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Assessment of pain, fatigue, sleep and quality of life (QoL) in elderly hospitalized cancer patients
Archives of Gerontology and Geriatrics 51 (2010) e57–e61
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Assessment of pain, fatigue, sleep and quality of life (QoL) in elderly hospitalized cancer patients Sibel Eyigor a,*, Can Eyigor b, Ruchan Uslu c a
Ege University, Faculty of Medicine, Physical Therapy and Rehabilitation Department, Tulay Aktas Oncology Hospital, Supportive Care Unit, 35100 Bornova-Izmir, Turkey Ege University, Faculty of Medicine, Anesthesiology Department, Pain Clinic, 35100 Bornova-Izmir, Turkey c Ege University, Faculty of Medicine, Medical Oncology Department, Tulay Aktas Oncology Hospital, Supportive Care Unit, 35100 Bornova-Izmir, Turkey b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 September 2009 Received in revised form 24 November 2009 Accepted 25 November 2009 Available online 30 December 2009
As the proportion of older adults in the population continues to grow, the number of patients with cancer is expected to increase proportionally. In the previously conducted studies, data on elderly cancer patients were generally compared with the QoL scores of elderly patient group and with the data of noncancer individuals. The purpose of this study was to examine differences in reported pain, fatigue, sleep problems and QoL between middle-aged and elderly hospitalized patients with cancer. We included 53 middle-aged (between 18 and 50 years) hospitalized cancer patients and 47 elderly (>60 years) hospitalized cancer patients in this study. Pain (visual analog scale = VAS, verbal pain rating), fatigue (brief fatigue inventory = BFI), sleep problems, QoL (Short Form 36 = SF36), and European Organization for Research and Treatment of Cancer (EORTC)-QoL-C30 data were gathered using standardized measures. In the elderly group, no significant difference was detected in terms of VAS, verbal pain rating, fatigue, fatigue type, sleep problems and QoL scores (p > 0.05). When the two age groups were compared, BFI scores were found to be significantly high among the elderly patients (p < 0.05). A significant relationship was observed in both age groups between the scores of pain, fatigue and sleep problems, and QoL (p < 0.05). Elderly hospitalized cancer patients did not demonstrate a distinctive difference in terms of pain, sleep and QoL compared to the younger group. The relationship between pain, fatigue, sleep and QoL should be definitely kept in mind in clinical practice. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cancer Elderly Pain Fatigue Sleep Quality of life
1. Introduction Cancer is observed to be the most common disease all over the world, and for most types of cancer, incidence rates increase with advancing age (Wedding et al., 2007). As the proportion of older adults in the population continues to grow, the number of patients with cancer is expected to increase proportionally. Therefore, the points to be taken into consideration, such as the multi-perspective evaluation of the patient and expectations from the treatment, differ for elderly patients. The significance of this issue has recently increased among geriatrists and oncologists (Gosney, 2007; Maas et al., 2007). Although young cancer patients reach the maximum physical and psychological function approximately 1 year after the primary treatment, older adult cancer survivors face with several problems (Robb et al., 2007). The prevalence of chronic diseases is high in the elderly group and co-morbidities add to the existing stress in these patients. The incidence of functional, physical and psychological problems increases with age. Besides, the two age groups show differences in terms of response to treatment, side * Corresponding author. Tel.: +90 232 3903 6887; fax: +90 232 3881 953. E-mail address: [email protected] (S. Eyigor). 0167-4943/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2009.11.018
effects and treatment expectations (e.g., relatively shorter life expectancy, side effects) (Mandelblatt et al., 2003; Robb et al., 2007). However, few studies have focused solely on elderly people with cancer (Thome´ et al., 2004). Many adverse events can be observed in cancer patients, either due to the disease itself or the treatment. Pain is one of the major problems faced by cancer patients (Yates et al., 2002; McBeth et al., 2003). It has been argued that pain is present in 30% of the patients at the time of diagnosis, increasing to 65–85% as the disease progress (Yates et al., 2002). Data also exist showing that widespread pain decreases cancer survival (McBeth et al., 2003). Pain is also present in 90% of all hospitalized cancer patients (McMillan et al., 2000). Despite its prevalence, our knowledge on pain among elderly hospitalized cancer patients is limited (Torvik et al., 2008). Meanwhile, fatigue, observed in some 61% of cancer patients, is the most common complaint (Moore and Dimsdale, 2002). Pain and fatigue are important because they stand at the forefront of factors adversely affecting these patients with regard to general health, function and QoL (Schag et al., 1993). As another important symptom, research in cancer survivors in general has shown that sleep difficulties are a common concern with 36.9–58.7% of cancer survivors reporting sleep symptoms an
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average of 1 year after diagnosis (Gooneratne et al., 2007). Fatigue and insomnia have previously been found as predictors of change in elderly cancer patients’ functioning (Given et al., 2001; Esbensen et al., 2006). Nevertheless, there are no available data about fatigue and sleep problems in hospitalized elderly cancer patients. Elderly cancer patients tend to weight their QoL as more important than gain in survival, when compared to younger patients (Wedding et al., 2007). QoL data are of prognostic importance for survival in a hospitalized elderly population in general in a variety of types of cancer. Therefore, QoL is a major area of concern in the treatment of patients with cancer, especially in elderly patients and those treated within a non-curative approach (Wedding et al., 2007). Cancer survivors tend to have significantly lower scores in QoL than age-matched non-cancer individuals (Baker et al., 2003). In the previously conducted studies, data on elderly cancer patients were generally compared with the QoL scores of elderly patient group and with the data of non-cancer individuals (Gooneratne et al., 2007; Robb et al., 2007; Baumann et al., 2009). Thus, in our study, the characteristics of elderly hospitalized cancer patients such as pain, fatigue, sleep symptoms and QoL were compared with the results of middle-aged hospitalized cancer patients. 2. Subjects and methods
impact of fatigue on daily routine activities. Zero point denotes no fatigue, while 1–3, 4–6, and 7–10 points indicate mild, moderate and severe fatigue, respectively (Mendoza et al., 1999). The Short Form 36 – SF36: on this widely used index, there are 36 questions evaluating the QoL. The SF36 explores eight dimensions of the QoL, labeled as ‘‘physical function’’, ‘‘role physical’’, ‘‘bodily pain’’, ‘‘general health’’, ‘‘vitality’’, ‘‘social function’’, ‘‘role emotional’’, and ‘‘mental health’’. Higher scores indicate better health (Ware et al., 2000). The EORTC-QoL-C30 is a 30-item scale that measures the QoL of cancer patients in which respondents receive scores for functional scale, symptom scale and global health scale. High scores for functional and global health scales indicate a good QoL while high scores in symptom scale represent a high level of problems (Aaronson et al., 1993). 2.4. Statistical methods All data were analyzed using SPSS version 14 statistical software package for Windows. Descriptive statistics were used to characterize the sample. Preliminary inferences were made using t-tests for two independent samples and Chi-square for proportions. For statistical methods we preferred using nonparametric tests. The p < 0.05 were considered statistically significant.
