© 2004 by Oxford University Press
2004 © Oxford University Press
ARTICLE |
Symptom Management in the Elderly Cancer Patient: Fatigue, Pain, and Depression
Duke University and VA Medical Centers, Durham, NC
Correspondence to: Harvey Jay Cohen, MD, Center for Aging, Duke University Medical Center, Box 3003, Durham, NC 27710 (harvey.cohen{at}duke.edu)
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ABSTRACT |
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 Top Abstract Cancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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Patients who are
65 years of age are the fastest growing segment of the U.S. population. These patients with already existing physiologic decline and comorbidities, when diagnosed with cancer, provide considerable challenges in management issues. Along with therapy for the tumor the practicing oncologist must also keep in mind the various symptoms, like fatigue, pain, and depression, that may occur due to the tumor itself or due to therapy. The prevalence of fatigue is greater than 50-70% in advanced cancer. The tools to measure fatigue are all subjective in nature and no one tool has been tested in the elderly cancer patient. Treatment of fatigue in the elderly may involve education, antidepressants, treatment of anemia, exercise, and use of psychostimulants. Pain is present is 80% of elderly patients with advanced cancer. Pain should be assessed in a systematic way and it has been shown that the Visual Descriptor Scale is the tool most preferred by the elderly. Several guidelines for management of pain exist and options include acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, adjuvant analgesics, and education of patients and caregivers. Depression is also a prevalent symptom arising from a variety of causes. There are many validated tools to measure depression in the elderly like the Geriatric Depression Scale. Treatment includes use of education, selective serotonin reuptake inhibitors, psychotherapy, and electroconvulsive therapy. There exists an interplay of many of these symptoms and quite often they can occur simultaneously in the elderly cancer patient. Future research is needed to expand our base of knowledge on the occurrence and management of each of these symptoms and to better understand how aging systems interact with these phenomena to produce unique situations in older adults.
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CANCER AND THE ELDERLY |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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One of the most challenging tasks for the practicing oncologist today is the care of the elderly cancer patient. In part this is because people who are
65 years of age comprise the fastest growing segment of the population and by the year 2030, will comprise 20% of the U.S. population (1). Fifty-seven percent of all newly diagnosed malignancies and 71% of all cancer deaths occur in those 65 years of age (2). Thus, a typical patient with cancer today is >65 years, has multiple medical problems, is taking several medications simultaneously, and whose caretaker is often elderly. Elderly patients often do not present with typical signs and symptoms of disease, making timely and accurate diagnosis more difficult. The elderly patient has a number of aging organ systems that require functional assessment to assist the clinician in anticipating toxicity and responses to therapy. The oncologist should have a working knowledge of geriatric principles in order to provide comprehensive care for these very challenging symptoms. |
AGE-RELATED PHYSIOLOGIC DECLINE |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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To understand supportive care in the elderly we have to understand age-related physiologic decline and other changes that occur as we grow older. Classically, the various changes seen with aging in different organ systems include decreased heart rate and cardiac output (with decreased perfusion to most organs including kidneys) along with increased systolic blood pressure (3,4). The aging lung has decreased vital capacity and expiratory reserve volume while residual volume increases (5). The brain undergoes atrophy with widening sulci and shrinkage of gyri caused by loss of nerve cells and synapses (6). There is decreased gastric emptying and absorption in the gastrointestinal tract (7). Lipschitz et al. have demonstrated an overall reduction in hematopoiesis in the elderly with low peripheral neutrophil and platelet counts and mild anemia (8). Aging also affects the immune system and it is thought that T-cell function is altered with increased suppressor cell activity. There is also an increase in memory cells, a decrease in naïve cells, decreased mitogen response, decreased IL-2, IgG, and IgA, and an increase in IL-6 and IL-1B (9). There is also evidence that natural killer cells in the elderly undergo immunosenescence (10). The elderly patient also has a component of neuroendocrine dysregulation with decreased growth hormone along with cortisol dysregulation and increased sympathetic tone (11). Sex hormones like estrogen and testosterone are also decreased (12), and there is a significant decrease in muscle mass and strength (13).
Comorbidity, a measure of concurrent independent health conditions, in the elderly cancer patient may be a predictor of survival and resource requirements. The commonly used indices to measure comorbidity include the following: Charlson Comorbidity index (14), Cumulative Illness Rating Scale (15), and the Kaplan-Feinstein Index (16). Elderly patients with cancer may have chronic undernutrition with micronutrient deficiencies, which may be secondary to decreased appetite from the neoplasm itself or as a side effect of chemotherapy and/or radiation therapy (17). At the cellular level, the elderly patient with cancer exhibits aging cell populations that show changes in DNA repair, altered mRNA stability (18), and decreased capacity for drug metabolism. There is evidence that cytochrome P450 levels decrease with increasing age and this directly affects the metabolism of hepatically cleared drugs, especially chemotherapeutic agents (19). Based on changes in these parameters we can categorize the elderly cancer patient as healthy, vulnerable, or frail. In the latter case, the above physiologic changes of aging along with comorbidities have an aggregate impact resulting in a vulnerable or frail elderly individual, now additionally burdened with cancer (20).
Becker and Cohen proposed a comprehensive geriatric model in 1984, wherein the patient exists in a setting composed of levels beginning from cellular and molecular and continuing through to complex interpersonal, social, and cultural influences (21). Of note, chronological age alone is not a predictor of the host's ability to withstand different treatment modalities. Studies have shown that the better an individual is able to cope with activities of daily living, the more likely they are to be able to tolerate treatment of cancer, regardless of age (22).
