|Ahead of print
Does perceived social support, psychological problems, and fatigue impact quality of life of geriatric patients with cancer?
Revathi Rajagopal1, Prasanth Ganesan2, Surendran Veeraiah1
1 Department of Psycho-Oncology and Resource Centre for Tobacco Control (RCTC), Cancer Institute (WIA), Chennai, Tamil Nadu, India
2 Department of Medical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
|Date of Submission||16-Sep-2019|
|Date of Decision||16-Sep-2019|
|Date of Acceptance||29-May-2020|
|Date of Web Publication||27-Jan-2021|
Department of Psycho-Oncology and Resource Centre for Tobacco Control (RCTC), Cancer Institute (WIA), Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Health-related comorbidities often increase due to cancer among the ageing population. However, the domains of psychological functioning of geriatric patients remain undetected especially in the Indian scenario. This study aimed to evaluate psychological problems, perceived social support, fatigue, and quality of life among geriatric patients with cancer.
Methods: A cross sectional study was conducted in a tertiary cancer center. Geriatric patients with cancer (n = 130) having solid malignancies categorized as older patients (>65 years) and younger geriatric patients (60–65 years) were included in the study. Depression, anxiety, perceived social support, fatigue, and quality of life was assessed using the Geriatric Depression Screening Scale, Geriatric Anxiety Scale, Multidimensional Scale of Perceived Social Support, Symbolic Assessment of Fatigue Extent, and the Old People Quality of life Scale, respectively. Descriptive and inferential statistics such as cross tab analysis, correlation and regression analysis.
Results: A majority of patients 80 (61.5%) had low perceived social support, moderate-severe depression 61 (47.7%) and mild-moderate anxiety 55 (43.1%). Half of the patients were found to have poor quality of life. Further, psychological problems were higher among older geriatric patients (p = 0.000). Very few patients had a higher impact of fatigue on their daily functioning 17 (13.3%). There was a positive correlation between perceived social support, depression, anxiety, extent of fatigue, and quality of life (r = 0.256, P = 0.003).
Conclusion: Psychological problems are higher among older geriatric patients with cancer undergoing treatment. Clinical implications could aim at regular screening to identify specific psychological issues and provide appropriate interventions. Future research warrants the efficacy of such therapeutic interventions for better quality of life outcomes.
Keywords: Anxiety, depression, elderly, quality of life, social support systemKey Message The older geriatric cancer population experience higher physical and psychosocial problems compared to the younger geriatric population that negatively impact their quality of life . Therefore early identification and screening of these concerns is a must to facilitate holistic and adaptive coping with cancer.
|How to cite this URL:|
Rajagopal R, Ganesan P, Veeraiah S. Does perceived social support, psychological problems, and fatigue impact quality of life of geriatric patients with cancer?. Indian J Cancer [Epub ahead of print] [cited 2022 Sep 28]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=308057
| » Introduction|| |
Population ageing is a demographic reality that is inevitable and irreversible. It is projected that by 2020 the population of elderly would be more than 700 million globally, with two-third belonging to the developing countries. India is witnessing such a transformation from a younger society to a mature one. The Government of India adopted the National Policy on Older Persons in 1999 and defined a “senior citizen” or “elderly” as a person who is of age 60 years or above. Because of improvement in public health, the percentage of the elderly in India has been increasing at an exponential rate in recent years and the trend is likely to continue in the coming decades. The share of population over the age of 60 is projected to increase from 8% in 2015 to 19% in 2050. One of the major risk factors for chronic, non-communicable diseases is advancing age. Cancer is one such disease. Studies have shown that almost half of all cancers occur after the age of 66 years.
Despite the high burden of cancer in the elderly, they have been traditionally underrepresented in clinical trials. Just like younger patients, the elderly also face emotional distress related to their illness, such as difficulties in adjustment, demoralization, fear about dependency, death, and dying. Health-related Quality of Life (HRQOL) has been considered important for clinical research and treatment of elderly cancer patients which may become impaired during the course of treatment or when there is poor social support available.
As opposed to younger patients, much less emphasis is given to the psychosocial needs of the elderly. Lower levels of psychosocial problems are reported in older cancer patients due to less aggressive cancer treatments and reluctance to report problems because of fear towards additional testing and treatments as many view their health problems as a normal part of aging.
