Older cancer patients in an Italian hospice
Authors: C. Cacioppo, E. Morello, L. Casiraghi, R. Sandri, S. Monfardini
Journal: Annals of Oncology (2009)

In frail patients with advanced cancer, symptom control may be the primary objective of therapy, but quality of life is also strictly related to management of social and emotional problems [1.Higginson I.J. Costantini M. Dying with cancer, living well with advanced cancer.Eur J Cancer. 2008; 44: 1414-1424Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar]. This leads to a growing need for improving palliative care in the elderly in different settings such as hospitals, nursing homes, homes, and also in hospices [2.Davies E, Higginson IJ. Better Palliative Care for Older PeopleWorld Health Organization. Regional Office for Europe. (http://www.euro.who.int/document/E82933.pdf) 2004Google Scholar, 3.Davies E. What Are the Palliative Care Needs of Older People and How might They be Met?World Health Organization (http://www.euro.who.int/document/E83747.pdf) 2004Google Scholar]. In the hospice Santa Maria alle Grazie in Monza, 1639 patients were admitted from 2000 to 2007. In all cases, the reason for admission was cancer. Sixty one percent of patients were ≥70. Patients were predominantly admitted because of advanced lung (21%), breast (10%), colorectal (11%), prostate (5%), gastric (7%), and gynecologic carcinomas (5%). The patients were predominantly referred from hospitals (53%) and home (46.5%), compared with nursing homes (0.5%). Most patients died in the hospice (87%). The length of stay of the latest was 22 days. Almost 87% (86.5%) of patients received an analgesic treatment with opioid drugs. To better detect possible differences between younger and older patients, the cases were divided in two groups of age (≤60 years old, n = 287 and ≥70 years old, n = 998). We did not find any significant difference between the two samples. The point that all older patients were referred because of advanced cancer and not for other severe chronic illnesses of the old age (e.g. heart failure, dementia) is due to the fact that these seem to be managed in other settings such as nursing homes. Probably the less predictable nature of most non-malignant disease and the difficult estimation of short-term survival favor a different care planning. The referral pattern for other neoplasm mirrored incidence of cancer types in the community [4.Karim-Kos H.E. de Vries E. Soerjomataram I. et al.Recent trends of cancer in Europe: a combined approach of incidence, survival and mortality for 17 cancer sites since 1990s.Eur J Cancer. 2008; 44: 1345-1389Abstract Full Text Full Text PDF PubMed Scopus (620) Google Scholar]. Old and young patients were referred mainly from hospitals and home. Absence of admission from nursing homes is likely due to the fact that here also palliation of symptoms is provided although it should still be improved. The length of stay was short for older and younger patients due to a late referral. In older patients, opioid use was high with no significant differences with younger patients without following the trend of undertreatment of elderly pain often observed in the community. Management of pain in a hospice is guided by a comprehensive evaluation of the physiologic sources of pain and an attentive assessment of the atypical expression of pain in noncommunicating elderly; this leads to an effective treatment while minimizing side-effects [5.Goldstein N.E. Morrison R.S. Treatment of pain in older patients.Crit Rev Oncol Hematol. 2005; 54: 157-164Crossref PubMed Scopus (25) Google Scholar] and may explain why in this hospice older patients were managed in the same way as younger ones. In this hospice, older patients did not receive a comprehensive geriatric assessment (CGA). Our opinion is that in hospice multidisciplinary assessment and care are already carried out by the hospice team and are as effective as CGA in evaluating the needs of the patients. Nevertheless, CGA could be a useful tool in addressing the needs of individual patients and consequently in identifying the best setting for care.