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SUPPORTIVE CARE IN THE ELDERLY CANCER PATIENT |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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Good supportive care has been defined as interventions intended to manage the adverse effect of the tumor itself and antineoplastic therapy. With improved diagnostic techniques and treatment modalities the elderly cancer patient has improved survival, and with the aging of the population there are an increasing number of survivors in this age group. As cancer becomes a chronic illness, patients may have numerous symptoms, physical impairments, social, psychological, and spiritual issues to deal with and a good quality of life becomes very important for such patients. One way to positively affect quality of life is by providing the elderly patient with comprehensive geriatric assessment (CGA) linked to management. The main domains for CGA include functional status, gait, balance and risk for falls, cognitive status, affective status, nutritional status, pain, and social function (23). Recently, Bernabei et al. proposed that using comprehensive geriatric assessment might allow better management and more efficient care of elderly patients with cancer (24). CGA can be time-consuming but a recent Veterans Affairs study reported the feasibility of self-report methods in comprehensive assessment of elderly cancer patients (25).
Another study has revealed that CGA adds information to performance status in elderly cancer patients, but did not comment on the effect on quality of life (26). A recent report suggests that care of elderly cancer patients in geriatric evaluation and management units has a positive and sustained effect on their quality of life, including emotional limitation, mental health, and especially bodily pain (27). Symptoms in the elderly cancer patient are usually overlapping and commonly include the following: nausea and vomiting, pain, depression, fatigue, insomnia, loss of appetite, decreased sex drive, and increased anxiety. In this review, we address three symptoms that are extremely common in the elderly cancer patient: fatigue, pain, and depression. For the purposes of this article the "elderly" patient will be defined as persons 65 years of age.
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FATIGUE |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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Fatigue is one of the symptoms most commonly reported by older cancer patients. Prior studies have shown that the prevalence of fatigue is greater than 50% for advanced cancer patients and for cancer patients undergoing radiotherapy or chemotherapy (28,29). Fatigue is also prevalent in long-term survivors who may not suffer from cancer itself. Fatigue has a serious impact on a person's quality of life (30). A study at University of California at Los Angeles of 190 elderly patients in a nursing home (mean age = 88 years) showed that 40% of the subjects had moderate fatigue and 7% had severe fatigue as measured by a modified Piper scale (31). The pathophysiology of fatigue may depend on the underlying etiology as shown in Table 1.
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Assessment of Cancer-Related Fatigue
The measurement of fatigue requires a multidisciplinary approach to be able to capture the physical, emotional, and psychological aspects of this symptom. Patients should be routinely asked if fatigue is a problem and if the answer is affirmative the clinician should try to assess its severity and impact on the patient's life. The most common, efficient, and popular way of recording fatigue during clinic visits is by using a simple unidimensional severity scale. One could use a verbal rating scale (none, mild, moderate, severe) or a numeric rating scale (0-10 scale where "0" equals no fatigue and "10" equals the worst fatigue imaginable). This may be a good way to test for fatigue in the elderly cancer patient and needs further evaluation.
There are several other fatigue assessment tools that have been tested for reliability and are valid and include quality-of-life assessment scales, e.g., the Functional Assessment of Cancer Therapy for Anemia (FACT-AN) (32), Piper Fatigue scale (33), the Brief Fatigue Inventory (34), Schwartz Cancer Fatigue Scale (35), and the Multidimensional Fatigue Inventory (MIF-20) (36). Of note, none of these scales have been specifically tested in elderly cancer patients. The Brief Fatigue Inventory, which has only nine items to measure, is easy to use, and could be studied as a measurement tool in the elderly cancer patient.
Treatment of Cancer-Related Fatigue
Treatment of cancer-related fatigue in the elderly has been poorly studied. Education of the patient and physician regarding this topic is necessary and has thus far only been addressed in the nursing literature (37). The first approach may be to remove or modify potential etiologies, e.g., use of non-centrally acting drugs, using a hypnotic for insomnia, and, correction of metabolic and electrolyte disturbances (38). Drugs like selective serotonin reuptake inhibitors, secondary amine tricyclics (nortriptyline and desimipramine), and buproprion may help with increased energy by treating underlying depression or anxiety. This intervention needs to be studied in the elderly cancer patient with fatigue.
Recombinant erythropoietin has been used in the treatment of anemia in older adults but not specifically for the elderly cancer patient (39). This may be limited by the fact that the erythropoietin response to anemia is blunted in older patients with anemia due to chronic disorders like cancer or inflammation. Also, the erythropoietin level in non-anemic elderly is lower than a healthy young person (40). Treatment with erythropoietin needs to be studied in a randomized controlled trial in the elderly cancer patient with fatigue secondary to anemia.
Psychostimulants like methylphenidate (Ritalin) (41) have been used for cancer-related fatigue but have not been specifically studied in the elderly. There is very limited data on the use of low dose corticosteroids, especially prednisone and dexamethasone for the treatment of cancer-related fatigue, again, not specifically for the elderly (42).
There have been attempts to use exercise to treat fatigue in cancer patients on therapy. This might prove useful in the elderly because exercise maintains muscle strength and flexibility and also reduces depression by increasing endorphins (43), and could also help in preserving the functional status of the elderly patient. The use of exercise as a form of therapy needs to be better studied in this population. The most important aspect of treatment is to help patients understand that this is a slow process and that they may need to make and maintain these changes for the rest of their life (38). Patients should be advised to develop a realistic schedule with periods of activity and rest. They should be advised not to over exert themselves, yet prolonged rest is also detrimental. Regular exercises, rehabilitation, good nutritional support, use of assist devices and treatment of the underlying pathology will offer the most effective form of relief. Clearly, there is a dearth of studies with respect to etiology, evaluation, and treatment of cancer-related fatigue in the elderly and exploration in the form of randomized controlled trials and prospective studies is imperative.
