Symptom assessment in elderly cancer patients receiving palliative care

Critical Reviews in Oncology/Hematology 47 (2003) 281 /286 www.elsevier.com/locate/critrevonc Symptom assessment in elderly cancer patients receivin...
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Critical Reviews in Oncology/Hematology 47 (2003) 281 /286 www.elsevier.com/locate/critrevonc

Symptom assessment in elderly cancer patients receiving palliative care Sophie Pautex *, Andre´ Berger, Catherine Chatelain, Franc¸ois Herrmann, Gilbert B. Zulian CESCO, Department of Geriatrics, Geneva University Hospitals, Ch. De la Savonnie`re 11, CH-1245 Collonge-Bellerive, Switzerland Accepted 13 January 2003

Contents 1.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2.

Patients and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3.

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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4.

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5.

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Biography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Abstract Background: The purpose of this study is to examine the concordance of symptom assessment among the multiple raters in French-speaking elderly patients with an advanced cancer benefiting from palliative care. Patients and methods: This study was conducted in a geriatric hospital with palliative care specificity. During 6 months, patient, nurse and physician completed the Edmonton symptom assessment system on two consecutive days. Results: 42 patients with an advanced oncological disease were included. Mean age was 729/9.04 (range 52 /88) and 23 were females. Mean mini mental status examination (MMSE) was 27.59/1.6. First assessment was completed at a median of day 8 after admission. Nurses, physicians and patients assessments were reproducible between days 1 and 2 (P /0.05). Pearson correlation coefficient significantly associated nurse assessment with patient assessment for pain, depression, anxiety, drowsiness, appetite and wellbeing (P B/0.05). Physician assessment was associated with patient assessment for pain, depression, drowsiness, appetite, wellbeing and shortness of breath (P B/0.05). However, regression analysis looking for patient score from both physicians and nurses scores weakly correlated all these factors (R2 B/0.6), except for appetite (R2 for day 1/day 2: 0.79/0.64). Conclusions: French-speaking elderly cancer patients without cognitive failure and in stable general condition are consistent in their symptom assessment, and they have to be considered as the gold standard. Nevertheless, interdisciplinary assessment is probably a valid surrogate to self-assessment by the patient but only when the latter is truly impossible. # 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Cancer patients; Elderly; Symptom assessment; Palliative care; Edmonton symptom assessment system

1. Introduction * Corresponding author. Tel.: /41-22-305-70-85; fax: /41-22-30571-15. E-mail address: [email protected] (S. Pautex).

Cancer is one of the first cause of death in the elderly population. Cancer is also an important source of suffering for the patient and a great burden for the

1040-8428/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S1040-8428(03)00043-X

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families. Beside pain, a high prevalence of symptoms such as fatigue, loss of appetite and depression has been demonstrated in patients with advanced cancer. In geriatric medicine and in palliative care, adequate symptom management is important to allow the best possible quality of life and the precise clinical assessment of symptoms is paramount [1 /3]. Despite this, pain remains often underestimated by caregivers leading to an inappropriate treatment [4,5]. In addition, elderly patients may be at further risk of poor treatment because of an underestimation of their sensitivity to pain and the assumption that they tolerate pain well [6]. In a clinical setting, symptoms need to be assessed with a simple and reliable bedside tool. Patients with an oncological disease are often assessed with Kanofsky and Burchenal [7] performance status. These tools are completed by the caregivers and measure the functionality of the patient. They have an important prognostic value, but their utility for the daily follow-up of the patient is questionable. Several scales such as SF-36, FACT and EORTC-QLQC30 have been developed to assess quality of life of the patients [8 /10]. Other complex multidimensional assessment tools are available, like the Memorial Symptom Assessment Scale or the Rotterdam Symptom Checklist [11,12]. These tools are very important in research setting, but are difficult to use in clinical daily practice. The Edmonton symptom assessment system (ESAS) is a combination of visual analogue scales intended to be used by the patient and handed to the caregivers who can then take appropriate measures [13]. It is simple and fairly easy to complete. This has been first validated in hospitalised cancer patients and recently in a cancer outpatient clinic [13,14]. The reliability of assessment of other symptoms than pain between cancer patients and caregivers has so far been demonstrated to be very weak, except perhaps for family caregivers [15 /18]. However, no studies have been specifically targeted to elderly cancer patients and none have been done in a French-speaking country. The purpose of this study was thus to examine the concordance of symptom assessment between patient, nurse and physician in elderly cognitively intact Frenchspeaking cancer patients, to determine the reliability of ESAS under these circumstances and finally to find out which symptom was best assessed by nurses or physicians.

