyperkalemia, hyperuricemia, and hyperphosphatemia, which can enhance the risk of renal failure, reduced cardiac function, and mortality (Cantril & Haylock, 2004; Mughal et al., 2010; Shah, 2014). As chemotherapy agents become more effective, the risks increase for TLS.
Hyperphosphatemia and hypocalcemia can occur about 24 to 48 hours following the first chemotherapy administration. Signs and symptoms, such as muscle cramps, anxiety, depression, confusion, hallucinations, cardiac arrhythmia, and seizures, can result (Cantril & Haylock, 2004). The use of biomarkers (superoxide dismutase, malondialdehyde, glutathione, and catalase) may help one to recognize TLS so that treatment can be started (Rasool et al., 2014).
Other issues associated with TLS are hyperkalaemia, which is created by a release of potassium from the debilitation of the tumor cells. High serum potassium levels can cause severe arrhythmias and sudden death (Cairo & Bishop, 2004). Hyperuricemia (uric acid > 10 mg/dL) can result in acute obstruction uropathy and cause hematuria, flank pain, hypertension, edema, lethargy, and restlessness (Cairo & Bishop, 2004; Cantril & Haylock, 2004) and is caused by underexcretion (Oka et al., 2014). Hydration, administration of allopurinol, and diuresis are generally the first-line treatment (Ahmad et al., 2015; Cantril & Haylock, 2004). Treatment with rasburicase has been found to be effective in the treatment by lowering plasma uric acid levels (Dinnel, Moore, Skiver, & Bose, 2015).
The signs and symptoms associated with TLS include decreased urine output, seizures, and arrhythmias. Electrolytes must be assessed to determine the presence of hyperkalemia, hyperuricemia, and hyperphosphatemia. Electrocardiograms should be obtained to assess arrhythmia.
Spinal Cord Compression
Spinal cord compression (SCC) is not uncommon and can occur when metastasis spreads to the vertebral bodies and invades the spinal cord. The spinal column in the thoracic area is the most common location for this and must be recognized immediately to prevent critical, irreversible damage (Halfdanarson et al., 2006). SCC can lead to long-term neurological deficits and is often detected in solid tumors such as prostate, lung, breast, and kidney cancers (Savage et al., 2014).
Signs and symptoms are numbness, tingling and weakness in the extremities, sensory changes, and upper thorax and back pain (Lowey, 2006; Tsukada et al., 2015). Pain can radiate or localize and may seem chronic, which may disguise the emergent SCC and delay critical treatment. Bowel and bladder dysfunction can also occur. For patients who are experiencing SCC, the inability to walk into the clinic or emergency department often results in a delay of care (Tsukada et al., 2015) and it is important to recognize that the ability to ambulate does not exclude the existence of SCC.
Diagnosis is often made with MRI and CT and sometimes plain radiographic films of the affected area. Treatment is often initiated with glucocorticoids followed by either radiation therapy and/or surgery. For people who are ambulatory, radiation therapy can be considered. Patients with paraplegia, nonradiosensitive tumors, and a predicted survival of more than 3 months may benefit from surgery to decompress the spine (George et al., 2008). In some cases, combination therapy of surgery and radiation therapy can be beneficial to preserving ambulatory status and survival (Lee, Kwon, et al., 2014).
Neutropenic Fever
Neutropenic fever is an oncological medical emergency, which is caused by the diminishment of neutrophils by chemotherapeutic agents. Neutropenia is defined by an oral temperature of 101°F, an absolute neutrophil count (ANC) of less than 1,500 cells/µL. An ANC of less than 500 cells/µL is considered severe (Freifeld et al., 2011). Neutropenia can be the motivator for a severe infection and timely treatment is essential (Villafuerte-Gutierrez, Villalon, Losa, & Henriquez-Camacho, 2014). Generally, fever is the presenting sign; however, skin rashes and mucositis may also be present. For some patients, neutropenic fever can occur after the first cycle of chemotherapy and patients who have undergone aggressive surgery with bowel resections are at enhanced risk (Sharma, Rezai, Driscoll, Odunsi, & Lele, 2006).
Myelosuppression is associated with many chemotherapies, and growth factors, such as granulocyte-colony stimulating factor (G-CSF), work to elevate white blood cell counts necessary in fighting infection (Miller & Steinbach, 2014). A great amount of nursing literature exists on the definition, prevention, and management of neutropenic fever. Prevention of neutropenia and neutropenic fever should be proactive in the administration of G-CSFs in patients who are considered at high risk (Aapro et al., 2011). An older cancer patient receiving myelotoxic chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisolone) is considered high risk and should receive prophylactic G-CSF administration (Aapro et al., 2011; Repetto et al., 2003), yet many patients are not treated with growth factors despite the potential positive outcomes (Lugtenburg et al., 2012).
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