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PAIN |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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Cancer-related pain is experienced by 50-90% of patients with advanced disease and in about 60-70% patients who are receiving active treatment for their tumors (44). Age-associated changes in pain have been studied and there is no evidence in humans of any changes in the spinal tracts or receptors with aging. It is thought that nociception appears not to change with age, although a person's perception of pain and willingness to report it may change (45). The Hospitalized Elderly Longitudinal Project (HELP) (46) showed that one out of three patients in this study died in severe pain. Older patients are at risk for undertreatment of pain because of underestimation of their sensitivity to pain, the expectation that they tolerate pain well, and misconception about their ability to benefit from the use of opioids. Bernabei et al. studied 13 625 institutionalized patients over the age of 65 years (47). A total of 4003 patients (24%, 29%, and 38% of those aged
85 years, 75-84 years, and 65-74 years, respectively) reported daily pain. Age, gender, race, marital status, physical functioning, depression, and cognitive status were all independently associated with the presence of pain. It was found that 26% of patients with daily pain received no analgesic treatment. Patients older than 85 years in daily pain were more likely not to receive any analgesia. Only 13% of patients aged 85 years and older received codeine or other weak opioids or morphine, compared with 38% of those aged 65-74 years. Other independent predictors of failing to receive an analgesic agent were related to racial background (e.g., African Americans) low cognitive ability and number of other medications received. Assessment of Pain
The patient's self report should be the primary source for pain assessment, even among cognitively impaired patients. It is important to assess pain in a systematic way, especially in the elderly, i.e., look for onset, duration, character and location of pain (48). Identifying factors that aggravate or relieve the pain is also useful (48). Elderly patients often react more slowly and clinicians should allow ample time to perform the assessment (49,50). In the cognitively impaired elderly, one may use simple tools with Yes/No answers (51). These patients may also demonstrate increased vocalizations like moaning or crying and observe behaviors like grimacing, irritability, and guarding. Asking caregivers about recent changes in function, mood, and gait can provide a lot of information.
Different scales have been used to assess the intensity of pain in the elderly. A verbal descriptor scale (VDS) contains a set of numbers with words representing different levels of pain, whereas a visual analogue scale (VAS) (52) typically uses a 10-cm line marked "no pain" on the left to "worst possible pain" on the right. A study done by Herr showed that VDS is preferred by elderly patients and has a high rate of completion (53). The pain thermometer is most preferred, even amongst the cognitively impaired elderly (54). The Faces Pain scale might be unreliable in the elderly especially in those with cognitive impairment who might identify the facial expressions with their overall well-being and feelings rather than their pain (53). Other pain scales, including the McGill Pain Questionnaire (MPQ) (55), the Wisconsin Brief Pain Inventory (BPI), and the Memorial Pain Assessment Card (56), are very comprehensive, time-consuming, and may be too complex for evaluating pain in the elderly patient. The key to using these tools in the elderly population is to find the most effective tool and use it consistently (50,57). Data suggests that elderly patients traditionally underreport their pain because they assume that pain is a normal part of aging. Also, cancer patients tend to equate worsening pain with worsening cancer and therefore deny their pain. Undertreatment of pain in the elderly cancer patient is common, the reasons for which are shown in Table 2 (47,49). We need studies that delineate ways to overcome these barriers, e.g., education of patients, physicians, and caregivers; better communication skills; and use of different pain measurement scales specifically in the elderly cancer patient.
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Treatment of Pain
The American Geriatrics Society has established guidelines for the management of chronic, persistent pain in the elderly (48) (Table 3), and this may be applied to the elderly cancer patient. Pharmacologic measures include acetaminophen and salicylates, which are used for mild pain (58). Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen are available over the counter and are effective in managing bone pain. These drugs should be avoided in elderly patients with abnormal renal function, history of peptic ulcer disease, and bleeding diathesis. High dose, long-term NSAID use and use of more than one NSAID should be avoided (48). COX-2 (cyclooxygenase-2 receptor) inhibitors like celecoxib and refecoxib have been used and may have less gastric side effects (59). These drugs along with acetaminophen and NSAIDs may be used for mild-moderate cancer pain or can be used in combination with the opioids (58). This needs to be studied in the elderly cancer patient.
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Opioids offer relief in almost 75% patients with cancer pain and it is now accepted that opioids should be used as first-line therapy for moderate-severe cancer pain (60). Ferrell recommends that morphine given orally should be the standard with which other opioids should be compared in elderly patients, because the effects of morphine are the best understood and the most predictable (61). Side effects to be aware of in the elderly include constipation, sedation, respiratory depression, and tolerance. The elderly patient also uses multiple medications; hence, we should be aware of drug interactions. Analgesics to avoid in the elderly are methadone, levorphanol, meperidine, propoxyphene, indomethacin, metaxalone, and pentazocine (62). General guidelines have been suggested for pain management using opioids in the elderly cancer patient and are given in Table 4 (48,61,63,64). It is important to treat baseline pain and breakthrough pain at the same time.
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The elderly cancer patient may have increased sensitivity to opioids because of decreased number of opioid receptors in the brain, decreased cytochrome P450 levels in the liver, and hypoalbuminemia, which allows for increased free drug in the circulation. This allows opioids to remain in the body longer and at higher concentrations; therefore, their effects are greater and last longer in the elderly than in younger patients. Thus, it is best to start with low doses of opioids in the elderly (64). The literature suggests beginning with one-half or one-third of the normal adult dose (63,64). It is important to titrate doses to achieve maximal analgesia without side effect and to monitor both renal and hepatic function. It has also been demonstrated that patient controlled analgesia can be used safely and effectively in the frail elderly (65,66). Studies that offer more data on pharmacokinetics and pharmacodynamics of opioids and other analgesics in the elderly cancer patient are necessary. Trials specifically aimed at this population are required to be able to study side-effect profiles and drug-drug interactions. It would also be useful to know if oncologists make effective use of general clinical guidelines and, if not, what measures might be implemented to do so.
