Caring for Hospitalized Older Adults With Chemotherapy-Associated Toxicities

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1 Caring for Hospitalized Older Adults With Chemotherapy-Associated Toxicities Diane G. Cope, PhD, ARNP-BC, AOCNP Oncology Nurse Practitioner Florida Cancer Specialists and Research Institute Fort Myers, Florida Cancer Treatment: Then and Now Shift from hospital admission for chemotherapy administration to outpatient settings: Financial Clinical and pharmacologic parameters Aging population Increased incidence of cancer in older adult Complexity of care Page 2 Assessment of the Hospitalized Older Adult with Treatment Toxicities Complex Treatment vs Disease vs Co-morbidity? Functional status Physical status Assessment: Oncology Specific History Physical Oncology Specific 1. Chief complaint 2. History of present illness 3. Review of systems 4. Past medical, family and social history 1. Constitutional 2. Eyes 3. Ears, nose, mouth and throat 4. Neck 5. Respiratory 6. Cardiovascular 7. Chest (breasts) 8. Gastrointestinal 9. Genitourinary 10.Lymphatic 11.Musculoskeletal 12.Skin 13.Neurologic 14.Psychiatric 1. Nutritional status 2. Functional status 3. Poly-pharmacy 4. Affect/mood 5. Emotional reactions 6. Socioeconomic Social/lifestyle Financial issues Page 3 Page 4 Nutrition Quantitative measurement: Body mass index (based on height and weight) Mini Nutritional Assessment Normal/usual weight Involuntary weight loss: Have you lost 10 lbs. or more over the last 6 months without trying to do so? Over the past 3 days, how many meals have you eaten? What do you think is effecting your appetite? Page 5 Functional Status ADL & IADL classically used to measure degree of dependency with tasks in everyday life ADL: Bathing, dressing, toileting, transfer, feeding, continence IADL Use telephone, get groceries, travel, prepare meals, do housework or repair work, laundry, take medications, manage money Page 6 1

Affect/Mood Depression is a major factor in reduced physical functioning which in turn impacts outcome and survival 5-Item Geriatric Depression Scale (Hoyl,1999) On the whole, are you content with

Emotional Reactions Coping mechanisms Fatalistic view about cancer Multiple losses Isolation Abandonment Depression Anxiety The only person that likes change is a wet baby 0-1 not depressed; >

2 Affect/Mood Depression is a major factor in reduced physical functioning which in turn impacts outcome and survival 5-Item Geriatric Depression Scale (Hoyl,1999) On the whole, are you content with your life? Do you often feel bored? Do you often feel helpless? Are there many days when you prefer to stay home rather than going out? Do you often feel worthless? Emotional Reactions Coping mechanisms Fatalistic view about cancer Multiple losses Isolation Abandonment Depression Anxiety The only person that likes change is a wet baby 0-1 not depressed; > Powerpoint 2 possible Templates depression Page 7 Page 8 Socioeconomic Living arrangements Transportation Major source of support Proximity of help in emergency Financial Issues Shrinking financial resources Fixed income Prescription drugs Home care Medical supplies Page 9 I wish the buck stopped here. I could use a few Page 10 Summary: Assessment Foundation of Care Standard history Standard physical Oncology specific CGA components Common Chemotherapy Toxicities Hematologic Anemia Immunocompromised Neutropenic fever Gastrointestinal Mucositis Diarrhea Page 11 Page 12 2

Hematologic Toxicities: Anemia Anemia Most common hematologic abnormality seen with malignancies More than 50% of patients with cancer Chemotherapy Radiation GI bleed Heart disease Chronic renal

response Decreased hematopoiesis response (Balducci, 2001; 2003; Wedding et al.

3 Hematologic Toxicities: Anemia Anemia Most common hematologic abnormality seen with malignancies More than 50% of patients with cancer Chemotherapy Radiation GI bleed Heart disease Chronic renal insufficiency Page 13 Hematologic Function and Aging Decreased reserve of heme and stem cells Decreased ability to tolerate hemopoietic stress Decreased function of stem cells Decreased neutrophil response Decreased hematopoiesis response (Balducci, 2001; 2003; Wedding et al., 2007) Page 14 Chemotherapy and Hematologic Function Anemia: < 12 g/dl Alterations in erythrocyte binding drugs Anthracyclines Oxaliplatin Older adult at higher risk due to decreased bone marrow reserves Complications of Anemia Reduction in volume of distribution Fatigue Decreased quality of life Increased risk of delirium Increased risk of cardiac complication Potentially poorer disease and treatment outcomes Increased risk of adverse drug reactions Page 15 Page 16 Nursing Assessment of Anemia Nursing Management of Anemia Fatigue Activity level Respiratory symptoms; SOB; DOE Chest pain; cardiac palpitations Laboratory studies Iron studies Renal function Stool for guiac Erythropoietin therapy to maintain Hgb < 12 g/dl Transfusional support Follow-up lab studies Patient/caregiver education Exercise Conserve energy Frequent rest periods Page 17 Page 18 3

