Cancer is the second leading cause of death for adults over 65 years of age.1 Although individuals over 65 represent approximately 12% of the population, they account for more than half of all cancer diagnoses and 60% of all cancer deaths.2 As the population ages, nurses will be working with increased numbers of elderly cancer patients. So that optimal care can be delivered to this patient population, it is imperative that nurses gain an understanding of the aging process and an appreciation of the cancer experience in the older adult.3 The purpose of this article is to examine how nursing assessment can be guided by the unique age-related changes, as well as the complications of cancer.
As the first step in the nursing process, the nursing assessment is intended to elicit significant data related to the patient's health history, which, when analyzed, provides a picture of the patient's present situation as well as a framework for the identification of problems and needs. The development of an appropriate nursing care plan depends on this assessment process. Because of the complex, ever-changing nature of advanced cancer presentation, it is necessary that nurses caring for these patients be knowledgeable in cancer pathophysiology and the nature of cancer symptoms and treatments. A carefully planned, well-focused nursing assessment allows the nurse to identify the important data and investigate each patient's concern or potential complication.
Calvary Hospital, a 200-bed acute care specialty hospital, accredited by the Joint Commission on Accreditation of Healthcare Organizations, exclusively for advanced cancer patients, is the only institution of its kind in the country. Since 1899. Calvary has offered a comprehensive program of care for patients in need of acute medicalnursing intervention. A modified form of primary nursing allows for optimum use of both the professional staff and the specially trained paraprofessional staff, known as cancer care technicians. In addition, a variety of nursing specialists assist the staff in the management of specific nursing issues. To complement the inpatient services. Calvary also provides comprehensive outpatient services, as well as a certified home health agency.
Consistent with the statistics on cancer and age, almost two thirds of the patients cared for at Calvary Hospital are over 65 years of age.4 In planning care for the elderly advanced cancer patient, it is necessary to appreciate the frequency with which concurrent health problems may compound this already complex situation. By aggravating or influencing cancer-related symptoms and their treatments, or by inducing non-cancer related symptoms, concurrent health problems may inadvertently be thought to be associated with malignancy progression. Thus, it becomes apparent that a careful and thorough nursing assessment is crucial to the planning of care for the elderly advanced cancer patient. This is further illustrated in the case study.
Mr J, 83 years old, has a past medical history that includes arthritis in the lumbosacral spine and adult onset diabetes mellitus, In April 1987, after complaints of difficulty voiding, he was diagnosed with carcinoma of the prostate. He underwent a radical prostatectomy in May 1987, followed by a course of external radiotherapy. His postoperative and postradiotherapy course was uneventful and he was asymptomatic until December 1987 when he presented with increased weakness and "moderate" back pain. Diagnostic studies revealed regional lymph node involvement and metastases to the pelvis. The malignancy was found to be non-responsive to hormonal therapy. Mr J received one course of cisplatin and, based on renal function studies, did not continue on the chemotherapy. In April 1988, a liver scan revealed hepatic metastases.
Mr J was admitted to Calvary Hospital with complaints of progressive lower back pain and increasing weakness. He appeared to be markedly cachectic, having lost 45 pounds since the initial diagnosis. He described his appetite as "poor." He was able to transfer out of bed to a chair with the assistance of two people, but was usually not able to sit for long, due to the aggravation of back pain. He was alert but lethargic, and the transfer note described Mr J as being "depressed and withdrawn" with occasional periods of confusion. His laboratory values and medications are listed in the Table.
LABORATORY VALUES AND MEDICATIONS FOR MR J
As Mr J's history is reviewed, it is evident that in many aspects he presents with a number of usual or expected problems for a man of his age. Carcinoma of the prostate is a disease that primarily affects elderly men and it is estimated that 80% of all prostate cancer occurs in men over the age of 65.- Additionally, the symptomatology and concurrent health problems are fairly typical and expected for an 83year old man with prostatic cancer.
An in-depth investigation of Mr J's history may well reveal a vast number of actual and potential health problems. For the purpose of this discussion, attention will focus on the assessment of three areas that pose special concerns for the elderly: nutrition, pain, and psychosocial aspects.
