Nursing older people with cancer
The final article in our series on how cancer affects different patient demographics focuses on older people
Older people are more likely than any other age group to be diagnosed with cancer. More than one third of new cancer cases in the UK were in people aged 75 and over in the two years to 2016.
age for peak rate of cancer incidence in the UK
Source: Cancer Research UK
Nurses are more likely to treat older people than other age groups for cancer, and generally the treatment is more complicated, says University of Bolton clinical practice lecturer Carole Farrell.
‘Older people have often developed a number of co-morbidities, making clinical oncology management more complex,’ she says.
Helping patients to understand
‘Many older people are taking more than five medicines for general conditions, creating issues of polypharmacy when they need to take oral anticancer medication and supporting medicines such as analgesics.’
Dr Farrell, who has worked in oncology for more than 30 years, including as a clinical nurse specialist and nurse clinician, says it can be particularly challenging for older people to understand their medication, the timings for taking it and possible side effects.
‘Nurses play a crucial role in helping patients’ understanding and monitoring concordance,’ she says.
Dr Farrell, who is developing a ‘patient reported experience’ measure for those with secondary breast cancer, says her research shows older people are often reluctant to contact their cancer team if they are unwell or struggling with treatment side effects.
‘Older people are often stoical and try to cope on their own rather than seek help. They often seek to minimise the severity and impact of treatment toxicities and sometimes fail to report life-threatening toxicities to health professionals.’
With this in mind, she advises nurses to adopt a proactive rather than reactive approach. ‘We need to prompt and explore more during consultations to better understand the full impact of treatment. This includes exploring several aspects of their physical functioning, such as changes to activities in their daily lives and social contacts.’
‘We need to prompt and explore more during consultations to better understand the full impact of treatment’
Carole Farrell, clinical practice lecturer
She also says that while diet and nutrition need to be monitored, other factors such as whether patients can manage to go out shopping and have the energy to stand for long enough in their kitchen to prepare food should also be considered.
Taking time to talk openly
As with nursing any group, it is vital to understand the patient’s priorities during cancer treatment and the things they find most difficult, so they can be addressed, she says.
‘Taking time to talk openly to older people about their lives, family and general experiences helps to build up a picture of them as a person. This will then help nurses to explore how the diagnosis and treatment has affected their lives and impacted on their family.’
RCN older people’s forum chair Vicki Leah agrees, and says the most important and rewarding intervention is to ‘make contact with the person on a human level’.
‘Sharing a bit of yourself, such as interests, and showing an interest in the patient, helps to develop a therapeutic relationship. The patient is then more likely to share their fears, tell you if they are in pain, and ask questions they would not ask others – and that’s a privilege.’
Ms Leah, a consultant nurse for older people and the dementia lead at University College London Hospitals NHS Foundation Trust, says it is vital to find out what is important to the patient when drawing up treatment plans. ‘It may well not be what is important to the healthcare worker,’ she explains.
She says the Comprehensive Geriatric Assessment, a toolkit used to assess frailty, helps focus on what is important to the patient. ‘This should help optimise their health and social status, giving the best chance to live with or die from cancer well.’
of cancer deaths in the UK in 2014-16 were people aged 75 and over
Source: Cancer Research UK
Older people are more likely to develop delirium, which is often unrecognised and undertreated in all settings, she says.
As well as being stoic, older people may ascribe treatment side effects to old age or present them in a non-specific way, as children can do, says Ms Leah, who leads a team of older peoples’ clinical nurse specialists.
Delays in diagnosis
She says that despite cancer being more common among them, older people can wrongly attribute symptoms to their age or other pre-existing long-term conditions, leading to a delay in diagnosis. ‘This overshadowing is compounded by social isolation as the slow, insidious symptoms will go unnoticed. It is often a family member or friend who notices weight loss or shortness of breath.’
Cancer charities’ fundraising advertisements, such as those on TV that often feature young or middle-aged people, do little to help, she says. This is despite data from Cancer Research UK showing age-specific incidence rates rise steeply from around age 55-59. The highest rates are in the 85-89 age group.
‘Sharing a bit of yourself, such as interests, and showing an interest in the patient, helps to develop a therapeutic relationship’
Vicki Leah, chair of RCN older people’s forum
‘These adverts never cease to amaze me, and in my opinion they send out the wrong message. Will using older people who have the highest incidence of cancer not incentivise members of the public to give money?’
Education, motivation and role-modelling
Ms Leah wants to improve the experience of older people in hospital through changing staff attitudes via education, motivation and role-modelling.
She recalls distressed patients with brain tumours who were refusing treatment, which she describes as ‘extremely difficult emotionally’ for nurses.
‘My gentle message in this situation was to remind the nurses that no matter how distressing the behaviour, the person is not a bad person but a dying person, and they and their family are more distressed than you.’
Most common causes of cancer in UK
Men aged 75 plus:
Lung 20%, prostate 19%, bowel 10%, cancer of unknown primary 6%, bladder 5%, other 40%
Women aged 75 plus:
Lung 19%, breast 13%, bowel 11%, cancer of unknown primary 8%, pancreas 6%, other 43%
Source: Cancer Research UK
Leeds Beckett University research nurse Rachael Kelley is working on a project to calculate for the first time the prevalence of people living with cancer and dementia in the UK.
The research, due to be completed in August, includes interviews with oncology staff, people with cancer and dementia and their families, as well as observations in hospital cancer services. GP records from hundreds of practices are being analysed as part of the study, funded by the National Institute for Health Research.
Dr Kelley, who was a mental health nurse specialising in dementia before the research project, says that while there are currently no accurate figures, the little research available suggests patients with both conditions have worse outcomes in terms of diagnosis, treatment and survival than those with cancer, but not dementia.
‘Nurses can help by allowing more time for communication to take place’
Rachael Kelley, research nurse
‘There can be delays in obtaining a cancer diagnosis, practical challenges in attending oncology settings, and difficulties in communication and understanding about diagnoses and treatment options.’
Allow more time for communication
of new cancer cases in the UK are in people aged over 75
Source: Cancer Research UK
Good communication, she says, is particularly important when someone has dementia, as it can affect their ability to remember and understand information, as well as affecting their ability to find the right words when asking questions. ‘Nurses can help by allowing more time for communication to take place, slowing down their speech and giving extra time for people to process information and respond.’
Early findings suggest dementia is not always well-recorded in hospital records, and Dr Kelley suggests nurses assess patients for memory problems and check during the consultation that they understand what is going on. ‘Using visual information such as pictures and diagrams or providing information that has been discussed in written form so people can take it home is often helpful,’ she says.
The findings, due to be available from early next year, will be used to raise awareness of the numbers and needs of people with cancer and dementia and to make recommendations on how services can be improved. Summary reports for NHS clinicians and best practice recommendations for providing care will also be issued.
Points for nurses to keep in mind
- Leave your assumptions at the door – not all older people are frail, incontinent or have cognitive problems
- Don’t think of older people as cartoon stereotypes – picture someone like Sir David Attenborough
- Make contact on a human level – show an interest in the patient and talk about your own interests
- Find out about the patient’s life, family and general experiences to build up a picture of them
- Understand what is important to the patient and plan around that
- Prompt and explore to get a better understanding of the effect on them of treatment
Tamsin Newton Snow is a health writer
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