Initial psychometric testing of the Head and Neck Cancer Patient Self-Management Inventory (HNC-PSMI).

PURPOSE: Head and neck cancer (HNC) and its treatment are associated with significant symptom burden and functional impairment. HNC patients must engage in intensive and complex self-management protocols to minimize acute and late treatment effects. Self-management among HNC patients is understudied due to the limited availability of disease-specific self-management measures. This article describes the initial psychometric testing of the HNC Patient Self-Management Inventory (HNC-PSMI), an instrument that characterizes self-management tasks in the HNC population. METHOD: A cross-sectional survey design was used. One hundred HNC patients completed the HNC-PSMI, the Vanderbilt Head and Neck Cancer Symptom Survey plus General Symptom Survey, and the Profile of Mood States-Short Form. To evaluate the psychometric properties of the HNC-PSMI, the relevance of items, internal consistency of domain item responses, and the direction and strength of associations between domain scores and other measures were examined. RESULTS: There was variability both in the number of self-management tasks performed overall and in each domain as well as in the reported difficulty completing those tasks. Kuder-Richardson values for domains with > 3 items ranged from 0.61 to 0.86. Hypothesized associations were supported. CONCLUSIONS: Overall, the psychometric properties for the HNC-PSMI were acceptable. The HNC-PSMI can be used to advance an understanding of self-management requirements and challenges in HNC patients.

Chronic Systemic Symptoms in Head and Neck Cancer Patients.

The systemic effects and manifestations of disease and treatment have been of interest for millennium. Until recently, basic and clinical research is just now reaching a watershed. Systemic symptoms usually do not occur in isolation but rather in clusters; however, much of the cutting-edge research pertaining to the etiology, mechanism, manifestations, and moderators of systemic symptoms in humans has been directed at individual symptoms, thus creating silos of knowledge. Breaching these silos and bridging the knowledge from disparate arenas of investigation to build a comprehensive depiction of acute and chronic systemic symptoms has been a challenge. In addition, much of the recent work in systemic symptoms has been conducted in the setting of nonmalignant disease. The degree to which the findings from other chronic disease processes can be translated into the oncologic realm is unknown. This article will explore inflammation as a major contributing factor to systemic symptoms and sickness behavior, discuss the most common manifestations in cancer survivors, and, where available, discuss specific data pertaining to head and neck cancer survivors.

Impact of patient symptoms and caregiving tasks on psychological distress in caregivers for head and neck cancer (HNC).

OBJECTIVE: To determine the association of caregiving task burden and patient symptom burden with psychological distress among caregivers of head and neck cancer (HNC) patients. METHODS: Adults with HNC and their primary caregivers were included. Patient symptom burden was assessed with the Vanderbilt Head and Neck Symptom Survey-2.0. Caregiving task burden was quantified as task number and task difficulty/distress using the HNC Caregiving Task Inventory. Psychological distress was measured with the Profile of Mood States-Short Form. Two-step clustering analysis was conducted for patient symptom burden, caregiving task burden, and psychological distress. Associations of the resultant clusters of task burden and patient symptoms with caregiver distress were tested using logistic regressions. RESULTS: Eighty-nine HNC caregivers and 84 patients were included. Among patients, two clusters of symptom burden were found (51% mod-high, 49% low). Among caregivers, two clusters of caregiving task burden (40% mod-high, 60% low) and caregiver psychological distress (40% mod-high, 60% low) were found. Caregivers with mod-high task numbers and task difficulty/distress reported higher levels of psychological distress. After controlling for caregiver number of tasks, respective difficulty/distress, and patient symptom burden, caregiver perceived task difficulty/distress had the strongest association with caregiver psychological distress (adjusted OR = 3.83; 95% CI, 1.0-14.64; P = 0.049). CONCLUSIONS: Psychological distress in HNC caregivers is associated with caregiving task burden, with caregivers experiencing high task difficulty/distress at greatest risk. Further study of the caregiver and task characteristics leading to psychological distress should inform supportive interventions for HNC patients and caregivers.

