Cognitive alterations and complex treatments of

symptoms in elderly patients with cancer

Dr Matthieu FRASCA

Palliative care department

Bordeaux university Hospital

Disclosure

I do not have any conflict of interest to declare.

SUMMARY

• Introduction• Cognitive alterations • Guidelines / Personalized treatments• Objectives

• Case-based situations• Presentation• Clinical assessment• Treatment adaptations

• Conclusions• Clinical reasoning• Early and integrated palliative cares

Introduction: Context• Aging and cancers → cognitive alterations1

• Many possible causes• Cancer-related2

• Symptoms (pain, mood disturbance, …)3

• Treatment-induced (chemotherapy, opioids, benzodiazepines, …) 3,4

• Guidelines • for treatment of cancer-related symptoms →multimodal approach

• for elderly → avoid inappropriate prescriptions

• Cancer-related symptoms + elderly = complexity 4

• Personalization / rigorous clinical approach required

1. Magnuson A et al. Cognition and Cognitive Impairment in Older Adults with Cancer. 2016.2. Allen DH et al. Assessment and Management Cancer- and Cancer Treatment Related Cognitive Impairment. 2018.3. Cheng KK et al. Symptom distress in older adults during cancer therapy: impact on performance status and quality of life. 2013.4. Boland JW et al. Effect of Opioids and Benzodiazepines on Clinical Outcomes in Patients Receiving Palliative Care. 2017.

Objectives - Program

• To propose some good multimodal practices of treatment of cancer-related symptoms based on recommendations in oncology and geriatrics

• To detail the different clinical approaches required to understand a cancer-related symptom and to adjust a multimodal treatment

• To give some clinical keys to attach these good practices in the singular situations of elderly patients with cancer

Case 1. Mrs A., 78 yo

• Non curable bronchial epidermoid carcinoma

• Mediastinal nodes → vena cava syndrome

• Pleurisy

• Agitation poorly controlled despite

• high-concentration O2 mask 6L/min

• Clorazepate 40 mg IV qd

• ↗ Drowsiness since benzodiazepines increasing

• Poorly communicant but “No” when asking if painful

• Short breathing / Cough

Case 1. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Case 1. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Node

Pleura

Bronchi

Case 1. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Node MediastinalCompression

Pleura Thoracic compression

Bronchi Inflammation ContractionSecretion

Case 1. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Node MediastinalCompression

Oppression Short BreathingAnxiety

Pleura Thoracic compression OppressionShort BreathingAnxiety

Bronchi Inflammation ContractionSecretion

Cough, burningSibilantsExpectorations

Case 1. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Node MediastinalCompression

Oppression Short BreathingAnxiety

Restrictivesyndrome

Pleura Thoracic compression OppressionShort BreathingAnxiety

Restrictivesyndrome

Bronchi Inflammation ContractionSecretion

Cough, burningSibilantsExpectorationsAnxiety

Obstructivesyndrome

+ Anxio-depressive syndrome associated

Case 1. What was the final treatment? • Restrictive syndrome

+ Oxynorm 15 mg 1,0,1 (starting with low doses) 1,2,3

↘ O2 therapy 3L/min2

+ Prednisolone 20 mg/d 2.1.1 during 5 days progressively ↘

+ Non-pharmaceutical

Room ventilation, atmosphere (frequent visits, active listening) 2,3

Hypnosis therapy3

• Obstructive syndrome

↘ artificial hydration 250 mL/d4

+/- Scopolamine 0,25 mg SC or IV (max 4qd) 4

1. The use of opioids for dyspnea in advanced disease. 2011. 2. Kamal AH et al. Dyspnea review for the palliative care professional: treatment goals and therapeutic options. 2012.3. Palliative Care Experts in the Erie St. Clair and South West LHINs. Palliative Pain and Symptom Management Pocket Reference Guide. 2009 .4. Tison A. L’encombrement des voies respiratoires en fin de vie. Med Pal. 2003.

Case 1. Final treatments against agitation?

• ↘ Benzodiazepines • Switch Clorazepate by Oxazepam• + reduced doses with 10 mg 1.1.1 (tab)• Usual over-use against dyspnoea-related anxiety and elderly1,2

• Non-pharmaceutical• If needed, glasses, hearing aids, dentures 2

• Calendar and clock visible• Involve family members for

• reorientation • prevention of self-harm 2

1. Alexander K. Treatment of Cancer Pain in the Elderly. Handbook of Geriatric Oncology: Practical Guide to Caring for the Older Cancer Patient. 20172. Sharon K Inouye et al. Delirium in elderly people. 2014.3. Minniti G et al. Radiation therapy for older patients with brain tumors. 2017.