Adjuvant analgesics include tricyclic antidepressants (amitriptyline), anticonvulsants (gabapentin), NMDA receptor antagonists (dextromethorphan, ketamine), corticosteroids (prednisone, dexamethasone), topical agents (capsaicin, local anesthetics) (58,64), and agents for bone pain (bisphosphonates, strontium-80) (67). Nonpharmacologic measures: Comprehensive geriatric care involving other geriatric team members, e.g., physical therapists, can help in management of pain syndromes. A recently completed study has shown a positive and sustained effect of geriatric evaluation and management units in the management of pain in the frail elderly cancer patient (27). Massage therapy, foot reflexology, music therapy, and meditation have all been tried to help with pain management (68,69). Rehabilitation with exercise and physical therapy may also be helpful (70). One study indicated that an educational intervention (patients watched a 14-minute video that presented information contained in the booklet "Managing Cancer Pain") aimed at elderly people with cancer was effective in prevention and management of cancer pain in the elderly (71). Caregivers of elderly patients have also been targeted successfully with education programs (72).
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DEPRESSION |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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The prevalence of depression is 3% in elders living in the community, but is higher (10-15%) for those elders in nursing homes (73). There are 63 million seniors worldwide living with this symptom. Blazer et al. evaluated a community sample of 4163 patients and found a 9% incidence of depressive symptoms, more prevalent in the oldest old and females with no racial differences (74). Although older women have higher rates of depression, the incidence of suicide is highest in the elderly white male patient (mainly over the age of 85 years) (75). Recent studies indicate that the prevalence of depression in cancer patients is between 17 and 25% (76). Patients at greatest risk are women with severe illness, poor performance and functional status, and advanced cancer (77).
A major obstacle in the study of depression in cancer patients is the difficulty clinicians have in separating symptoms associated with depression from those associated with the cancer itself. Diagnosis is usually made using the DSM-IV criteria (78). This is more challenging in the elderly because symptoms may be accompanied by loss of social support systems due to death of spouse and/or siblings, retirement, or relocation of residence. Depression in late life frequently coexists with multiple chronic diseases, e.g., cancer, cardiovascular disease, neurological disorders, and sensory loss. Among cancer patients there is a strong relationship between pain and depression (79,80), but this data needs to be confirmed in the elderly cancer patient. Etiology is multifold; Table 5 includes common causes and pathophysiology of depression in the elderly non-cancer and elderly cancer patient.
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Assessment of Depression
Screening instruments that are self-report scales for depression have been developed for office use and include the Center for Epidemiologic Studies-Depression scale (CES-D) (81), and Geriatric Depression Scale (GDS) (82). With the GDS, patients answer a series of questions and the answers are given points. A score of 5 suggests depression. The sensitivity and specificity of these scales are between 70% and 85%. A scale developed by Koenig et al. used a combination of the GDS and the Carroll depression scale. It was 83% sensitive and 77% specific in identifying major depression in medically ill, hospitalized elderly (83). These instruments should be used along with good history and physical exam. Also, before making the diagnosis in the elderly it may be prudent to rule out common causes of depression with the help of TSH, B12, calcium, and liver function tests. Of note, we need studies to test the validity of these measurement scales in the elderly cancer patient.
Treatment of Depression
Depression can be treated using pharmacologic and nonpharmacologic modalities. In the pharmacologic treatment for mild to moderate depression, duration of therapy should be at least 6-12 months. Selective serotonin reuptake inhibitors like citalopram, fluoxetine, paroxetine, and sertraline are first-line choice of drugs in the elderly especially if patients have ischemic heart disease or conduction heart defects, prostatic hypertrophy, or uncontrolled glaucoma (84,85). Venlafaxine (86), mirtazipine (87), and bupropion are considered second-line drugs to use. Nortriptyline or desipramine are used as third-line drugs and for severe melancholic depression (88). The disadvantage of using drugs is that they can be difficult to tolerate because of side effects or, in the case of monoamine oxidase inhibitors, dietary and medication restrictions (89). SSRIs have fewer side effects than the older drugs, making it easier for patients including older adults to adhere to treatment. It is also important to remember that only 25%-35% of elderly patients remain well after 1-3 years of follow-up and hence often require maintenance therapy for a period of 6-12 months (90). Therapy with antidepressants in the elderly cancer patient with depression is an area of ongoing study and we soon hope to have more data specific to this population. Antidepressant drugs to avoid in the elderly include amitriptyline, amoxapine, clomipramine, doxepin, imipramine, maprotiline, protriptyline, trimipramine, and St. John's Wort (91). Electroconvulsive therapy is generally considered safe and very effective, but has not been studied specifically in the elderly cancer patient (92). In nonpharmacologic approaches, education plays an important role, and a meta-analysis of various studies confirms that psychoeducational interventions reduce depressive symptoms in patients with cancer (93). One study provided information and taught physicians and caregivers the skills needed to recognize and respond to depression and suicidal behavior in the elderly (94). There has been no specific educational intervention in the elderly cancer patient. Psychotherapy, i.e., interpersonal therapy, behavior therapy, cognitive behavior therapy, and dynamic psychotherapy (95), may be useful but needs to be specifically tested in elderly cancer patients.