Thus, measurement tools used to assess various psychosocial or physical issues must be appropriate and adjusted for use in older persons.
To the best of our knowledge, no study has investigated age-specific differences regarding quality of life (QOL) in addition to psychosocial needs among elderly cancer patients in the Indian context.
Therefore, the purpose of this study was to assess, evaluate and understand the impact of perceived social support, psychological problems (depression and anxiety), fatigue and quality of life among younger geriatric patients (60–65 years) and older geriatric patients (>65 years) with cancer.
| » Subjects and Methods|| |
We used a cross-sectional research design that implemented a purposive sampling technique.
Two age categorizations of patients; the younger geriatric patients aged between 60 and 65 years and older geriatric patients >65 years were included between August to October 2017.
Sample size estimation
A sample size of 130 patients (with the ratio of 1:1 between the groups) was required to detect a difference of 4-5 units in means of overall QOL or perceived social support in the two groups with standard deviation (SD) of 20, 80% power, and a 5% significance level.
Inclusion and exclusion criteria
Patients were included with a cancer stages of I, II, or III irrespective of the type of cancer diagnosis. Those receiving treatment with curative intent, belonged to the inpatient unit of the tertiary cancer centre and out-patient departments were enrolled within three months after diagnosis. They were English or Tamil (local language) speaking patients. Those patients diagnosed with a second primary and who had a past history of psychiatric illness or age-related cognitive impairment were excluded from the study. This was assessed via previous medical records that were available.
Study settings and measurement tools
This study was conducted in Cancer Institute (WIA) in Chennai, India. Data regarding perceived social support, psychological problems such as depression and anxiety, fatigue, and QOL were collected using assessment tools that are described below:
Depression was evaluated using the Geriatric Depression Scale (GDS-15), a 15-item scale which was designed specifically to screen for depression in an older population. The total sum score ranges from 0 to 15. The mean score was used to indicate the severity of depression. A cut-off for the frequency of depression that was used was a score of =5 for which sensitivity and specificity against a standard clinical interview have been shown to be 91% and 72%, respectively. Furthermore, the GDS-15 has a high level of internal consistency (Cronbach's alpha = 0.80).
Anxiety was measured using the Geriatric Anxiety Scale (GAS). It is a self-report measure consisting of 30 items used to assess anxiety symptoms among older adults. Based on how often each symptom is experienced during the last week, patients are asked to indicate the response on a 4-point Likert scale ranging from “Not at all” (0) to “All the time” (3). Items from the GAS are derived from the symptoms of anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorder, fourth edition, text revision (DSM-IV-TR). Scoring involves a total score and three subscales (somatic symptoms, cognitive symptoms, and affective symptoms). The first 25 items are based on the GAS total score that ranges from 0 to 75. It demonstrates high internal consistency and validity for the quantitative assessment of symptoms in diverse community and samples of older adults.
The QOL of the geriatric patients was assessed using the old people quality of life questionnaire (OPQOL-35). It is a 32 to 35 item QOL measure. It has a 5-point likert scale ranging from strongly agree to strongly disagree, having 32 or 35 items, representing: life overall, health, social relationships and participation, independence, control over life, freedom, home and neighborhood, psychological and emotional wellbeing, financial circumstances, and religion/culture. Items are reversely scored for positive responses, so that higher scores mean higher QOL; the scale ranges are 35 (poor QOL) to 175 (good QOL).,
Perceived social support
Perceived social support of the patients was obtained using the Multidimensional Scale of Perceived Social Support (MSPSS). It is a brief research tool designed to measure perceptions of support from 3 sources: family, friends, and significant others. The scale is comprised of total of 12 items, with 4 items for each subscale. The MSPSS, across many studies has been shown to have good internal and test retest reliability. It has been translated into many languages, including Urdu, Hebrew, Tamil, Danish, Farsi (Persian), French, Italian, and Korean.,
Fatigue was assessed using the Symbolic Assessment of Fatigue Extent (SAFE). This was developed to assess fatigue in an adult clinical population. The tool assesses both extent (4 items) and impact (8 items) of fatigue. Responses are either symbolic or visual representations on a 5-point Likert scale (smileys, shape gradients, or body caricatures). Further, items assessing impact (activities at home, work, sleep, etc.) are represented pictorially. The scores range from 0 to 48. The face validity of this tool was established through expert consultation using the Delphi procedure. The internal consistency Cronbach's alpha coefficients of SAFE are 0.906 and 0.834, respectively. The test retest reliability are 0.847 and 0.943, respectively.
