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Utilizing geriatric skills in radiation oncology
Utilizing Geriatric Skills in Radiation Oncology
Marilyn L. Haas, PhD, RN, CNS, ANP-C
After heart disease, cancer is the second leading cause of death in the United States and is expected to become the leading cause of death in the next decade.1 Approximately 60% of all cancer patients will receive radiation therapy at some point in their oncology continuum. It becomes important for nurses to be familiar with the physiological changes in older adults and be able to recognize the changes that could occur from an oncology treatment such as radiation therapy. Radiation therapy is one modality that the elderly can tolerate if they have adequate functional status. Astute physical assessment skills are needed to distinguish between normal aging and the acute and long-term effects of radiation therapy. (Geriatr Nurs 2004;25:355-60) November/December 2004
355
ith a growing older population, it is external beam radiation, is delivering radioactive energy not surprising that cancer is a disease at a distance from the treatment or target area. External of older adults. According to Maes,2 beam is given daily, Monday through Friday, generally 60% of all cancers occur in the elderover 2 to 7 weeks, depending on the purpose of treatment ly population. In 2004, a total of and total dose.10 Brachytherapy, also referred to as inter1,368,030 new cancer cases and nal or implant radiation therapy, is a type of modality in 563,700 deaths are expected in the which the radioactive source is placed on or within the United States.3 The median age for older adults diagtumor (interstitial, intracavitary, or systemic). Brachynosed with cancer remains 70 to 74 years old.4,5 With life therapy can be temporary or permanent and use low or expectancy reaching 80 years old for women and 73 high-energy doses.10 The type of brachytherapy deteryears old for men, it is doubtful that cancer will ever mines the length of hospital stay or outpatient time change in the hierarchy of diseases. involved. The choice of modality depends on tumor type, Sadly enough, many older adults are not offered cansize, and location. cer therapies because of their age.6,7 Age should never be Like any oncology treatment, radiation therapy has the deciding factor for the elderly who are seeking cancer its own distinct advantages. Because radiotherapy’s aim treatments.8 Rather, activity and energy levels, such as is loco-regional control, side effects are limited and typthe Karnofsky Performance Scale (KPS), should weigh ically do not produce the systemic effects.14 For this 9 heavier into the treatment decision process. Furtherreason alone, radiation therapy provides the elderly a more, comorbidities affect treatment decisions and delivstrong therapeutic option. The elderly are often relieved ery plans. when informed that this treatment does not automaticalIt is hoped that nurses can recognize age bias issues ly cause nausea and vomiting or hair loss. Although and support older adults searching for more aggressive mortality is rare, radiotherapy has definite acute toxicitherapies. It becomes even more important to explain ties, but these are generally manageable for the older treatments that are safe, have favorable therapeutic indexadult. With newer technology (3-dimensional conformal es, without impinging on the physiological or psychologradiation and intensity modulated radiation), organs can ical reserves of the elderly. The usually be spared and better elderly should be offered clinifunction preserved. In addiRadiation therapy is a cancer tion, improvement in medicacal trials based on their functional ability rather than age. tions can control acute sympmodality that can be an Therefore, it becomes the tomatology, thus improving responsibility of nursing to help excellent option for the elderly radiosensitization, or even explain possible treatment offering radioprotection. because of its limited Radiotherapy is definitely an options, related side effects, and alternative for the elderly when know how to assess and manage systemic toxicities. surgery or chemotherapy is older adults oncology care. contraindicated. R A D I OT H E R A P Y A N D T H E E L D E R LY Radiation therapy does have its potential disadvantages. The main disadvantage to radiotherapy is the long Radiation therapy is a cancer modality that can be an duration of treatment, especially when the intent is curaexcellent option for the elderly because of its limited systive.14 Older adults can fatigue easily with daily treattemic toxicities. Radiation therapy is a local cancer treatment that can be effective for curative, prophylactic, conments over 6 to 7 weeks. While physiologic reserve has trol, or palliative purposes.10 Sixty percent of all cancer diminished with age, recovery may be slower in the older patients receiving treatment will at some point have radiadult population. Depending on the area being treated, ation treatments.11,12 Although widely used, there are site-related disturbances (toxicities) may be more prolimited radiation oncology clinical trials designed strictly nounced in the older adult, which can affect quality of for the elderly. Therefore, it is imperative to explore the life, need for treatment interruptions, and the need for issue of radiotherapy in the elderly population in regard additional medical or surgical interventions or hospitalto its effectiveness, tolerance, and management. izations. For example, there are concerns for the elderly Radiation therapy uses high-energy particles or waves, when treating the whole brain irradiation (fear of neurosuch as x-rays, gamma rays, electrons, and photons, to logic sequelae, including dementia) or the pelvis (fear of destroy or damage cancer cells so they cannot multiply or marrow aplasia or radiation enteritis). Generally, geriatric spread. The major effect is on the DNA; some cells lose nurses may not see older adults as they go through radiatheir proliferative ability and because cells cannot multition therapy, but it is still important to be aware of the ply, cell death occurs.13 Two common radiation modaliacute symptoms that can develop into chronic problems ties available for cancer patients are teletherapy and in the ongoing care of the elderly after radiation therapy. Therefore, it is important to distinguish between aging brachytherapy. Teletherapy, commonly referred to as