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INTERRELATIONSHIP BETWEEN PAIN, FATIGUE, AND DEPRESSION |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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Pain, fatigue, and depression each by itself, can be extremely distressing for the elderly cancer patient. Although there already is a paucity of studies in the diagnosis and management of pain, fatigue, and depression in the elderly cancer patient, there is even less known about the possible interactions between these symptoms and the effect it may have on the patient. A recent study from Michigan assessed the predictors of pain and fatigue in the year after diagnosis among elderly cancer patients (96). They reviewed 841 patients age
65 years diagnosed with breast, colon, lung, or prostate cancer and found that women (as compared with men) patients with late stage cancer (as compared with early stage) and patients with lung cancer (as compared with colon, breast and prostate) were more likely to experience pain and fatigue. Patients using symptom management drugs (growth stimulating factors, antibiotics, anti-emetics, and pain medication) were more likely to report neither pain nor fatigue. Another study assessing the multidimensional independent predictors of cancer-related fatigue found dyspnea, pain, lack of appetite, feeling drowsy, feeling sad, and feeling irritable predicted fatigue independently (97). The authors suggest a symptom-oriented approach to assessment of cancer-related fatigue and this may prove to be especially useful in the elderly cancer patient and needs further study. Liao et al. assessed fatigue in the elderly and found a statistically significant relationship between fatigue and depression, pain, number of medications, and physical function (31). Hickie et al. studied 1593 patients; 25% had prolonged fatigue and 37% had psychological disorder (98). Of the 399 patients with fatigue, 70% had both fatigue and psychological disorder. Of note most of the existing data is from studies in the general population and not specifically in the elderly cancer patient. The interrelationship between symptoms especially pain, fatigue, and depression needs to be further evaluated in patients >65 years.
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CONCLUSION |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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With aging, an individual's organ reserve decreases, comorbidities develop, and functional status is affected. Such an individual when burdened with cancer and the effects of therapy for cancer may develop multiple symptoms like pain, fatigue, and depression. Diagnosis and management of these symptoms require knowledge of the biology of aging. It will also be necessary to understand how aging systems interact with these phenomena to produce unique situations in older adults. The best assessment of these symptoms may come from the patient themselves, and different assessment tools need to be specifically studied in the elderly cancer patient. Family members and caregivers also need to be educated so they can better understand these symptoms. Future research is needed to expand our knowledge base on the occurrence and management of each of these symptoms, especially fatigue in the elderly cancer patient. A recent issue of Seminars in Oncology has tried to address some of the issues pertinent to the elderly cancer patient (99). Therapy for these patients' symptoms has thus far been poorly studied and we need more randomized controlled trials in this arena. The goal of therapy should be to improve quality of life and functional status. The need for geriatric expertise in oncology is increasing and evidence-based data is needed on how best to care for this growing population. We hope this review has shed some light on the paucity of clinical trials with respect to assessment and management of cancer-related symptoms in the elderly, and trust that it has identified areas for future study.
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REFERENCES |
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TopAbstractCancer and the ElderlyAge-Related Physiologic DeclineSupportive Care in the...FatiguePainDepressionInterrelationship Between Pain,...ConclusionReferences |
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1 Yancik R, Reis LA. Cancer in older persons: an international issue in an aging world. Sem Oncol 2004;31:125–296.[Web of Science]
2 Kinsella K Velkoff VA. An Aging World: 2001. U.S. Census Bureau P95/01-1. Washington (DC): U.S. Government Printing Office; 2001 .
3 Bennett T, Gardiner SM. Physiological aspects of the aging cardiovascular system. J Cardiovasc Pharmacol 1988;12:S1–10.
4 Kennedy RD, Caird FI. Physiology of aging of the heart. Cardiovasc Clin 1981;12:1–8.
5 Sheahan SL, Musialowski R. Clinical implications of respiratory system changes in aging. J Gerontol Nurs 2001;27:26–34; quiz 48-9.
6 Anderton BH. Ageing of the brain. Mech Ageing Dev 2002;123:811–7.[CrossRef][Web of Science][Medline]
7 Blechman MB, Gelb AM. Aging and gastrointestinal physiology. Clin Geriatr Med 1999;15:429–38.[Web of Science][Medline]
8 Lipschitz DA, Udupa KB. Age and the hematopoietic system. J Am Geriatr Soc 1986;34:448–54.[Web of Science][Medline]
9 Shen SS, Kim JS, Weksler ME. Effect of age on thymic development, T cell immunity, and helper T cell function. Rev Physiol Biochem Pharmacol 1999;139:123–39.[Web of Science][Medline]
10 Solana R, Alonso MC, Pena J. Natural killer cells in healthy aging. Exp Gerontol 1999;34:435–43.[CrossRef][Web of Science][Medline]
11 Cocchi D. Age-related alterations in gonadotropin, adrenocorticotropin and growth hormone secretion. Aging (Milano) 1992;4:103–13.[Medline]
12 Anawalt BD, Merriam GR. Neuroendocrine aging in men. Andropause and somatopause. Endocrinol Metab Clin North Am 2001;30:647–69.[CrossRef][Web of Science][Medline]
13 Bick EM. The physiology of the aging process in the musculoskeletal apparatus. 1955. Clin Orthop 1995: 5 –9.
14 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chr Dis 1987;40:373–83.
15 Miller MD, Paradis CF, Houck PR, Mazumdar S, Stack JA, Rifai AH, et al. Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Res 1992;41:237–48.[CrossRef][Web of Science][Medline]
16 Extermann M. Measuring comorbidity in older cancer patients. Eur J Cancer 2000;36:453–71.
17 Pironi L. Nutritional aspects of elderly cancer patients. Rays 1997;22:42–6.[Medline]
18 Pitot HC. Carcinogenesis and aging—two related phenomena? A review. Am J Pathol 1977;87:444–72.[Web of Science][Medline]
19 Sotaniemi EA, Arranto AJ, Pelkonen O, Pasanen M. Age and cytochrome P450-linked drug metabolism in humans: an analysis of 226 subjects with equal histopathologic conditions. Clin Pharmacol Therap 1997;61:331–9.[CrossRef][Web of Science][Medline]
20 Ferrucci L, Guralnik JM, Cavazzini C, Bandinelli S, Lauretani F, Bartali B, et al. The frailty syndrome: a critical issue in geriatric oncology. Crit Rev Oncol-Hematol 2003;46:127–37.[Web of Science][Medline]
21 Becker PM, Cohen HJ. The functional approach to the care of the elderly: a conceptual framework. J Am Geriatr Soc 1984;32:923–9.[Web of Science][Medline]
22 Greenfield S, Blanco DM, Elashoff RM, Ganz PA. Patterns of care related to age of breast cancer patients. JAMA 1987;257:2766–70.
