Deconditioning in Older Adults With Cancer: A Cascade to Dependency


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Lorraine K. McEvoy, DNP, MSN, RN, OCN

Stuart M. Lichtman, MD

It is important for all oncology clinicians to recognize that reconditioning can take twice as long as deconditioning and requires diligent work on the part of the patient, caregivers, and the multidisciplinary team to reconstitute prior levels of functional status.

—Lorraine K. McEvoy, DNP, MSN, RN, OCN

It is estimated that nearly half of adults over age 80 living in the community are frail despite apparent functional well-being.1 Frailty is recognized as a clinical syndrome in which three or more of the following criteria are present: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity.2 Deconditioning is a syndrome in which an acute stressor event in a frail older adult causes the physiologic reserve capacity threshold to be surpassed, resulting in the simultaneous deterioration of physical, physiologic, and psychological processes.

The subtle onset of deconditioning manifests as a constellation of health issues: weakness, fatigue, altered cognition, inactivity, decreased food intake, weight loss, and depression that can begin within hours of an acute event and rapidly become profound during hospitalization.3 Deconditioning in the setting of an urgent clinical scenario may go unrecognized by the health-care team focused on the patients’ immediate needs. The result is a cascade of decline leading to dependency.

Impact on Care

In addition to increasing the risk for complications and reducing the quality of life for the older adult, deconditioning is associated with a several-fold increase in the risk of dying.4 During the past decade, oncologists, geriatricians, nurses, and allied health professionals have begun to work together to integrate the principles of geriatrics into oncology care.5 Early detection and prevention of deconditioning are acknowledged as a benchmark of good practice,4 yet deconditioning is often unrecognized and undertreated in older adults.

Interventions to ameliorate deconditioning are often missed opportunities to enhance outcomes when older adults undertake cancer treatment.4,6 It is important for all oncology clinicians to recognize that reconditioning can take twice as long as deconditioning7 and requires diligent work on the part of the patient, caregivers, and the multidisciplinary team to reconstitute prior levels of functional status.

Comprehensive Approach to Reconditioning

Changes in U.S. cancer care delivery have distanced the specialties of cancer treatment, survivorship, and rehabilitation,8 presenting significant challenges to coordination of care. Nevertheless, care delivery that focuses on effective disease management, preservation of pretreatment levels of functioning and independence, prevention of decline, and aggressive reconditioning in older adults with cancer has demonstrated effectiveness.9

The integration of a multidisciplinary team of providers to optimize the patient’s physical, psychological, occupational, and social functioning is required to simultaneously take action to enhance capacity and reduce task demands.10 Close coordination of the timing and types of interventions is required to optimize reconditioning outcomes.11

Depending on the specific treatment, older cancer patients face numerous adverse sequelae. These consequences include fatigue, depression, anxiety, fear of recurrence, cognitive dysfunction, pain syndromes, peripheral neuropathy, sexual dysfunction, balance and gait problems, mobility issues, lymphedema, bladder and bowel problems, stoma care, dysphagia, communication difficulty, and depression—any of which can lead to profound deconditioning in the older adult.12,13

In a comprehensive care approach, the team evaluates the totality of problems that the patient faces and coordinates treatment to address specific issues.14 Assessment of the patient-caregiver support system, intensive patient-caregiver education, behavior modification, nutritional support, physical activity, weight stabilization, and psychosocial support can be strategies that promote management of symptoms.12 Comprehensive care management begins with cancer treatment and integrates the multidisciplinary team to preserve the ability to remain independent, functionally active, and maximize health and longevity.15

Promoting Health Outcomes

Available data clearly indicate that social relationships have the potential for health promotion in older adults and that there are biologically plausible pathways for these effects.16 The complex physical, physiologic, and psychological interplay of adaptive capacity and functional reserve suggests that aspects of the social environment play an important role in reconditioning interventions following cancer treatment.17

Both the quantity and quality of social relationships have been reliably related to morbidity and mortality.16 In a large survey of community-dwelling older adults, risk for debilitated activities of daily living and mobility disability was related to psychosocial alterations. Less physical activity and fewer social contacts among older adults increased disability over time.

Seeman et al studied the relationship of social ties and support to patterns of cognitive aging and demonstrated that participants receiving more emotional support had better baseline performance and better cognitive function at 7.5-year follow-up.16 The findings support the need for ongoing interactions among patients, their caregivers, and their health-care professionals to provide assessment, monitoring, and reassurance. Furthermore, evidence suggests that the degree to which older people are engaged in their social environment is associated with a clear survival benefit, whether this engagement is defined by specific social or productive activities or by the nature and quality of their social relationships.18

Implications for Practice

Oncology physicians, nurses, and allied health professionals can readily leverage their access to the settings in which patients are accessing care and assess an individual’s risk for deconditioning. Greater efforts are needed to screen for and recognize deconditioning as well as to intervene early on in the treatment planning process in order to prevent the downward spiral in terms of functional decline, loss of independence, and impaired health-related quality of life.