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Geriatric Nursing
Volume 25
Number 6
Table 1. Physical Consequences of Aging and Toxicities of Radiation Therapy Organ Site Skin
Bone Brain
Oral cavity
Lung
Heart
Effects of Aging Thinning of epidermis Unchanged stratum corneum, except moisture and cohesiveness Decreased melanocytes Decreased Langerhans cells Decreased fibroblasts Hypovascular endothelium Decreased mast cells Loss of bone density Decrease in brain weight Loss of gray and white matter Changes in nerve cells Less production of ptyalin and amylase in saliva glands Dry mouth (medication-induced) Decrease olfactory senses Decrease in mastication muscles Reduction in glandular epithelial cells Enlargement of alveoli and alveoli ducts Reduction in respiratory muscle functioning Ossification of costal cartilage Decreased heart rate Vascular stiffness Increased platelet adhesiveness Decreased aerobic capacity
Breast
Less glandular tissue, more connective and fat tissue
Bladder
Loss of muscle tone, leading to incomplete bladder emptying Decreased bladder capacity
Vagina/Ovaries Atrophy of organs
Prostate
Hyperplasia
Colon/Rectum Slow peristalsis Decreased muscle strength in abdomen
Acute Toxicities of Radiation
Late Toxicities of Radiation
Mild to brisk erythema Dry desquamation Moist desquamation
Telangiectasias Fibrosis Necrosis
Thrombocytopenia Neutropenia Cerebral edema Seizures Alopecia Mucositis/Stomatitis Acute xerostomia Taste changes Pharyngitis Increasing cough, dyspnea Pain (tumor) Esophagitis Hoarseness Skin reactions (see above) Delayed acute pericarditis Delayed pericardial effusion
Spinal cord myelopathy
Diffuse myocardial fibrosis Late coronary artery disease Conduction defects Breast pain, swelling, tenderness Radiodermatitis Tanning/telangiectasias Frequency Urgency Dysuria Hesitancy Hematuria Hot flashes Vaginal dryness Dyspareunia Diarrhea
Tenesmus Proctalgia Rectal bleeding Erectile dysfunction Abdominal cramping Diarrhea
Radiation necrosis Cerebral atrophy Cranial neuropathy Osteoradionecrosis Chronic xerostomia Trismus Pneumonitis Fibrosis
Firmness Fibrosis Hematuria Telangiectasia
Thinning Atrophy Adhesions Shortening, narrowing Persistent bowel changes of diarrhea, fistula formation, perforation, incomplete bowel mucosa healing
Fibrosis Diarrhea Proctitis Adhesions Stenosis
Adapted from Haas M. Radiation therapy. In: Varricchio C, editor. A cancer source book for nurses. 8th ed. American Cancer Society. Sudbury, MA: Jones and Bartlett; 2004.
November/December 2004
357
effects and radiation therapy’s acute and long-term toxicities (see Table 1).
allowing additional time for the procedure, ensuring that glasses are given back to the patient if head molds are required for radiation treatments, talking directly and IMPORTANCE OF GERIATRIC ASSESSMENTS clearly (especially if individuals have hearing aids), and W H I L E U N D E R G O I N G R A D I OT H E R A P Y using stepping stools to get on and off the treatment table Physical aging affects functioning of the human body. can help older adults through treatment. With functional It reduces the viability at all levels (cells, molecules, tisreserves possibly diminished, extra time may be allotted sues, organs, and control systems) and increases the vulif using multiple treatment fields, protracting the treatnerability to diseases and comorbid conditions.15 Agement time. associated factors can exacerbate radiation therapy side Gait and balance of the older adult is dependent on the effects. A summary of physical changes and radiation strength of the musculoskeletal system. Risk of falls consequences can be found in Table 1. should be evaluated at any clinician’s visit with elderly Comprehensive geriatric assessment (CGA) should be patients. Recognizing that bone loss begins between the performed before radiotherapy to establish baseline funcages of 35 and 40 years in both sexes and accelerates for tioning. CGA reviews the main domains of functional women after menopause, osteoporosis becomes an issue. status, gait, balance and risk for falls, cognitive status, When cancer is found in the bones, the older person more than likely has metastatic disease. For example, cancer affective status, nutritional status, pain, and social funccan start in the breast or lungs and then spread to the tioning.16 This helps to develop a comprehensive manbones. Fortunately, radiotherapy can be effective to treat agement and care plan because it distinguishes between painful bony metastases. Research has shown that single age-related changes and those caused by radiation. fraction can provide the necessary bone pain relief.19,20 Functional status is an important predictor of response 17,18 to therapy. In geriatrics this is measured by activities The main concern when treating any large bony areas of daily living (ADLs) of (pelvis, spine, sternum, ribs, bathing, dressing, toileting, long bones, and skull) with Teletherapy, commonly transferring, feeding and contiradiation is bone marrow supnence. In radiation oncology, pression. Weekly, complete referred to as external beam the KPS, an evaluation of carblood counts may be indicated, diac function, pulmonary funcradiation, is delivering radioac- especially if the older adult is tion, and exercise tolerance, is receiving combined chemothertive energy at a distance from apy.11 commonly used. The KPS is rated by multiples of tens, from Cognitive functioning plays the treatment or target area. 10% to 100%, with 10% reprea major role in the management senting the lowest level of funcof the elderly cancer patient and tioning, representing a moribund condition in which disis included in the CGA. Fortunately, understanding the ease is progressing rapidly, to 100%, representing normal changes in the brain has changed