Mr J presents with many factors that contribute to his alteration in nutritional intake. Anorexia, a problem for many advanced cancer patients, is being reported by about one third of the patients admitted to Calvary.4 As with any patient concern, it is essential that an assessment be conducted to determine Mr J's perception of the nutritional problem. Identification of the patient's perception of distress and his goals assists in formulating a patientspecific plan of care.
Initially, a nutritional assessment should be conducted to determine the most appropriate diet selection for Mr J. Both age- and cancer-related factors may alter the structure or function of the gastrointestinal system, and they along with Mr J's ability to eat should be appropriately identified. Mr J's complaint of increasing weakness directs the nurse toward determining if he possesses the energy required to chew a regular diet and feed himself. One would assess for adequate lubrication of the oral cavity since age-related changes may decrease salivary production. For Mr J, this may be further complicated by narcotic administration and, perhaps, dehydration, which can further dry the mucous membranes of the mouth, making it susceptible to cracking and discomfort. Since Mr J has dentures, they should be checked for proper fit since changes in the oral cavity secondary to a 45-pound weight loss may necessitate a re-evaluation.
Because Mr J has documented liver metastases, one would monitor the presence and extent of ascites, which may contribute to a feeling of fullness after even small amounts of food. It is also important to determine if pain is negatively influencing Mr J's appetite.
A nursing assessment should investigate the extent to which age-related slowing of peristalsis and narcoticinduced bowel changes have resulted in constipation. Since constipation may result in feelings of fullness or nausea, this often interferes with a patient's ability to eat.
Mr J's "poor" appetite is further complicated by the fact that he is an insulin-dependent diabetic. Initially, blood glucose would be monitored to determine if insulin doses are appropriate. Since the demand for insulin is influenced by a great variety of factors, the nurse should assess Mr J continually for signs of fever, stress, and, very importantly, fluctuations in intake. One would assess Mr J's level of understanding and knowledge regarding signs and symptoms of hypoglycemia and reinforce this information as needed.
Mr J was put on a 2,000 calorie ADA diet with Sustacal 240 cm3 q.i.d. An investigation of Mr J's nutritional likes and dislikes may provide information helpful in diet planning. Identification of eating patterns may assist in determining the most advantageous times for meals.
Another major problem that Mr J presented with was pain. Pain is by far the most common symptom encountered by advanced cancer patients, and the one that accounts for the greatest distress. In the literature, 60% to 90% of patients with advanced disease report a problem with pain.5
In assessing Mr J's pain, the presence of bone metastases is a major factor. Bone involvement is the most common cause of pain in cancer patients. His liver metastases are also relevant as they may influence the metabolism of medications. Mr J's general debilitation, poor nutritional status, and cachexia may also interfere with the absorption of medications.
In addition to cancer-related changes, the aging process itself needs to be considered in assessing pain. Some neurophysiological differences that appear with aging may decrease the sensation, appreciation, or manifestations of pain. Other common debilities of old age may cause discomfort. Assessment of Mr J's back pain, for example, must include evaluation of his arthritis as well as the presence of bone metastases. The intermittent confusion that Mr J experiences is a problem for some older individuals. When there is cognitive impairment, the patient may be less able to describe pain and to request analgesics. There is data suggesting that older patients may not verbalize their complaints as well as younger patients.6 This reinforces the necessity for the nurse to assess nonverbal signs that may indicate the presence of pain, such as moaning, grimacing, restlessness, and changes in physical appearance.
The nurse needs to obtain a detailed history of Mr J's pain profile: how he perceives pain, what has been helpful in controlling it, what aggravates it, and the ineffectiveness of the medication regimen. There are a variety of pain measurement scales available, such as visual analogues and verbal indicators. Older patients often find some tools more difficult to use and this needs to be evaluated. The location of the pain and its radiation, severity, and duration must be determined. The relationship of pain to various positions needs to be considered (eg, Mr J's back pain is aggravated by sitting for long periods). The relationship between pain and mobility is important. Analgesic administration can be coordinated with transfer activities.