Hematologic Toxicities: Immunosuppression Most common toxicity of chemotherapy Reluctance to treat older adult with chemotherapy Definition Absolute neutrophil count (ANC) < 5000 cells/mm 3

Risk decreased by 50% with use of growth factors NCCN, 2012 Page 19 Complications Associated with Chemotherapy-induced Neutropenia Neutropenia Multidimensional experience Vulnerability to infection

4 Hematologic Toxicities: Immunosuppression Most common toxicity of chemotherapy Reluctance to treat older adult with chemotherapy Definition Absolute neutrophil count (ANC) < 5000 cells/mm 3 Significant increase by 65 years of age Older adult at higher risk for first cycle neutropenia especially after age 70 Incidence of neutropenic infection related mortality varying between 5% and 30%. Risk decreased by 50% with use of growth factors NCCN, 2012 Page 19 Complications Associated with Chemotherapy-induced Neutropenia Neutropenia Multidimensional experience Vulnerability to infection Fever and infection Delirium Fatigue Anorexia Sepsis Dehydration Psychosocial alterations in quality of life Page 20 Reducing Chemotherapy-induced Neutropenia Guidelines recommend: primary prophylaxis for patients expected to experience levels of febrile neutropenia (ASCO) Dosage reduction primary prophylactic use of colony-stimulating factors (CSFs) for > 65 years of age (NCCN) CSFs reduce incidence of neutropenia, febrile neutropenia, and infections in older adults receiving myelotoxic chemotherapy for: (IDSA) NHL Small cell lung cancer Urothelial carcinomas Dosage reduction ASCO, 2006; IDSA, 2009; Powerpoint NCCN, Templates 2012 Page 21 Nursing Assessment of Neutropenia Vital signs Medications Laboratory studies CBC Cultures Liver and renal function tests Skin exam VAD exam Respiratory exam Chest x-ray Page 22 Nursing Management of Neutropenia Same as for all populations Promote good hygiene Promote nutrition Intravenous hydration Antibiotic therapy Follow-up laboratory results Patient education Gastrointestinal Complications Mucositis Diarrhea Page 23 Page 24 4

Aging and Body Composition Aging and Gastrointestinal Function Decrease in lean body weight Decrease in total body water Decrease in plasma albumin Increase in body fat Middle age is when your age

atrophy Page 26 Chemotherapy and Body Composition Changes Increase in body fat Lipid soluble drugs Decrease in plasma albumin Decrease in total body water Water soluble drugs Decrease in lean body

5 Aging and Body Composition Aging and Gastrointestinal Function Decrease in lean body weight Decrease in total body water Decrease in plasma albumin Increase in body fat Middle age is when your age starts to show around your middle --- Bob Hope Page 25 Decrease in GI motility Decrease in saliva production Decrease in secretion of gastric acid and pepsin Prolonged gastric emptying Mucosal atrophy Page 26 Chemotherapy and Body Composition Changes Increase in body fat Lipid soluble drugs Decrease in plasma albumin Decrease in total body water Water soluble drugs Decrease in lean body mass Mucositis: Definition MUCOSITIS: injury of the mucosal lining of the alimentary and gastrointestinal (GI) tract, including the mouth, pharynx, esophagus, stomach, intestines, colon, rectum and anus. Specific terms refer to mucositis in different regions: Stomatitis -- oropharyngeal mucositis Gastritis -- stomach mucositis Enteritis -- bowel mucositis Proctitis -- rectum mucositis (Hurria & Lichtman, 2007) Page 27 Page 28 Mucositis Increases with age Oral mucositis: 40% with standard chemotherapy up to 80% in high-dose regimens associated with bone marrow and stem cell transplants GI mucositis: 5% to 10% with standard-dose chemotherapy regimens: more than 20% with certain doses and regimens of irinotecan up to 100% with high-dose chemotherapy regimens or radiation therapy involving regions of the head and neck or the chest, abdomen or pelvis Page 29 Risk Factors for Mucositis Oral hygiene Poor nutritional status Smoking Baseline neutrophil level Prior cancer treatment Radiation Concomitant radiation and chemotherapy Advanced age (Crivellari et al, 2000; Jacobson et al, 2001; NCCN, 2009) Page 30 5

Risk Factors: Chemotherapy Agents Antimetabolites Antitumor antibiotics Anthracyclines Taxanes Vinca alkaloids High dose therapy with alkylating agents Usually develops within 5 to 7 days after