A total of 130 geriatric patients with cancer participated in the study. Informed consent was obtained from the patients. A data sheet was used to collect information consisting of patients' name, age, gender, education, occupation, marital status, other treatment related information and biomedical factors.
Patients were asked to complete the self-administered questionnaires which took about 15-20 minutes. For the native Tamil speaking patients, a previously available validated, translated version (Tamil) of the Geriatric Depression Scale (GDS) was administered. The other questionnaires such as the Geriatric Anxiety Scale (GAS), the Old people quality of life questionnaire (OPQOL- 35), Multidimensional Scale of Perceived Social Support (MSPSS), and the Assessment of Fatigue Extent (SAFE) were originally available in English. Hence, these tools were translated, back translated and face validated from English to Tamil to ease the process of comprehension for the native Tamil speaking patients. The responses were recorded in a separate answer sheet.
Statistical analysis was performed using SPSS software version 17. Descriptive statistics (mean, standard deviation and percentages) was calculated for all the socio-demographic and clinical characteristics of the variables. Comparisons between different groups were performed using independent sample t-test since the data was seen to be normally distributed. Pearson moment correlation and linear regression analysis was performed to see the relationship between the variables. Significance was assessed at P < 0.050.
The Institutional Thesis Review Committee (ITRC) of Cancer Institute (WIA) reviewed and approved.
| » Results|| |
A total of 130 patients, younger geriatric patients 62 (47.7%) and older geriatric patients 68 (52.3%) participated in the study. Of this, more than half were women (52.3%) and 76.9% were married. Around 50% of the patients had completed their secondary level of education and were self-employed. The type of treatment for majority (73%) of the geriatric patients (younger and older) was curative in nature. Most of the patients (40%) in both groups had a head and neck diagnosis. Approximately 30% of the patients had a past history of tobacco use. Surgery (36.9%) was the most common modality of treatment that patients underwent. No significant association was seen between QOL and gender, occupation, educational qualification, and diagnosis (r = 0.314, P = 0.89) [Table 1].
|Table 1: Socio.demographic characteristics of geriatric (older and younger) patients with cancer in Cancer Institute (WIA), Chennai, India (August- October, 2017)|
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Age-specific differences among younger and older geriatric patients
No significant age-specific differences were observed among older and younger geriatric patients with regard to perceived social support. The older geriatric patients experienced higher symptoms of anxiety (somatic, cognitive and affective) which is indicated through higher mean scores (Mean±standard deviation = 22.3 ± 2.2, P = 0.040) and depression (7.07 ± 4.61, P = 0.000). Similarly, older patients reported having more extent (9.05 ± 5.43) and impact (12.42 ± 8.28, P = 0.020) of fatigue compared to younger geriatric patients. The older patients had a lower functioning in terms of their overall QOL (74.95 ± 27.38, P = 0.050) and in specific domains of health, emotional and psychological wellbeing and finance. Age-specific differences were observed with regard to overall QOL (t = 2.063, P = 0.041) but not in its domains of life overall, social relationships, independence, control and freedom, home and neighborhood, and leisure activities (t = -0.160, P = 0.874) [Table 2].
|Table 2: Differences in perceived social support, psychological problems, fatigue and quality of life (QOL) between the older and younger geriatric patients in Cancer Institute (WIA) Chennai, India (August- October, 2017)|
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Association between psychosocial aspects and QOL
The association between psychosocial aspects and QOL was analyzed using Pearson product moment correlation as the data was normally distributed [Table 3]. A positive correlation was found between perceived social support and overall QOL (r = 0.58, P = 0.040). Anxiety (r = -0.68, P = 0.001), depression (r = -0.64, P = 0.001), fatigue (r = -0.73, P = 0.001) was found to be inversely associated with QOL. Geriatric patients who experienced a lower perceived social support with higher levels of psychological problems were found to have reduced QOL.
|Table 3: Correlation between total quality of life and elderly characteristics in Cancer Institute (WIA) Chennai, India (August- October, 2017)|
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Relationship between psychosocial factors and quality of life
Results using linear regression analysis indicated that 71% variability in QOL was due to fatigue (β = 0.540, R2 = 0.718 P < 0.001) and 56% variability in QOL was because of perceived social support (β = .749, R2 = .560 P < 0.001) [Table 4].
