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Dementia may complicate cancer care, study finds

Review authors make recommendations for treatment of cancer in patients with dementia.



Pre-existing dementia complicates cancer care and increases the risk of worse clinical outcomes and inferior patient experience, according to a review of studies.

People living with dementia are more likely to have cancer diagnosed at an advanced stage and receive no or less extensive cancer treatment, which negatively affects survival after cancer diagnosis.

In addition to presenting an overview of dementia and cancer, the review authors, who are from the United Kingdom, Ireland and Australia, as well as the United States, make pragmatic recommendations for clinicians treating cancer in patients with dementia.

Dementia prevalence increases steeply with age, approximately doubling every five years after the age of 65-years-old.

Review co-author, Regenstrief Institute and Indiana University School of Medicine faculty member, Nicole Fowler, PhD, said: “An increasing number of people are living longer, and advanced age is one of the biggest risk factors for both dementia and cancer; the co-occurrence of these two diseases is increasing as the population ages.

“It’s a tough scenario for patients, their caregivers and clinicians. People with dementia may not be able to describe symptoms that might alert a physician early-on to a developing or existing cancer. Also, screening for cancer and cancer treatment can add additional burden to patients with dementia and their caregivers.”

Dr Fowler continued: “Few guidelines exist to support oncologists’ understanding of how best to talk with patients with dementia, identify their ability to participate in decision-making about cancer treatment and work with families to identify their goals for cancer care and treatment.

“Oncologists need to navigate carefully between underdiagnosis and undertreatment and overdiagnosis and overtreatment, ensuring that a dementia diagnosis informs, but doesn’t automatically rule out or specify, any particular course of action.”

She added: “Optimal cancer care for people living with dementia needs quality indicators and targets that recognise the patient’s functional status – a cancer patient with moderate cognitive impairment may be treated differently than someone in the end stage of the disease – and the personal preferences of the patient and family caregiver.”

Supporting an individual living with dementia through cancer treatment and making care decisions contribute significantly to the caregiver’s burden, adding additional pressure to already stressful responsibilities.

The paper includes a dozen pragmatic recommendations for oncologists treating patients living with dementia:

  • Identify pre-existing dementia in patients as soon as possible and document it in patient records.
  • Involve caregivers and support their emotional, financial and other needs.
  • Review decision-making capacity and legal decision-making powers as well as verify advance medical directives.
  • Consider and make reasonable adjustments to cancer-related care and treatment.
  • Minimise the risk of poorly controlled pain and other symptoms and side effects including dementia decline.
  • Reduce the risk of emergency presentation for medical care.
  • Increase dementia knowledge and training among cancer clinicians.
  • Provide information and communicate in dementia-friendly ways:
    • Use simple language, pictures and recap.
    • Supply take-away summaries.
    • Give warm, empathetic, non-verbal communication.
    • Communicate directly with other involved clinicians and keep them updated.
  • Allow more time for patients with dementia.
  • Make clinical environments more dementia friendly.
  • Minimise and improve care-related travel for people with dementia including remote and mobile care options and parking.
  • Establish features, pathways and models of cancer care that support caring for people with dementia.

The authors note: “Protection from harm is an intensified concern because of the increased vulnerability of people living with dementia to the potential harms inherent in receiving cancer screening, diagnosis, and treatment and because of concerns about additional harms uniquely related to pre-existing dementia.”

They conclude: “Coming years are likely to see cancer care for people with dementia become a bigger and more salient challenge because of population aging and as medical advancements (e.g., single blood test multi cancer screening, targeted therapies with lower toxicity) potentially improve the feasibility and tolerability of cancer detection and treatment options. 

“We make comprehensive recommendations for clinical practice and future research to help clinicians and providers deliver best and equitable cancer care for people with dementia and their families.”


Air pollution linked to increased hospital admission for heart and lung diseases



Exposure to fine particulate matter (PM2.5) air pollution is linked to an increased risk of hospital admission for major heart and lung diseases, find two large US studies, published by The BMJ.

Together, the results suggest that no safe threshold exists for heart and lung health.

According to the Global Burden of Disease study, exposure to PM2.5 accounts for an estimated 7.6% of total global mortality and 4.2% of global disability adjusted life years (a measure of years lived in good health).

In light of this extensive evidence, the World Health Organization (WHO) updated the air quality guidelines in 2021, recommending that an annual average PM2.5 levels should not exceed 5 μg/m3 and 24 hour average PM2.5 levels should not exceed 15 μg/m3 on more than 3-4 days each year.

In the first study, researchers linked average daily PM2.5 levels to residential zip codes for nearly 60 million US adults (84 per cent white, 55 per cent women) aged 65 and over from 2000 to 2016. They then used Medicare insurance data to track hospital admissions over an average of eight years.

After accounting for a range of economic, health and social factors, average PM2.5 exposure over three years was associated with increased risks of first hospital admissions for seven major types of cardiovascular disease – ischemic heart disease, cerebrovascular disease, heart failure, cardiomyopathy, arrhythmia, valvular heart disease, and thoracic and abdominal aortic aneurysms.

Compared with exposures of 5 μg/m3 or less (the WHO air quality guideline for annual PM2.5), exposures between 9 and 10 μg/m3, which encompassed the US national average of 9.7 μg/m3 during the study period, were associated with a 29% increased risk of hospital admission for cardiovascular disease.

On an absolute scale, the risk of hospital admission for cardiovascular disease increased from 2.59% with exposures of 5 μg/m3 or less to 3.35% at exposures between 9 and 10 μg/m3.