2.1. Study participants 3. Results This study has been designed to be a descriptive study and included 85 patients between 18 and 50 years of age and 75 patients above 60 years of age who were admitted to Tulay Aktas Oncology Hospital for treatment and followed by the Supportive Care Unit. Inclusion criteria were: being 18 years of age and over, hospitalized cancer patients, consenting to participate in the study, having general status and cognitive functions good enough to understand and answer the questions. Among these patients, 2 patients between 18 and 50 years of age died, 20 patients could not be contacted and 10 patients refused to participate in the study; while 5 patients in the group over 60 years of age died, 15 patients could not be contacted and 8 patients refused to participate in the study. Patients were given information about the study and those who agreed to participate were included in the study.
Fifty-three patients from the 18–50 age group and 47 patients from the group over 60 years of age were included in the assessment. Demographical, medical and clinical characteristics of the patients are presented in Tables 1 and 2. When the two age groups were compared, no significant difference was detected between VAS, verbal rating scale, fatigue status and fatigue type, sleep problems, SF36 (excluding vital subscore) and EORTC-QoL-C30 scores (p > 0.05) (Tables 2 and 3). BFI score was found to be significantly higher in the elderly group (p < 0.05) (Table 3). When the patients were compared according to the extent of pain (widespread pain-local pain-no pain), there were no statistically significant differences between the two age groups (p > 0.05) (Table 2).
2.2. Evaluation of demographical and clinical data Patient query form was used to obtain demographical data. Disease histories were extracted from the patient records. Pain, fatigue and sleep statuses were explored with short-answer questions. Short-answer questions such as the localization of pain (widespread pain-local pain-no pain), fatigue, type of fatigue (morning fatigue-getting tired easily during the day), sleep disorder, were answered as ‘‘present’’ or ‘‘absent’’. Pain was assessed using a visual analog scale (VAS) and verbal pain rating (0: no pain, 1: mild, 2: moderate, 3: severe, 4: unbearable). For sleep disorders, patients were asked questions regarding the number of nights with difficulty falling asleep, the frequency of waking up at night during the previous week (0: did not wake up at all, 1: woke up some nights, 2: woke up every night), mean length of sleep in the previous week, and un-refreshing sleep (0: waking up refreshed, 1: sometimes waking up refreshed, 2: never waking up refreshed). 2.3. Study variables Fatigue, QoL and health statuses were assessed using the following measures: the BFI assesses the severity of fatigue and the
Table 1 Demographic variables of hospitalized cancer patients, mean S.D. or n (%). Middle-aged
Elderly
Number
53
47
Age Range
36.72 10.74 (17–50)
65.77 4.97 (60–78)
Gender (female/male)
27 (50.9)/26 (49.1)
23 (48.9)/24 (51.1)
Occupation* House working Retired Employee Workman Other
19 (35.8) 9 (17) 5 (9.4) 7 (13.2) 13 (24.5)
20 (42.6) 27 (57.4)
Marital status* Married Single
33 (62.3) 20 (37.7)
39 (83) 8 (17)
Education level Primary High school University No school
22 (41.5) 21 (39.6) 9 (17) 1 (1.9)
18 (38.3) 18 (38.3) 9 (19.1) 2 (4.3)
*
p < 0.05.
S. Eyigor et al. / Archives of Gerontology and Geriatrics 51 (2010) e57–e61 Table 2 Medical and clinical variables of hospitalized cancer patients, n (%), or mean S.D. Middle-aged
Elderly
Number Chemotherapy (Yes/No)* Radiation therapy (Yes/No) Co-morbidites (Yes/No)* Metastasis (Yes/No) Living alone (Yes/No) VAS
53 50 (94.3)/3 (5.7) 24 (45.3)/29 (54.7) 11 (20.8)/42 (79.2) 25 (47.2)/28 (52.8) 3 (5.7)/50 (94.3) 3.75 3.63
47 37 (78.7)/10 (21.3) 17 (36.2)/30 (63.8) 24 (51.1)/23 (48.9) 27 (57.4)/20 (42.6) 6 (12.8)/41 (87.2) 2.83 3.04
Pain Widespread pain Local pain No pain
16 (30.2) 23 (43.4) 14 (26.4)
15 (31.9) 16 (34) 16 (34)
45 (84.9)/8 (15.1) 35 (66.0)/18 (34.0) 3.09 2.21
42 (89.4)/5 (10.6) 28 (59.6)/19 (40.4) 2.89 2.51
7.17 2.50
6.91 1.60
Fatigue (Yes/No) Sleep problems (Yes/No) The number of nights with difficulty falling asleep Mean length of sleep *
p < 0.05.