The Older Adult With Locoregionally Advanced Head and Neck Squamous Cell Carcinoma: Knowledge Gaps and Future Direction in Assessment and Treatment.

Older adults with head and neck squamous cell carcinoma (HNSCC) pose unique treatment and supportive care challenges to oncologists and other cancer care providers. The majority of patients with HNSCC present with locoregionally advanced disease, for which combined-modality treatment integrating chemotherapy and radiation therapy is often necessary to maximize tumor control. However, applying these approaches to an older population with concomitant comorbidities and a higher risk of functional impairments remains challenging and is exacerbated by the paucity of studies involving older adults. The purpose of this article is to identify knowledge gaps in the evaluation and management of older adults with HNSCC-particularly those undergoing concurrent chemoradiation therapy-and their caregivers through a review of the literature conducted by clinicians, researchers, and patient advocates. The findings highlight the importance of a geriatric assessment and the therapeutic paradigms and challenges relevant to this population. Furthermore, we identify the need for additional research and interventions related to key supportive care issues that arise during and after treatment in older adults with locoregionally advanced HNSCC. On the basis of our findings, we prioritize these issues to guide future patient-oriented research endeavors to address these knowledge gaps and thus better serve this growing patient population.

Development of the Head and Neck Cancer Caregiving Task Inventory.

PURPOSE: Family caregivers provide vital support for patients with head and neck cancer (HNC), yet few studies have focused on HNC caregiving. Our objective was to develop and conduct initial validation of the HNC Caregiving Task Inventory, an instrument to characterize caregiving task burden in the HNC population. METHODS: This 5-phase instrument development project involved the conceptualization of caregiving task burden (Phase 1), initial instrument development (Phase 2), assessment of content validity through expert panel review (Phase 3), assessment of face validity through family caregiver review (Phase 4), and preliminary validation in a sample of 106 family caregivers (Phase 5). RESULTS: We identified 11 domains of the HNC caregiving role and caregiving tasks for each domain. In Phase 3, the experts deemed all tasks relevant to HNC family caregiving. No tasks were eliminated and 19 were added. In Phase 4, family caregiver feedback indicated that the tasks were comprehensive and relevant. Wording and formatting changes were made and one task was added. In Phase 5, we evaluated discrimination of responses to derive a final version comprised of 58 tasks in 11 domains. Kuder-Richardson values for domains with ≥3 items ranged from 0.65 to 0.94. Associations were generally high with the Caregiving Burden Scale, moderate with the Caregiver Reaction Assessment and Profile of Mood States-Short Form, and low or non-existent with the Preparedness Scale. CONCLUSION: Convergent and divergent validity were supported. The HNC Caregiving Task Inventory can be used to evaluate caregiving task burden across the treatment trajectory and identify targets for intervention.

Neurocognitive function in patients with head and neck cancer undergoing primary or adjuvant chemoradiation treatment.

PURPOSE: Cancer and cancer therapy-related neurocognitive changes negatively affect quality of life, yet few studies have examined neurocognitive changes in patients with head and neck cancer. The purpose of this study was to evaluate neurocognitive performance in patients with head and neck cancer at baseline before starting treatment and 3 months after treatment completion to assess treatment-associated changes in performance. METHODS: Patients with head and neck cancer who were to receive primary or adjuvant chemoradiation (N = 55) underwent neuropsychological testing before and 3 months posttreatment. Changes in neurocognitive performance were assessed using a practice effect adjusted Reliable Change Index. RESULTS: At baseline, 38 % of patients exhibited global neurocognitive impairment. Posttreatment, 21.8 % demonstrated declines in neurocognitive performance in at least one domain. Declines in domain-specific performance ranged from 1.8 to 12.7 % with the greatest decline in language, specifically verb retrieval. Domain-specific improvements ranged from 0 to 7.3 %. CONCLUSIONS: Patients had a high prevalence of baseline neurocognitive impairment. While neurocognitive performance posttreatment remained unchanged in the majority, almost 13 % suffered declines in language. Small percentages of patients exhibited improvements in their performance. Long-term effects and risk factors for neurocognitive decline in this population should be studied on a larger scale.

