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The oldest old within the comprehensive home palliative care program of the ANT Foundation in Italy for advanced cancer patients
JGO-00466; No. of pages: 3; 4C: Journal of Geriatric Oncology xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Geriatric Oncology
Letter to the Editor The oldest old within the comprehensive home palliative care program of the ANT Foundation in Italy for advanced cancer patients
Keywords: Oldest old Palliative care End of life Advanced cancer patients Home care
Dear Editor-in-Chief, To date, little attention has been paid to the oldest old patients (aged ≥85 years) with neoplastic diseases. Studies providing information on the natural history of tumors, clinical characterization and quality of care in this patient population are lacking. In particular, care location trajectories for very old people approaching death are poorly described and understood [1]. The comprehensive home palliative care program (CHPCP) of the Assistenza Nazionale Tumori (ANT) Foundation represents the largest private non-profit initiative of home palliative care for cancer patients in Italy [2]. Established in 1985 in Bologna, the CHPCP is now active in nine Italian regions, and is most developed in the Bologna metropolitan area. In this area, the CHPCP is acknowledged and integrated into the palliative care network of the local public healthcare system. If home care has been indicated, patients may request their own general practitioner to activate the CHPCP in lieu of community home care services. This occurs in approximately 50% of patients who receive public home care services [3]. The CHPCP focuses on the needs of the patient and family, and provides various services, free of charge, including doctor and nurse visits (experts in palliative care), psychological support, and several social and health services (e.g. rehabilitation, enteral/parenteral nutritional support, pharmaceutical coverage, and health facility provision) in the home setting [4]. In addition, a multidisciplinary team of doctors provide 24-h home care assistance. The activity of the ANT Foundation is funded by private and public grants and donations; the Foundation's overall revenue in 2014 was approximately 20 million Euros, with 84% provided through private donations and 16% provided by the public health system. We performed a retrospective observational study to compare the oldest old patients with younger groups within the patient population assisted by the CHPCP in the Bologna metropolitan area. Eligibility criteria for enrolment in the CHPCP are (a) diagnosis of advanced (metastatic or locally advanced) cancer; (b) caregiver availability; (c) family doctor consent; and (d) signed informed consent of patient and family caregiver. The present analysis refers to adult patients who entered the CHPCP in 2014. In the Bologna metropolitan area, the CHPCP
includes 37 doctors, 24 nurses and seven psychologists assigned in three territorial subunits. The majority of patients had previously received antitumoral treatments (i.e. chemotherapy, target therapy, hormonal therapy). Approximately 30% were still receiving anticancer drugs at the hospitals, where they continued to attend planned admissions in an integrated manner with the CHPCP. The primary analysis was conducted on a selection of demographic, clinical, social and health parameters at entry in all patients. Additional analyses were performed on the place of death (i.e. home, hospital, hospice) in patients who died during the year, and on intensity and duration of home care in patients who died at home. Baseline assessment of the main symptoms was performed using a coding scale (used by ANT physicians for more than 40 years) based on physician assessment. Pain symptoms were assessed, as follows, on the basis of pain characteristics and the type and effectiveness of analgesic drugs: 0, no pain; 1, non-continuous pain requiring non-opiate analgesics when needed; 2, continuous pain requiring continuous non-opiates or minor opiates; and 3, severe pain requiring continuous administration of major opiates. For other symptoms, such as asthenia and anorexia, a three-point scale was used: 0, absent; 1, moderate; and 2, severe. The moderate/severe scores were based on objective semi-quantitative evaluation. Awareness of diagnosis and prognosis was based on the clinical judgment of the doctor who took care of the patient using a simple four-point scale. Intensity of home care was expressed as the ratio of days of actual home care/ home care duration in days, according to Italian Ministry of Health indications [5]. Days of actual home care were those on which at least one home visit (excluding telephone calls) was made by a member of the multidisciplinary team. Home care duration was the number of days from enrolment in the CHPCP to the date of death. Study data were extracted from the electronic patient database (Vitaever) of the ANT Foundation; data were collected at each home visit by the health professionals using a smartphone device. Patients were subdivided into three age groups: 18–64, 65–84, ≥ 85 years, and the distribution of selected demographic, clinical and health factors were compared. Descriptive statistics were reported as mean, range (min–max) or median (and 95% confidence intervals when appropriate) for numeric variables, and as absolute and relative percentages for categorical variables. Chisquared test was used to compare categorical variables. Kruskal-Wallis test [6] was used to compare age, home care duration and care intensity between the three age groups. For all the analyses, an alpha level of 0.05 was assumed. P b 0.05 was considered to indicate statistical significance. All P-values quoted are two-sided. The study was approved by the Ethics Committee of the Bologna-Imola local health system. In total, 1863 patients were enrolled in 2014. Table 1 reports data pertaining to the overall population and the three age groups. At entry, the median age of the whole series was 76 years (range 19–102 years). The three age groups were composed as follows: 363 (19.5%) were aged 18–64 years, 1107 (59.4%) were aged 65–84 years and 393 (21.1%) were aged ≥85 years. The oldest old patients differed from the younger groups in the following respects: (1) higher percentage of females; (2) lower Karnofsky performance status; (3) different
http://dx.doi.org/10.1016/j.jgo.2017.08.014 1879-4068/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article as: Martoni AA, et al, The oldest old within the comprehensive home palliative care program of the ANT..., J Geriatr Oncol (2017), http://dx.doi.org/10.1016/j.jgo.2017.08.014
2
Letter to the Editor
Table 1 Patients admitted to the CHPCP during 2014: Comparison between different age groups. A) Characteristics on entry
All
18–64 years
65–84 years
≥85 years
P
N Gender: M (%) Age median (range) KPS median (range) Primary tumor site (%) GI Lung & pleura Gyn Breast GU Hem CNS HN Others Awareness of diagnosis Evaluable Awareness of prognosis Evaluable Cohabitation Spouse/partner Sons/daughters Parents Non-family caregiver None Evaluable Main symptoms Severe pain (score 3) Evaluable Severe asthenia (score 2) Evaluable Severe anorexia (score 2) Evaluable
1863 913 (49.0%) 76 (19–102) 50 (0–100)
363 (19.5%) 175 (48.2%) 57 60 (20–100)
1107 (59.4%) 566 (51.1%) 75 50 (0–100)
393 (21.1%) 172 (44.0%) 88 50 (10–80)
– 0.040b 0.000c 0.000c
35.8% 18.3% 10.3% 8.9% 7.4% 5.1% 3.2% 2.7% 8.3% 922 (54.4%) 1695 259 (22.0%) 1176
35.0% 17.9% 7.7% 13.2% 5.2% 2.5% 4.4% 6.1% 8.0% 260 (78.1%) 333 92 (40.0%) 230
36.0% 20.2% 10.7% 7.4% 7.7% 5.3% 3.1% 2.3% 7.3% 575 (56.7%) 1014 149 (20.9%) 713
36.1% 13.0% 11.7% 9.2% 8.7% 6.9% 2.5% 0.5% 11.4% 87 (25.0%) 348 18 (7.7%) 233
916 (56.3%) 214 (13.2%) 19 (1.2%) 305 (18.8%) 172 (10.6%) 1626
202 (64.1%) 24 (7.6%) 19 (6.0%) 42 (13.3%) 28 (8.9%) 315
611 (62.7%) 121 (12.4%) 0 (0%) 138 (14.2%) 105 (10.8%) 975
103 (30.7%) 69 (20.5%) 0 (0%) 125 (37.2%) 39 (11.6%) 336
349 (23.8%) 1467 369 (25.2%) 1467 133 (9.2%) 1445
95 (33.7%) 282 48 (17.1%) 281 23 (8.3%) 277
207 (23.7%) 874 204 (23.2%) 876 76 (8.8%) 861
47 (15.1%) 311 117 (37.7%) 310 34 (11.1%) 307
0.000b
0.000b
0.000b 0.000b
0.000b 0.000b 0.427b
B) Patients died in the perioda
All
18–64 years
65–84 years
≥85 years
P
N Place of death Home Hospice Hospital Unknown Patients died at home (n = 618) Median home care duration (days) Mean Care intensity
872
151 (17.3%)
494 (56.7%)
227 (26.0%)
–
618 (70.9%) 110 (12.6%) 141 (16.2%) 3 (0.3%)
91 (60.3%) 28 (18.5%) 32 (21.2%) 0 (0%)
339 (68.6%) 68 (13.8%) 86 (17.4%) 1 (0.2%)
188 (82.8%) 14 (6.2%) 23 (10.1%) 2 (0.9%)
0.000b
46 (1–295) 0.43 (0.01–1.0)
47 (3–295) 0.42 (0.09–1.00)
44 (4–291) 0.45 (0.03–1.00)
47 (1–273) 0.40 (0.01–1.00)
0.469c 0.059c
When the data was not available for all enrolled patients, the percentages shown were related to the total number of patients for whom the data was available. CHPCP: Comprehensive Home Palliative Care Program of ANT Foundation; KPS: Karnofsky Performance status. a Before December 31, 2014 Statistical analysis. b Pearson's Chi-square. c Kruskal-Wallis.
