Abstract
Context
To provide effective palliative care (PC) to the geriatric population, an understanding of the reasons for consultation, main diagnoses related to referral, and symptom severity in chronic disease states is essential.
Objectives
We compared the baseline characteristics, referral patterns, and symptom severity among older and younger patients referred for inpatient PC consultation.
Methods
. We conducted a retrospective review of 2382 inpatient PC consultations. We excluded “re-consultations” and patients under the age of 18. Patient characteristics (reason for consultation, diagnosis) and symptom severity were compared across three age groups: Younger: <65 years of age; Older: 65–84 years of age; and Oldest: 85 years of age and older. Multivariable logistic regression adjusted for the effects of gender, ethnicity, and diagnostic subset was performed.
Results
The majority of patients referred for inpatient PC consultation were over the age of 65. Oldest patients were consulted on earlier and more often for “end-of-life care.” Oldest adults were less likely to report pain, anxiety and nausea (adjusted odds ratios [AOR] of 0.25, 0.39, and 0.19, respectively) and more likely to report anorexia than Younger adults (OR= 1.66). There was no clear difference between age groups in reporting of dyspnea and depression.
Conclusion
Older adults in need of PC appear to have symptom burdens and consultation referral patterns that are different from those of younger patients. Further research is needed to determine whether these symptom patterns are caused by psychosocial factors, reflect true differences among age groups, and whether symptom measurement instruments should be tailored to patient age.
Keywords: Symptom burden, referral patterns, inpatient consultation, geriatrics, palliative care
Introduction
Individuals over the age of 85 constitute the fastest growing population in the United States (1) and geriatric patients with chronic disease in the United States are increasingly in need of quality palliative care (2). Hospitalized palliative care patients with chronic disease may be highly symptomatic (3–4), and effective symptom management is dependent on accurate identification and measurement of symptoms.
Despite the rapid aging of our society and the growing need for palliative care, data on the reasons for palliative care consultation and main diagnoses related to consultation in the geriatric population are limited, and reports of symptom frequencies among older adults differ among published reports (5–8). Prior studies suggest that older adults have less measured pain than younger adults (9–11). However, little is known about whether the severity of other symptoms differs between older and younger age groups. Nevertheless, in one study of an inpatient palliative care service, fewer team recommendations for symptom management were made for patients aged 80 and over (12). A better understanding of symptom patterns among older adults is particularly relevant given the increasing numbers of geriatric patients seen in palliative care consultation. Many studies specific to symptom patterns in older adults have been performed in the community (10, 13–14) or nursing homes (8,11), and have relied on caregiver reports (6) or retrospective chart reviews.
Our current study adds to the existing literature by evaluating a large, inpatient database composed of primary patient interviews by palliative care providers, which may help to obtain a more complete picture of the needs of hospitalized older adults. Our aim was to learn more about the needs of hospitalized elders to educate palliative care providers about the needs of this population, and ensure the highest quality of care for this group of patients. Based on the limited available literature, we hypothesized that we would find differences in symptom severity between older and younger age groups. We also were interested in the referral patterns of different age groups to the palliative care service, of which there are few studies to date (12).
Methods
Setting
Strong Memorial Hospital (SMH) is a 765-bed teaching hospital that is part of the University of Rochester Medical Center (URMC) in upstate New York. An average of 38,000 inpatients per year are treated at the hospital, and between the years 2005 and 2008, a total of 2904 patients were seen for palliative care consultation. As of 2010, the Palliative Care Service consists of 10 part-time physicians, two full-time nurse practitioners, a massage therapist, a music therapist, several part-time chaplains, a bereavement coordinator, and a social worker.
Study Design, Inclusion and Exclusion Criteria
This study was a retrospective database review using data collected from referrals to an inpatient palliative care service between January 1, 2005 and December 31, 2008. Patients under the age of 18 were excluded, and in the case of “re-consultations,” only the first consultation was included in the analysis. We evaluated this database to determine patterns of palliative care referral (including reasons for consultation and main diagnoses), patient performance status and capacity, patient preferences regarding treatment, and symptom severity at the time of initial consultation.
