Commentary (Burdette-Radoux/Muss): Psychiatric Assessment and Symptom Management in Elderly Cancer Patients

Even now, cancer is a disease of aging; the average age of a newly diagnosed cancer patient in the United States is greater than 65 years. Safe and effective medical care for the elderly will become an increasingly important issue as our population ages over the next several decades. By 2025, 20% of the US population will be over the age of 65. It will be essential for physicians to be well versed in assessing and treating patients in this age group in a manner appropriate to their unique medical needs. As the population ages, and better treatment for other diseases contributes to longer life expectancy, the assessment and treatment of cancer in the elderly will be an increasingly common problem for oncologists. In this article, Winell and Roth address psychiatric issues facing the elderly patient with cancer. They methodically describe the approach to diagnosis and treatment of several common psychiatric conditions in the elderly: depression, anxiety, fatigue, pain, delirium, and dementia. Each section begins with diagnostic criteria for the condition, frequently with reference to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, along with an analysis of how factors specific to the elderly may be problematic or influence diagnostic decisions. Assessment Tools and Interventions
Various assessment tools are mentioned as aids to diagnosis. This comprehensive approach may be useful for those clinicians who are familiar with this type of assessment tool, but may be less useful for those who are not experienced in using these tools. A stepwise algorithm to assess psychiatric symptoms, similar to the treatment guidelines for oncologic care of the elderly developed by the National Comprehensive Cancer Network,[1] can be a practical tool for the busy practicing oncologist. Such an algorithm can start with clusters of symptoms easily recognizable to the practicing oncologist, such as depressed mood, sleep disturbance, and decreased appetite, as symptoms of depression, for example. The practitioner is then guided to appropriate assessment tools for the symptoms, such as the Comprehensive Geriatric Assessment or the Beck Depression Inventory. Results of the assessment then direct the practitioner to appropriate therapy or referral to mental health practitioners. Following each section on diagnosis, the authors discuss therapeutic interventions used to treat psychiatric conditions in the elderly. Although nonpharmacologic interventions are included, the specific indications for these interventions and how to integrate them in the elder cancer patient's care are less clear than those for pharmacologic treatment. Their Table 1 lists interventions used for anxiety and depression; an algorithm incorporating these interventions into an overall treatment plan, as described above, would be helpful for the practicing oncologist. A list of symptoms that should prompt consultation with a psychiatrist would also be useful. The sections on pharmacologic treatment are comprehensive and contain a wealth of practical information with special attention to drug interactions and side effects that are important in the elderly population. Tables of antidepressants, anxiolytics, and neuroleptics provide a handy reference for dosing with helpful notes on common side effects. Pain Management
Pain management in the elderly presents a number of challenges unique to this population. The authors provide a basic approach to pain management and cover some of the many problems encountered in providing effective pain control in the elderly. Patients' perception of pain, and the clinician's ability to assess their pain, may be problematic. Oversedation is a common problem, partly due to metabolic differences and concomitant medications in the elderly, but also due to dosing errors. The patients' ability to maintain a medication schedule, and their ability to effectively use breakthrough pain medication due to mental status changes, can be impaired by the same medication that is being used to treat the pain. Constipation is a more common problem in the elderly, is exacerbated by narcotic analgesics, and may sometimes be severe enough to cause patients to stop taking their pain medication. Maneuvers such as the use of the transdermal route of administration, simplification of medication regimens, and institution of an effective bowel regimen at the same time narcotic therapy is started may all go a long way toward effective pain control in the elderly. Global Approach to Assessment and Support
Problems specific to the elderly population affect all aspects of their medical care. A global approach with a multidisciplinary team will be most successful in addressing all of these issues in a coordinated fashion. Tools such as the Comprehensive Geriatric Assessment, which includes a component of psychiatric assessment, can be helpful in assessing the needs of the elderly population and determining which services may be useful for supporting the patient during cancer treatment.[2] A modified self-administered form of this assessment has been studied for use in the oncology population[3] and may be helpful in choosing appropriate treatment. In these types of assessment tools, psychiatric, social, spiritual, and familial factors may all be considered. Family relationships are particularly important in the elderly population, as family members may be providing both physical and emotional support to the elderly patient. Interventions involving treatment of psychiatric symptoms should closely involve family members since they may provide valuable insights into symptoms not always revealed by the patient to their oncologist, and they may be instrumental for the success of any treatment, whether for cancer treatment or supportive care. Aspects of Decision-Making
Decision-making in the elderly population may follow a different pathway from that of a younger group of patients. In the past, elderly patients were not always offered the same treatment as younger patients due to fear of side effects, or an assumption that they would not understand a complicated risk/benefit analysis. Recent studies have shown that elderly patients can tolerate, and do benefit from, the same treatment as younger patients.[4,5] Involvement of the elderly patient in the decisionmaking process and full discussion of options and potential side effects is crucial to optimal treatment in this population. A psychiatric assessment may be helpful in determining competence for decision-making and capability of understanding complex decisions. Whatever the level of competence, the elderly patient should be afforded the opportunity to participate in the decision-making process to the best of their ability. The Cancer and Leukemia Group B is currently assessing decision-making in patients who choose not to undergo adjuvant chemotherapy for breast cancer in order to better understand this process. Conclusion
An understanding of psychiatric issues and treatment of psychiatric conditions in the elderly will become more and more important as the population ages. This article provides a compendium of diagnostic approaches and pharmacologic treatments that will be a useful reference in the multidisciplinary assessment of the elderly patient.

Disclosures:

The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. Available at www.nccn.org/professionals/ physician_gls/PDF/senior.pdf. Accessed September 15, 2005.
2. Repetto L, Fratino L, Audisio RA: Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: An Italian Group for Geriatric Oncology Study. J Clin Oncol 20:494-502, 2002.
3. Ingram SS, Seo PH, Martell RE, et al: Comprehensive assessment of the elderly cancer patient: The feasibility of self-report methodology. J Clin Oncol 20:770-775, 2002.
4. Muss HB, Woolf S, Berry D, et al: Adjuvant chemotherapy in older and younger women with lymph node-positive breast cancer. JAMA 293:1073-1081, 2005.
5. Dees EC, O’Reilly S, Goodman SN, et al: A prospective pharmacologic evaluation of agerelated toxicity of adjuvant chemotherapy in women with breast cancer. Cancer Invest 18:521-529, 2000.