Table 3 QoL and fatigue scores of hospitalized cancer patients. Middle-aged
Elderly
p
Number BFI
53 5.21 3.33
47 7.30 1.30
0.046*
SF36 Physical functioning Physical role Bodily pain General health Vitality Social functioning Emotional role Mental health
42.30 29.99 6.13 23.46 57.56 35.41 41.08 23.29 47.83 11.16 28.77 29.98 44.22 39.97 46.06 16.72
30.77 18.60 0 63.74 30.70 38.40 16.02 43.09 8.11 19.15 17.84 57.42 40.37 43.85 12.99
0.134 0.056 0.465 0.753 0.027* 0.261 0.077 0.776
EORTC-QoL-C30 Function scales Symptom scales Global health scale
52.49 21.46 32.67 17.80 35.07 30.73
44.70 13.49 36.80 10.53 22.64 20.51
0.058 0.169 0.076
*
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Significant correlations were detected between BFI and the scores of SF36 subgroups like physical functioning (r = 0.604**), general health (r = 0.743**), vitality (r = 0.749**), social functioning (r = 0.766**), emotional role (r = 0.501**), mental health (r = 0.760**), VAS (r = 0.405*), verbal rating scale (r = 0.420*) (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoL-C30 function scale and the scores of SF36 subgroups like physical functioning (r = 0.784**), physical role (r = 0.330*), bodily pain (r = 0.406**), general health (r = 0.657**), vitality (r = 0.743**), social functioning (r = 0.768**), emotional role (r = 0.449**), mental (r = 0.808**) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoL-C30 symptom scales and the scores of SF36 subgroups like physical functioning (r = 0.458**), physical role (r = 0.317*), bodily pain (r = 0.712**), general health (r = 0.640**), vitality (r = 0.649*), social functioning (r = 0.487**), emotional role (r = 0.596**) and mental health (r = 0.574*) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoL-C30 global health scale and the scores of SF36 subgroups like physical functioning (r = 0.516**), bodily pain (r = 0.316**), general health (r = 0.679**), vitality (r = 0.628**), social functioning (r = 0.620**), emotional role (r = 0.508**) scores (*p < 0.05, **p < 0.01). 3.2. In elderly group
p < 0.05.
3.1. In middle-aged group Significant correlations were found between VAS score and the scores of SF36 subgroups like physical functioning (r = 0.440**), bodily pain (r = 0.953**), general health (r = 0.460**), vitality ( 0.384**), social functioning (r = 0.398), mental health (r = 0.293*) and EORTC-QoL-C30 function scale ( 0.460**), EORTC-QoL-C30 symptom scales (r = 0.721**) and EORTC-QoLC30 global health scale ( 0.362*) (*p < 0.05, **p < 0.01). Significant correlations were detected between verbal rating scale and the scores of SF36 subgroups like physical functioning (r = 0.421**), bodily pain (r = 0.936**), general health (r = 0.451**), vitality ( 0.368**), social functioning (r = 0.400), mental health (r = 0.324*) and EORTC-QoL-C30 function scale ( 0.482**), EORTC-QoL-C30 symptom scales (r = 0.745**), EORTCQoL-C30 global health scale ( 0.362*) (*p < 0.05, **p < 0.01). Significant correlations were detected between mean length of sleep and the scores of SF36 subgroups like mental health (r = 0.303*) and EORTC-QoL-C30 symptom scales (r = 0.304**) (*p < 0.05, **p < 0.01). Significant correlations were detected between the number of nights with difficulty falling asleep and the scores of SF36 subgroups like bodily pain (r = 0.330*), emotional role (r = 0.371**) and EORTC-QoL-C30 symptom scales (r = 0.510**), VAS (r = 0.294*), verbal rating scale (r = 0.323**) (*p < 0.05, **p < 0.01).
Significant correlations were detected between VAS and the scores of SF36 subgroups like bodily pain (r = 0.951**) and EORTC-QoL-C30 symptom scales (r = 0.418**) (*p < 0.05, **p < 0.01). Significant correlations were detected between verbal rating scale and SF36 subgroups of bodily pain (r = 0.948**), EORTCQoL-C30 symptom scales (r = 0.456**) and EORTC-QoL-C30 global health scale (r = 0.322**) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between the mean length of sleep and SF36 subgroups of physical functioning (r = 0.316*), bodily pain (r = 0.302*) and EORTC-QoL-C30 global health scale (r = 0.430**) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between BFI and the EORTC-QoL-C30 symptom scales (r = 0.693**), EORTC-QoL-C30 global health scale (r = 0.444*) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoLC30 function scale and the scores of SF36 subgroups of physical functioning (r = 0.633**), social functioning (r = 0.667**), emotional role (r = 0.394**), mental health (r = 0.481**) and the number of nights with difficulty of falling asleep (r = 0.373*) (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoLC30 symptom scales and SF36 subgroups of physical functioning (r = 0.409**), bodily pain (r = 0.515**), social functioning ( 0.418**) and mental health (r = 0.414**) scores (*p < 0.05, **p < 0.01). 4. Discussion According to the results of our study, no difference was observed between the age groups in terms of pain, sleep problems and QoL scores, and fatigue scores were found to be higher in the elderly group. In both age groups, a relationship was found between pain, fatigue and sleep symptoms, and QoL in elderly hospitalized cancer patients. Cancer-related symptoms may affect the biological behavior of the tumor and therefore may be important for prognosis (Chen and Chang, 2004; Hwang et al., 2004; Hauser et al., 2006). It should be kept in mind that if the clinicians do not have the knowledge on QoL and symptoms such as pain and fatigue, they may be mistaken
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in their choice of appropriate and realistic treatment and estimation of survival (Hwang et al., 2004; Hauser et al., 2006). It has been reported that pain (Chen and Chang, 2004) and fatigue (Herndon et al., 1999) are particularly important for survival. In another study, prevalence of pain in hospitalized cancer patients has been found to be higher than for patients with other chronic diseases and it has been argued that it is related to distress in cancer patients (Tranmer et al., 2003). Cancer, as well as factors caused by cancer treatment, may have increased the percentage of pain in that study. When the middle-aged and elderly groups were compared in patients with bone metastases, the results have demonstrated that pain severity and pain percentages are higher in the elderly group (Torvik et al., 2008). On the other hand, another study has shown that older adults with cancer may experience less intense pain than their younger counterparts (McMillan, 1989). Contrary to these results, our study has not revealed any difference between the two age groups in terms of pain scores. There are not many available studies with which we can compare the pain level in hospitalized cancer patients. This result may be due to the fact that the two age groups were assessed during the period in which they were hospitalized. Further studies are needed in order to demonstrate the relationship between pain and hospitalization in elderly cancer patients. It is emphasized in literature that the relationship between pain and QoL should also be taken into account (Tavoli et al., 2008). Our study has also shown that pain and QoL scores are related in both age