distribution of primary tumors (lower percentage of lung cancer, and higher percentage of hematological, breast, ovarian and genito-urinary cancers); (4) lower percentage of patients with awareness of their own cancer diagnosis and prognosis; (5) higher percentage of patients who lived with a non-family caregiver; (6) lower percentage of patients with severe pain treated with major opiates; and (7) higher prevalence of severe asthenia. The oldest old patients represented 26% of the total number of deaths. The percentage of deaths at home was higher among the oldest old patients than the other age groups (82.8% vs 68.6% in the 65–84 group and 60.3% in the 18–64 group). Therefore, both similarities and differences were found between the oldest old patients and the other age groups. Some were obvious or expected, and others were worthy of more thorough review. Among the similarities, it should be highlighted that the intensity and duration of CHPCP for the oldest old patients were similar to those of the younger patients. Specifically, a care intensity of 0.40 indicates one home visit by doctors or nurses every 2–3 days for an average time span of 47 days. This result
contrasts with previous findings by other authors that the oldest old patients have reduced access to palliative care programs [7,8]. Lower prevalence of pain and reduced use of opiates in the oldest old patients compared with younger patients has been reported previously [9], but the reasons remain unclear. One hypothesis is the existence of physiological changes in the perception of pain and an altered sensitivity to opiates in the elderly. However, the more frequent and severe copathologies and cognitive impairment in the oldest old patients may result in under-reporting of pain, and physicians may be more cautious about prescribing opiates for this age group. Therefore, it is possible that elderly patients, and specifically the oldest old patients, are at risk for undertreatment of pain. Another difference that distinguishes the oldest old patients from other age groups is that they are more likely to live with a non-family caregiver. In the last 15 years, the phenomenon of home minders for the elderly has developed spontaneously in Italy. They are represented mainly by female immigrants from Eastern European countries who
Please cite this article as: Martoni AA, et al, The oldest old within the comprehensive home palliative care program of the ANT..., J Geriatr Oncol (2017), http://dx.doi.org/10.1016/j.jgo.2017.08.014
Letter to the Editor
are willing to accept low salaries in order to assist and cohabit with the elderly. This phenomenon mainly concerns the oldest old patients, and tends to make up for the difficulties that families have to face in order to take care of their loved ones. The most relevant finding of this study was the fact that a greater proportion of the oldest old patients (82.8%) die at home compared with the other age groups. This finding differs from a study of older patients in the UK, where the oldest patients had a lower likelihood of dying at home [10]. It is assumed that the completeness and reliability of the CHPCP services offered by the ANT Foundation represent the main reasons why this study found a greater number of deaths at home in the oldest old patients. In conclusion, this study shows that the CHPCP is a home care model that is particularly useful for the oldest old patients suffering from advanced cancer. It allows the majority of these patients to be at home at the end of their lives. Confirmation of this finding by a prospective study comparing the CHPCP with community health services, taking into account patient and family preferences, family satisfaction, and service quality and costs, could induce the regional healthcare system authorities to extend the ANT Foundation's home care model to a greater number of patients. Acknowledgements The authors wish to thank Dr. Neil Kolazek for his support in editing the manuscript. References [1] Perrels AJ, Fleming J, Zhao J, Barclay S, Farquhar M, Buiting HM, et al. Cambridge City over-75s cohort (CC75C) study collaboration: place of death and end-of-life transitions experienced by very old people with differing cognitive status: retrospective analysis of a prospective population-based cohort aged 85 and over. Palliat Med 2014;28:220–33. [2] Pannuti F, Tanneberger S. The Bologna Eubiosia Project: hospital-at-home care for advanced cancer patients. J Palliat Care 1992;8:11–7.