Evaluation of a peer mentoring program for early career gerontological nursing faculty and its potential for application to other fields in nursing and health sciences.

BACKGROUND: As the retirement rate of senior nursing faculty increases, the need to implement new models for providing mentorship to early career academics will become key to developing and maintaining an experienced faculty. PURPOSE: This evaluation of a peer mentorship program for predoctoral and postdoctoral gerontological nurses examined its efficacy, utility, and potential for improvement. METHODS: A web-based survey was developed, implemented, and completed by 22 mentees and 17 mentors (71% and 61% response rates, respectively) as part of the evaluation. DISCUSSION: The peer mentorship program was found to be valuable by both mentors (64.7%) and mentees (72.7%) in helping mentees further develop their careers and networks and providing mentors with supported mentorship experience. CONCLUSION: The peer mentorship program could serve as a model for other professional organizations, academic institutions, and consortiums to enhance and extend the formal vertical mentorship provided to early academic career individuals.

The Evolution of Gero-Oncology Nursing.

OBJECTIVES: This article summarizes the evolution of gero-oncology nursing and highlights key educational initiatives, clinical practice issues, and research areas to enhance care of older adults with cancer. DATA SOURCES: Peer-reviewed literature, position statements, clinical practice guidelines, Web-based materials, and professional organizations' resources. CONCLUSION: Globally, the older adult cancer population is rapidly growing. The care of older adults with cancer requires an understanding of their diverse needs and the intersection of cancer and aging. Despite efforts to enhance competence in gero-oncology and to develop a body of evidence, nurses and health care systems remain under-prepared to provide high-quality care for older adults with cancer. IMPLICATIONS FOR NURSING PRACTICE: Nurses must take a leadership role in integrating gerontological principles into oncology settings. Working closely with interdisciplinary team members, nurses should utilize available resources and continue to build evidence through gero-oncology nursing research.

Development and implementation of a peer mentoring program for early career gerontological faculty.

PURPOSE: The Hartford Gerontological Nursing Leaders (HGNL) formerly known as the Building Academic Geriatric Nursing Capacity Initiative (BAGNC), in conjunction with the National Hartford Centers of Gerontological Nursing Excellence (NHCGNE), developed and executed a peer mentoring program beginning in 2011 to enhance both (a) the experience of newly selected scholars and fellows to the NHCGNE and (b) the ongoing professional development of HGNL members. The purpose of this article is to describe key strategies used to develop and execute the peer mentoring program and to present formative program evaluation. DESIGN: The program was launched in January 2011 with seven peer mentor and mentee matches. In June 2012, the peer mentoring committee solicited feedback on the development of the peer mentoring program and changes were made for the subsequent cohorts. FINDINGS: An additional 12 matches were made in the following 2 years (2012 and 2013), for a total of 31 matches to date. We have learned several key lessons from our three cohorts regarding how to structure, implement, and carefully evaluate a peer mentoring program. CONCLUSIONS: Informal evaluation of our peer mentoring program noted several challenges for both peer mentors and mentees. Having knowledge of and addressing those challenges may increase the overall quality and effectiveness of peer mentoring programs and, in turn, benefit academic nursing by strengthening the faculty workforce. CLINICAL RELEVANCE: Findings from development and implementation of a peer mentoring program for gerontological faculty could lead to new and adaptable programs in a variety of clinical and education settings.

Caregiver-reported neuropsychiatric symptoms in patients undergoing treatment for head and neck cancer: a pilot study.