groups. The effect of effective pain treatment on patient’s QoL should be taken into consideration in clinical practice. Cancer-related fatigue is one of the most common and disabling symptoms experienced by elderly cancer patients and by cancer survivors. However, this has not led to an increase in clinical trials for assessment and therapy of fatigue in this population. The early recognition and formal assessment of this symptom is important in order to be able to treat it before it negatively impacts the patient’s QoL (Rao and Cohen, 2008). Emotional distress, sleep disorders, and the physical effects of the disease have been implicated in development of fatigue (Rao and Cohen, 2008). It is known that it has a negative impact on the QoL and functional capacity (Tranmer et al., 2003). In our study, although no difference was found between the two age groups in terms of fatigue status and type, it was observed that BFI score assessing the effect of fatigue was higher in the elderly group. As reported in literature (Reiner and Lacasse, 2006), the higher rate of co-morbidities in the elderly group may account for this result obtained in our study. We are of the opinion that necessary attention should be paid also to this symptom regarding the relationship between fatigue and QoL. Sleep disorders is a common complaint in cancer patients that is often neglected during clinical oncology practice (Moore and Dimsdale, 2002). The insomnia complaints noted by Davidson et al. (2002) in their study of predominantly older patients with various types of cancer tended primarily to be difficulty maintaining sleep (76%), followed by difficulty falling asleep (44%) and early morning awakenings (33%). Despite the effects of sleep difficulties on QoL, these sleep disorders are often not evaluated or treated. In part this is because health care providers do not inquire about sleep, but the patients themselves do not report it as well in many cases (Gooneratne et al., 2007). In our study, no difference was found between the middle-aged and elderly patient groups in terms of sleep problems. In the literature, these complaints are especially common in patients with chronic pain (88%) (Moore and Dimsdale, 2002). Results of the present study demonstrate a relationship between sleep status and pain. Considering the relationship observed in our study between pain, fatigue, sleep and QoL, the necessity of treating these symptoms collectively should be noted.
Cancer is a serious health problem that affects the patients’ QoL considerably (Peters and Sellick, 2006). QoL has been recommended as one of the hard end-points for clinical cancer research (Di Maio and Perrone, 2003). As a conclusion, no distinctive difference was found between elderly patients and their younger counterparts in terms of QoL scores. Contrary to our results, Fehlauer et al. (2005) noticed that older breast cancer survivors (>65 years versus <65 years) had decreased physical functioning, role functioning, and sexual functioning compared to their younger counterparts. Furthermore, QoL scores were determined to be higher in cancer patients compared to young patients living alone (Rustoen et al., 1999). Yet, literature includes results that support our study on breast cancer patients and non-small-cell lung cancer patients (Crivellari et al., 2000; Langer et al., 2002). This finding was explained by the authors with the tendency of elderly patients to complain less and endure symptoms better. In the study carried out by Torvik et al. (2008), no difference was observed between middle-aged and elderly cancer patients in terms of QoL in patients with bone metastases. In a study carried out in Germany (Baumann et al., 2009), hospitalized cancer patients of 60 years and over were compared with patients hospitalized for other medical reasons and with the normal population in terms of QoL. QoL scores were found to be low in cancer patients and the patients hospitalized for other medical reasons compared to the general population. As a result, it was reported that the low QoL in elderly patient group cannot be associated only with cancer diagnosis, and similar deterioration may be seen in other medical diseases (Baumann et al., 2009). If the results of elderly cancer patients are not different from the results of younger population and show similarity with the results of patients with other medical problems, the observed changes may be related to the disease rather than old age. Besides, it should be kept in mind that QoL is multi-faceted. Powerful aspect of our study is that it is the first study in which pain, fatigue, sleep and QoL were assessed together in elderly hospitalized cancer patients and the results of these assessments were compared with the data obtained from younger generation. This study also has certain limitations. Assessment could have been made for only one type of cancer. Yet, probably due to the difficulty of performing a study on cancer patients, similar studies also included different cancer types. It has been demonstrated that pain management in hospitalized cancer patients is not well known and adequately carried out. In our study, the assessment and follow up of pain treatments could have been valuable. Besides, anxiety and depression status should also be evaluated in future studies. In a conclusion, elderly hospitalized cancer patients did not demonstrate a distinctive difference in terms of pain, sleep and QoL compared to the younger group. The relationship between pain, fatigue, sleep and QoL should be definitely kept in mind in clinical practice. By all means, special attention should be paid to elderly patients in terms of assessment and treatment. Yet, if the results of cancer patients are not different from those of younger population and show similarities with the results of patients with other medical problems, the differences in QoL and associated factors may be due to cancer diagnosis rather than old age. We think that our study results sand hypothesis should be supported also with other studies. Conflict of interest statement None. References Aaronson, N.K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull, A., Duez, N.J., Filiberti, A., Flechtner, H., Fleishman, S.B., DeHaes, J.C.J.M., Kaasa, S., Klee, M., Osoba, D., Razavi, D., Rofe, P.B., Schraub, S., Sneeuw, K., Sullivan, M., Takeda, F., 1993. The
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Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Assessment of pain, fatigue, sleep and quality of life (QoL) in elderly hospitalized cancer patients Sibel Eyigor a,*, Can Eyigor b, Ruchan Uslu c a
Ege University, Faculty of Medicine, Physical Therapy and Rehabilitation Department, Tulay Aktas Oncology Hospital, Supportive Care Unit, 35100 Bornova-Izmir, Turkey Ege University, Faculty of Medicine, Anesthesiology Department, Pain Clinic, 35100 Bornova-Izmir, Turkey c Ege University, Faculty of Medicine, Medical Oncology Department, Tulay Aktas Oncology Hospital, Supportive Care Unit, 35100 Bornova-Izmir, Turkey b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 September 2009 Received in revised form 24 November 2009 Accepted 25 November 2009 Available online 30 December 2009
