Half of people newly diagnosed with cancer are aged 70 or over. As nurses, we have a vitally important role to play.
Nationally there is a drive to improve treatment standards for this age group as mortality rates are not improving quickly enough.
Complexity of nursing older people with numerous co-morbidities requires in depth assessment to inform assessment and future care planning. So much so, that the Dignity Commission recently recommended that every patient newly admitted to hospital should receive a comprehensive geriatric assessment. Add a diagnosis of cancer into the mix, and a thorough assessment becomes essential.
For the last ten months, I have been working as a research nurse as part of the national Improving Cancer Treatment Assessment and Support for Older People Project. My role focuses on undertaking comprehensive geriatric assessment on older people with a diagnosis of colorectal cancer. I frequently assess patients in their own homes. Over this period, I have witnessed the real benefits an assessment like this can bring to an older person cancer. However, an assessment like this can often be time consuming. Is this nursing time well spent?
Comprehensive geriatric assessment is an approach which examines psychosocial, functional, medical, and environmental issues to inform a plan for treatment and follow up involving nursing, medical and social interventions. As nurses, we are well placed to undertake assessments of older people as this uses our traditional nursing skills such as subtle listening skills, observing non-verbal cues and observing the wider living environment. I find patients are more likely to open up to nurses about the problems that they face. We fulfill the role as advocate for our patients, liaising with primary care, social services, voluntary sector providers and medical professionals to meet identified needs.
It is estimated that people aged over 70 have an average of three co-morbidities each. To maximize an older person’s chance of benefitting from treatment, it is vital that their other health problems are appropriately managed. Many older patients will commonly present with a poor performance status, often as a result of such co-morbidities. This can then raise concerns over their ability to tolerate treatment.
We shouldn’t forget that on many occasions the issues contributing toward the poor performance status can be optimized. Common issues such as falls, malnutrition and polypharmacy can be managed to improve a patient’s ability to tolerate treatment. I see patients in their 70s and 80s doing well on treatments that may not have been considered had their other health problems not been managed effectively.
Simple interventions can make a huge difference. Many older people I assess have not had a medication review in quite some time. I frequently find older people who are experiencing dizziness and falls as a result of incorrect anti-hypertensive drug dosages. It is estimated that one in three older people have existing problems with their medications at the time of a cancer diagnosis.
Practical and social barriers such as being able to prepare meals, or get to and from hospital appointments can present a barrier to accessing treatment. This is worsened by the fact that as many as one third of people in this age group live alone. Once these issues have been identified, I will liaise with general practice, social services and the voluntary sector to put an appropriate intervention in place.
We must make time for older cancer patients. I’ll often ask an older person how well they are eating and they’ll reply “fine thank you”. I’ll then ask what they’re eating and it turns out they’re eating one meal a day. If the issues are related to difficulties with shopping or cooking, we can engage local voluntary sector organisations such as Age UK to provide assistance. About 35% of people over 80 have some form of malnutrition. This can deteriorate during cancer treatment and impact on wound healing and infection risk.
We must make older people feel that we have the time to listen to their concerns. I would say the assessments are definitely nursing time well spent.
Lorraine Goodwin is a Clinical Research Nurse at Royal Sussex County Hospital.