Narcotics are the mainstay of pain treatment, and it is important to assess the patient's feelings about the use of narcotics. There is a suggested ladder approach to the control of cancer pain. For moderate pain, such as Mr J's, codeine 30 mg to 60 mg, and acetaminophen 650 mg orally is recommended. Meperidine hydrochloride, prescribed on admission, is not a good choice for this patient population. Orally, it has a very low potency, rapid onset, and short (1 to 2 hours) duration of effect. If pain becomes more severe, morphine may be indicated.
The use of narcotics in the older population raises certain concerns. There may be age-related sensitivities to drugs and greater adverse side effects. Older patients may require less narcotics than younger patients to control their pain. The benefits of an around-the-clock versus an as-needed schedule need to be determined. An as-needed schedule may be an effective way of balancing the degree of pain relief and the development of side effects.
On admission, Mr J presents with two problems that fall within the realm of psychosocial assessment: depression and occasional episodes of confusion. It is acknowledged that neither of these are automatic correlates of the aging process or should be assumed as "normal." Both problems may have multiple, complex etiologies and warrant thorough and accurate nursing evaluation. Psychological alterations that are not associated with the physiological aging process can often be alleviated or prevented by modifying the environment.
Nursing assessment includes evaluation of Mr J's cognitive (thinking, problem-solving, orientation) and affective (mood, feeling, tone) functioning. The present problem needs to be assessed in terms of comparison with Mr J's prior levels of functioning, adequacy of current capabilities, and satisfaction with present status.
Depression is the most prevalent psychiatric disorder in the elderly population,7 and thus frequently encountered by nurses. Depression has posed many assessment difficulties in this age population, and these are compounded with a disease diagnosis of advanced cancer. Many of the manifestations and symptoms of depression are similar or identical to those of advanced cancer such as anorexia, insomnia, lethargy, and saddened mood. It is important to distinguish reactive depression to a situation versus depression associated with an organic state. It is also necessary to determine and clarify what has come to be known as the "appropriately depressed" syndrome.
Health-care professionals with wellmeaning intentions often identify terminally ill patients as appropriately and naturally depressed, and thus limit therapeutic interventions on their behalf. Patients may be left to tolerate the burden of depression with limited recognition by professionals that depression may be as great a suffering as any physical pain.
Assessment of confusion also presents difficulties and challenges. Agerelated causes of altered mental status, such as degenerative Alzheimer's or vascular disease, need to be considered in assessing the older adult. Physiological dimensions of cancer (eg, brain metastasis) may also have a great impact on cognitive abilities and functioning. Mr J has bone metastasis, which might cause hypercalcemia, manifesting itself at times as confusion and depression. Mr J's diabetic state may contribute to mood and personality changes. Attention to metabolic and pharmacological concerns should be stressed, given the disease state of this patient.
The nurse needs to incorporate a mental status examination into her assessment focusing on affect, memory, orientation, judgment, and comprehension to determine the severity of the episodes of confusion. Environmental conditions, such as a hospital transfer, new nursing personnel, and unfamiliar routine, may magnify more subtle problems of confusion.
A thorough nursing assessment is crucial to the development of an effective plan of care for the older advanced cancer patient. Mr J's situation highlights a few problem areas that may be encountered in nursing practice. The case also reinforces the necessity for considering both age- and cancerrelated alterations in providing nursing care for the elderly advanced cancer patient.
- 1. Yancik R (Ed). Perspectives on Prevention and Treatment of Cancer in the Elderly. New York: Raven Press, 1983.
- 2. Baranovsky A, Myers MH. Cancer incidence and survival in patients 65 years of age and older. CA. 1986;36:26-41.
- 3. Dellefield ME. Caring for the elderly patient with cancer. Oncology Nursing Forum. 1986; 13(3): 19-27.
- 4. Gray G, Adler D, Fleming C, Brescia F. A clinical data base for advanced cancer patients: Implications for nursing. Cancer Nurs. 1988;11:77-83.
- 5. R>ley K. The treatment of cancer pain. N Engl J Med. 1985:313:84.
- 6. Serpick AA. Cancer in the aged. Am Fam Physician. 1982;26:113-117.
- 7. St Pierre J, Craven R, Bruno P. Late life depression: A guide for assessment. Journal of Gerontological Nursing. 1986; 12:7.
LABORATORY VALUES AND MEDICATIONS FOR MR J