As the proportion of older adults in the population continues to grow, the number of patients with cancer is expected to increase proportionally. In the previously conducted studies, data on elderly cancer patients were generally compared with the QoL scores of elderly patient group and with the data of noncancer individuals. The purpose of this study was to examine differences in reported pain, fatigue, sleep problems and QoL between middle-aged and elderly hospitalized patients with cancer. We included 53 middle-aged (between 18 and 50 years) hospitalized cancer patients and 47 elderly (>60 years) hospitalized cancer patients in this study. Pain (visual analog scale = VAS, verbal pain rating), fatigue (brief fatigue inventory = BFI), sleep problems, QoL (Short Form 36 = SF36), and European Organization for Research and Treatment of Cancer (EORTC)-QoL-C30 data were gathered using standardized measures. In the elderly group, no significant difference was detected in terms of VAS, verbal pain rating, fatigue, fatigue type, sleep problems and QoL scores (p > 0.05). When the two age groups were compared, BFI scores were found to be significantly high among the elderly patients (p < 0.05). A significant relationship was observed in both age groups between the scores of pain, fatigue and sleep problems, and QoL (p < 0.05). Elderly hospitalized cancer patients did not demonstrate a distinctive difference in terms of pain, sleep and QoL compared to the younger group. The relationship between pain, fatigue, sleep and QoL should be definitely kept in mind in clinical practice. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cancer Elderly Pain Fatigue Sleep Quality of life
1. Introduction Cancer is observed to be the most common disease all over the world, and for most types of cancer, incidence rates increase with advancing age (Wedding et al., 2007). As the proportion of older adults in the population continues to grow, the number of patients with cancer is expected to increase proportionally. Therefore, the points to be taken into consideration, such as the multi-perspective evaluation of the patient and expectations from the treatment, differ for elderly patients. The significance of this issue has recently increased among geriatrists and oncologists (Gosney, 2007; Maas et al., 2007). Although young cancer patients reach the maximum physical and psychological function approximately 1 year after the primary treatment, older adult cancer survivors face with several problems (Robb et al., 2007). The prevalence of chronic diseases is high in the elderly group and co-morbidities add to the existing stress in these patients. The incidence of functional, physical and psychological problems increases with age. Besides, the two age groups show differences in terms of response to treatment, side * Corresponding author. Tel.: +90 232 3903 6887; fax: +90 232 3881 953. E-mail address: [email protected] (S. Eyigor). 0167-4943/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2009.11.018
effects and treatment expectations (e.g., relatively shorter life expectancy, side effects) (Mandelblatt et al., 2003; Robb et al., 2007). However, few studies have focused solely on elderly people with cancer (Thome´ et al., 2004). Many adverse events can be observed in cancer patients, either due to the disease itself or the treatment. Pain is one of the major problems faced by cancer patients (Yates et al., 2002; McBeth et al., 2003). It has been argued that pain is present in 30% of the patients at the time of diagnosis, increasing to 65–85% as the disease progress (Yates et al., 2002). Data also exist showing that widespread pain decreases cancer survival (McBeth et al., 2003). Pain is also present in 90% of all hospitalized cancer patients (McMillan et al., 2000). Despite its prevalence, our knowledge on pain among elderly hospitalized cancer patients is limited (Torvik et al., 2008). Meanwhile, fatigue, observed in some 61% of cancer patients, is the most common complaint (Moore and Dimsdale, 2002). Pain and fatigue are important because they stand at the forefront of factors adversely affecting these patients with regard to general health, function and QoL (Schag et al., 1993). As another important symptom, research in cancer survivors in general has shown that sleep difficulties are a common concern with 36.9–58.7% of cancer survivors reporting sleep symptoms an
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average of 1 year after diagnosis (Gooneratne et al., 2007). Fatigue and insomnia have previously been found as predictors of change in elderly cancer patients’ functioning (Given et al., 2001; Esbensen et al., 2006). Nevertheless, there are no available data about fatigue and sleep problems in hospitalized elderly cancer patients. Elderly cancer patients tend to weight their QoL as more important than gain in survival, when compared to younger patients (Wedding et al., 2007). QoL data are of prognostic importance for survival in a hospitalized elderly population in general in a variety of types of cancer. Therefore, QoL is a major area of concern in the treatment of patients with cancer, especially in elderly patients and those treated within a non-curative approach (Wedding et al., 2007). Cancer survivors tend to have significantly lower scores in QoL than age-matched non-cancer individuals (Baker et al., 2003). In the previously conducted studies, data on elderly cancer patients were generally compared with the QoL scores of elderly patient group and with the data of non-cancer individuals (Gooneratne et al., 2007; Robb et al., 2007; Baumann et al., 2009). Thus, in our study, the characteristics of elderly hospitalized cancer patients such as pain, fatigue, sleep symptoms and QoL were compared with the results of middle-aged hospitalized cancer patients. 2. Subjects and methods
impact of fatigue on daily routine activities. Zero point denotes no fatigue, while 1–3, 4–6, and 7–10 points indicate mild, moderate and severe fatigue, respectively (Mendoza et al., 1999). The Short Form 36 – SF36: on this widely used index, there are 36 questions evaluating the QoL. The SF36 explores eight dimensions of the QoL, labeled as ‘‘physical function’’, ‘‘role physical’’, ‘‘bodily pain’’, ‘‘general health’’, ‘‘vitality’’, ‘‘social function’’, ‘‘role emotional’’, and ‘‘mental health’’. Higher scores indicate better health (Ware et al., 2000). The EORTC-QoL-C30 is a 30-item scale that measures the QoL of cancer patients in which respondents receive scores for functional scale, symptom scale and global health scale. High scores for functional and global health scales indicate a good QoL while high scores in symptom scale represent a high level of problems (Aaronson et al., 1993). 2.4. Statistical methods All data were analyzed using SPSS version 14 statistical software package for Windows. Descriptive statistics were used to characterize the sample. Preliminary inferences were made using t-tests for two independent samples and Chi-square for proportions. For statistical methods we preferred using nonparametric tests. The p < 0.05 were considered statistically significant.
