Symptom burden: in need of more attention and more evidence.

In this issue of the journal, Chaudhry et al1 raise a number of important quest ions for those of us caring for community-dwelling older adults. How can we do a better job of relieving symptoms at the end of life? What efforts will be required to improve quality of life in those last months of living? How should we best manage symptoms in the context of multimorbidity? Do we have sufficient evidence to know what to do? Chaudhry et al1 evaluated 15 physical and psychological symptoms among 754 community-dwelling older persons that led to restrictions in daily activities during the last year of life. Approximately three-quarters of this cohort had multimorbidity (defined by Chaudhry et al1 as the presence of 2 or more comorbid conditions). Two findings are particularly noteworthy: the increase in occurrence of symptoms that negatively affected function and quality of life in the months preceding death and the increased risk for meaningful symptoms among those with multimorbidity. At 5 months prior to death, the occurrence of symptoms negatively affecting function started to accelerate, increasing from one-quarter to more than one-half of all decedents in the month prior to death. Those with multimorbidity were more likely to experience these symptoms. Thehigh rate of symptoms in this cohort is reminiscent of rates seen inhospitals in the SUPPORTstudy (Study toUnderstand Prognoses and Preferences for Outcomes and Risks of Treatments),2 suggesting that system barriers are preventing good symptom management. Progress has been made to increase access of patientswith serious illness to palliative care services and to hospice.3 Yet, we know that 55.4% of patients still do not receive hospice care at the end of life and that for those who do, referrals to hospice care often occur late in the illness course.4 For those who do not want hospice care but need aggressive management of their symptoms, access to community-basedpalliative care services is relatively scarce.5 Among a representative cohort of decedents older than 65 years, 51% visited the emergency department during the last month of life, and 75% during the last 6 months of life; likely many of these visits were for uncontrolled symptoms.6 Most palliative care programs are found in hospitals, not in the clinic or home care setting. Although we do not know what percentage of the population that Chaudhry et al1 studied receivedhospice services during the last 6months of their lives, their findings suggest thatmore aggressive efforts need to be made to control symptoms at the end of life, regardless of settingor servicesprovided.These efforts should spanboth systematic approaches to increase access to prehospice, community-based palliative care and increased training in primary palliative care.7 Clearly, with only 5000 board-certified palliative care physicians in the country, it will be critical to ensure that all physicians going into practice have command of basic symptommanagement skills and have strategies for referring thosewithmore complex symptomsupport andpalliative care needs to palliative care specialists. The findings of Chaudhry et al1 also suggest that symptommanagement ismore challenging among thosewithmultimorbidity. The higher likelihood of symptoms at the end of life in those withmultimorbidity could be due to an accumulationofconditionscausinga largerarrayof symptomsormight represent the special challenges of attending to symptoms in the setting of multimorbidity. Managingandaddressingsymptoms in thecontextofmore than 1 condition is complex for several reasons. First, 1 symptom may represent more than 1 underlying condition. When symptoms reflect more than 1 pathologic process, ascertainingwhich process is driving the symptomcan be challenging. In the common scenario of co-occurring chronic obstructive pulmonary disease and chronic heart failure,8 it is often not straightforward todetermine theetiologyof fatigueandshortness of breath and what may be the best treatment option. In addition,management of 1 symptomcan often exacerbate another symptom or concurrent condition. Musculoskeletal pain, a common symptom in the study by Chaudhry et al,1 when treated with nonsteroidal anti-inflammatory agents, couldexacerbatehypertension, renal insufficiency,and heart failureand increase risk forgastrointestinalbleeding.Opioids administered for painmay induce problemswith constipation, falls, and confusion. Use of antidepressants, often appropriate for anxiety and depression in older adults, could increase risks for electrolyte disturbances and falls. Finally, management of symptoms is problematic for this population because so little research has been done to identify optimal treatment strategies for those with multimorbidity. The number of adults with multimorbidity is expected to increase by more than one-third between 2000 and 2030.9 Nevertheless, clinical trials routinely exclude this population, leaving clinicians in a quandary regarding the best way to support those with symptoms without causing unintentional harm. Large longitudinal cohort studies, especially those linked to electronic health records or claims data, have the potential to offer some guidance; most of these studies, however, lack adequate patient reported outcomes or symptom assessment strategies to truly elucidate the comparative value of 1 treatment over another. Assessment intervals are also too infrequent to capture the effect of variable combinations and doses of medications, along with nonpharmacologic treatments, on symptoms that are likewise dynamic and fluctuating in severity and functional Related article page 1534 Restricting Symptoms in the Last Year of Life Original Investigation Research