2. Patients and methods Study was conducted at the CESCO which is a 104bed geriatric hospital with longstanding palliative care specificity. About 800 patients are admitted each year and 300 of them die, mostly of cancer.

Study protocol was approved by the Ethic Committee of Geneva University Hospitals. From May to September 2000, patients hospitalised for at least 3 days were included if they met the following criteria: ]/50 years of age, advanced cancer, fluency in French, intact cognition and stable general condition. Patients must have had intact cognition and be in stable condition to be included in the study. This was done to enhance the validity of the study. The study was conducted by two senior physicians, who explained the aim of the study, the utilisation of the assessment tool and who obtained patient’s written informed consent. Folstein mini mental status examination (MMSE) was used to differentiate patients cognitively intact (MMSE ]/24) from those cognitively impaired (MMSE B/24) [19]. MMSE was administered before symptom assessment by trained physicians. Symptom assessment was completed using the French version of ESAS [20]. ESAS is a nine 10-cm visual analogue scale measuring the intensity of the following symptoms: pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath (dyspnoea). Scores ranged from 0 (absence of symptom) to 10 (worst possible symptom). Patients, nurses and physicians completed ESAS on two separate occasions, approximately 24 h apart from a total of six assessments per patient. On each occasion, ESAS was independently administered by the three raters in an undetermined order but during a limited interval of an hour. Days 1 and 2 assessment was completed by the same physician on both occasions (in total eight different physicians). Intra-raters and interraters concordance of the nurses were measured on days 1 and 2. In total 15 different nurses assessed the patient. Intra-raters concordance was measured in half of the patients with the assessment on days 1 and 2 by the same nurse; inter-raters concordance was measured in the other half of the patients with the assessment on days 1 and 2 by two different nurses. For the statistical analysis, scores of the visual analogue scale were used as a continuous variable. The mean values among the assessment performed by the patient, the nurse and the physician on days 1 and 2 were compared using analysis of variance (ANOVA) with a repeated measures design, including day effect, subject effect (patient /nurse /physician) and a day/ subject interaction term. The concordance between assessment of the patient, of the nurse and of the physician on days 1 and 2 were established using paired t -test. The concordance between the assessment of the nurse and of the physician was established with Pearson correlation coefficient and regression analysis. During the study period, 320 patients were admitted to the hospital, 150 patients with advanced cancer, but only 49 met the inclusion criteria. 101 patients were not included because of poor general conditions (n /75), MMSE lower than 24 (dementia (n/4), delirium (n/20) and

S. Pautex et al. / Critical Reviews in Oncology/Hematology 47 (2003) 281 /286 Table 1 Patients characteristics Variable

Number or mean (range)

Number of patients Age Female/male

42 72 years (52 /94) 23/19

Breast cancer Gastrointestinal cancer Lung cancer Genitourinary cancer Thyroid cancer Multiple myeloma

6 11 14 9 1 1

MMSE mean

27.3 (27 /30)

Current drugs Weak analgesia Strong opioids Corticosteroids Benzodiazepine Antidepressant Antiemetics

11 21 15 8 8 2

Mean length of stay

59.45 days (11 /240)

communication problems (n /2)). Seven patients dropped out before the end of the study, because of delirium (n/4), sudden death (n/2) and withdrawal before complete evaluation (n /1), resulting in a final group of 42 patients. No patient refused to take part in the study.

3. Results The final sample consisted of 42 patients. Their characteristics are listed in Table 1. ESAS was completed by three different raters on median day 8 after patient’s admission (patient in stable condition). Results of symptom evaluation by the three raters on days 1 and

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2 are presented in and Table 2. Highest scored symptoms were fatigue, loss of appetite and wellbeing on both days. Physicians and nurses underestimated pain, drowsiness, shortness of breath (dyspnoea) and overestimated depression and anxiety. P -values measured by ANOVA comparing globally patients, nurses and physician were not statically significant. Intra-raters reproducibility of patients, nurses and physician was consistent between days 1 and 2 (P /0.05 on paired ttest) for all symptoms (Table 3). Inter-raters assessment of nurses was also consistent between days 1 and 2. Pearson correlation coefficient significantly associated nurse assessment with patient assessment for pain, depression, anxiety, drowsiness, appetite and wellbeing on days 1 and 2 (P B/0.05, Table 4). Physician assessment was associated with patient assessment for pain, depression, drowsiness, appetite, wellbeing and shortness of breath (dyspnoea) on days 1 and 2 (P B/0.05). Finally, nurses and physicians assessments on days 1 and 2 were significantly associated for all symptoms. However, appetite was the single symptom evaluated by nurses and physicians that was statically correlated with the patient score by regression analysis looking for patient score from both the physicians and nurses scores (R2 for day 1/day 2: 0.79/0.64; Table 5).