with the advancement level of functioning, no complaints, and no evidence of in neuroimaging techniques (e.g., computerized tomogradisease. phy, magnetic resonance imaging, and position emission Functional status in the CGA also includes other tomography). With higher technology, more information assessments of bodily functions (e.g., urinary status, is revealed about the changes in the brain that might provisual and hearing abilities, sense of touch). During the vide insight into problems of memory, intellect, or locoaging process, the bladder tends to lose muscle tone, motion. Baseline assessment of mental deterioration sometimes resulting in incomplete emptying of the blad(failing memory, emotional irritability, confusion, anxider. This places the older adult at higher risk for urinary ety, depression, delusions, or hallucinations, and even retention and cystitis.18 If the bladder is in the radiation dementia) is gathered at consultation and should be treatment field during pelvic irradiation, urinary tract obtained at the onset of radiation therapy. This helps clinsymptoms are intensified and can begin after 10 fractions icians know what to expect from the older person during treatment. When treating the brain with radiation, cereor 20 Gy.14 Symptoms include dysuria, frequency, urgenbral edema can quickly change the mental and physical cy, nocturia, hesitancy, and decreased urinary capacity. status of the older adult, and distinctions need to be made Baseline functioning for the older adult is essential rapidly. Symptoms of cerebral edema that can mimic before beginning radiation treatments to recognize differmental deterioration are headache, nausea, vomiting, ences between radiation-induced cystitis, aging effects, visual changes, changes in motor ability, slurred speech, or bacterial infections. confusion, and seizure activity. The 5 senses are diminished as one grows older. Affective assessment can also reveal how the elderly Presbyopia and hearing loss are given considerations in will tolerate therapy overall. The prevalence of depresany care plan. Because of possible decreases in the funcsion in cancer patients is between 17% and 25%.21 tioning of the senses (especially vision and hearing), 358
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Therefore, long-term effects of or Brachytherapy, also referred to (e.g., the esophagus, liver, radiation should not be conheart) and cause pain.23 Thus, as internal or implant radiation radiation can shrink tumors and fused with depression from other reasons. provide pain relief. Radiation therapy, is a type of modality Nutrition is a challenge for can also induce pain, such as clinicians when treating elderly in which the radioactive source painful skin reactions. Ionizing cancer patients because weight radiation causes damage to the is placed on or within the loss is the common presenting mitotic ability of stem cells symptom.16 Body mass index within the basal layer, thus tumor (interstitial, intracavitary, weakening integrity of the skin. or biochemical parameters (albumin or total protein) can With repeated radiation, skin or systemic). be used in the assessment proreactions tend to become visible cess. There are numerous oral around the second to third week changes in normal aging: salivary glands secrete less of radiation therapy, reaching a peak at the end or withptyalin and amylase, making the saliva more alkaline; in 1 week of completion of treatment.24 Different stages bony structures of the mouth shrink and tooth decay of skin reactions occur and should be treated early (see becomes problematic; gustatory and olfactory sensations Table 1). decrease, along with the muscles used in mastication Social functioning and assessment is important at this decrease, causing less chewing ability. All of these later stage of life. Assessment of a patient’s caregiver(s) changes affect food intake in the elderly. When giving is important as well. Advance directives and powers of radiation to the oral cavity, even if it is palliative doses, attorney should be discussed and never avoided. significant toxicities occur during treatment (Table 1). Recognizing that spirituality plays a large role in therapy Many of these side effects are long-lasting and the older for many patients, asking about religious preferences adult is extremely vulnerable to physiological and psymay provide insight to facilitate care. chological distress. Nutritional problems resulting from N U R S I N G RO L E S irradiation cause stomatitis, xerotomia, or alterations in taste buds. These affect the older adult’s ability to comGeriatric and radiation oncology nurses can help older plete therapy without treatment breaks. Inadequate nutripatients and caregiver(s) anticipate the acute and longtion can further exacerbate fatigue and depression for the term toxicities that may develop during and after radioolder adult undergoing radiation treatments.22 therapy. Although evidence-based nursing interventions Aging also affects the lower gastrointestinal tract. related to radiation therapy are scarce, there are general Slowed peristalsis and decreased muscular strength can principles that can be shared. There are minimal acute cause constipation. Some individuals even have problems side effects associated with a palliative course of therapy with their anal sphincter (hemorrhoids and anal ulcers), (under 2000–3000 cGy, or 10 fractions or less, given thus further aggravating constipation. When the abdomen under 2 weeks) and more with curative treatments or pelvis receives radiation, the opposite occurs. (>6000 cGy, 6–8 weeks of therapy), and the nursing role Radiation irritates the mucosal lining and causes diaris often that of an educator and facilitator. Caring for the rhea. Although this is dose-limiting, it can become probolder adult may require more frequent nursing assesslematic, requiring breaks in treatment and, in some cases, ments and closer monitoring of interventions. Ultimately, discontinuation of radiation therapy. Radiation-induced distinguishing between the effects of aging and radiation diarrhea for the older