BACKGROUND: Patients with cancer experience multiple neuropsychiatric symptoms. Whereas individual symptoms have been studied in patients with head and neck cancer, the broader context of neuropsychiatric symptoms needs to be explored. OBJECTIVE: The aims of this pilot study were to (a) determine the caregiver-reported prevalence and severity of neuropsychiatric symptoms in patients with head and neck cancer, (b) determine the associated level of caregiver distress, and (c) describe the effects of neuropsychiatric symptoms on patients and their caregivers. METHODS: Twenty-three family caregivers of patients with head and neck cancer completed the Neuropsychiatric Inventory Questionnaire and participated in a semistructured interview. RESULTS: All caregivers reported that patients experienced at least 1 neuropsychiatric symptom (mean, 7.5; range, 1-12). The most frequently reported symptoms were trouble with appetite and eating (95.7%), altered nighttime behaviors (82.6%), depression/dysphoria (78.3%), decreased alertness (69.6%), inattention (60.9%), apathy/indifference (56.5%), anxiety (56.5%), irritability/lability (52.5%), agitation/aggression (52.2%), and slowed behavior (43.5%). The mean severity rating for 9 symptoms was moderate to severe. Most symptoms caused mild to moderate levels of caregiver distress. Qualitative data indicated that neuropsychiatric symptoms negatively affected patients, their caregivers, and other family members. Patients required more caregiver support resulting in increased caregiver burden and distress. CONCLUSIONS: Neuropsychiatric symptoms are common and troubling in patients with head and neck cancer during treatment. Further investigation of their effects on patients and family caregivers is needed. IMPLICATIONS FOR PRACTICE: Clinicians should monitor for and treat neuropsychiatric symptoms throughout treatment and provide caregiver and patient education and support.

A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer-related lymphedema.

PURPOSE/OBJECTIVES: To examine the impact of advanced practice nurse (APN)-administered low-level laser therapy (LLLT) as both a stand-alone and complementary treatment for arm volume, symptoms, and quality of life (QOL) in women with breast cancer-related lymphedema. DESIGN: A three-group, pilot, randomized clinical trial. SETTING: A private rehabilitation practice in the southeastern United States. SAMPLE: 46 breast cancer survivors with treatment-related lymphedema. METHODS: Patients were screened for eligibility and then randomized to either manual lymphatic drainage (MLD) for 40 minutes, LLLT for 20 minutes, or 20 minutes of MLD followed by 20 minutes of LLLT. Compression bandaging was applied after each treatment. Data were collected pretreatment, daily, weekly, and at the end of treatment. MAIN RESEARCH VARIABLES: Independent variables consisted of three types of APN-administered lymphedema treatment. Outcome variables included limb volume, extracellular fluid, psychological and physical symptoms, and QOL. FINDINGS: No statistically significant between-group differences were found in volume reduction; however, all groups had clinically and statistically significant reduction in volume. No group differences were noted in psychological and physical symptoms or QOL; however, treatment-related improvements were noted in symptom burden within all groups. Skin improvement was noted in each group that received LLLT. CONCLUSIONS: LLLT with bandaging may offer a time-saving therapeutic option to conventional MLD. Alternatively, compression bandaging alone could account for the demonstrated volume reduction. IMPLICATIONS FOR NURSING: APNs can effectively treat lymphedema. APNs in private healthcare practices can serve as valuable research collaborators. KNOWLEDGE TRANSLATION: Lasers may provide effective, less burdensome treatment for lymphedema. APNs with lymphedema certification can effectively treat this patient population with the use of LLLT. In addition, bioelectrical impedance and tape measurements can be used to assess lymphedema.

A randomized clinical trial comparing advanced pneumatic truncal, chest, and arm treatment to arm treatment only in self-care of arm lymphedema.