2.1. Study participants 3. Results This study has been designed to be a descriptive study and included 85 patients between 18 and 50 years of age and 75 patients above 60 years of age who were admitted to Tulay Aktas Oncology Hospital for treatment and followed by the Supportive Care Unit. Inclusion criteria were: being 18 years of age and over, hospitalized cancer patients, consenting to participate in the study, having general status and cognitive functions good enough to understand and answer the questions. Among these patients, 2 patients between 18 and 50 years of age died, 20 patients could not be contacted and 10 patients refused to participate in the study; while 5 patients in the group over 60 years of age died, 15 patients could not be contacted and 8 patients refused to participate in the study. Patients were given information about the study and those who agreed to participate were included in the study.
Fifty-three patients from the 18–50 age group and 47 patients from the group over 60 years of age were included in the assessment. Demographical, medical and clinical characteristics of the patients are presented in Tables 1 and 2. When the two age groups were compared, no significant difference was detected between VAS, verbal rating scale, fatigue status and fatigue type, sleep problems, SF36 (excluding vital subscore) and EORTC-QoL-C30 scores (p > 0.05) (Tables 2 and 3). BFI score was found to be significantly higher in the elderly group (p < 0.05) (Table 3). When the patients were compared according to the extent of pain (widespread pain-local pain-no pain), there were no statistically significant differences between the two age groups (p > 0.05) (Table 2).
2.2. Evaluation of demographical and clinical data Patient query form was used to obtain demographical data. Disease histories were extracted from the patient records. Pain, fatigue and sleep statuses were explored with short-answer questions. Short-answer questions such as the localization of pain (widespread pain-local pain-no pain), fatigue, type of fatigue (morning fatigue-getting tired easily during the day), sleep disorder, were answered as ‘‘present’’ or ‘‘absent’’. Pain was assessed using a visual analog scale (VAS) and verbal pain rating (0: no pain, 1: mild, 2: moderate, 3: severe, 4: unbearable). For sleep disorders, patients were asked questions regarding the number of nights with difficulty falling asleep, the frequency of waking up at night during the previous week (0: did not wake up at all, 1: woke up some nights, 2: woke up every night), mean length of sleep in the previous week, and un-refreshing sleep (0: waking up refreshed, 1: sometimes waking up refreshed, 2: never waking up refreshed). 2.3. Study variables Fatigue, QoL and health statuses were assessed using the following measures: the BFI assesses the severity of fatigue and the
Table 1 Demographic variables of hospitalized cancer patients, mean S.D. or n (%). Middle-aged
Elderly
Number
53
47
Age Range
36.72 10.74 (17–50)
65.77 4.97 (60–78)
Gender (female/male)
27 (50.9)/26 (49.1)
23 (48.9)/24 (51.1)
Occupation* House working Retired Employee Workman Other
19 (35.8) 9 (17) 5 (9.4) 7 (13.2) 13 (24.5)
20 (42.6) 27 (57.4)
Marital status* Married Single
33 (62.3) 20 (37.7)
39 (83) 8 (17)
Education level Primary High school University No school
22 (41.5) 21 (39.6) 9 (17) 1 (1.9)
18 (38.3) 18 (38.3) 9 (19.1) 2 (4.3)
*
p < 0.05.
S. Eyigor et al. / Archives of Gerontology and Geriatrics 51 (2010) e57–e61 Table 2 Medical and clinical variables of hospitalized cancer patients, n (%), or mean S.D. Middle-aged
Elderly
Number Chemotherapy (Yes/No)* Radiation therapy (Yes/No) Co-morbidites (Yes/No)* Metastasis (Yes/No) Living alone (Yes/No) VAS
53 50 (94.3)/3 (5.7) 24 (45.3)/29 (54.7) 11 (20.8)/42 (79.2) 25 (47.2)/28 (52.8) 3 (5.7)/50 (94.3) 3.75 3.63
47 37 (78.7)/10 (21.3) 17 (36.2)/30 (63.8) 24 (51.1)/23 (48.9) 27 (57.4)/20 (42.6) 6 (12.8)/41 (87.2) 2.83 3.04
Pain Widespread pain Local pain No pain
16 (30.2) 23 (43.4) 14 (26.4)
15 (31.9) 16 (34) 16 (34)
45 (84.9)/8 (15.1) 35 (66.0)/18 (34.0) 3.09 2.21
42 (89.4)/5 (10.6) 28 (59.6)/19 (40.4) 2.89 2.51
7.17 2.50
6.91 1.60
Fatigue (Yes/No) Sleep problems (Yes/No) The number of nights with difficulty falling asleep Mean length of sleep *
p < 0.05.
