Palliative care aims to relieve the suffering of patients with life-limiting illnesses, and that of their carers, and is applicable at all stages of disease, not simply limited to end-of-life care. It incorporates thorough symptom assessment and management, as well as psychosocial and spiritual support, and aims to establish the goals of care for patients and plan for their future. The purpose of this chapter is to review the issues specific to the older cancer patient in palliative care. It discusses where special care is needed; it is therefore not a comprehensive overview of general palliative care, symptom control and advance care planning.
In the older population with cancer there are additional challenges to symptom control. As well as their primary cancer diagnosis, patients are more likely to have multiple comorbidities, and these conditions, such as heart failure and chronic obstructive pulmonary disease (COPD), present their own symptom challenges and are life-limiting conditions in their own right. In a study of 226 people aged over 60 with advanced COPD, heart failure or cancer, it was found that symptom prevalence such as pain (27%), fatigue (47%) and depression (11%) was the same across all three conditions.1 Furthermore, older people are less likely to die in their usual place of care or hospice and more likely to die in hospital,2 meaning that hospital physicians need to be able to provide palliative care and refer to specialist services when needed. Finally, older patients are more likely to have older spouses as carers who have their own health issues, or have no informal carers because they live alone. These factors all contribute to the complexity of the palliative management of older patients with cancer.
Symptom assessment in the older cancer patient
In the older patient with cancer the spectrum of symptoms is different from that of their younger counterparts. Frailty is much more common, and this can lead to restricted mobility, urinary incontinence, falls and delirium. However, common malignant symptoms such as pain are just as prevalent in this population and will be discussed in more detail.
Additional difficulties in assessing this population arise from the increased likelihood of significant sensory or cognitive impairment, and this must be incorporated into the selection and prescription of any medications. This poses a challenge to assessment and may therefore require more frequent reassessment or use of pain and symptom assessment tools to monitor symptom management, as recall of symptoms and assessment of benefit of interventions may be poor.3 If the patient has significant cognitive impairment, subjective symptom assessment may be impossible and objective assessment such as observing changes in behaviour and body language will be required.
There is discrepancy in the management of symptoms between the older and younger population. Pain is often overlooked and under-assessed in the older population, especially if the patient ...