23 Monfardini S, Balducci L. A comprehensive geriatric assessment (CGA) is necessary for the study and the management of cancer in the elderly. Eur J Cancer 1999;35:1771–2.
24 Bernabei R, Venturiero V, Tarsitani P, Gambassi G. The comprehensive geriatric assessment: when, where, how. Crit Rev Oncol-Hematol 2000;33:45–56.[Web of Science][Medline]
25 Ingram SS, Seo PH, Martell RE, Clipp EC, Doyle ME, Montana GS, et al. Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology. J Clin Oncol 2002;20:770–5.
26 Repetto L, Fratino L, Audisio RA, Venturino A, Gianni W, Vercelli M, et al. Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. J Clin Oncol 2002;20:494–502.
27 Rao AV, Hsieh F, Cohen HJ. Geriatric Evaluation Management Units are useful in managing pain in the elderly cancer patient. J Gerontol:Med Sci. In press. 2005 .
28 Greenberg DB, Sawicka J, Eisenthal S, Ross D. Fatigue syndrome due to localized radiation. J Pain Symptom Manage 1992;7:38–45.[CrossRef][Web of Science][Medline]
29 Irvine D, Vincent L, Graydon JE, Bubela N, Thompson L. The prevalence and correlates of fatigue in patients receiving treatment with chemotherapy and radiotherapy. A comparison with the fatigue experienced by healthy individuals. Cancer Nurs 1994;17:367–78.[Web of Science][Medline]
30 Portenoy RK. Cancer-related fatigue: an immense problem. Oncologist 2000;5:350–2.
31 Liao S, Ferrell BA. Fatigue in an older population. J Am Geriatr Soc 2000;48:426–30.[Web of Science][Medline]
32 Cella D. The functional assessment of Cancer Therapy-Anemia (FACT-An) Scale: a new tool for the assessment of outcomes in cancer anemia and fatigue. Semin Hematol 1997;34:13–9.[Web of Science][Medline]
33 Piper BF. Piper fatigue scale available for clinical testing. Oncol Nurs Forum 1990;17:661–2.
34 Mendoza TR, Wang XS, Cleeland CS, Morrissey M, Johnson BA, Wendt JK, et al. The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory. Cancer 1999;85:1186–96.[CrossRef][Web of Science][Medline]
35 Schwartz AL. The Schwartz Cancer Fatigue Scale: testing reliability and validity. Oncol Nurs Forum 1998;25:711–7.[Medline]
36 Smets EM, Garssen B, Bonke B, De Haes JC. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res 1995;39:315–25.[CrossRef][Web of Science][Medline]
37 Stacey D. Coping with fatigue: an education session for cancer patients. Can Oncol Nurs J 1998;8:S15.[Medline]
38 Portenoy RK, Itri LM. Cancer-related fatigue: guidelines for evaluation and management. Oncologist 1999;4:1–10.
39 Ershler WB, Artz AS, Kandahari MM. Recombinant erythropoietin treatment of anemia in older adults. J Am Geriatr Soc 2001;49:1396–7.[CrossRef][Web of Science][Medline]
40 Joosten E, Van Hove L, Lesaffre E, Goossens W, Dereymaeker L, Van Goethem G, et al. Serum erythropoietin levels in elderly inpatients with anemia of chronic disorders and iron deficiency anemia. J Am Geriatr Soc 1993;41:1301–4.[Web of Science][Medline]
41 Bruera E, Driver L, Barnes EA, Willey J, Shen L, Palmer JL, et al. Patient-controlled methylphenidate for the management of fatigue in patients with advanced cancer: a preliminary report. J Clin Oncol 2003;21:4439–43.
42 Bruera E, Roca E, Cedaro L, Carraro S, Chacon R. Action of oral methylprednisolone in terminal cancer patients: a prospective randomized double-blind study. Cancer Treat Rep 1985;69:751–4.[Web of Science][Medline]
43 Schwartz AL, Mori M, Gao R, Nail LM, King ME. Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy. Med Sci Sport Exerc 2001;33:718–23.[CrossRef][Web of Science][Medline]
44 Twycross RG, Fairfield S. Pain in far-advanced cancer. Pain 1982;14:303–10.[CrossRef][Web of Science][Medline]
45 Gloth FM, 3rd. Geriatric pain. Factors that limit pain relief and increase complications. Geriatrics 2000;55:46–8, 51-4.[Web of Science][Medline]
46 Puchalski CM, Zhong Z, Jacobs MM, Fox E, Lynn J, Harrold J, et al. Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project. J Am Geriatr Soc 2000;48:S84–90.
47 Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. JAMA 1998;279:1877–82.
48 AGS. AGS Panel on Persistent Pain in Older Persons. The Management of Persistent Pain in Older Persons. J Am Geriatr Soc 2002;50:S205–24.[CrossRef][Web of Science][Medline]
49 Herr KA, Mobily PR. Complexities of pain assessment in the elderly. Clinical considerations. J Gerontol Nurs 1991;17:12–9.
