Co-occuring symptoms in older oncology patients with distinct attentional function profiles

Highlights

• Older adults experience numerous concurrent symptoms.

• Worsening attentional function is associated with a higher symptom burden.

• A “dose response effect” was observed with higher symptom scores and a progressive decline in attentional function.

Abstract

Purpose

Evaluate how subgroups of older adults with distinct attentional function profiles differ on the severity of nine common symptoms and determine demographic and clinical characteristics and symptom severity scores associated with membership in the low and moderate attentional function classes.

Methods

Three subgroups of older oncology outpatients were identified using latent profile analysis based on Attentional Function Index (AFI) scores. Symptoms were assessed prior to the second or third cycle of CTX. Logistic regressions evaluated for associations with attentional function class membership.

Results

For trait anxiety, state anxiety, depression, sleep disturbance, morning fatigue, and evening fatigue scores, differences among the latent classes followed the same pattern (low > moderate > high). For morning and evening energy, compared to high class, patients in low and moderate classes reported lower scores. For pain, compared to moderate class, patients in low class reported higher scores. In the logistic regression analysis, compared to high class, patients with lower income, higher comorbidity, higher CTX toxicity score, and higher levels of state anxiety, depression, and sleep disturbance were more likely to be in low AFI class. Compared to high class, patients with higher comorbidity and trait anxiety and lower morning energy were more likely to be in moderate AFI class.

Conclusions

Consistent with the hypothesis that an increased risk for persistent cognitive decline is likely related to a variety of physical and psychological factors, for six of the nine symptoms, a “dose response” effect was observed with higher symptom severity scores associated with a progressive decline in attentional function.

Introduction

In the United States, of the more than 1.7 million individuals who will be diagnosed with cancer in 2018, approximately two thirds of them will be over 60 years of age (Siegel et al., 2019). While cancer treatments have become more effective, the number of acute and long term adverse effects are increasing. Impairment in cognitive function is one such effect that occurs in 12%–75% of patients receiving chemotherapy (CTX) (Loh et al., 2016). Recent evidence suggests that older adults may be more vulnerable to this adverse effect (Ahles and Root, 2018; Ahles et al., 2012; Hurria et al., 2006b; Lange et al., 2014). While cancer-related cognitive impairment (CRCI) is one of the most feared adverse effects (Ahles et al., 2012), only a limited amount of information is available on the impact of CTX on older oncology patients’ cognitive function (Joly et al., 2015).

In a longitudinal study of older women (>65 years) with breast cancer (Lange et al., 2016), compared to healthy controls, no differences in cognitive function were found from before to after the completion of CTX or radiation therapy. However, patients who were ≥75 years of age were at the highest risk for cognitive decline following the completion of treatment. In another study of older patients with breast cancer (>65 years) (Hurria et al., 2006a), 51% perceived a decline in memory after CTX, in particular in their ability to learn new information. Neither of these studies evaluated for changes in cognitive function at multiple time points over two cycles of CTX.

Recent evidence suggests that patients receiving CTX experience multiple co-occurring symptoms (Lange et al., 2016; Mandelblatt et al., 2014b; Ritchie et al., 2014). For example, in one study that evaluated for differences in the symptom experience of four older groups of oncology patients (i.e., 60–64, 65–69, 70–74, ≥75 years of age) receiving active treatment (Ritchie et al., 2014), regardless of age group, patients reported an average of 10 symptoms on the Memorial Symptom Assessment Scale (MSAS). The five most common symptoms were pain, lack of energy, feeling drowsy, difficulty sleeping, and difficulty concentrating.

In the two studies that evaluated for associations between changes in cognitive function and common co-occurring symptoms in older adults (Lange et al., 2016; Mandelblatt et al., 2014b), no associations were found between CRCI and fatigue, anxiety, or depression. The authors suggested that this lack of association may be related to the small sample size (Lange et al., 2016) or that subgroups of older patients may be more susceptible to CRCI (Mandelblatt et al., 2014a). As noted in one review on potential mechanisms for CRCI (Janelsins et al., 2014), additional research is needed to understand how co-occurring symptoms may influence the occurrence and severity of CRCI. In addition, in three reviews (Joly et al., 2015; Loh et al., 2016; Mandelblatt et al., 2014a), it was noted that longitudinal studies of changes in and factors associated with decrements in cognitive function in older adults receiving CTX are urgently needed to inform clinical decisions and follow-up care. In a recent review (Ahles and Root, 2018), Ahles and Root hypothesized that an increased risk for persistent cognitive decline may be related to a variety of physical (e.g., fatigue, comorbidities) and psychological (e.g., anxiety, depression) factors and recommended that research is needed to verify this hypothesis.

Most of the studies of CRCI in older oncology patients are cross-sectional and tended to categorize patients as impaired or not impaired (Ahles and Root, 2018). The absence of longitudinal studies, with multiple assessments, precludes any evaluation of changes in CRCI over time and the identification of subgroups of patients with distinct CRCI profiles. This analysis builds on our previous work that used latent profile analysis (LPA) to identify three subgroups of older oncology patients with distinct attentional function profiles (i.e., low function (36.7%), moderate function (37.3%), and high attentional function (26.0%)), using the Attentional Function Index (AFI) (Utne et al., 2018). This instrument assesses two of the key components of CRCI, namely attention and executive function (Cimprich et al., 2011). In our previous analysis, we evaluated for demographic and clinical characteristics that were associated with worse attentional function. Compared to the high class (i.e., better attentional function scores), older adults in the low and moderate attentional function classes had lower functional status scores, a worse comorbidity profile, and were more likely to be diagnosed with depression. In this paper, we extend these findings and evaluate how these subgroups of older adults differed on the severity of nine of the most common co-occurring symptoms (i.e., trait anxiety, state anxiety, depression, sleep disturbance, morning fatigue, evening fatigue, morning energy, evening energy, pain) in oncology patients. In addition, we evaluated which demographic and clinical characteristics, as well as symptom severity scores, were associated with membership in the low and moderate attentional function classes.