Cancer is largely a disease of an aged population. Estimates suggest that about 60% of all cancers are diagnosed in individuals aged 65 or older, and that number is expected to increase to 70% by 2030. Yet many nurses have little formal geriatric-specific training to care for this population’s unique needs.
In their article in the gero-oncology supplement to the December 2018 issue of the Clinical Journal of Oncology Nursing, Goldberg, Burhenn, and Ginex provided an overview of what oncology nurses need to know about assessing and caring for older adults with cancer.
Needs and Concerns
The physiologic changes associated with aging and increased incidence of comorbidities put older adults with cancer at greater risk for adverse events, inability to tolerate treatment, and issues such as polypharmacy. Goldberg et al. stressed the need for care coordination and an interprofessional approach to geriatric assessment to identify all potential areas of concern.
Patient histories and physical exams may miss elements such as difficulties with activities of daily living, physical functioning, nutritional status, falls, psychosocial functioning, or cognitive capacity, Goldberg et al. said. Early interventions have the greatest potential to improve patient outcomes.
Once the healthcare team has identified concerns, optimal care should follow an interprofessional approach involving medicine, nursing, palliative care, social work, physical and occupational therapy, chaplaincy, pharmacy, and nutrition.
The gold standard of assessing older adults with cancer is through a comprehensive geriatric assessment (CGA), but a full CGA takes time that many practices and practitioners don’t have. However, shorter screening tools can identify at-risk older adult patients who would benefit from a full CGA workup.
Goldberg et al. provided an overview of screening tools that oncology nurses can use in assessments, including the Geriatric 8 from the International Society of Geriatric Oncology that can be completed in less than five minutes, Vulnerable Elders Survey, and Triage Risk Screening Tool.
Considerations for Care
Oncology nurses should, at a minimum, assess patients’ activity levels, medication use, nutritional status, social support, cognitive function, and risk of toxicity to chemotherapy.
Exercise: Thanks to ONS’s Get Up, Get Moving resources, oncology nurses understand the importance of exercise in patients with cancer no matter their age. Goldberg et al. reminded that exercise has been shown to improve physical and emotional well-being in patients, contributing to positive health outcomes. For example, studies have shown that yoga decreases fatigue and reduces side-effect burden in older adult patients with cancer.
If patients are too frail to tolerate an exercise program, even interventions such as interrupted sedentary time or periods of standing may improve outcomes, but Goldberg et al. emphasized the importance of continually assessing patients’ functional status to ensure safe and appropriate activity.
Polypharmacy: Studies have shown that 33% of older adults take at least five medications and that the use of herbal and dietary supplements is increasing among older adults. It’s important to assess for inappropriate use, interactions, or duplications. For example, medications such as amitriptyline are no longer appropriate for long-term use in older adults because of an increased risk for falls. Oncology nurses should review and reconcile patients’ medications at every appointment and encourage patients to bring in all medications, including prescriptions, over-the-counter drugs, and supplements.
Additionally, older adult patients may process certain medications differently than younger patients because of age-related changes that affect all organ systems, but particularly the liver and kidneys. Drugs are primarily metabolized in the liver and excreted through the kidneys, but as a person ages, mass and blood flow decrease in both organs, reducing their function and increasing the risk of drug accumulation. For example, morphine should be used with caution in older adults with hepatic or renal insufficiency because accumulation of morphine metabolites can cause sedation, confusion, or respiratory depression.
Screening tools may help nurses identify polypharmacy concerns. Goldberg et al. identified the Screening Tool of Older Person’s Prescriptions (STOPP), Screening Tool to Alert Doctors to Right Treatment (START), or Beers criteria.
Because geriatric education typically is not part of nursing school curricula, oncology nurses should seek continuing nursing education opportunities to update themselves on caring for their older adult patients. According to preliminary data presented at the 43rd Annual ONS Congress in May 2018, gerontology-focused oncology nursing education improves self-rated preparedness, skill, and comfort in caring for older adult patients with cancer.
Goldberg et al. discussed formal programs available through the Geriatric Nursing Education Consortium, End-of-Life Nursing Education Consortium, or Hartford Institute for Geriatric Nursing at the New York University College of Nursing. Online resources are available for nurses who are unable to participate in formal programs (see sidebar).
For more information on gero-oncology care considerations for nurses, refer to the full article by Goldberg et al. in the Clinical Journal of Oncology Nursing.
This monthly feature offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes “Nursing Education: Review of Assessment, Clinical Care, and Implications for Practice Regarding Older Adult Patients With Cancer,” by Jessica I. Goldberg, RN, MSN, AGPCNP-BC, Peggy S. Burhenn, MS, RN-BC, CNS, AOCNS®, and Pamela K. Ginex, EdD, RN, OCN®, which was published in the gero-oncology supplement to the December 2018 issue of CJON. Questions regarding the information presented in this article should be directed to the CJON editor at CJONEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.