3
[3] Protonotari A, Annicchiarico M, Castaldini I, Frezza G, Renopi A, Valenti D. Il percorso assistenziale di pazienti in fase terminale attraverso i servizi dell'AUSL di Bologna. Riv Ital Cure Pall 2014;15:17–24. [4] Casadio M, Biasco G, Abernethy A, Bonazzi V, Pannuti R, Pannuti F. The National Tumor Association Foundation (ANT): a 30 year old model of home palliative care. BMC Palliat Care 2010;9:12. [5] Nuova caratterizzazione dell'assistenza territoriale domiciliare e degli interventi ospedalieri a Domicilio. http://www.salute.gov.it/portale/documentazione/p6_2_2_ 1.jsp?lingua=italiano&id=572. [6] Kruskal JB. Multidimensional scaling by optimizing goodness of fit to a nonmetric hypothesis. Psychometrika 1964;29:1–27. [7] Burge FI, Lawson BJ, Johnston GM, Grunfeld E. A population-based study of age inequalities in access to palliative care among cancer patients. Med Care 2008;46: 1203–11. [8] Abarshi E, Echteld MA, Van den Block L, Donker G, Deliens L, Onwuteaka-Philipsen B. The oldest old and GP end-of-life care in the Dutch community: a nationwide study. Age Ageing 2010;39:716–22. [9] Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic assessment of geriatric drug use via epidemiology. JAMA 1998;279:1877–82. [10] Lock A, Higginson I. Patterns and predictors of place of cancer death for the oldest old. BMC Palliat Care 2005;4:6.
Andrea A. Martoni* Brunella Boltri Assistenza Nazionale Tumori (ANT) Foundation, Bologna, Italy *Corresponding author at: ANT Foundation, via J. Di Paolo 36, 40128 Bologna, Italy. E-mail address: [email protected] (A.A. Martoni). Elena Strocchi Industrial Chemistry Department, University of Bologna, Italy Franco Pannuti Assistenza Nazionale Tumori (ANT) Foundation, Bologna, Italy 9 March 2017 Available online xxxx
Please cite this article as: Martoni AA, et al, The oldest old within the comprehensive home palliative care program of the ANT..., J Geriatr Oncol (2017), http://dx.doi.org/10.1016/j.jgo.2017.08.014
Contents lists available at ScienceDirect
Journal of Geriatric Oncology
Letter to the Editor The oldest old within the comprehensive home palliative care program of the ANT Foundation in Italy for advanced cancer patients
Keywords: Oldest old Palliative care End of life Advanced cancer patients Home care
Dear Editor-in-Chief, To date, little attention has been paid to the oldest old patients (aged ≥85 years) with neoplastic diseases. Studies providing information on the natural history of tumors, clinical characterization and quality of care in this patient population are lacking. In particular, care location trajectories for very old people approaching death are poorly described and understood [1]. The comprehensive home palliative care program (CHPCP) of the Assistenza Nazionale Tumori (ANT) Foundation represents the largest private non-profit initiative of home palliative care for cancer patients in Italy [2]. Established in 1985 in Bologna, the CHPCP is now active in nine Italian regions, and is most developed in the Bologna metropolitan area. In this area, the CHPCP is acknowledged and integrated into the palliative care network of the local public healthcare system. If home care has been indicated, patients may request their own general practitioner to activate the CHPCP in lieu of community home care services. This occurs in approximately 50% of patients who receive public home care services [3]. The CHPCP focuses on the needs of the patient and family, and provides various services, free of charge, including doctor and nurse visits (experts in palliative care), psychological support, and several social and health services (e.g. rehabilitation, enteral/parenteral nutritional support, pharmaceutical coverage, and health facility provision) in the home setting [4]. In addition, a multidisciplinary team of doctors provide 24-h home care assistance. The activity of the ANT Foundation is funded by private and public grants and donations; the Foundation's overall revenue in 2014 was approximately 20 million Euros, with 84% provided through private donations and 16% provided by the public health system. We performed a retrospective observational study to compare the oldest old patients with younger groups within the patient population assisted by the CHPCP in the Bologna metropolitan area. Eligibility criteria for enrolment in the CHPCP are (a) diagnosis of advanced (metastatic or locally advanced) cancer; (b) caregiver availability; (c) family doctor consent; and (d) signed informed consent of patient and family caregiver. The present analysis refers to adult patients who entered the CHPCP in 2014. In the Bologna metropolitan area, the CHPCP