Resources for reconditioning should be assessed and interventions initiated concurrently so that opportunities to enhance outcomes when older adults undertake cancer treatment are incorporated into current practice. Oncology clinicians should recognize the potential benefits of routine assessment of deconditioning risk and providing patient/caregiver education for maintaining current levels of performance.

The goal of reducing the burden of deconditioning during cancer treatment can best be achieved through an ongoing multidisciplinary, multimodal, collaborative approach that integrates the patient, family, caregivers, and their supportive network with the clinical team.7 In order for this approach to be successful, it must be initiated when cancer treatment is undertaken and be conscientiously maintained throughout the disease course and during transitions in care. Additionally, gerontology education programs for health-care providers should incorporate deconditioning assessment, recognition, and prevention as core components of the instruction curriculum.3

Disclosure: Dr. McEvoy reported no potential conflicts of interest.

References

1. Palacios-Ceña D, Alvarez-López C, Cachón-Pérez M, et al: Early detection of functional and cognitive decline after hospital discharge: The role of community nursing and multidisciplinary teams. J Gerontol Nurs 35(9):13-17, 2009.

2. Bond SM, Davis ME, McEvoy L: Physiology of aging and its impact on the older adult, in McEvoy L, Cope D (eds): Caring for the Older Adult With Cancer in the Ambulatory Setting, pp 9-31. Pittsburgh, Oncology Nursing Society, 2012.

3. Cheruiyot J, Reinhard J, Laoingco C, et al: Knowledge of staff nurses on management of deconditioning in older adults: A cross-sectional study. J Nat Sci Res 3:82-91, 2013.

4. Gillis A, McDonald B: Nurses’ knowledge, attitudes, and confidence regarding preventing and treating deconditioning in older adults. J Contin Educ Nurs 39:547-554, 2008.

5. Extermann M, Hurria A: Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol 25:1824-1831, 2007.

6. Luctkar-Flude MF, Groll DL, Tranmer JE, et al: Fatigue and physical activity in older adults with cancer: A systematic review of the literature. Cancer Nursing 30(5):E35-E45, 2007.

7. Hardy SE, Dubin JA, Holford TR, et al: Transitions between states of disability and independence among older persons. Am J Epidemiol 161:575-584, 2005.

8. Barr TR, Towle EL: National oncology practice benchmark: An annual assessment of financial and operational parameters—2010 report on 2009 data. J Oncol Pract 7S(suppl):2s-15s, 2011.

9. Alfano CM, Ganz PA, Rowland JH, et al: Cancer survivorship and cancer rehabilitation: Revitalizing the link. J Clin Oncol 30:904-906, 2012.

10. Boyd CM, Landefeld CS, Counsell SR, et al: Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc 56:2171-2179, 2008.

11. King BD: Functional decline in hospitalized elders. Medsurg Nursing 15:265-272, 2006.

12. Stubblefield M, O’Dell M: Cancer Rehabilitation: Principles and Practice, pp 1-1093. New York, Demos Medical Publishing, 2009.

13. Bowman KF, Rose JH, Deimling GT: Families of long-term cancer survivors: Health maintenance advocacy and practice. Psychooncology 14:1008-1017, 2005.

14. Hewitt M, Greenfield S, Stovall E (eds): From Cancer Patient to Cancer Survivor: Lost in Transition, pp 1–506. Washington, DC, National Academies Press, 2006.

15. Davis ME, Derby SA, McEvoy L: Symptom management, in McEvoy L, Cope D (eds): Caring for the Older Adult With Cancer in the Ambulatory Setting, pp 57-111. Pittsburgh, Oncology Nursing Society, 2012.

16. Seeman TE, Lusignolo TM, Albert M, et al: Social relationships, social support, and patterns of cognitive aging in healthy, high-functioning older adults: MacArthur studies of successful aging. Health Psychol 20:243-255, 2001.

17. Seeman TE: Health promoting effects of friends and family on health outcomes in older adults. Am J Health Promot 14:362-370, 2000.

18. Wang HX, Karp A, Winblad B, et al: Late-life engagement in social and leisure activities is associated with a decreased risk of dementia: A longitudinal study from the Kungsholmen project. Am J Epidmiol 155:1081-1087, 2002.

GUEST EDITOR

Geriatrics for the Oncologist is guest edited by Stuart M. Lichtman, MD, and developed in collaboration with the International Society of Geriatric Oncology (SIOG). Dr. Lichtman is an Attending Physician at Memorial Sloan Kettering Cancer Center, Commack, New York, and Professor of Medicine, Weill Cornell Medical College, New York. He is also President Elect of the International Society of Geriatric Oncology (www.siog.org).

 

 



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