Case 2. Mr M., 74 yo• Non curable prostatic adenocarcinoma

• Urethral stenosis

• Retroperitoneal nodes with psoas infiltration

• Rachis metastases on L3 with cruralgia

• Pain syndrome poorly controlled despite

• Increased doses of Fentanyl patch 75 yg/h

• Oxazepam tab 10 mg 1.1.2

• Urinary catheter (badly tolerated)

• Memory loss and disorientation since the increase of Fentanyl

Case 2. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Case 2. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Solid organs

Node

Bone

Hollow organs

Urethra

Bladder

Muscle

Psoas

Nerve

Root L3

Case 2. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Solid organs

Node Mass + Inflammation

Bone Mass + Inflammation

Hollow organs

Urethra Distention, inflammation Contraction

Bladder Distention, inflammation Contraction

Muscle

Psoas Contraction, inflammation

Nerve

Root L3 Compression / inflammation

Infiltration / destruction

Case 2. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Solid organs

Node Mass + Inflammation Continue (↗ night) →Weight + Burning

Bone Mass + Inflammation Continue (↗ night) →Weight + Burning

Hollow organs

Urethra Distention, inflammation Contraction

Continue → Tension + Burning Paroxysmal → Spasm

Bladder Distention, inflammation Contraction

Continue → Tension + Burning Paroxysmal → Spasm

Muscle

Psoas Contraction, inflammation Continue→ Tension + Burning

Nerve

Root L3 Compression / inflammation Paroxysmal + continue / Burning, …

Infiltration / destruction Paroxysmal + continue / Burning, …

Case 2. What clinical approaches may we use?

Anatomical Functional Semiotic Physiological

Solid organs

Node Mass + Inflammation Continue (↗ night) →Weight + Burning Nociceptive

Bone Mass + Inflammation Continue (↗ night) →Weight + Burning Nociceptive

Hollow organs

Urethra Distention, inflammation Contraction

Continue → Tension + Burning Paroxysmal → Spasm

Nociceptive

Bladder Distention, inflammation Contraction

Continue → Tension + Burning Paroxysmal → Spasm

Nociceptive

Muscle

Psoas Contraction, inflammation Continue→ Tension + Burning Nociceptive

Nerve

Root L3 Compression / inflammation Paroxysmal + continue / Burning, … Mixed pain

Infiltration / destruction Paroxysmal + continue / Burning, … Mixed pain

Case 2. What clinical approaches may we use?

Anatomical Functional Physiological Related analgesic

Solid organs

Node Mass + Inflammation Nociceptive Opioids + Corticosteroids

Bone Mass + Inflammation Nociceptive Opioids + Nsaids + Bisphosphonates

Hollow organs

Urethra Distention, inflammation Contraction

Nociceptive Weak analgesics Antispasmodics

Bladder Distention, inflammation Contraction

Nociceptive Weak analgesics Antispasmodics

Muscle

Psoas Contraction, inflammation Nociceptive Benzodiazepines + Relaxation therapies

Nerve

Root L3 Compression / inflammation Mixed pain Opioids / Nsaids (low dose)

Infiltration / destruction Mixed pain Anti-epileptic or anti-depressive

Case 2. What was final co-analgesia?• Mass effect

↘ Fentanyl transdermal patch 37 µg/hIf back or crural pain: Fast acting Fentanyl 100 µg

• Inflammatory effect

+ Prednisolone tab 20 mg/d 2.1.1 progressively decreased to 1.0.01

+ Diclofenac tab 25 mg 1.1.1

+ Zoledronic acid 4mg IV all 4 weeks1

• Nerve lesion

Idem mass and inflammatory: Fentanyl / Diclofenac low doses

+ Pregabaline cap 150 mg 1.0.11

1. Palliative Care Experts in the Erie St. Clair and South West LHINs. Palliative Pain and Symptom Management Pocket Reference Guide. 2009.

Case 2. What was final co-analgesia ?

• Muscular contraction

↘ Oxazepam tab 10 mg ½.0.1 1

+ Psychomotricity

• Distension / contraction of hollow organs

Urinary catheter removal

“If bladder pain”→ Paracetamol 1 g + Phloroglucinol 80 mg

1. Palliative Care Experts in the Erie St. Clair and South West LHINs. Palliative Pain and Symptom Management Pocket Reference Guide. 2009.