includes 37 doctors, 24 nurses and seven psychologists assigned in three territorial subunits. The majority of patients had previously received antitumoral treatments (i.e. chemotherapy, target therapy, hormonal therapy). Approximately 30% were still receiving anticancer drugs at the hospitals, where they continued to attend planned admissions in an integrated manner with the CHPCP. The primary analysis was conducted on a selection of demographic, clinical, social and health parameters at entry in all patients. Additional analyses were performed on the place of death (i.e. home, hospital, hospice) in patients who died during the year, and on intensity and duration of home care in patients who died at home. Baseline assessment of the main symptoms was performed using a coding scale (used by ANT physicians for more than 40 years) based on physician assessment. Pain symptoms were assessed, as follows, on the basis of pain characteristics and the type and effectiveness of analgesic drugs: 0, no pain; 1, non-continuous pain requiring non-opiate analgesics when needed; 2, continuous pain requiring continuous non-opiates or minor opiates; and 3, severe pain requiring continuous administration of major opiates. For other symptoms, such as asthenia and anorexia, a three-point scale was used: 0, absent; 1, moderate; and 2, severe. The moderate/severe scores were based on objective semi-quantitative evaluation. Awareness of diagnosis and prognosis was based on the clinical judgment of the doctor who took care of the patient using a simple four-point scale. Intensity of home care was expressed as the ratio of days of actual home care/ home care duration in days, according to Italian Ministry of Health indications [5]. Days of actual home care were those on which at least one home visit (excluding telephone calls) was made by a member of the multidisciplinary team. Home care duration was the number of days from enrolment in the CHPCP to the date of death. Study data were extracted from the electronic patient database (Vitaever) of the ANT Foundation; data were collected at each home visit by the health professionals using a smartphone device. Patients were subdivided into three age groups: 18–64, 65–84, ≥ 85 years, and the distribution of selected demographic, clinical and health factors were compared. Descriptive statistics were reported as mean, range (min–max) or median (and 95% confidence intervals when appropriate) for numeric variables, and as absolute and relative percentages for categorical variables. Chisquared test was used to compare categorical variables. Kruskal-Wallis test [6] was used to compare age, home care duration and care intensity between the three age groups. For all the analyses, an alpha level of 0.05 was assumed. P b 0.05 was considered to indicate statistical significance. All P-values quoted are two-sided. The study was approved by the Ethics Committee of the Bologna-Imola local health system. In total, 1863 patients were enrolled in 2014. Table 1 reports data pertaining to the overall population and the three age groups. At entry, the median age of the whole series was 76 years (range 19–102 years). The three age groups were composed as follows: 363 (19.5%) were aged 18–64 years, 1107 (59.4%) were aged 65–84 years and 393 (21.1%) were aged ≥85 years. The oldest old patients differed from the younger groups in the following respects: (1) higher percentage of females; (2) lower Karnofsky performance status; (3) different
http://dx.doi.org/10.1016/j.jgo.2017.08.014 1879-4068/© 2017 Elsevier Ltd. All rights reserved.