Measures
Since 2005, data from the palliative care consultation service have been collected using a standardized Health Database (HDB) form. Standard information collected on each patient includes: date of consultation, reason for consultation (symptom control [management of pain and other symptoms], goals of care [assistance with eliciting patient and family preferences regarding medical treatments], end-of-life planning [including disposition planning and hospice referral], and family support [support for family and loved ones]), main diagnosis, symptom severity, capacity for medical decisions, resuscitation preferences, current therapies (ventilator, dialysis, feeding tube), and performance status as measured by the previously validated Palliative Performance Scale (PPS) (15). The categories “Reason for Consultation” and “Main Diagnosis” are not mutually exclusive and could have more than one response option.
The HDB incorporates an adapted version of the Edmonton Symptom Assessment Scale (ESAS) for measurement of symptom severity (16). The ESAS has been validated in a large population of patients with cancer and has been shown to be internally consistent (17). Symptoms on the HDB form are reported in stratified categories as: none (0), mild (1–3), moderate (4–6), severe (7–10), or unknown (rather than on a 0–10 scale as with the ESAS).
The HDB form is completed by a nurse practitioner, medical student, resident, or palliative care fellow and verified by an attending upon initial interview with the patient. Some information such as date of birth, presence of advance directives, and “current therapies” is abstracted from the medical record and transferred to the database form, and symptom ratings are obtained during the patient interview. Patient self-report is strongly encouraged whenever possible, but in some cases information from family or staff members caring for the patient may be obtained. The HDB form is electronically scanned into a computer database with routine quality control of the data. Patient data are matched with hospital administrative data to append demographic information (e.g., sex, ethnicity) and hospital-level data (e.g., date of admission, date of discharge) to the database. The data are stored in a password-protected network drive.
Statistical Analysis
All analyses were conducted using the SAS software package, version 9.2 (SAS Institute, Cary, NC). We stratified patients by age into three groups: Younger (age 18 to 64), Older (age 65 to 84), and Oldest (age 85 and above) and used the Chi-square test to assess for statistical differences among proportions. Performance status and time to consultation were continuous variables that were not normally distributed; therefore, the non-parametric Wilcoxon Rank-Sum test was used to compare differences between age groups. In multivariable logistic regression, we compared the association between age and symptom severity (in two groups: moderate/severe vs. none/mild), adjusting for the effects of gender, ethnicity, and diagnostic subset (cancer vs. non-cancer). All tests were two-sided, and P-values <0.05 were considered statistically significant. Patients with missing entries for current therapies, treatment preference and symptom severity were not included in the analyses related to these variables. Frequencies of missing data did not differ significantly among age-stratified groups of patients, suggesting that excluding patients with missing data would not greatly impact our findings. This study was approved by the Institutional Review Board (IRB) at the University of Rochester.
Results
Baseline characteristics for the sample population are shown in Table 1. During the four-year period between January 2005 and December 2008, a total of 2382 new consultations were performed. The majority of consultations during our study period were among those aged 65 and older (55% of all consultations), with a mean age of 66.2 ± 16.6 years. There were slightly more women than men in the Oldest age group (P = 0.02). The Older and Oldest patients were less diverse and had a higher proportion of whites than the Younger patients (P<0.001).
Table 1.
Baseline Characteristics
| Total n = 2382 | Younger < 65 | Older 65–84 | Oldest ≥ 85 | P (X2) |
|---|---|---|---|---|
| N (%) | 1077 (45) | 967 (41) | 338 (14) | |
| Mean Age, years (SD) | 51 (10.5) | 75 (5.7) | 89 (3.5) | |
| Gender,a n (%) | 0.02 | |||
| Male | 575 (54) | 538 (56) | 157 (47) | |
| Female | 497 (46) | 427 (44) | 177 (53) | |
| Ethnicity,b n (%) | <0.0001 | |||
| White | 785 (73) | 810 (84) | 301 (89) | |
| Black | 212 (20) | 105 (11) | 16 (5) | |
| Hispanic | 33 (3) | 16 (1) | 4 (1) | |
| Other | 46 (4) | 36 (4) | 17 (5) |
11 patients missing gender.
1 patient missing ethnicity.
The distribution of main diagnosis across the three age groups is shown in Fig. 1. For all main diagnoses except cancer, the majority of consultations were in patients over the age of 65, although many of those with renal disease were younger (45%). The majority of consultations for those with dementia were in patients over the age of 85.