Treatment of the truncal lymphatics prior to treatment of the lymphedematous arm is an accepted, although not empirically tested, therapeutic intervention delivered during decongestive lymphatic therapy (DLT). Breast cancer survivors with arm lymphedema are encouraged to use these techniques when performing simple lymphatic drainage as part of their life-long lymphedema self-care. Self-massage is at times difficult and pneumatic compression devices are used by many patients to assist with self-care. One such device, the Flexitouch(®) System, replicates the techniques used during DLT; however, the need for application of pneumatic compression in unaffected truncal areas to improve self-care outcomes in arm only lymphedema is not established. The objective of this study was to compare the therapeutic benefit of truncal/chest/arm advanced pneumatic compression therapy (experimental group) verses arm only pneumatic compression (control group) in self-care for arm lymphedema without truncal involvement using the Flexitouch(®) System. Outcomes of interest were self-reported symptoms, function, arm impedance ratios, circumference, volume, and trunk circumference. Forty-two breast cancer survivors, (21 per group), with Stage II lymphedema completed 30 days of home self-care using the Flexitouch(®) System. Findings revealed a statistically significant reduction in both the number of symptoms and overall symptom burden within each group; however, there were no statistically significant differences in these outcomes between the groups. There was no statistically significant overall change or differential pattern of change between the groups in function. A statistically significant reduction in bioelectrical impedance and arm circumference within both of the groups was achieved; however, there was no statistically significant difference in reduction between groups. These findings indicate that both configurations are effective, but that there may be no added benefit to advanced pneumatic treatment of the truncal lymphatics prior to arm massage when the trunk is not also affected. Further research is indicated in a larger sample.

Vanderbilt Head and Neck Symptom Survey version 2.0: report of the development and initial testing of a subscale for assessment of oral health.

BACKGROUND: The prevalence, severity, and functional implications of adverse oral health outcomes attributed to head and neck cancer therapy are largely undefined. We report development of an oral health outcome subscale for the Vanderbilt Head and Neck Symptom Survey (VHNSS). METHODS: Oral health outcome questions were formulated through literature review and consultation with an expert panel. Questions were incorporated into the VHNSS resulting in a 50-item survey, scored 0 (none) to 10 (severe). The tool was administered to 70 subjects who completed radiation to assess for feasibility. RESULTS: Patient acceptance was high with a completion time <10 minutes. A full range of scores was noted for 46 of 50 questions. Oral health symptom burden was high early and late posttreatment. CONCLUSIONS: The VHNSS version 2.0 was feasible and could be completed in a timely manner. Validation studies are ongoing. The high prevalence of adverse oral health outcomes warrants further study.

Neurocognitive function in head and neck cancer patients prior to treatment.

PURPOSE: Neurocognitive impairment is a common and clinically important problem in patients with cancer, but few studies have been conducted in head and neck cancer (HNC) patients. Our aims were to (1) determine the prevalence of baseline neurocognitive impairment in patients with newly diagnosed HNC, (2) examine the relationships between neurocognitive performance and self-reported neurocognitive function, and (3) explore relationships between neurocognitive function and sociodemographic, clinical, symptom distress, and mood variables. METHODS: Seventy patients underwent testing with a brief neuropsychological test battery and completed self-report measures before starting treatment. RESULTS: Forty-seven percent of HNC patients in the current cohort exhibited global neurocognitive impairment on neuropsychological testing prior to starting induction chemotherapy or concurrent chemoradiation. Impairment was more common in the following neurocognitive domains: verbal learning (36%), executive function (32%), verbal memory (30%), and processing speed (27%). Neurocognitive performance was not associated with self-reported neurocognitive function. Few significant associations were noted between neurocognitive performance and other physical or psychological symptoms; however, moderately strong associations were found between self-reported neurocognitive function and these symptoms. CONCLUSIONS: Neurocognitive impairment is common in patients with newly diagnosed HNC before starting treatment. The impact of pretreatment neurocognitive impairment on treatment tolerance, treatment outcomes, and caregiving needs are important areas for future research. Mechanisms of pretreatment neurocognitive impairment also need to be explored.