Please cite this article as: Martoni AA, et al, The oldest old within the comprehensive home palliative care program of the ANT..., J Geriatr Oncol (2017), http://dx.doi.org/10.1016/j.jgo.2017.08.014
2
Letter to the Editor
Table 1 Patients admitted to the CHPCP during 2014: Comparison between different age groups. A) Characteristics on entry
All
18–64 years
65–84 years
≥85 years
P
N Gender: M (%) Age median (range) KPS median (range) Primary tumor site (%) GI Lung & pleura Gyn Breast GU Hem CNS HN Others Awareness of diagnosis Evaluable Awareness of prognosis Evaluable Cohabitation Spouse/partner Sons/daughters Parents Non-family caregiver None Evaluable Main symptoms Severe pain (score 3) Evaluable Severe asthenia (score 2) Evaluable Severe anorexia (score 2) Evaluable
1863 913 (49.0%) 76 (19–102) 50 (0–100)
363 (19.5%) 175 (48.2%) 57 60 (20–100)
1107 (59.4%) 566 (51.1%) 75 50 (0–100)
393 (21.1%) 172 (44.0%) 88 50 (10–80)
– 0.040b 0.000c 0.000c
35.8% 18.3% 10.3% 8.9% 7.4% 5.1% 3.2% 2.7% 8.3% 922 (54.4%) 1695 259 (22.0%) 1176
35.0% 17.9% 7.7% 13.2% 5.2% 2.5% 4.4% 6.1% 8.0% 260 (78.1%) 333 92 (40.0%) 230
36.0% 20.2% 10.7% 7.4% 7.7% 5.3% 3.1% 2.3% 7.3% 575 (56.7%) 1014 149 (20.9%) 713
36.1% 13.0% 11.7% 9.2% 8.7% 6.9% 2.5% 0.5% 11.4% 87 (25.0%) 348 18 (7.7%) 233
916 (56.3%) 214 (13.2%) 19 (1.2%) 305 (18.8%) 172 (10.6%) 1626
202 (64.1%) 24 (7.6%) 19 (6.0%) 42 (13.3%) 28 (8.9%) 315
611 (62.7%) 121 (12.4%) 0 (0%) 138 (14.2%) 105 (10.8%) 975
103 (30.7%) 69 (20.5%) 0 (0%) 125 (37.2%) 39 (11.6%) 336
349 (23.8%) 1467 369 (25.2%) 1467 133 (9.2%) 1445
95 (33.7%) 282 48 (17.1%) 281 23 (8.3%) 277
207 (23.7%) 874 204 (23.2%) 876 76 (8.8%) 861
47 (15.1%) 311 117 (37.7%) 310 34 (11.1%) 307
0.000b
0.000b
0.000b 0.000b
0.000b 0.000b 0.427b
B) Patients died in the perioda
All
18–64 years
65–84 years
≥85 years
P
N Place of death Home Hospice Hospital Unknown Patients died at home (n = 618) Median home care duration (days) Mean Care intensity
872
151 (17.3%)
494 (56.7%)
227 (26.0%)
–
618 (70.9%) 110 (12.6%) 141 (16.2%) 3 (0.3%)
91 (60.3%) 28 (18.5%) 32 (21.2%) 0 (0%)
339 (68.6%) 68 (13.8%) 86 (17.4%) 1 (0.2%)
188 (82.8%) 14 (6.2%) 23 (10.1%) 2 (0.9%)
0.000b
46 (1–295) 0.43 (0.01–1.0)
47 (3–295) 0.42 (0.09–1.00)
44 (4–291) 0.45 (0.03–1.00)
47 (1–273) 0.40 (0.01–1.00)
0.469c 0.059c
When the data was not available for all enrolled patients, the percentages shown were related to the total number of patients for whom the data was available. CHPCP: Comprehensive Home Palliative Care Program of ANT Foundation; KPS: Karnofsky Performance status. a Before December 31, 2014 Statistical analysis. b Pearson's Chi-square. c Kruskal-Wallis.
distribution of primary tumors (lower percentage of lung cancer, and higher percentage of hematological, breast, ovarian and genito-urinary cancers); (4) lower percentage of patients with awareness of their own cancer diagnosis and prognosis; (5) higher percentage of patients who lived with a non-family caregiver; (6) lower percentage of patients with severe pain treated with major opiates; and (7) higher prevalence of severe asthenia. The oldest old patients represented 26% of the total number of deaths. The percentage of deaths at home was higher among the oldest old patients than the other age groups (82.8% vs 68.6% in the 65–84 group and 60.3% in the 18–64 group). Therefore, both similarities and differences were found between the oldest old patients and the other age groups. Some were obvious or expected, and others were worthy of more thorough review. Among the similarities, it should be highlighted that the intensity and duration of CHPCP for the oldest old patients were similar to those of the younger patients. Specifically, a care intensity of 0.40 indicates one home visit by doctors or nurses every 2–3 days for an average time span of 47 days. This result
contrasts with previous findings by other authors that the oldest old patients have reduced access to palliative care programs [7,8]. Lower prevalence of pain and reduced use of opiates in the oldest old patients compared with younger patients has been reported previously [9], but the reasons remain unclear. One hypothesis is the existence of physiological changes in the perception of pain and an altered sensitivity to opiates in the elderly. However, the more frequent and severe copathologies and cognitive impairment in the oldest old patients may result in under-reporting of pain, and physicians may be more cautious about prescribing opiates for this age group. Therefore, it is possible that elderly patients, and specifically the oldest old patients, are at risk for undertreatment of pain. Another difference that distinguishes the oldest old patients from other age groups is that they are more likely to live with a non-family caregiver. In the last 15 years, the phenomenon of home minders for the elderly has developed spontaneously in Italy. They are represented mainly by female immigrants from Eastern European countries who