Figure 1.
Distribution of consultations for each main diagnosis by age group.
Table 2 shows the timing and specific reasons for consultation in the three different age groups. The Oldest patients received palliative care consultation earlier than the Older and Younger patients by a mean of four days. The most frequent reason for consultation among all age groups was for “goals of care,” followed by “symptom management.” In the Oldest age group, there were more consultations for “end-of-life care,” while the consultations for the Younger age group were more often for “symptom management.” The variable “Reason for Consultation” was not mutually exclusive; 51% of Oldest, 46% of Older, and 44% of Younger patients had more than one reason for consultation.
Table 2.
Reasons for Consultation/Current Therapies/Advance Directives by Age
| Database Variable (Total n=2382) | n | Younger < 65 | Older 65–84 | Oldest ≥ 85 | P |
|---|---|---|---|---|---|
| Days to Consult, Mean (Median) | 12 (5) | 12 (6) | 8 (4) | 0.0016 | |
| Reason for Consult,a n (%) | |||||
| Goals of Care | 610 (57) | 652 (67) | 231 (68) | ||
| Symptom Management | 464 (43) | 299 (31) | 68 (20) | ||
| End-of-Life Care | 162 (15) | 159 (16) | 83 (25) | ||
| Patient/Family Support | 308 (29) | 294 (30) | 118 (35) | ||
| > 1 Reason For Consult | 470 (44) | 442 (46) | 173 (51) | ||
| >2 Reasons For Consult | 123 (11) | 117 (12) | 42 (12) | ||
| Missing Reason For Consult | 144 (13) | 138 (14) | 57 (17) | ||
| Performance Status, Mean (Median) | 1830 | 43.4 (40) | 37.2 (40) | 31.3 (30) | < 0.0001 |
| Capacity at Consult,b n (%) | 1573 | < 0.0001 | |||
| Full | 444 (61) | 280 (45) | 73 (34) | ||
| Partial/None | 288 (39) | 349 (55) | 139 (66) | ||
| Current Therapies,b n (%) | |||||
| Ventilator | 2126 | 194 (20) | 173 (20) | 50 (17) | 0.3419 |
| Hemodialysis | 2099 | 80 (9) | 54 (6) | 8 (3) | 0.0018 |
| Feeding Tube | 2054 | 197 (21) | 190 (23) | 48 (17) | 0.0854 |
| Advance Care Planning,b n (%) | |||||
| DNR (Do-not-resuscitate) | 2052 | 347 (39) | 512 (60) | 230 (76) | <0.001 |
| DNI (Do-not-intubate) | 2003 | 290 (33) | 436 (53) | 197 (68) | <0.001 |
Not mutually exclusive; P-value cannot be computed.
Missing data are not included in analysis; frequency of missing values similar among age groups.
The median PPS status among the Oldest patients (median 30) was 10 points lower than that of Older and Younger patients (median 40 for each group, P<0.0001), indicating that the Oldest group might be more ill or less capable of making medical decisions. The Older and Oldest patients were also less likely to have full capacity for medical decision-making (45% and 34%, respectively, with full capacity) than the Younger patients (61% with full capacity, P<0.0001). More Older and Oldest patients had documented preferences regarding limitations on resuscitation and intubation than Younger patients (60% and 76% vs. 39%, respectively, had already documented “do-not-resuscitate” [DNR] at the time of initial consultation [Pp<0.001]). The prevalence of those receiving hemodialysis declined with age (6% of Older and 3% of Oldest patients were receiving hemodialysis compared to 9% of Younger patients, P= 0.0018) at time of initial consultation. Proportions of patients receiving other medical therapies, including mechanical ventilation and feeding tubes, were not different across the different age groups.
Table 3 outlines the severity of symptoms by age-stratified groups, as measured by the adapted ESAS on the HDB. We did not include missing observations in this analysis, but the frequencies of missing observations were similar among the age groups. Older and Oldest patients were less likely to report severe pain than Younger patients (13% of Older and only 6% of Oldest vs. 22% of younger patients, P < 0.0001), and differences were even more pronounced when the analysis was limited only to those with full capacity (Table 4: 15% of Older and only 10% of Oldest vs. 30% of Younger patients, P < 0.0001). The same pattern was observed for anxiety and nausea; only 3% of Oldest patients reported severe anxiety while two times as many Younger patients (6%) reported severe anxiety (P<0.0001), and less than 1% of Oldest patients reported severe nausea while 3% of Younger patients did (P<0.0001). These findings were also consistent when limited to patients with full capacity (Table 4).