adults can potentially cause nutriwill assist the nurse in explaining what to expect both tional problems of dehydration and electrolyte imbalduring therapy and at follow-up visits. An individualized plan of care should be offered, ances. Long-term problems can continue with chronic diarrhea, Generally, geriatric nurses may and cure should never be compromised or confused with palfibrosis, stenosis, or even fistunot see older adults as they go liation. For further discussion of las. specific nursing interventions Pain is another domain that should be assessed both before through radiation therapy, but it for acute and long-term side and during treatment. Whether is still important to be aware of effects of radiation therapy, contumor related (pressure caused sult the Manual for Radiation the acute symptoms that can Oncology Nursing Practice and by tumors) or potential acute reactions (skin reactions), clinEducation.25 develop into chronic problems icians should assess pain at CONCLUSION each visit. For example, tumors in the ongoing care of the arising from the lungs may Radiation therapy may be elderly after radiation therapy. given safely and effectively to press against other vital organs November/December 2004
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older adults when the treatment is individualized and precautions are taken to minimize the complications of treatment. The risk of serious complications from radiation therapy is small. However, radiation therapy requires a multidisciplinary approach to offer the older adult the various modalities and resources that will ensure a quality outcome. Age alone should never be a deterrent in deciding whether radiation therapy is appropriate for the older adult. Recognizing that radiation therapy causes stress on the body, careful attention is given to early physical difficulties or behavior changes. Older adults should be encouraged to remain active during therapy; suggestions should be offered to help them maintain their level of functioning. Explanations should be offered in a relaxed environment and may be written for clarity and memory. Monitoring should occur more frequently and be adjusted as needed. Certainly, the older person who knows what to expect is better able to tolerate the radiotherapy and able to maintain an optimal quality of life during therapy.22 Even after therapy, clinicians should be alert to possible long-term toxicities. Author’s Note Materials were drawn from the author’s chapter, “The Older Adult Receiving Radiotherapy.” In: An Evidence-Based Approach to the Treatment and Care of the Older Adult with Cancer. Oncology Nursing Society Press; in press. REFERENCES 1. American Cancer Society. Cancer facts and figures 2004. Atlanta, GA: American Cancer Society; 2004. 2. Maes S. Geriatric oncology nursing comes of age. ONS NEWS 2004;19(2):1, 4. 3. Jemal A, Tiwari R, Murray T, et al. A cancer journal for clinicians. Baltimore: Lippincott, Williams and Wilkins; 2004. 4. Ershler W, Longo, D. Oncology. Geriatrics Review Syllabus. 5th ed. Blackwell Publishing; 2004. 5. Satariano W, Muss H. Effects of comorbidity on cancer. Exploring the role of cancer centers for integrating aging and cancer research. Bethesda, MD: National Institute of Health; 2001. 6. Muss H, Longo D. Introduction: cancer in the elderly. Semin Oncol 2004;31:125-7.
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7. Fentiman I, Tirelli U, Monfardini S, et al. Cancer in the elderly: why so badly treated? Lancet 1990;335:1020-2. 8. Zachariah B, Balducci L, Venkattarmanabalaji G, et al. Radiotherapy for cancer patients aged 80 and older: a study of effectiveness and side effects. Int J Radiat Oncol Biol Physics 1997;39:1125. 9. Olmi P, Cefaro A, Balzi M, et al. Radiotherapy in the aged. Clin Geriatr Med 1997;13:143-68. 10. Haas M, Kuehn E. Teletherapy: external radiation therapy. In: Watkins-Bruner D, Haas M, editors. Clinical outcomes in radiation therapy: multidisciplinary approach. Sudbury, MA: Jones and Bartlett; 2001. 11. Iwamoto R. Radiation therapy. In: Otto S, editor. Oncology nursing. Philadelphia: Mosby; 2001. 12. Casey L, Zachariah B, Balducci L. Radiation therapy of older persons. In: Overcash J, Balducci L, editors. The older cancer patient. New York: Springer; 2003. 13. Hall E, Cox, J. Physical and biologic basis of radiation therapy. In: Cox JD, editor. Moss’ radiation oncology: rationale, technique, results. 7th ed. St. Louis: Mosby; 1994. 14. Perez C, Brady L, Halperin E, Schmidt-Ullrich P. Principles and practice of radiation oncology, 4th ed. Philadelphia: Lippincott; 2004. 15. Archley R, Barusch A. Social forces and aging: an introduction to social gerontology. 10th ed. Belmont, CA: Wadsworth, Thomson Learning; 2004. 16. Rao A, Seo P, Cohen H. Geriatric assessment and comorbidity. Semin Oncol 2004;31:149-59. 17. Haas M, Kuehn E. Head and neck cancers. In: Watkins-Bruner D, Haas M, editors. Clinical outcomes in radiation therapy: multidisciplinary approach. Sudbury, MA: Jones and Bartlett; 2001. 18. Sale P. Genitourinary infection in older women. J Obstet Gynecol Neonatal Nurs 1995;24:769-75. 19. Sze W, Shelley M, Held I, et al. Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy—a systematic review of randomized trials. Clin Oncol 2003;15:345-52. 20. Wai M, Mike S, Ines H, Malcolm M. Palliation of metastatic bone pain: Single fraction versus multifraction radiotherapy—A systematic review of the randomized trials. Cochrane Database Syst Rev 2004(2):CD004721. 21. Kennedy G, Kelman H, Thomas C, et al. Hierarchy of characteristics associated with depressive symptoms in an urban elderly sample. Am J Psychiatry 1989;146:220-5. 22. Strohl R. The elderly patient receiving radiation therapy: treatment sequelae and nursing care. Geriatr Nurs 1992;13:153-7. 23. Haas M. Pocket guide to lung cancer. Sudbury, MA: Jones and Bartlett; 2004 24. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic radiation. Int J Radiat Oncol Biol Physics 1991;21:109-22. 25. Watkins-Bruner D, Haas M, Gosselin T. Manual for radiation oncology nursing practice and education. Pittsburgh: ONS Press; 2004.