“This means that if we were able to manage to reduce annual PM2.5 below 5 µg/m3, we could avoid 23% in hospital admissions for cardiovascular disease,” say the researchers.*

These cardiovascular effects persisted for at least three years after exposure to PM2.5, and susceptibility varied by age, education, access to healthcare services, and area deprivation level.

The researchers say their findings suggest that no safe threshold exists for the chronic effect of PM2.5 on overall cardiovascular health, and that substantial benefits could be attained through adherence to the WHO air quality guideline.

“On February 7, 2024, the US Environmental Protection Agency (EPA) updated the national air quality standard for annual PM2.5 level, setting a stricter limit at no more than 9 µg/m3. This is the first update since 2012. However, it is still considerably higher than the 5 µg/m3 set by WHO. Obviously, the newly published national standard was not sufficient for the protection of public health,” they add.*

In the second study, researchers used county-level daily PM2.5 concentrations and medical claims data to track hospital admissions and emergency department visits for natural causes, cardiovascular disease, and respiratory disease for 50 million US adults aged 18 and over from 2010 to 2016.

During the study period, more than 10 million hospital admissions and 24 million emergency department visits were recorded.

They found that short term exposure to PM2.5, even at concentrations below the new WHO air quality guideline limit, was statistically significantly associated with higher rates of hospital admissions for natural causes, cardiovascular disease and respiratory disease, as well as emergency department visits for respiratory disease.

For example, on days when daily PM2.5 levels were below the new WHO air quality guideline limit of 15 μg/m3, an increase of 10 μg/m3 in PM2.5 was associated with 1.87 extra hospital admissions per million adults aged 18 and over per day.

The researchers say their findings constitute an important contribution to the debate about the revision of air quality limits, guidelines, and standards.

Both research teams acknowledge several limitations such as possible misclassification of exposure and point out that other unmeasured factors may have affected their results. What’s more, the findings may not apply to individuals without medical insurance, children and adolescents, and those living outside the US.

However, taken together, these new results provide valuable reference for future national air pollution standards.

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Home health care linked to increased hospice use at end-of-life – study



Patients who had previously received home health care had a higher likelihood of accessing hospice care at the end of their life, according to a new study.

Researchers, whose findings are published in the Journal of Palliative Medicine, examined the home health care and hospice care experiences of more than two million people.

Using Medicare data, researchers found when individuals received home health care before the last year of their life, they had higher odds of using hospice care than those who had never received home health care.

Researchers said this association underscores the potential benefits of receiving end-of-life care in the comfort of one’s home.

As the aged population increases, the findings also show the need for more resources in the health care sector and staff training in end-of-life care.

Home health care services including skilled nursing, therapy, social work and aide services are used to maintain functioning or slow decline in health. Hospice care provides similar services but is intended for those with life expectancies of six months or less and is focused on pain relief, minimising hospital visits and providing comfort and support. Both services provide patients the opportunity to receive more personalised care in their home.

Researchers say home-based care also encourages greater involvement of family caregivers in the caregiving process.

Olga Jarrín, senior author of the study, the Hunterdon Professor of Nursing Research at the Rutgers School of Nursing and director of the Community Health and Aging Outcomes Laboratory within the Rutgers Institute for Health, Health Care Policy and Aging Research, commented: “In addition to benefits for the patient, hospice care also provides resources and support to help family caregivers cope with the physical, emotional and practical challenges of caring for a loved one at the end of life.”

Hyosin (Dawn) Kim, research assistant professor at Oregon State University and first author of the study, added: “By providing personalised care, reducing hospitalisations, fostering family involvement and support, and improving symptom management, home-based care can enhance the quality of end-of-life experiences for patients with terminal illnesses and their families.”


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Sleep programme shows promise in those with memory problems – study



A new study has shown promising results in improving sleep and quality of life in individuals living with memory problems.

A group of researchers from Penn Nursing, Penn Medicine, Rutgers School of Nursing, and Drexel University’s College of Nursing and Health Professions, have delved into the efficacy of a non-pharmacological approach in a trial known as the Healthy Patterns Sleep Program.

The study involved 209 pairings of community-residing individuals with memory problems and their care partners. Participants were assigned to either the Healthy Patterns Sleep Program, which consisted of one-hour home activity sessions administered over four weeks, or a control group that received sleep hygiene training, plus education on home safety and health promotion.

The Healthy Patterns Sleep Program trained care partners in timed daily activities such as reminiscence in the morning, exercise in the afternoon and sensory activities in the evening that can decrease daytime sleepiness and improve nighttime sleep quality.

Nancy Hodgson, PhD, RN, FAAN, the Claire M. Fagin Leadership Professor in Nursing and Chair of Department of Biobehavioral Health Sciences, who led the study, said: “The results from this study provide fundamental new knowledge regarding the effects of timing activity participation and can lead to structured, replicable treatment protocols to address sleep disturbances. Overall, the Healthy Patterns program resulted in improved QOL compared to an attention-control group.”

The findings also indicate that, compared to a control group, the four-week Healthy Patterns program improved sleep quality among persons living with memory issues who had depressive symptoms or poor sleep quality.  The study indicates the Healthy Patterns Intervention might need a longer dose to induce improvements in other sleep-wake activity metrics.

The study’s significance lies in its confirmation of the effectiveness of behavioural interventions in not only improving quality of life and addressing sleep quality issues in this population, but also potentially reducing care partner burden and overall care costs for persons living at home with memory problems.

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