Table 3.
Severity of Symptoms by Age Group
| Symptom | na | Younger < 65 | Older 65–84 | Oldest ≥85 | P (X2)b |
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | |||
| Pain | 2286 | <0.0001 | |||
| Unknown | 277 (27) | 250 (27) | 129 (40) | ||
| None | 174 (17) | 265 (28) | 113 (35) | ||
| Mild | 140 (13) | 155 (17) | 35 (11) | ||
| Moderate | 220 (21) | 137 (15) | 26 (8) | ||
| Severe | 228 (22) | 117 (13) | 20 (6) | ||
| Anxiety | 2263 | <0.0001 | |||
| Unknown | 409 (40) | 383 (41) | 167 (52) | ||
| None | 265 (26) | 300 (33) | 95 (30) | ||
| Mild | 163 (16) | 119 (13) | 32 (10) | ||
| Moderate | 124 (12) | 88 (10) | 17 (5) | ||
| Severe | 61 (6) | 32 (3) | 8 (3) | ||
| Nausea | 2288 | <0.0001 | |||
| Unknown | 387 (38) | 372 (40) | 164 (51) | ||
| None | 406 (39) | 407 (44) | 135 (42) | ||
| Mild | 132 (13) | 87 (9) | 18 (6) | ||
| Moderate | 77 (7) | 44 (5) | 4 (1) | ||
| Severe | 33 (3) | 20 (2) | 2 (0.6) | ||
| Dyspnea | 2282 | 0.0061 | |||
| Unknown | 359 (35) | 310 (33) | 132 (41) | ||
| None | 376 (36) | 289 (31) | 79 (25) | ||
| Mild | 116 (11) | 125 (14) | 38 (12) | ||
| Moderate | 100 (10) | 118 (13) | 40 (12) | ||
| Severe | 81 (8) | 87 (9) | 32 (10) | ||
| Depression | 2239 | 0.2723 | |||
| Unknown | 507 (50) | 493 (55) | 204 (65) | ||
| None | 228 (22) | 210 (23) | 63 (20) | ||
| Mild | 146 (14) | 99 (11) | 27 (8) | ||
| Moderate | 98 (10) | 76 (8) | 16 (5) | ||
| Severe | 39 (4) | 27 (3) | 6 (2) | ||
| Anorexia | 2274 | 0.0395 | |||
| Unknown | 450 (44) | 404 (44) | 172 (54) | ||
| None | 225 (22) | 170 (18) | 52 (16) | ||
| Mild | 131 (12) | 100 (11) | 28 (9) | ||
| Moderate | 110 (11) | 130 (14) | 40 (12) | ||
| Severe | 111 (11) | 122 (13) | 29 (9) |
Missing data are not included in analysis.
“Unknown” symptom scores not included in Chi-square analysis.
Table 4.
Severity of Symptoms by Age Group: Those With Full Capacity
| Symptom | na | Younger < 65 | Older 65–84 | Oldest ≥85 | p (X2)b |
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | |||
| Pain | 787 | <0.0001 | |||
| Unknown | 16 (3) | 12 (4) | 8 (11) | ||
| None | 83 (19) | 92 (33) | 38 (52) | ||
| Mild | 82 (19) | 60 (21) | 13 (17) | ||
| Moderate | 126 (29) | 69 (25) | 7 (10) | ||
| Severe | 132 (30) | 42 (15) | 7 (10) | ||
| Anxiety | 772 | 0.0032 | |||
| Unknown | 55 (13) | 43 (16) | 18 (25) | ||
| None | 153 (36) | 125 (46) | 33 (45) | ||
| Mild | 113 (27) | 57 (21) | 16 (22) | ||
| Moderate | 70 (16) | 39 (14) | 4 (5) | ||
| Severe | 35 (8) | 9 (3) | 2 (3) | ||
| Nausea | 783 | 0.0005 | |||
| Unknown | 38 (9) | 34 (12) | 11 (15) | ||
| None | 236 (54) | 172 (63) | 53 (74) | ||
| Mild | 87 (20) | 39 (14) | 6 (9) | ||
| Moderate | 51 (12) | 22 (8) | 1 (1) | ||
| Severe | 24 (5) | 8 (3) | 1 (1) | ||
| Dyspnea | 780 | <0.0001 | |||
| Unknown | 41 (10) | 17 (6) | 8 (11) | ||
| None | 231 (53) | 106 (39) | 23 (32) | ||
| Mild | 71 (16) | 52 (19) | 11 (16) | ||
| Moderate | 58 (13) | 60 (22) | 15 (21) | ||
| Severe | 33 (8) | 40 (14) | 14 (20) |
Note: Displayed are those symptoms with P < 0.05.