MARILYN L. HAAS, PHD, RN, CNS, ANP-C, is a nurse practitioner at Mountain Radiation Oncology in Asheville, North Carolina. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2004.09.001
Geriatric Nursing
Volume 25
Number 6
Marilyn L. Haas, PhD, RN, CNS, ANP-C
After heart disease, cancer is the second leading cause of death in the United States and is expected to become the leading cause of death in the next decade.1 Approximately 60% of all cancer patients will receive radiation therapy at some point in their oncology continuum. It becomes important for nurses to be familiar with the physiological changes in older adults and be able to recognize the changes that could occur from an oncology treatment such as radiation therapy. Radiation therapy is one modality that the elderly can tolerate if they have adequate functional status. Astute physical assessment skills are needed to distinguish between normal aging and the acute and long-term effects of radiation therapy. (Geriatr Nurs 2004;25:355-60) November/December 2004
355
ith a growing older population, it is external beam radiation, is delivering radioactive energy not surprising that cancer is a disease at a distance from the treatment or target area. External of older adults. According to Maes,2 beam is given daily, Monday through Friday, generally 60% of all cancers occur in the elderover 2 to 7 weeks, depending on the purpose of treatment ly population. In 2004, a total of and total dose.10 Brachytherapy, also referred to as inter1,368,030 new cancer cases and nal or implant radiation therapy, is a type of modality in 563,700 deaths are expected in the which the radioactive source is placed on or within the United States.3 The median age for older adults diagtumor (interstitial, intracavitary, or systemic). Brachynosed with cancer remains 70 to 74 years old.4,5 With life therapy can be temporary or permanent and use low or expectancy reaching 80 years old for women and 73 high-energy doses.10 The type of brachytherapy deteryears old for men, it is doubtful that cancer will ever mines the length of hospital stay or outpatient time change in the hierarchy of diseases. involved. The choice of modality depends on tumor type, Sadly enough, many older adults are not offered cansize, and location. cer therapies because of their age.6,7 Age should never be Like any oncology treatment, radiation therapy has the deciding factor for the elderly who are seeking cancer its own distinct advantages. Because radiotherapy’s aim treatments.8 Rather, activity and energy levels, such as is loco-regional control, side effects are limited and typthe Karnofsky Performance Scale (KPS), should weigh ically do not produce the systemic effects.14 For this 9 heavier into the treatment decision process. Furtherreason alone, radiation therapy provides the elderly a more, comorbidities affect treatment decisions and delivstrong therapeutic option. The elderly are often relieved ery plans. when informed that this treatment does not automaticalIt is hoped that nurses can recognize age bias issues ly cause nausea and vomiting or hair loss. Although and support older adults searching for more aggressive mortality is rare, radiotherapy has definite acute toxicitherapies. It becomes even more important to explain ties, but these are generally manageable for the older treatments that are safe, have favorable therapeutic indexadult. With newer technology (3-dimensional conformal es, without impinging on the physiological or psychologradiation and intensity modulated radiation), organs can ical reserves of the elderly. The usually be spared and better elderly should be offered clinifunction preserved. In addiRadiation therapy is a cancer tion, improvement in medicacal trials based on their functional ability rather than age. tions can control acute sympmodality that can be an Therefore, it becomes the tomatology, thus improving responsibility of nursing to help excellent option for the elderly radiosensitization, or even explain possible treatment offering radioprotection. because of its limited Radiotherapy is definitely an options, related side effects, and alternative for the elderly when know how to assess and manage systemic toxicities. surgery or chemotherapy is older adults oncology care. contraindicated. R A D I OT H E R A P Y A N D T H E E L D E R LY Radiation therapy does have its potential disadvantages. The main disadvantage to radiotherapy is the long Radiation therapy is a cancer modality that can be an duration of treatment, especially when the intent is curaexcellent option for the elderly because of its limited systive.14 Older adults can fatigue easily with daily treattemic toxicities. Radiation therapy is a local cancer treatment that can be effective for curative, prophylactic, conments over 6 to 7 weeks. While physiologic reserve has trol, or palliative purposes.10 Sixty percent of all cancer diminished with age, recovery may be slower in the older patients receiving treatment will at some point have radiadult population. Depending on the area being treated, ation treatments.11,12 Although widely used, there are site-related disturbances (toxicities) may be more prolimited radiation oncology clinical trials designed strictly nounced in the older adult, which can affect quality of for the elderly. Therefore, it is imperative to explore the life, need for treatment interruptions, and the need for issue of radiotherapy in the elderly population in regard additional medical or surgical interventions or hospitalto its effectiveness, tolerance, and management. izations. For example, there are concerns for the elderly Radiation therapy uses high-energy particles or waves, when treating the whole brain irradiation (fear of neurosuch as x-rays, gamma rays, electrons, and photons, to logic sequelae, including dementia) or the pelvis (fear of destroy or damage cancer cells so they cannot multiply or marrow aplasia or radiation enteritis). Generally, geriatric spread. The major effect is on the DNA; some cells lose nurses may not see older adults as they go through radiatheir proliferative ability and because cells cannot multition therapy, but it is still important to be aware of the ply, cell death occurs.13 Two common radiation modaliacute symptoms that can develop into chronic problems ties available for cancer patients are teletherapy and in the ongoing care of the elderly after radiation therapy. Therefore, it is important to distinguish between aging brachytherapy. Teletherapy, commonly referred to as