Conclusion

Clinical reasoning and interdisciplinarity• Numerous psychoactive drugs required1

• Mis- or under-uses→ over-use of others

• Clinical reasoning still required in the 21st century

• Integrated and early palliative cares strongly recommended2,3 ++

• Advanced cancer (non curable, metastatic status)

• High symptoms burden

• Psychologic or social disorders

• Unfortunately, until now, aging decreases access to palliative care4

1. Boland JW et al. Effect of Opioids and Benzodiazepines on Clinical Outcomes in Patients Receiving Palliative Care. 2017.2. Cardoso F et al. 4th ESO–ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC 4)†, Annals of Oncol 2018;29(8):1634–16573. Ferrell et al. Integration of Palliative Care Into Standard Oncology Care: ASCO Clinical Practice Guideline Update. JCO 2017;35:1, 96-1124. Gardiner et al. Barriers to providing palliative care for older people in acute hospitals, Age and Ageing, 2011;40(2):1,233–238

Thank you for your attention

References1. Magnuson A et al. Cognition and Cognitive Impairment in Older Adults with Cancer. Curr Geriatr Rep 2016; 5: 213-219.2. Allen DH et al. Assessment and Management Cancer- and Cancer Treatment Related Cognitive Impairment. The J. Nurse Practitioners 2018; 14: 217-224.e215.3. Cheng KK et al. Symptom distress in older adults during cancer therapy: impact on performance status and quality of life. J Geriatr Oncol 2013; 4: 71-77.4. Boland JW et al. Effect of Opioids and Benzodiazepines on Clinical Outcomes in Patients Receiving Palliative Care: An Exploratory Analysis. J PalliatMed 2017; 20: 1274-1279.5. Palliative Care Experts in the Erie St. Clair and South West LHINs. Palliative Pain and Symptom Management Pocket Reference Guide. SouthWestern Ontario; 2009 6. The use of opioids for dyspnea in advanced disease. CMAJ. 2011;183(10):1170. 7. Kamal AH et al. Dyspnea review for the palliative care professional: treatment goals and therapeutic options. J Palliat Med. 2012;15(1):106-14.8. Tison A. L’encombrement des voies respiratoires en fin de vie. Med Pal 2003;2: 149-157.9. Palliative Care Experts in the Erie St. Clair and South West LHINs. Palliative Pain and Symptom Management Pocket Reference Guide. SouthWestern Ontario; 2009 10. Alexander K. Treatment of Cancer Pain in the Elderly. Handbook of Geriatric Oncology: Practical Guide to Caring for the Older Cancer Patient, 2017, 305.11. Sharon K Inouye, Rudi GJ Westendorp, Jane S Saczynski. Delirium in elderly people. The Lancet. 2014;383(9920):911-922.12. Minniti G, Filippi AR, Osti MF, Ricardi U. Radiation therapy for older patients with brain tumors. Radiat Oncol. 2017;12(1):101. Published 2017 Jun 19. doi:10.1186/s13014-017-0841-913. Cardoso F et al. 4th ESO–ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC 4)†, Annals of Oncol 2018;29(8):1634–165714. Ferrell et al. Integration of Palliative Care Into Standard Oncology Care: ASCO Clinical Practice Guideline Update. JCO 2017;35:1, 96-11215. Gardiner et al. Barriers to providing palliative care for older people in acute hospitals, Age and Ageing, 2011;40(2):1,233–238

Conclusion 2 One rule = clinical reasoning

•Anatomical approach →Which are the organs concerned?

• Functional approach →What is dysfunctional?

• Semeiotic approach→What are the characteristics of the symptom?

•Physiological approach→What is the physiopathology?

Pallia10 Geriatric version• Item 1 required

• > 75 yo• + non curable disease(s)

• One more positive item indicates necessity of palliative care referral

• Physical, psychological, social vulnerabilities

• Disease(s) quickly progressive

• Demand for palliative cares

• Adaptation troubles for patients or relatives

• Questioning from caregivers

• Ethical issues

Introduction: Treatment-indcuced cognitive impairments and inappropriate prescribing

“Over-Use”

• Uncertain advantages or non evaluated (EBM)

• Overdose

• Excessive length of treatment

“Under-Use”

• Absence of prescribing of the required medicine

• No observance

• Under dose: systematic ½ dose in older patient

“Mis-Use”

• Risks > advantages : « risk of killing the patient »

• Interactions: medicine-medicine, medicine-disease

Case 1. Treatments for obstructive syndrome?

• To reduce obstruction• Reduced artificial hydration 250 mL/d 1

• If needed: Scopolamine 0,25 mg SC or IV (max 4qd) 1

• To decrease aspiration risks• Buccal cares + swallow tests 1

• Meals’ texture 1

• Positioning (Seat at 60° or decubitus at ¾ lateral) 2

• +/- Respiratory kinesitherapy

• +/- Specific treatments

• +/- Soft suctioning (usually non indicated)1,2

1. Tison A. L’encombrement des voies respiratoires en fin de vie. Med Pal. 2003.2. Palliative Care Experts in the Erie St. Clair and South West LHINs. Palliative Pain and Symptom Management Pocket Reference Guide.2009.