Commentary (Pirl): Psychiatric Assessment and Symptom Management in Elderly Cancer Patients

Drs. Winell and Roth provide a good overview of the common psychiatric disorders and cancer-related symptoms in elderly individuals with cancer. Because of the large and growing percentage of cancer patients who are over age 65, the authors duly highlight the importance of this topic. The article is highly relevant to the clinical practice of oncology and detailed information is included to help guide treatment options for major depression, anxiety, delirium, and other cancer-related symptoms. Although the article nicely describes the assessment and treatment of specific disorders and symptoms, it does not discuss some overarching principles for approaching the psychosocial care of the elderly with cancer. A few special features of psychosocial care for this population include the underreporting of distress, the impact of cognitive impairment, the greater need for some aspects of family support, and financial barriers to prescription medications. Accurate Assessment of Symptoms
Elderly patients are more likely to underreport psychological distress.[1] Corroborative data from talking with family members or friends of the elderly patient are frequently required to evaluate changes in mood, anxiety, mental status, and ability to cope. Elderly patients may describe distress more in terms of somatic symptoms (such as complaints of weakness and dizziness or preoccupation with the bowels) rather than psychological symptoms (sadness, feeling anxious). As Drs. Winell and Roth noted, it may be difficult to tease apart some of the overlapping physical and psychological symptoms in the elderly. The presence of anhedonia, or loss of the ability to experience pleasure, can often help support the diagnosis of depression in patients with physical comorbidities.[2] One of the most useful questions in getting a sense of patients' functioning and the impact of symptoms is to ask them to describe a typical day, from the time they wake up to the time they go to bed. Cognitive Impairment
Cognition should be assessed as part of the initial evaluation of elderly individuals with cancer. There may be cognitive impairment from aging and dementing processes that can affect the patient's ability to fully understand and consent to treatments and to adequately participate in complicated treatment plans. The rate of cognitive impairment in elderly medical inpatients may be as high as onethird.[ 3] If the patient has severe cognitive impairment, a health-care proxy could be invoked to help with treatment decisions or the process of obtaining a guardian for the patient can be initiated. A baseline assessment of cognition may also help in treatment planning. If a patient already has impaired cognition, treatments that can cause further impairment such as whole-brain irradiation or anticholinergic medications might be used with caution. Importance of Support Systems
Family and social support is critical for all patients with cancer, but may be more important for elderly patients at the most basic levels. Elderly patients often need help getting to treatment, which can be difficult if they live alone and are physically debilitated. Some assessment of the patient's support system should be included in the initial evaluations and treatment planning. If daily visits to the hospital are required for radiation therapy, transportation problems will need to be solved in order for the patient to receive treatment. When there is no one family member or friend who could assist with supporting all of the patient's needs, sometimes scheduling multiple people for shifts or certain duties can take advantage of larger support systems of extended family, friends, and even local organizations and institutions, such as the patient's church. A social worker and/or case manager in a clinic can often assist in accessing the patient's support system or problem-solving in finding alternative ways or services. In addition to transportation, a sick elderly patient may have difficulty managing their medications, especially as-needed medications for symptoms that can interfere with their physical capacity to take the medication on their own, like pain or nausea. Difficulty managing medications can lead to worsening symptoms and changes in mental status. Finally, elderly patients may have lost their spouses, close family members, and friends, which can leave them feeling alone and isolated at a time when they need even more emotional support. Cost of Medications
Financial issues can also affect the treatment of psychiatric disorders in the elderly. Many elderly patients do not have prescription drug coverage; the cost of psychiatric medications may be prohibitive on small fixed incomes. Atypical antipsychotics, some antidepressants, and other medications such as gabapentin can each cost over $100 a month (some substantially more than $100). Some elderly patients with cancer may not be able to receive the medications listed in the article by Drs. Winell and Roth because the may not be able to afford to have their prescriptions filled. When elderly patients already on many other medications have to choose between medications because of cost, prescriptions for psychiatric medications are often the ones that go unfilled. Asking patients how they pay for medications can sometimes help in strategizing possible solutions to potential barriers- prescribing lower-cost alternatives when available or providing supplies of sample medications. Conclusion
In summary, Drs. Winell and Roth have written a well-organized and knowledgeable review of the common psychiatric disorders and cancer- related symptoms encountered in elderly cancer patients, focusing on the assessment and treatment of specific disorders. The general considerations for the psychosocial care of elderly individuals with cancer described above serve as a supplement to their article.

Disclosures:

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

References:

1. Hale WD, Cochran CD: Age differences in self-reported symptoms of psychological distress. J Clin Psychol 48:633-637, 1992.
2. Reuter K, Harter M: Fatigue and/or depression? Examination of the construct validity of CRF. Psychooncology 12(suppl):S259- S260, 2003.
3. Joray S, Wietlisbach V, Bula CJ: Cognitive impairment in elderly medical inpatients: Detection and associated six month outcomes. Am J Geriatr Psychiatry 12:839-647, 2004.