W
356
Geriatric Nursing
Volume 25
Number 6
Table 1. Physical Consequences of Aging and Toxicities of Radiation Therapy Organ Site Skin
Bone Brain
Oral cavity
Lung
Heart
Effects of Aging Thinning of epidermis Unchanged stratum corneum, except moisture and cohesiveness Decreased melanocytes Decreased Langerhans cells Decreased fibroblasts Hypovascular endothelium Decreased mast cells Loss of bone density Decrease in brain weight Loss of gray and white matter Changes in nerve cells Less production of ptyalin and amylase in saliva glands Dry mouth (medication-induced) Decrease olfactory senses Decrease in mastication muscles Reduction in glandular epithelial cells Enlargement of alveoli and alveoli ducts Reduction in respiratory muscle functioning Ossification of costal cartilage Decreased heart rate Vascular stiffness Increased platelet adhesiveness Decreased aerobic capacity
Breast
Less glandular tissue, more connective and fat tissue
Bladder
Loss of muscle tone, leading to incomplete bladder emptying Decreased bladder capacity
Vagina/Ovaries Atrophy of organs
Prostate
Hyperplasia
Colon/Rectum Slow peristalsis Decreased muscle strength in abdomen
Acute Toxicities of Radiation
Late Toxicities of Radiation
Mild to brisk erythema Dry desquamation Moist desquamation
Telangiectasias Fibrosis Necrosis
Thrombocytopenia Neutropenia Cerebral edema Seizures Alopecia Mucositis/Stomatitis Acute xerostomia Taste changes Pharyngitis Increasing cough, dyspnea Pain (tumor) Esophagitis Hoarseness Skin reactions (see above) Delayed acute pericarditis Delayed pericardial effusion
Spinal cord myelopathy
Diffuse myocardial fibrosis Late coronary artery disease Conduction defects Breast pain, swelling, tenderness Radiodermatitis Tanning/telangiectasias Frequency Urgency Dysuria Hesitancy Hematuria Hot flashes Vaginal dryness Dyspareunia Diarrhea
Tenesmus Proctalgia Rectal bleeding Erectile dysfunction Abdominal cramping Diarrhea
Radiation necrosis Cerebral atrophy Cranial neuropathy Osteoradionecrosis Chronic xerostomia Trismus Pneumonitis Fibrosis
Firmness Fibrosis Hematuria Telangiectasia
Thinning Atrophy Adhesions Shortening, narrowing Persistent bowel changes of diarrhea, fistula formation, perforation, incomplete bowel mucosa healing
Fibrosis Diarrhea Proctitis Adhesions Stenosis
Adapted from Haas M. Radiation therapy. In: Varricchio C, editor. A cancer source book for nurses. 8th ed. American Cancer Society. Sudbury, MA: Jones and Bartlett; 2004.
November/December 2004
357
effects and radiation therapy’s acute and long-term toxicities (see Table 1).
allowing additional time for the procedure, ensuring that glasses are given back to the patient if head molds are required for radiation treatments, talking directly and IMPORTANCE OF GERIATRIC ASSESSMENTS clearly (especially if individuals have hearing aids), and W H I L E U N D E R G O I N G R A D I OT H E R A P Y using stepping stools to get on and off the treatment table Physical aging affects functioning of the human body. can help older adults through treatment. With functional It reduces the viability at all levels (cells, molecules, tisreserves possibly diminished, extra time may be allotted sues, organs, and control systems) and increases the vulif using multiple treatment fields, protracting the treatnerability to diseases and comorbid conditions.15 Agement time. associated factors can exacerbate radiation therapy side Gait and balance of the older adult is dependent on the effects. A summary of physical changes and radiation strength of the musculoskeletal system. Risk of falls consequences can be found in Table 1. should be evaluated at any clinician’s visit with elderly Comprehensive geriatric assessment (CGA) should be patients. Recognizing that bone loss begins between the performed before radiotherapy to establish baseline funcages of 35 and 40 years in both sexes and accelerates for tioning. CGA reviews the main domains of functional women after menopause, osteoporosis becomes an issue. status, gait, balance and risk for falls, cognitive status, When cancer is found in the bones, the older person more than likely has metastatic disease. For example, cancer affective status, nutritional status, pain, and social funccan start in the breast or lungs and then spread to the tioning.16 This helps to develop a comprehensive manbones. Fortunately, radiotherapy can be effective to treat agement and care plan because it distinguishes between painful bony metastases. Research has shown that single age-related changes and those caused by radiation. fraction can provide the necessary bone pain relief.19,20 Functional status is an important predictor of response 17,18 to therapy. In geriatrics this is measured by activities The main concern when treating any large bony areas of daily living (ADLs) of (pelvis, spine, sternum, ribs, bathing, dressing, toileting, long bones, and skull) with Teletherapy, commonly transferring, feeding and contiradiation is bone marrow supnence. In radiation oncology, pression. Weekly, complete referred to as external beam the KPS, an evaluation of carblood counts may be indicated, diac function, pulmonary funcradiation, is delivering radioac- especially if the older adult is tion, and exercise tolerance, is receiving combined chemothertive energy at a distance from apy.11 commonly used. The KPS is rated by multiples of tens, from Cognitive functioning plays the treatment or target area. 10% to 100%, with 10% reprea major role in the management senting the lowest level of funcof the elderly cancer patient and tioning, representing a moribund condition in which disis included in the CGA. Fortunately, understanding the ease is progressing rapidly, to 100%, representing normal changes in the brain has changed with the advancement level of functioning, no complaints, and no evidence of in neuroimaging techniques (e.g., computerized tomogradisease. phy, magnetic resonance imaging, and position emission Functional status in the CGA also includes other tomography). With higher technology, more information assessments of bodily functions (e.g., urinary status, is revealed about the changes in the brain that might provisual and hearing abilities, sense of touch). During the vide insight into problems of memory, intellect, or locoaging process, the bladder tends to lose muscle tone, motion. Baseline assessment of mental deterioration sometimes resulting in incomplete emptying of the blad(failing memory, emotional irritability, confusion, anxider. This places the older adult at higher risk for urinary ety, depression, delusions, or hallucinations, and even retention and cystitis.18 If the bladder is in the radiation dementia) is gathered at consultation and should be treatment field during pelvic irradiation, urinary tract obtained at the onset of radiation therapy. This helps clinsymptoms are intensified and can begin after 10 fractions icians know what to expect from the older person during treatment. When treating the brain with radiation, cereor 20 Gy.14 Symptoms include dysuria, frequency, urgenbral edema can quickly change the mental and physical cy, nocturia, hesitancy, and decreased urinary capacity. status of the older adult, and distinctions need to be made Baseline functioning for the older adult is essential rapidly. Symptoms of cerebral edema that can mimic before beginning radiation treatments to recognize differmental deterioration are headache, nausea, vomiting, ences between radiation-induced cystitis, aging effects, visual changes, changes in motor ability, slurred speech, or bacterial infections. confusion, and seizure activity. The 5 senses are diminished as one grows older. Affective assessment can also reveal how the elderly Presbyopia and hearing loss are given considerations in will tolerate therapy overall. The prevalence of depresany care plan. Because of possible decreases in the funcsion in cancer patients is between 17% and 25%.21 tioning of the senses (especially vision and hearing), 358
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Therefore, long-term effects of or Brachytherapy, also referred to (e.g., the esophagus, liver, radiation should not be conheart) and cause pain.23 Thus, as internal or implant radiation radiation can shrink tumors and fused with depression from other reasons. provide pain relief. Radiation therapy, is a type of modality Nutrition is a challenge for can also induce pain, such as clinicians when treating elderly in which the radioactive source painful skin reactions. Ionizing cancer patients because weight radiation causes damage to the is placed on or within the loss is the common presenting mitotic ability of stem cells symptom.16 Body mass index within the basal layer, thus tumor (interstitial, intracavitary, weakening integrity of the skin. or biochemical parameters (albumin or total protein) can With repeated radiation, skin or systemic). be used in the assessment proreactions tend to become visible cess. There are numerous oral around the second to third week changes in normal aging: salivary glands secrete less of radiation therapy, reaching a peak at the end or withptyalin and amylase, making the saliva more alkaline; in 1 week of completion of treatment.24 Different stages bony structures of the mouth shrink and tooth decay of skin reactions occur and should be treated early (see becomes problematic; gustatory and olfactory sensations Table 1). decrease, along with the muscles used in mastication Social functioning and assessment is important at this decrease, causing less chewing ability. All of these later stage of life. Assessment of a patient’s caregiver(s) changes affect food intake in the elderly. When giving is important as well. Advance directives and powers of radiation to the oral cavity, even if it is palliative doses, attorney should be discussed and never avoided. significant toxicities occur during treatment (Table 1). Recognizing that spirituality plays a large role in therapy Many of these side effects are long-lasting and the older for many patients, asking about religious preferences adult is extremely vulnerable to physiological and psymay provide insight to facilitate care. chological distress. Nutritional problems resulting from N U R S I N G RO L E S irradiation cause stomatitis, xerotomia, or alterations in taste buds. These affect the older adult’s ability to comGeriatric and radiation oncology nurses can help older plete therapy without treatment breaks. Inadequate nutripatients and caregiver(s) anticipate the acute and longtion can further exacerbate fatigue and depression for the term toxicities that may develop during and after radioolder adult undergoing radiation treatments.22 therapy. Although evidence-based nursing interventions Aging also affects the lower gastrointestinal tract. related to radiation therapy are scarce, there are general Slowed peristalsis and decreased muscular strength can principles that can be shared. There are minimal acute cause constipation. Some individuals even have problems side effects associated with a palliative course of therapy with their anal sphincter (hemorrhoids and anal ulcers), (under 2000–3000 cGy, or 10 fractions or less, given thus further aggravating constipation. When the abdomen under 2 weeks) and more with curative treatments or pelvis receives radiation, the opposite occurs. (>6000 cGy, 6–8 weeks of therapy), and the nursing role Radiation irritates the mucosal lining and causes diaris often that of an educator and facilitator. Caring for the rhea. Although this is dose-limiting, it can become probolder adult may require more frequent nursing assesslematic, requiring breaks in treatment and, in some cases, ments and closer monitoring of interventions. Ultimately, discontinuation of radiation therapy. Radiation-induced distinguishing between the effects of aging and radiation diarrhea for the older adults can potentially cause nutriwill assist the nurse in explaining what to expect both tional problems of dehydration and electrolyte imbalduring therapy and at follow-up