Missing data are not included in analysis.
“Unknown” symptom scores not included in Chi-square analysis.
The pattern of more severe symptoms in Younger patients did not apply to all symptoms; Older and Oldest patients were more likely to report higher frequencies of severe dyspnea and anorexia, and age differences were even more pronounced when adjusting for patient capacity (20% of Oldest patients with full capacity reported severe dyspnea compared to only 8% of Youngest patients with full capacity, P<0.0001). There were no statistically significant differences in the proportions of severe depression among age-stratified groups.
Results from multivariable analyses adjusting for the effects of gender, ethnicity, and diagnostic subset (cancer vs. non-cancer) were consistent with bivariate analyses (Table 5). For pain, anxiety, nausea and depression, the risk of moderate/severe symptoms was lower among the Oldest patients as compared to the Younger patients, whereas for dyspnea and anorexia, the risk for more severe symptoms was higher, although odds ratios for dyspnea and depression were not statistically significant.
Table 5.
Adjusted Odds Ratios for Moderate/Severe Symptoms by Age Group
| Symptoma | Moderate/Severe Symptoms (n) | None/Mild Symptoms (n) | Adjusted OR (95% CI)b |
|---|---|---|---|
| Pain | |||
| Younger < 65 | 448 | 314 | 1.0 (-) |
| Older 65–84 | 254 | 420 | 0.44 (0.36–0.55) |
| Oldest ≥85 | 46 | 148 | 0.25 (0.17–0.36) |
| Anxiety | |||
| Younger < 65 | 185 | 428 | 1.0 (-) |
| Older 65–84 | 120 | 419 | 0.61 (0.46–0.80) |
| Oldest ≥85 | 25 | 127 | 0.39 (0.23–0.62) |
| Nausea | |||
| Younger < 65 | 110 | 456 | 1.0 (-) |
| Older 65–84 | 64 | 471 | 0.58 (0.41–0.81) |
| Oldest ≥85 | 6 | 148 | 0.19 (0.08–0.45) |
| Dyspnea | |||
| Younger < 65 | 181 | 492 | 1.0 (-) |
| Older 65–84 | 205 | 414 | 1.28 (1.00–1.63) |
| Oldest ≥85 | 72 | 117 | 1.39 (0.97–1.98) |
| Depression | |||
| Younger < 65 | 137 | 374 | 1.0 (-) |
| Older 65–84 | 103 | 309 | 0.88 (0.65–1.19) |
| Oldest ≥85 | 22 | 90 | 0.61 (0.36–1.04) |
| Anorexia | |||
| Younger < 65 | 221 | 356 | 1.0 (-) |
| Older 65–84 | 252 | 270 | 1.57 (1.23–2.00) |
| Oldest ≥85 | 69 | 80 | 1.66 (1.13–2.43) |
Adjusted for the effects of gender, ethnicity (White, Black, Hispanic, Other), and diagnostic subset (cancer, non-cancer).
OR = odds ratio, 95% CI = 95% confidence interval. Missing data are not included in the analysis.
Discussion
This study determined whether the reasons for palliative care consultation, preferences regarding aggressive treatments, and symptom severity are affected by age. Strengths of our study include clear definitions of the reasons for consultation, main diagnoses, and symptom burdens among age-stratified patients seen in inpatient palliative care consultation. To date, many of the published data on older adults are based on samples of patients in nursing homes or the community and have been abstracted from caregivers or chart reviews. To our knowledge, this database review of 2382 palliative care consultations is the largest to date to provide a profile of hospitalized elderly inpatients referred for palliative care consultation (12).