Table 3 QoL and fatigue scores of hospitalized cancer patients. Middle-aged
Elderly
p
Number BFI
53 5.21 3.33
47 7.30 1.30
0.046*
SF36 Physical functioning Physical role Bodily pain General health Vitality Social functioning Emotional role Mental health
42.30 29.99 6.13 23.46 57.56 35.41 41.08 23.29 47.83 11.16 28.77 29.98 44.22 39.97 46.06 16.72
30.77 18.60 0 63.74 30.70 38.40 16.02 43.09 8.11 19.15 17.84 57.42 40.37 43.85 12.99
0.134 0.056 0.465 0.753 0.027* 0.261 0.077 0.776
EORTC-QoL-C30 Function scales Symptom scales Global health scale
52.49 21.46 32.67 17.80 35.07 30.73
44.70 13.49 36.80 10.53 22.64 20.51
0.058 0.169 0.076
*
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Significant correlations were detected between BFI and the scores of SF36 subgroups like physical functioning (r = 0.604**), general health (r = 0.743**), vitality (r = 0.749**), social functioning (r = 0.766**), emotional role (r = 0.501**), mental health (r = 0.760**), VAS (r = 0.405*), verbal rating scale (r = 0.420*) (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoL-C30 function scale and the scores of SF36 subgroups like physical functioning (r = 0.784**), physical role (r = 0.330*), bodily pain (r = 0.406**), general health (r = 0.657**), vitality (r = 0.743**), social functioning (r = 0.768**), emotional role (r = 0.449**), mental (r = 0.808**) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoL-C30 symptom scales and the scores of SF36 subgroups like physical functioning (r = 0.458**), physical role (r = 0.317*), bodily pain (r = 0.712**), general health (r = 0.640**), vitality (r = 0.649*), social functioning (r = 0.487**), emotional role (r = 0.596**) and mental health (r = 0.574*) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoL-C30 global health scale and the scores of SF36 subgroups like physical functioning (r = 0.516**), bodily pain (r = 0.316**), general health (r = 0.679**), vitality (r = 0.628**), social functioning (r = 0.620**), emotional role (r = 0.508**) scores (*p < 0.05, **p < 0.01). 3.2. In elderly group
p < 0.05.
3.1. In middle-aged group Significant correlations were found between VAS score and the scores of SF36 subgroups like physical functioning (r = 0.440**), bodily pain (r = 0.953**), general health (r = 0.460**), vitality ( 0.384**), social functioning (r = 0.398), mental health (r = 0.293*) and EORTC-QoL-C30 function scale ( 0.460**), EORTC-QoL-C30 symptom scales (r = 0.721**) and EORTC-QoLC30 global health scale ( 0.362*) (*p < 0.05, **p < 0.01). Significant correlations were detected between verbal rating scale and the scores of SF36 subgroups like physical functioning (r = 0.421**), bodily pain (r = 0.936**), general health (r = 0.451**), vitality ( 0.368**), social functioning (r = 0.400), mental health (r = 0.324*) and EORTC-QoL-C30 function scale ( 0.482**), EORTC-QoL-C30 symptom scales (r = 0.745**), EORTCQoL-C30 global health scale ( 0.362*) (*p < 0.05, **p < 0.01). Significant correlations were detected between mean length of sleep and the scores of SF36 subgroups like mental health (r = 0.303*) and EORTC-QoL-C30 symptom scales (r = 0.304**) (*p < 0.05, **p < 0.01). Significant correlations were detected between the number of nights with difficulty falling asleep and the scores of SF36 subgroups like bodily pain (r = 0.330*), emotional role (r = 0.371**) and EORTC-QoL-C30 symptom scales (r = 0.510**), VAS (r = 0.294*), verbal rating scale (r = 0.323**) (*p < 0.05, **p < 0.01).
Significant correlations were detected between VAS and the scores of SF36 subgroups like bodily pain (r = 0.951**) and EORTC-QoL-C30 symptom scales (r = 0.418**) (*p < 0.05, **p < 0.01). Significant correlations were detected between verbal rating scale and SF36 subgroups of bodily pain (r = 0.948**), EORTCQoL-C30 symptom scales (r = 0.456**) and EORTC-QoL-C30 global health scale (r = 0.322**) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between the mean length of sleep and SF36 subgroups of physical functioning (r = 0.316*), bodily pain (r = 0.302*) and EORTC-QoL-C30 global health scale (r = 0.430**) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between BFI and the EORTC-QoL-C30 symptom scales (r = 0.693**), EORTC-QoL-C30 global health scale (r = 0.444*) scores (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoLC30 function scale and the scores of SF36 subgroups of physical functioning (r = 0.633**), social functioning (r = 0.667**), emotional role (r = 0.394**), mental health (r = 0.481**) and the number of nights with difficulty of falling asleep (r = 0.373*) (*p < 0.05, **p < 0.01). Significant correlations were detected between EORTC-QoLC30 symptom scales and SF36 subgroups of physical functioning (r = 0.409**), bodily pain (r = 0.515**), social functioning ( 0.418**) and mental health (r = 0.414**) scores (*p < 0.05, **p < 0.01). 4. Discussion According to the results of our study, no difference was observed between the age groups in terms of pain, sleep problems and QoL scores, and fatigue scores were found to be higher in the elderly group. In both age groups, a relationship was found between pain, fatigue and sleep symptoms, and QoL in elderly hospitalized cancer patients. Cancer-related symptoms may affect the biological behavior of the tumor and therefore may be important for prognosis (Chen and Chang, 2004; Hwang et al., 2004; Hauser et al., 2006). It should be kept in mind that if the clinicians do not have the knowledge on QoL and symptoms such as pain and fatigue, they may be mistaken
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in their choice of appropriate and realistic treatment and estimation of survival (Hwang et al., 2004; Hauser et al., 2006). It has been reported that pain (Chen and Chang, 2004) and fatigue (Herndon et al., 1999) are particularly important for survival. In another study, prevalence of pain in hospitalized cancer patients has been found to be higher than for patients with other chronic diseases and it has been argued that it is related to distress in cancer patients (Tranmer et al., 2003). Cancer, as well as factors caused by cancer treatment, may have increased the percentage of pain in that study. When the middle-aged and elderly groups were compared in patients with bone metastases, the results have demonstrated that pain severity and pain percentages are higher in the elderly group (Torvik et al., 2008). On the other hand, another study has shown that older adults with cancer may experience less intense pain than their younger counterparts (McMillan, 1989). Contrary to these results, our study has not revealed any difference between the two age groups in terms of pain scores. There are not many available studies with which we can compare the pain level in hospitalized cancer patients. This result may be due to the fact that the two age groups