|Table 4: Regression between perceived social support, psychological problems, fatigue and quality of life among geriatric patients (younger and older) in Cancer Institute (WIA) Chennai, India (August- October, 2017)|
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Prevalence of overall perceived social support, psychological problems (depression and anxiety), fatigue, and QOL among geriatric patients with cancer
Geriatric patients (61.5%) perceived their overall social support to be poor. Approximately one third (16.6%) of the patients experienced moderate to severe fatigue. Among psychological problems, geriatric patients experienced almost a similar level of anxiety (43.1%) and depression (47.7%). Half of the geriatric patients (50%) reported poor quality of life [Figure 1].
|Figure 1: Assessment of overall perceived social support, psychological problems (depression and anxiety), fatigue and QOL among geriatric patients with cancer|
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| » Discussion|| |
The findings of our study indicate the occurrence of psychosocial problems in older and younger geriatric patients with cancer. There were significant differences observed in relation to the psychological problems perceived by the younger and older geriatric patients. The prevalence of depression, anxiety, and fatigue was higher and perceived social support, QOL was lower among older geriatric patients. Furthermore, the overall health and sub-domains of QOL and its functioning were significantly different between the two groups in physical, emotional, and social aspects. The prevalence of depression in cancer patients ranges from 1.5% to 58%. According to the World mental health survey in 2014, the prevalence of psychiatric conditions in India was found to be 24.4%. Previous literature has repeatedly established that geriatric patients experience a rise in the incidence of anxiety and depression.,,, Reactions to cancer diagnosis, difficulty in dealing with unpleasant treatment side effects (pain, nausea, and fatigue), and concerns about disease recurrence or progression are said to be some of the reasons for it. For some older patients, anxiety also co-exists with depression. On the contrary, a study in 2015 stated that the emergence of psychosocial problems such as anxiety and depression was similar among the younger and older geriatric patients.
QOL has become one of the main multi-dimensional, outcome measures in cancer treatment.,, We found that elderly patients had a lower physical functioning, suggesting that the influence of aging on the physical status may be reflected in QOL. Previous studies emphasized that elderly patients experienced worse physical and social wellbeing. Depression and anxiety are common psychological disorders that can impair HRQOL causing emotional, physical, and social dysfunction. Our study also depicts similar findings.
Patients perceived their social support to be lower. Several studies have revealed how elderly people have low perceived social support causing higher rates of depression in patients with and without cancer.,,,,
Many studies have shown that QOL of cancer patients is negatively correlated with depression and anxiety.,,, Fatigue and perceived social support are found to be better predictors of QOL. A study by Portenoy et al., (2000) states that 47% patients reporting moderate-severe fatigue has lower QOL thereby interfering with normal daily functioning. A recent study has found this symptom to be universal in 84% of the elderly age group.,, These are in line with our study.
The key strengths of this study are that it tries to understand the poignant psychosocial effects of ageing and cancer. Also, instruments of measurement that are only appropriate among older individuals have been used. Our study also has limitations. This was a single-center study. Only patients with a curative intent of treatment were chosen. Hence, the psychosocial issues of geriatric patients with advanced disease or who are in end of life care could not be explored.
Future research warrants exploration, to understand cancer site-specific psychosocial issues. Clinical implications could focus on regular screening for psychosocial problems at significant time points such as at diagnosis, during the treatment and at follow-up trajectories thereby highlighting the need for planning time-appropriate interventions for better psychological outcomes among the geriatric population.
In conclusion, geriatric patients with cancer have reduced perceived social support, quality of life as a result of increased fatigue and psychological problems such as depression and anxiety. Older geriatric patients scored high on psychological measures of depression, anxiety, fatigue, and lower on quality of life compared to the younger geriatric population. Fatigue and perceived social support were better predictors of QOL among geriatric patients. Significant differences were seen between psychological problems (depression and anxiety), fatigue and QOL among geriatric patients (younger and older) except for perceived social support.
The authors express their gratitude to all the participants of the study. The help and support of professors, colleagues of the department of psycho-oncology, the nursing staff and doctors of the surgical, medical and radiation oncology at Cancer Institute (WIA) are gratefully acknowledged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]