4. Discussion The results of this study demonstrated that Frenchspeaking elderly cancer patients without cognitive failure and in stable general condition are consistent in their symptom assessment on two consecutive occasions. Elderly cancer patients can thus be a valid raters. Previous experience has suggested that elderly cancer patients in palliative care were not used to paper sheets and that nurses and physicians were not willing to

Table 2 Mean scores of ESAS and standard deviation Day 1

Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Wellbeing Dyspnoea

P * (ANOVA)

Patient

Nurse

Physician

2.989/3.09 4.799/3.09 0.949/.2.05 1.959/2.40 2.409/2.81 3.349/2.90 4.799/3.86 4.289/2.86 3.219/2.90

2.419/2.69 4.109/2.69 0.769/1.81 2.719/2.82 3.199/2.75 2.139/2.38** 4.489/3.48 4.409/2.12 2.059/3.17**

2.219/2.56 3.959/2.77 0.639/1.45 3.029/2.51** 3.109/2.54 2.399/2.42 4.349/3.39 4.749/2.32 2.099/2.71**

0.062 0.224 0.618 0.045 0.187 0.021 0.533 0.463 0.021

Day 2

P * (ANOVA)

Patient

Nurse

Physician

3.229/2.96 4.139/2.76 0.839/1.77 1.949/2.53 2.389/3.01 3.119/2.38 4.519/3.63 4.519/3.64 4.089/2.58

1.949/2.09** 3.989/2.66 0.469/1.07 2.649/2.86 2.749/2.65 2.119/2.49 4.519/3.59 4.319/2.49 2.259/2.74

2.129/2.38** 3.849/2.65 0.999/1.54 2.979/2.43** 3.039/2.63 2.619/2.56 4.719/3.21 4.759/2.14 1.829/2.75**

0.001 0.838 0.188 0.033 0.319 0.055 0.888 0.255 0.039

No significant differences between nurse and physician assessment. * P for the subject effect, computed with ANOVA with a repeated measures design, there was neither significant day effect nor any significant day/subject interaction term. ** P B/0.05 between nurse and patient or physician and patient.

S. Pautex et al. / Critical Reviews in Oncology/Hematology 47 (2003) 281 /286

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Table 3 Reproducibility of ESAS scores for each symptom among raters evaluated by paired t -test P -value

Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Wellbeing Dyspnoea

Patient

Nurse

Physician

0.479 0.062 0.596 0.964 0.942 0.513 0.509 0.660 0.145

0.214 0.809 0.271 0.879 0.379 0.972 0.965 0.779 0.659

0.772 0.771 0.092 0.897 0.833 0.441 0.360 0.993 0.351

The higher the P -value, the better the reproducibility.

routinely use ESAS or other scales in those patients [21]. Ageism has been sometimes advocated to explain these attitudes towards elderly patients and the perception of the ageing process may also be detrimental in allowing elderly cancer patients to take an active place in their daily care [22]. However, factual information obtained from older adults by general practitioners seems to be as accurate as in younger patients [23 /25]. On the other hand, the non-oncological geriatric literature about selfrated symptom assessment is very poor, except for pain [6,26]. In addition, elderly patients may be at further risk of poor treatment because of an underestimation of their sensitivity to pain and the assumption that they tolerate pain well. Finally, misconceptions persist about

the ability of elderly patients to benefit from the use of opioids [6]. Our results showed that physicians and nurses symptom assessments of elderly cancer patients are also consistent between days 1 and 2, even if nurses are different on both occasions. This is important in the clinical setting, because the assessment is done by different individuals. Team perception of patients symptoms may be thus accurately translated by a single individual. In addition, the results confirmed the finding of the oncological and non-oncological literature that caregivers and proxies tend to underestimate physical symptoms of the patients, but overestimate psychological symptoms [17,18,27]. Another explanation for this discordance between patients and caregivers for the psychological symptoms is that defense mechanisms of depressed or anxious patients may obscure the assessment of his subjective state. Our results do not allow to differentiate between these two hypotheses. Some symptoms like pain, depression, anxiety or dyspnoea have multidimensional components (nociception, meaning of symptom, cognition, emotion, suffering, social support, etc.) and possibly patients, nurses or physicians do not always assess the same component. But our study does not allow to test this hypothesis. Finally, it is demonstrated that nurses evaluated more accurately anxiety than physicians, and that physicians were more accurate in assessing shortness of breath. Nevertheless, when looking for patient score from both the physicians and nurses scores, there is only a weak

Table 4 Pearson correlation coefficient on days 1 and 2 for patient versus nurse and physician assessment and nurse versus physician assessment Nurse versus patient assessment