50 Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med 2001;17:457–78, vi.[CrossRef][Web of Science][Medline]
51 Manz BD, Mosier R, Nusser-Gerlach MA, Bergstrom N, Agrawal S. Pain assessment in the cognitively impaired and unimpaired elderly. Pain Manage Nurs 2000;1:106–15.[CrossRef]
52 Wilkie D, Lovejoy N, Dodd M, Tesler M. Cancer pain intensity measurement: concurrent validity of three tools—finger dynamometer, pain intensity number scale, visual analogue scale. Hospice J 1990;6:1–13.
53 Herr KA, Mobily PR. Comparison of selected pain assessment tools for use with the elderly. Appl Nurs Res 1993;6:39–46.[Medline]
54 Taylor LJ, Herr K. Pain intensity assessment: a comparison of selected pain intensity scales for use in cognitively intact and cognitively impaired African American older adults. Pain Manage Nurs 2003;4:87–95.
55 Dudgeon D, Raubertas RF, Rosenthal SN. The short-form McGill Pain Questionnaire in chronic cancer pain. J Pain Symptom Manage 1993;8:191–5.[CrossRef][Web of Science][Medline]
56 Fishman B, Pasternak S, Wallenstein SL, Houde RW, Holland JC, Foley KM. The Memorial Pain Assessment Card. A valid instrument for the evaluation of cancer pain. Cancer 1987;60:1151–8.[CrossRef][Web of Science][Medline]
57 Rodriguez CS. Pain measurement in the elderly: a review. Pain Manage Nurs 2001;2:38–46.[CrossRef]
58 Benedetti C, Brock C, Cleeland C, Coyle N, Dube JE, Ferrell B, et al. NCCN Practice Guidelines for Cancer Pain. Oncology (Huntingt) 2000;14:135–50.
59 Hawkey CJ. COX-2 inhibitors. Lancet 1999;353:307–14.[CrossRef][Web of Science][Medline]
60 Grond S, Zech D, Schug SA, Lynch J, Lehmann KA. Validation of World Health Organization guidelines for cancer pain relief during the last days and hours of life. J Pain Symptom Manage 1991;6:411–22.[CrossRef][Web of Science][Medline]
61 Ferrell BA, Ferrell BR. Principles of pain management in older people. Compr Ther 1991;17:53–8.[Medline]
62 Pasero C, Reed BA, McCaffery M. Pain in the elderly. In Pain: clinical manual. 2nd ed. St. Louis (MO): Ed Mosby; 1999 . p. 674 –710.
63 Herr K. Chronic pain in the older patient: management strategies. 2. J Gerontol Nurs 2002;28:28–34; quiz 54-5.
64 Portenoy RK. Pain management in the older cancer patient. Oncology (Huntingt) 1992;6:86–98.
65 Gagliese L, Jackson M, Ritvo P, Wowk A, Katz J. Age is not an impediment to effective use of patient-controlled analgesia by surgical patients. Anesthesiology 2000;93:601–10.[CrossRef][Web of Science][Medline]
66 Lavand'Homme P, De Kock M. Practical guidelines on the postoperative use of patient-controlled analgesia in the elderly. Drugs Aging 1998;13:9–16.[CrossRef][Web of Science][Medline]
67 Robinson RG, Preston DF, Schiefelbein M, Baxter KG. Strontium 89 therapy for the palliation of pain due to osseous metastases. JAMA 1995;274:420–4.
68 Wilkie DJ, Kampbell J, Cutshall S, Halabisky H, Harmon H, Johnson LP, et al. Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain: a pilot study of a randomized clinical trial conducted within hospice care delivery. Hospice J 2000;15:31–53.
69 Beck SL. The therapeutic use of music for cancer-related pain. Oncol Nurs Forum 1991;18:1327–37.[Medline]
70 Huckstep RL. Early mobilization and rehabilitation in fractures and orthopaedic conditions. Austr N Z J Surg 1977;47:344–53.[CrossRef]
71 Clotfelter CE. The effect of an educational intervention on decreasing pain intensity in elderly people with cancer. Oncol Nurs Forum 1999;26:27–33.[Medline]
72 Ferrell BR, Grant M, Chan J, Ahn C, Ferrell BA. The impact of cancer pain education on family caregivers of elderly patients. Oncol Nurs Forum 1995;22:1211–8.[Medline]
73 Kennedy GJ, Kelman HR, Thomas C, Wisniewski W, Metz H, Bijur PE. Hierarchy of characteristics associated with depressive symptoms in an urban elderly sample. Am J Psychiatry 1989;146:220–5.
74 Blazer DG. Dysthymia in community and clinical samples of older adults. Am J Psychiatry 1994;151:1567–9.
75 Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. Deaths: final data for 1999. Natl Vital Stat Rep 2001;49:1–113.[Medline]
76 Bukberg J, Penman D, Holland JC. Depression in hospitalized cancer patients. Psychosom Med 1984;46:199–212.
77 Cassileth BR, Lusk EJ, Brown LL, Cross PA, Walsh WP, Hurwitz S. Factors associated with psychological distress in cancer patients. Med Pediatr Oncol 1986;14:251–4.[Web of Science][Medline]
78 Frances A, editor. Diagnostic and statistical manual of mental disorders. Washington (DC): American Psychiatric Association. 4th ed. 1994 .
79 Ahles TA, Blanchard EB, Ruckdeschel JC. The multidimensional nature of cancer-related pain. Pain 1983;17:277–88.[CrossRef][Web of Science][Medline]
80 Weisman AD, Worden JW. The existential plight in cancer: significance of the first 100 days. Int J Psychiatry Med 1976;7:1–15.[Web of Science][Medline]
81 Roberts RE, Vernon SW. The Center for Epidemiologic Studies Depression Scale: its use in a community sample. Am J Psychiatry 1983;140:41–6.