A recent study on the epidemiology of pain in the last two years of life reported that although clinically significant pain increased among study participants as death drew closer, the prevalence of pain decreased with each decade above age 65 years (10). The authors note that the prevalence of pain two years before death was 39% among patients 65 years of age or younger and only 23% among patients 86 years of age and older. Similarly, pooled data from the SUPPORT trial (The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) showed that older adults reported less pain than younger adults, with an adjusted odds ratio [AOR] for higher levels of pain of 0.85 per each increasing decade of age (9). The authors of a study, examining an inpatient palliative care consultation service, found that there were fewer interventions for symptom management among patients 80 years of age and older and that the palliative care needs of older adults appeared different from those of younger patients (12).
Our results were consistent with these prior studies with some notable new findings. We found that, after adjustment for gender, ethnicity, and diagnostic subset, Oldest adults exhibited lower levels of severe pain, anxiety and nausea. Our results were unchanged when we limited the analysis of symptom severity to those with full capacity. We also found that there were more consultations for “end-of-life care” in the Oldest age group while the majority of consultations for “symptom management” were in the Younger age group. In fact, only 20% of Oldest adults were consulted on for symptom needs.
One may interpret these findings several ways. For example, younger adults may be more apt to complain of severe pain and/or anxiety than older adults, or perhaps the ESAS itself is more sensitive in younger populations. This would suggest that a symptom scale more tailored to older adults should be incorporated into our HDB instrument. A recent study found that older cancer survivors were much less likely to report ongoing symptoms than younger cancer survivors (AOR of 1.36 vs. 2.96 for likelihood of reporting of pain compared to controls), which suggests that older adults may have developed more advanced coping strategies than younger patients (18).
We note that the proportion of those with “Unknown” symptom severity increased with age, even among those with full capacity. However, this observation may be due in part to the greater number of consultations for “goals of care” and “end of life” in the older patients and symptoms may not have been as thoroughly assessed by providers. Alternatively, this finding may lend strength to the argument that a more age-appropriate scale for measuring symptoms should be used in the older population so that categorizing symptom severity as “unknown” occurs less often. The finding that there were fewer consultations for “symptom management” in the Oldest patients compared with the Younger patients is consistent with prior studies of palliative care referral patterns (12) and may be an indication of lack of self-reporting in the older patients, thus prompting fewer consultations.
Older and Oldest adults were more likely to have placed limits on life-sustaining therapies (76% of Oldest adults had a DNR order compared to 39% of Younger adults), but the numbers of patients receiving aggressive therapies (ventilator, feeding tube, hemodialysis) were similar among age groups. It is not entirely clear why age groups were similar with regard to aggressive therapies, although it suggests that the severity of disease at the time of consultation is similar among age-stratified groups.
Our findings should be interpreted in light of several limitations. One limitation is common to retrospective database reviews – we cannot draw firm conclusions about the temporality of symptom development in the sample. There may be a difference in symptom severity in those closer to death or those with a new disease diagnosis, but our study was not designed to perform an analysis based on these variables, as these types of data were not available. Our results would be more generalizable if we had standardized the timing of symptom measurement (for example, symptoms measured on admission to the palliative care unit). We also were unable to adjust for severity of disease in our multivariable analysis; such adjustment could have tempered some of the differences in symptom severity that we observed. However, the numbers of patients receiving more aggressive therapies (such as mechanical ventilation and hemodialysis) was not significantly different among age groups, which suggests that the groups were similar with respect to disease severity. Finally, consultations were performed by various providers with different levels of palliative care training, which limits the reproducibility of our results; the inter-rater reliability of completion of the HDB forms has not been formally established.
More research is needed to determine whether our findings can be explained by differences in disease severity or other factors, such as a suboptimal symptom assessment tool or psychosocial factors unique to the age groups. This is particularly important given the growing population of hospitalized geriatric adults; inpatient providers of all specialties need to be sensitive to the needs of older adults and future studies are warranted to determine why such patterns in symptoms and referral patterns exist. Our study emphasizes the urgent need to better understand and develop age-appropriate approaches to identifying and reducing the physical suffering that exists in patients with serious illness.
Footnotes
Disclosures and Acknowledgments
The authors declare no conflicts of interest.
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