visits. An individualized plan of care should be offered, ances. Long-term problems can continue with chronic diarrhea, Generally, geriatric nurses may and cure should never be compromised or confused with palfibrosis, stenosis, or even fistunot see older adults as they go liation. For further discussion of las. specific nursing interventions Pain is another domain that should be assessed both before through radiation therapy, but it for acute and long-term side and during treatment. Whether is still important to be aware of effects of radiation therapy, contumor related (pressure caused sult the Manual for Radiation the acute symptoms that can Oncology Nursing Practice and by tumors) or potential acute reactions (skin reactions), clinEducation.25 develop into chronic problems icians should assess pain at CONCLUSION each visit. For example, tumors in the ongoing care of the arising from the lungs may Radiation therapy may be elderly after radiation therapy. given safely and effectively to press against other vital organs November/December 2004
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older adults when the treatment is individualized and precautions are taken to minimize the complications of treatment. The risk of serious complications from radiation therapy is small. However, radiation therapy requires a multidisciplinary approach to offer the older adult the various modalities and resources that will ensure a quality outcome. Age alone should never be a deterrent in deciding whether radiation therapy is appropriate for the older adult. Recognizing that radiation therapy causes stress on the body, careful attention is given to early physical difficulties or behavior changes. Older adults should be encouraged to remain active during therapy; suggestions should be offered to help them maintain their level of functioning. Explanations should be offered in a relaxed environment and may be written for clarity and memory. Monitoring should occur more frequently and be adjusted as needed. Certainly, the older person who knows what to expect is better able to tolerate the radiotherapy and able to maintain an optimal quality of life during therapy.22 Even after therapy, clinicians should be alert to possible long-term toxicities. Author’s Note Materials were drawn from the author’s chapter, “The Older Adult Receiving Radiotherapy.” In: An Evidence-Based Approach to the Treatment and Care of the Older Adult with Cancer. Oncology Nursing Society Press; in press. REFERENCES 1. American Cancer Society. Cancer facts and figures 2004. Atlanta, GA: American Cancer Society; 2004. 2. Maes S. Geriatric oncology nursing comes of age. ONS NEWS 2004;19(2):1, 4. 3. Jemal A, Tiwari R, Murray T, et al. A cancer journal for clinicians. Baltimore: Lippincott, Williams and Wilkins; 2004. 4. Ershler W, Longo, D. Oncology. Geriatrics Review Syllabus. 5th ed. Blackwell Publishing; 2004. 5. Satariano W, Muss H. Effects of comorbidity on cancer. Exploring the role of cancer centers for integrating aging and cancer research. Bethesda, MD: National Institute of Health; 2001. 6. Muss H, Longo D. Introduction: cancer in the elderly. Semin Oncol 2004;31:125-7.
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7. Fentiman I, Tirelli U, Monfardini S, et al. Cancer in the elderly: why so badly treated? Lancet 1990;335:1020-2. 8. Zachariah B, Balducci L, Venkattarmanabalaji G, et al. Radiotherapy for cancer patients aged 80 and older: a study of effectiveness and side effects. Int J Radiat Oncol Biol Physics 1997;39:1125. 9. Olmi P, Cefaro A, Balzi M, et al. Radiotherapy in the aged. Clin Geriatr Med 1997;13:143-68. 10. Haas M, Kuehn E. Teletherapy: external radiation therapy. In: Watkins-Bruner D, Haas M, editors. Clinical outcomes in radiation therapy: multidisciplinary approach. Sudbury, MA: Jones and Bartlett; 2001. 11. Iwamoto R. Radiation therapy. In: Otto S, editor. Oncology nursing. Philadelphia: Mosby; 2001. 12. Casey L, Zachariah B, Balducci L. Radiation therapy of older persons. In: Overcash J, Balducci L, editors. The older cancer patient. New York: Springer; 2003. 13. Hall E, Cox, J. Physical and biologic basis of radiation therapy. In: Cox JD, editor. Moss’ radiation oncology: rationale, technique, results. 7th ed. St. Louis: Mosby; 1994. 14. Perez C, Brady L, Halperin E, Schmidt-Ullrich P. Principles and practice of radiation oncology, 4th ed. Philadelphia: Lippincott; 2004. 15. Archley R, Barusch A. Social forces and aging: an introduction to social gerontology. 10th ed. Belmont, CA: Wadsworth, Thomson Learning; 2004. 16. Rao A, Seo P, Cohen H. Geriatric assessment and comorbidity. Semin Oncol 2004;31:149-59. 17. Haas M, Kuehn E. Head and neck cancers. In: Watkins-Bruner D, Haas M, editors. Clinical outcomes in radiation therapy: multidisciplinary approach. Sudbury, MA: Jones and Bartlett; 2001. 18. Sale P. Genitourinary infection in older women. J Obstet Gynecol Neonatal Nurs 1995;24:769-75. 19. Sze W, Shelley M, Held I, et al. Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy—a systematic review of randomized trials. Clin Oncol 2003;15:345-52. 20. Wai M, Mike S, Ines H, Malcolm M. Palliation of metastatic bone pain: Single fraction versus multifraction radiotherapy—A systematic review of the randomized trials. Cochrane Database Syst Rev 2004(2):CD004721. 21. Kennedy G, Kelman H, Thomas C, et al. Hierarchy of characteristics associated with depressive symptoms in an urban elderly sample. Am J Psychiatry 1989;146:220-5. 22. Strohl R. The elderly patient receiving radiation therapy: treatment sequelae and nursing care. Geriatr Nurs 1992;13:153-7. 23. Haas M. Pocket guide to lung cancer. Sudbury, MA: Jones and Bartlett; 2004 24. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic radiation. Int J Radiat Oncol Biol Physics 1991;21:109-22. 25. Watkins-Bruner D, Haas M, Gosselin T. Manual for radiation oncology nursing practice and education. Pittsburgh: ONS Press; 2004.
MARILYN L. HAAS, PHD, RN, CNS, ANP-C, is a nurse practitioner at Mountain Radiation Oncology in Asheville, North Carolina. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.gerinurse.2004.09.001
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