6 Risk Factors: Chemotherapy Agents Antimetabolites Antitumor antibiotics Anthracyclines Taxanes Vinca alkaloids High dose therapy with alkylating agents Usually develops within 5 to 7 days after chemotherapy and peaks around day 14. (Beck, 2004; Camp-Sorrell, 2000; Dodd, 2004) Page 31 Age Related Changes and Mucositis Decreased salivary production and flow Decreased keratinization of the mucosa Decreased renal function Decreased total body water Decreased hematopoietic reserve Increased prevalence of gingivitis Decrease in GI motility Decrease in secretion of gastric acid and pepsin Prolonged gastric emptying Mucosal atrophy Page 32 Complications of Mucositis Complications of Mucositis Nutritional Impairment Decreased oral intake Altered nutrient absorption Dehydration Decreased oral intake Nausea and vomiting Diarrhea Page 33 Infection Streptococcus species and gram-negative bacteria Candida Herpes Simplex Virus Pain Nutritional Intake Communication Taking medications Bleeding Chemotherapy-induced thrombocytopenia Page 34 Complications of Mucositis Oral Assessment: Nurse/Patient Late Effects Xerostomia Trismus Taste alterations Nutritional alterations Dental caries Esophageal strictures Bowel obstructions Perforations Page 35 Inspect mouth thoroughly on a daily basis Redness Ulcers Lesions White patches Bleeding Page 36 6

7 WHO and NCI Oral Mucositis Scales Grade 1 Grade 2 Grade 3 Grade 4 WHO Scale NCI-CTC Clinical NCI-CTC Functional Oral soreness, erythema Ulcers but able to eat solids Oral ulcers able to take liquids only Oral alimentation impossible Erythema Patchy ulcerations or pseudomembranes Confluent ulcerations; bleeding with minor trauma Tissue necrosis; spontaneous bleeding; life threatening Minimal symptoms, normal diet; minimal respiratory symptoms but not interfering with function Symptomatic but can eat and swallow modified diet; respiratory symptoms interfering with function but not interfering with ADL Symptomatic and unable to adequately hydrate orally; respiratory symptoms interfering with ADL Symptoms associated with life threatening consequences Nursing Management of Mucositis Conduct ongoing oral exam Pain management Intravenous hydration Soft bland diet Avoid dry, hard, hot, spicy, salty, acid foods Nutritional supplements Monitor weight Soft toothbrush Lip moisturizer Patient education Grade N/A Death Death Page 37 Page 38 NCCN Senior Adult Guidelines for Mucositis Chemotherapy dosage adjustment for glomerular filtration rate Use capecitabine instead of 5-FU Early hospitalization for IV hydration in patients with dysphagia or diarrhea Chemotherapy Toxicity: Diarrhea Risk factors for bowel alterations: Physiologic aging changes Comorbidities Alterations in dietary and fluid intake Polypharmacy Changes in physical activity (NCCN, 2012) Page 39 Page 40 Pathophysiology of Diarrhea Acute damage to the epithelial crypt cells from radiation and chemotherapy Necrosis, inflammation and ulceration of the intestinal mucosa Decreased absorption of water and electrolytes Page 41 Diarrhea-Related Etiologies Chemotherapy related Capecitabine Cisplatin Cyclophosphamide Daunorubicin Docetaxel Doxorubicin 5-fluorouracil Irinotecan Oxaliplatin Paclitaxel Topotecan Concurrent disease Diabetes Inflammatory bowel disease Bowel obstruction Infections of the bowel Diet Alcohol Diary products Caffeine containing products High fiber foods Fruit juices Page 42 7

Clinical Manifestations of Diarrhea Weight loss Weakness Lethargy Confusion Lightheadedness Orthostatic hypotension Dehydration Hypovolemia Electrolyte imbalances Nursing Assessment: Diarrhea Stool

8 Clinical Manifestations of Diarrhea Weight loss Weakness Lethargy Confusion Lightheadedness Orthostatic hypotension Dehydration Hypovolemia Electrolyte imbalances Nursing Assessment: Diarrhea Stool characteristics Health history Physical examination Weight Skin Oral mucosa Bowel sounds/abdominal exam Laboratory tests Page 43 Page 44 Nursing Management: Diarrhea Eliminate potential causative factors Intravenous hydration with electrolyte replacement Dietary management Antidiarrheal therapy Stool diary Discharge Planning Outpatient Follow-up Initiate day of admission Home health care Physical therapy Prescriptions Psycho-social needs Page 45 Page 46 Discharge Planning Discharge Planning Home Health Care Identify needs Check insurance coverage Identify physican follow-up Include caregiver Prescriptions Check insurance coverage Identify physican follow-up Patient education Review potential side-effects Include caregiver When to notify provider Page 47 Page 48 8

9 Discharge Planning Conclusion Psycho-social, economic needs Home environment Financial resources Social support Access to transportation for treatment/appointments/tests Caregiver availability/competency Who is available for emergency help Assess for emotional distress Assess emotional support Assess for sensory and learning deficits Older adults need individualized, specialized care, with recognition of their uniqueness during oncologic treatment. Chemotherapy toxicities can appear rapidly, requiring immediate intensive care and hospitalization, to prevent morbidity and mortality. Thorough, ongoing assessment Astute nursing care Critical discharge planning Page 49 An advocate Page 50 9

Neoplastic Disease KNH 406

Neoplastic Disease KNH 406 Cancer Carcinogenesis - Etiology Genes may be affected by antioxidants, soy, protein, fat, kcal, alcohol Nutritional genomics study of genetic variations that cause different