Physician versus patient assessment

Nurse versus physician assessment

R2

P

R2

P

R2

P

Day 1 Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Wellbeing Dyspnoea

0.66 0.32 0.54 0.43 0.53 0.44 0.79 0.49 0.32

0.000 0.040 0.000 0.040 0.003 0.003 0.000 0.001 0.030

0.67 0.38 0.14 0.49 0.21 0.33 0.61 0.44 0.45

0.000 0.010 0.340 0.000 0.180 0.030 0.000 0.004 0.003

0.81 0.31 0.34 0.49 0.37 0.33 0.78 0.59 0.70

0.000 0.044 0.029 0.001 0.016 0.030 0.000 0.000 0.000

Day 2 Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Wellbeing Dyspnoea

0.53 0.21 0.04 0.53 0.45 0.46 0.64 0.43 0.45

0.000 0.183 0.825 0.000 0.003 0.002 0.000 0.004 0.003

0.55 0.36 0.18 0.55 0.57 0.61 0.59 0.36 0.57

0.000 0.403 0.268 0.000 0.000 0.000 0.000 0.020 0.000

0.72 0.40 0.48 0.55 0.43 0.45 0.56 0.43 0.61

0.000 0.008 0.001 0.002 0.004 0.003 0.000 0.004 0.000

S. Pautex et al. / Critical Reviews in Oncology/Hematology 47 (2003) 281 /286

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Table 5 Regression analysis on days 1 and 2 R2

Nurse coefficient

Nurses (P )

Physician coefficient

Physician (P )

Day 1 Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Wellbeing Dyspnoea

0.48 0.19 0.30 0.20 0.28 0.23 0.63 0.28 0.20

0.40 0.26 0.63 0.32 0.54 0.45 0.90 0.48 0.01

0.080 0.150 0.000 0.032 0.001 0.017 0.000 0.042 0.990

0.46 0.36 0.05 0.14 0.02 0.25 /0.02 0.28 0.47

0.055 0.046 0793 0.410 0.905 0.172 0.900 0.184 0.036

Day 2 Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Wellbeing Dyspnoea

0.34 0.13 0.03 0.34 0.38 0.42 0.49 0.22 0.34

0.39 0.08 /0.11 0.33 0.29 0.27 0.46 0.36 0.16

0.156 0.634 0.722 0.022 0.080 0.093 0.002 0.034 0.352

0.44 0.33 0.24 0.30 0.53 0.56 0.38 0.25 0.48

0.068 0.053 0.258 0.077 0.002 0.001 0.019 0.191 0.006

correlation, except for appetite. Appetite is most probably the symptom best assessed because it is easy to measure how much the patient eats each day by looking at what is left on the trail. Our results come after similar studies already suggesting that concordance between cancer patients and caregivers is rather poor. General practitioners, district nurses, family caregivers, all failed in reliably assessing cancer patients [15,16]. However, these studies were often done in the outpatient settings and they were looking at a much younger population. In addition, the situation did not appear better for inpatients evaluated by nurses and physicians or family caregivers [17,18]. Only one-third of the patients admitted to our hospital during the study period could be included and this is a limitation of the study. As expected, poor general conditions and cognitive alterations were frequently encountered in this geriatric population. Nevertheless, inclusion criteria were very selective to improve the validity of the study. The second limitation is the large number of different raters (nurses and physicians) who have participated in this study. But this reflects the daily life of a clinical environment.

latter is truly impossible. Integrated symptom assessment scales completed either by the nurses only (e.g. for anxiety), or by the physicians only (e.g. for shortness of breath), or by both, should be developed to better assess symptoms. This is an encouragement to continue the development of tools such as Doloplus† , which has been successfully used to measure pain in communicatively impaired patients [28]. It is now our objective to improve and adapt this behavioural pain scale to other symptoms frequently encountered in the elderly through an interdisciplinary approach.

Reviewers Carla Ripamonti, National Cancer Institute, Rehabilitation and Palliative Care Division, Via Venezian 1, I20133 Milano, Italy. Eduardo Bruera , Department of Symptom Control and Palliative Care, MD Anderson Cancer Center, University of Texas, 1515 Holcombe Blvd., Box 008, Houston, TX 77030, USA.

5. Conclusion References French-speaking elderly cancer patients without cognitive failure and in stable general condition are consistent in their symptom assessment, and they have to be considered as the gold standard. Nevertheless, interdisciplinary assessment is probably a valid surrogate to self-assessment by the patient but only when the

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Biography Sophie Pautex is a medical consultant of the pain and palliative care consultation in the Department of Geriatric Medicine at Geneva University Hospital.

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