were assessed during the period in which they were hospitalized. Further studies are needed in order to demonstrate the relationship between pain and hospitalization in elderly cancer patients. It is emphasized in literature that the relationship between pain and QoL should also be taken into account (Tavoli et al., 2008). Our study has also shown that pain and QoL scores are related in both age groups. The effect of effective pain treatment on patient’s QoL should be taken into consideration in clinical practice. Cancer-related fatigue is one of the most common and disabling symptoms experienced by elderly cancer patients and by cancer survivors. However, this has not led to an increase in clinical trials for assessment and therapy of fatigue in this population. The early recognition and formal assessment of this symptom is important in order to be able to treat it before it negatively impacts the patient’s QoL (Rao and Cohen, 2008). Emotional distress, sleep disorders, and the physical effects of the disease have been implicated in development of fatigue (Rao and Cohen, 2008). It is known that it has a negative impact on the QoL and functional capacity (Tranmer et al., 2003). In our study, although no difference was found between the two age groups in terms of fatigue status and type, it was observed that BFI score assessing the effect of fatigue was higher in the elderly group. As reported in literature (Reiner and Lacasse, 2006), the higher rate of co-morbidities in the elderly group may account for this result obtained in our study. We are of the opinion that necessary attention should be paid also to this symptom regarding the relationship between fatigue and QoL. Sleep disorders is a common complaint in cancer patients that is often neglected during clinical oncology practice (Moore and Dimsdale, 2002). The insomnia complaints noted by Davidson et al. (2002) in their study of predominantly older patients with various types of cancer tended primarily to be difficulty maintaining sleep (76%), followed by difficulty falling asleep (44%) and early morning awakenings (33%). Despite the effects of sleep difficulties on QoL, these sleep disorders are often not evaluated or treated. In part this is because health care providers do not inquire about sleep, but the patients themselves do not report it as well in many cases (Gooneratne et al., 2007). In our study, no difference was found between the middle-aged and elderly patient groups in terms of sleep problems. In the literature, these complaints are especially common in patients with chronic pain (88%) (Moore and Dimsdale, 2002). Results of the present study demonstrate a relationship between sleep status and pain. Considering the relationship observed in our study between pain, fatigue, sleep and QoL, the necessity of treating these symptoms collectively should be noted.
Cancer is a serious health problem that affects the patients’ QoL considerably (Peters and Sellick, 2006). QoL has been recommended as one of the hard end-points for clinical cancer research (Di Maio and Perrone, 2003). As a conclusion, no distinctive difference was found between elderly patients and their younger counterparts in terms of QoL scores. Contrary to our results, Fehlauer et al. (2005) noticed that older breast cancer survivors (>65 years versus <65 years) had decreased physical functioning, role functioning, and sexual functioning compared to their younger counterparts. Furthermore, QoL scores were determined to be higher in cancer patients compared to young patients living alone (Rustoen et al., 1999). Yet, literature includes results that support our study on breast cancer patients and non-small-cell lung cancer patients (Crivellari et al., 2000; Langer et al., 2002). This finding was explained by the authors with the tendency of elderly patients to complain less and endure symptoms better. In the study carried out by Torvik et al. (2008), no difference was observed between middle-aged and elderly cancer patients in terms of QoL in patients with bone metastases. In a study carried out in Germany (Baumann et al., 2009), hospitalized cancer patients of 60 years and over were compared with patients hospitalized for other medical reasons and with the normal population in terms of QoL. QoL scores were found to be low in cancer patients and the patients hospitalized for other medical reasons compared to the general population. As a result, it was reported that the low QoL in elderly patient group cannot be associated only with cancer diagnosis, and similar deterioration may be seen in other medical diseases (Baumann et al., 2009). If the results of elderly cancer patients are not different from the results of younger population and show similarity with the results of patients with other medical problems, the observed changes may be related to the disease rather than old age. Besides, it should be kept in mind that QoL is multi-faceted. Powerful aspect of our study is that it is the first study in which pain, fatigue, sleep and QoL were assessed together in elderly hospitalized cancer patients and the results of these assessments were compared with the data obtained from younger generation. This study also has certain limitations. Assessment could have been made for only one type of cancer. Yet, probably due to the difficulty of performing a study on cancer patients, similar studies also included different cancer types. It has been demonstrated that pain management in hospitalized cancer patients is not well known and adequately carried out. In our study, the assessment and follow up of pain treatments could have been valuable. Besides, anxiety and depression status should also be evaluated in future studies. In a conclusion, elderly hospitalized cancer patients did not demonstrate a distinctive difference in terms of pain, sleep and QoL compared to the younger group. The relationship between pain, fatigue, sleep and QoL should be definitely kept in mind in clinical practice. By all means, special attention should be paid to elderly patients in terms of assessment and treatment. Yet, if the results of cancer patients are not different from those of younger population and show similarities with the results of patients with other medical problems, the differences in QoL and associated factors may be due to cancer diagnosis rather than old age. We think that our study results sand hypothesis should be supported also with other studies. Conflict of interest statement None. References Aaronson, N.K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull, A., Duez, N.J., Filiberti, A., Flechtner, H., Fleishman, S.B., DeHaes, J.C.J.M., Kaasa, S., Klee, M., Osoba, D., Razavi, D., Rofe, P.B., Schraub, S., Sneeuw, K., Sullivan, M., Takeda, F., 1993. The
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