Delirium in patients with head and neck cancer in the outpatient treatment setting.

PURPOSE: Delirium is a common neurocognitive disorder among patients with cancer. In patients with head and neck cancer, delirium has been examined in the postoperative setting. Because no studies have reported on delirium during outpatient cancer treatment, we conducted a prospective study in 69 patients with head and neck cancer to examine neurocognitive function before, during, and after outpatient treatment. We also conducted a retrospective study in a subset of caregivers. In this paper, we report the prevalence and incidence of delirium and subsyndromal delirium (SSD) during outpatient treatment. METHODS: Assessments were conducted before treatment, at scheduled treatment visits, and at a 3-month post-treatment visit. Delirium and SSD were assessed using the Confusion Assessment Method (CAM). Following treatment, we retrospectively asked patients (n = 58) and a subset of caregivers (n = 23) whether patients experienced delirium during treatment. RESULTS: Based on CAM assessments at scheduled treatment visits, six patients (8.6%) developed delirium during treatment. Additionally, 31% of patients and 43.5% of caregivers retrospectively reported delirium. The prevalence and incidence of SSD were 7.2% and 45.3%, respectively. CONCLUSIONS: These data suggest that delirium and SSD are frequent in patients with head and neck cancer undergoing outpatient treatment. Delirium was often associated with medical complications. The potential impact of delirium and SSD on treatment outcomes, recovery, and caregiving are significant clinical concerns.

Association of age and symptom burden in patients with head and neck cancer.

Patients with head and neck cancer experience significant treatment-related symptoms. Aging may predispose older patients to greater risk. We examined the association of age with symptom burden. Older patients may experience more symptom burden with swallowing, voice/speech, and nutrition. Nurses need to be especially aware of and monitor for these problems.

Physiological aging in older adults with cancer: implications for treatment decision making and toxicity management.

Because the risk of cancer increases with age, the growth of the aging population will lead to a larger number of older adults with cancer. Standard cancer treatments can be safe and effective in older adults and result in improved survival and enhanced quality of life. Because physiological decline varies among older adults, cancer treatment requires an individualized approach. Consideration of physiological age, rather than chronological age alone, is required to guide treatment decision making and prevent and manage treatment toxicities and other complications. This article examines the impact of physiological aging on treatment decision making and toxicity management in older adults with cancer.

Delirium at home: strategies for home health clinicians.

Delirium is a challenging, under-appreciated problem in the home care setting. When it is not detected early and managed effectively, delirium adversely affects outcomes and quality of life. Home healthcare nurses play a key role in the assessment, early identification, and management of delirium and in the support and education of patients and their family caregivers. This article reviews delirium and describes strategies for detecting and managing delirium in the home care setting.

Delirium resolution in hospitalized older patients with cancer.

Delirium is a troubling complication in hospitalized older patients with cancer. Although preventable and potentially reversible, delirium may be prolonged. Persistent delirium at the time of hospital discharge is common and associated with multiple adverse outcomes. We conducted a secondary data analysis to examine delirium resolution in 43 hospitalized older patients with cancer who had prevalent or incident delirium. We describe trajectories of delirium resolution and evaluate differences in patients with and without delirium resolution. Delirium was assessed using the NEECHAM confusion scale. Forty-one of the 43 patients had delirium during hospitalization before discharge; 2 had delirium only at the time of discharge. Although delirium resolved in 13 patients, a significant majority (70%) had delirium at discharge. Patients with delirium resolution were less functionally impaired before hospitalization and exhibited fewer etiologic risk patterns at admission. Mild delirium was more likely to resolve than severe delirium. All patients with chronic cognitive impairment had persistent delirium. Care for hospitalized older patients with cancer should incorporate delirium prevention and intervention strategies. Caregiver education, communication between providers, and follow-up are critical when delirium persists. Additional research focusing on the management and impact of persistent delirium in hospitalized older patients with cancer is needed.