82 Montorio I, Izal M. The Geriatric Depression Scale: a review of its development and utility. Int Psychogeriatr 1996;8:103–12.[Medline]
83 Koenig HG, Cohen HJ, Blazer DG, Meador KG, Westlund R. A brief depression scale for use in the medically ill. Int J Psychiatry Med 1992;22:183–95.[Web of Science][Medline]
84 Flint AJ. Choosing appropriate antidepressant therapy in the elderly. A risk-benefit assessment of available agents. Drugs Aging 1998;13:269–80.[CrossRef][Web of Science][Medline]
85 Reynolds CF, 3rd. Depression: making the diagnosis and using SSRIs in the older patient. Geriatrics 1996;51:28–34.
86 Mahapatra SN, Hackett D. A randomised, double-blind, parallel-group comparison of venlafaxine and dothiepin in geriatric patients with major depression. Int J Clin Pract 1997;51:209–13.[Web of Science][Medline]
87 Hoyberg OJ, Maragakis B, Mullin J, Norum D, Stordall E, Ekdahl P, et al. A double-blind multicentre comparison of mirtazapine and amitriptyline in elderly depressed patients. Acta Psychiatr Scand 1996;93:184–90.[Web of Science][Medline]
88 Lazarus LW, Davis JM, Dysken MW. Geriatric depression: a guide to successful therapy. Geriatrics 1985;40:43–8, 52-3.[Web of Science][Medline]
89 Peabody CA, Whiteford HA, Hollister LE. Antidepressants and the elderly. J Am Geriatr Soc 1986;34:869–74.[Web of Science][Medline]
90 Murphy E. The prognosis of depression in old age. Br J Psychiatry 1983;142:111–9.
91 Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 1997;157:1531–6.
92 Weiner RD. The role of electroconvulsive therapy in the treatment of depression in the elderly. J Am Geriatr Soc 1982;30:710–2.[Web of Science][Medline]
93 Barsevick AM, Sweeney C, Haney E, Chung E. A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncol Nurs Forum 2002;29:73–84; quiz 5-7.[Medline]
94 Pratt CC, Schmall VL, Wilson W, Benthin A. A model community education program on depression and suicide in later life. Gerontologist 1991;31:692–5.[Abstract]
95 Fawzy FI, Fawzy NW, Arndt LA, Pasnau RO. Critical review of psychosocial interventions in cancer care. Arch Gen Psychiatry 1995;52:100–13.
96 Given CW, Given B, Azzouz F, Kozachik S, Stommel M. Predictors of pain and fatigue in the year following diagnosis among elderly cancer patients. J Pain Symptom Manage 2001;21:456–66.[CrossRef][Web of Science][Medline]
97 Hwang SS, Chang VT, Rue M, Kasimis B. Multidimensional independent predictors of cancer-related fatigue. J Pain Symptom Manage 2003;26:604–14.[CrossRef][Web of Science][Medline]
98 Hickie IB, Hooker AW, Hadzi-Pavlovic D, Bennett BK, Wilson AJ, Lloyd AR. Fatigue in selected primary care settings: sociodemographic and psychiatric correlates. Med J Austr 1996;164:585–8.
99 Muss HB, Longo D, editors. Cancer in the elderly. Sem Oncol 2004;31:125–296.
100 Curtis EB, Krech R, Walsh TD. Common symptoms in patients with advanced cancer. J Palliat Care 1991;7:25–9.[Medline]
101 Visser MR, Smets EM. Fatigue, depression and quality of life in cancer patients: how are they related? Support Care Cancer 1998;6:101–8.[CrossRef][Web of Science][Medline]
102 Glaspy J. Anemia and fatigue in cancer patients. Cancer 2001;92:1719–24.[CrossRef][Web of Science][Medline]
103 Portenoy RK. Optimal pain control in elderly cancer patients. Geriatrics 1987;42:33–6, 9-40, 4.
104 Arato M, Banki CM, Nemeroff CB, Bissette G. Hypothalamic-pituitary-adrenal axis and suicide. Ann N Y Acad Sci 1986;487:263–70.[Medline]
105 Gambert SR, Pontzer CP, Dagon EM. Thyroid status and the depressed elderly. J Am Geriatr Soc 1980;28:433–8.[Web of Science][Medline]
106 Maes M, Meltzer HY, Stevens W, Calabrese J, Cosyns P. Natural killer cell activity in major depression: relation to circulating natural killer cells, cellular indices of the immune response, and depressive phenomenology. Prog Neuro-Psychopharmacol Biol Psychiatry 1994;18:717–30.[CrossRef][Medline]
107 Maes M. Evidence for an immune response in major depression: a review and hypothesis. Prog Neuro-Psychopharmacol Biol Psychiatry 1995;19:11–38.[CrossRef][Medline]
108 Seidel A, Arolt V, Hunstiger M, Rink L, Behnisch A, Kirchner H. Increased CD56+ natural killer cells and related cytokines in major depression. Clin Immunol Immunopathol 1996;78:83–5.[CrossRef][Web of Science][Medline]
109 Krishnan KR. Neuroanatomic substrates of depression in the elderly. J Geriatr Psychiatry Neurol 1993;6:39–58.
110 Van Someren EJ. Circadian rhythms and sleep in human aging. Chronobiol Int 2000;17:233–43.[CrossRef][Web of Science][Medline]
111 Sist TC, Florio GA, Miner MF, Lema MJ, Zevon MA. The relationship between depression and pain language in cancer and chronic non-cancer pain patients. J Pain Symptom Manage 1998;15:350–8.[CrossRef][Web of Science][Medline]
112 Massie MJ, Holland JC. Depression and the cancer patient. J Clin Psychiatry 1990;51:12–7; discussion 8-9.
113 Massie MJ, Gagnon P, Holland JC. Depression and suicide in patients with cancer. J Pain Symptom Manage 1994;9:325–40.[CrossRef][Web of Science][Medline]
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