Please cite this article as: Martoni AA, et al, The oldest old within the comprehensive home palliative care program of the ANT..., J Geriatr Oncol (2017), http://dx.doi.org/10.1016/j.jgo.2017.08.014
Letter to the Editor
are willing to accept low salaries in order to assist and cohabit with the elderly. This phenomenon mainly concerns the oldest old patients, and tends to make up for the difficulties that families have to face in order to take care of their loved ones. The most relevant finding of this study was the fact that a greater proportion of the oldest old patients (82.8%) die at home compared with the other age groups. This finding differs from a study of older patients in the UK, where the oldest patients had a lower likelihood of dying at home [10]. It is assumed that the completeness and reliability of the CHPCP services offered by the ANT Foundation represent the main reasons why this study found a greater number of deaths at home in the oldest old patients. In conclusion, this study shows that the CHPCP is a home care model that is particularly useful for the oldest old patients suffering from advanced cancer. It allows the majority of these patients to be at home at the end of their lives. Confirmation of this finding by a prospective study comparing the CHPCP with community health services, taking into account patient and family preferences, family satisfaction, and service quality and costs, could induce the regional healthcare system authorities to extend the ANT Foundation's home care model to a greater number of patients. Acknowledgements The authors wish to thank Dr. Neil Kolazek for his support in editing the manuscript. References [1] Perrels AJ, Fleming J, Zhao J, Barclay S, Farquhar M, Buiting HM, et al. Cambridge City over-75s cohort (CC75C) study collaboration: place of death and end-of-life transitions experienced by very old people with differing cognitive status: retrospective analysis of a prospective population-based cohort aged 85 and over. Palliat Med 2014;28:220–33. [2] Pannuti F, Tanneberger S. The Bologna Eubiosia Project: hospital-at-home care for advanced cancer patients. J Palliat Care 1992;8:11–7.
3
[3] Protonotari A, Annicchiarico M, Castaldini I, Frezza G, Renopi A, Valenti D. Il percorso assistenziale di pazienti in fase terminale attraverso i servizi dell'AUSL di Bologna. Riv Ital Cure Pall 2014;15:17–24. [4] Casadio M, Biasco G, Abernethy A, Bonazzi V, Pannuti R, Pannuti F. The National Tumor Association Foundation (ANT): a 30 year old model of home palliative care. BMC Palliat Care 2010;9:12. [5] Nuova caratterizzazione dell'assistenza territoriale domiciliare e degli interventi ospedalieri a Domicilio. http://www.salute.gov.it/portale/documentazione/p6_2_2_ 1.jsp?lingua=italiano&id=572. [6] Kruskal JB. Multidimensional scaling by optimizing goodness of fit to a nonmetric hypothesis. Psychometrika 1964;29:1–27. [7] Burge FI, Lawson BJ, Johnston GM, Grunfeld E. A population-based study of age inequalities in access to palliative care among cancer patients. Med Care 2008;46: 1203–11. [8] Abarshi E, Echteld MA, Van den Block L, Donker G, Deliens L, Onwuteaka-Philipsen B. The oldest old and GP end-of-life care in the Dutch community: a nationwide study. Age Ageing 2010;39:716–22. [9] Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic assessment of geriatric drug use via epidemiology. JAMA 1998;279:1877–82. [10] Lock A, Higginson I. Patterns and predictors of place of cancer death for the oldest old. BMC Palliat Care 2005;4:6.
Andrea A. Martoni* Brunella Boltri Assistenza Nazionale Tumori (ANT) Foundation, Bologna, Italy *Corresponding author at: ANT Foundation, via J. Di Paolo 36, 40128 Bologna, Italy. E-mail address: [email protected] (A.A. Martoni). Elena Strocchi Industrial Chemistry Department, University of Bologna, Italy Franco Pannuti Assistenza Nazionale Tumori (ANT) Foundation, Bologna, Italy 9 March 2017 Available online xxxx
Please cite this article as: Martoni AA, et al, The oldest old within the comprehensive home palliative care program of the ANT..., J Geriatr Oncol (2017), http://dx.doi.org/10.1016/j.jgo.2017.08.014