INTRODUCTION: HEALTHCARE, MENTAL HEALTHCARE AND THE ELDERLY
Cancer is a disease of all ages, but primarily of older adults. Approximately 60% of all cancers occur in ages 65 and above.1 Despite that, they are less likely to receive optimal comprehensive cancer care, including aggressive treatment, inclusion in clinical trials, and appropriate palliative treatment.2,3 According to Surbone et al,4 current practice for elderly cancer patients is based more on stereotypes than evidence. More than all it is sensed in the field of their mental health.
As the population grows older, many resources are being invested in the promotion of health of the elderly, being the most important component of quality of life. Their mental health, however, seems to be neglected, in particular among those coping with cancer. Their psychological essences are frequently not met properly and distress might be undetected. A lot of it has to do with the lack of research and knowledge about the experience of cancer in older people.5
Alike younger patients, the elderly also face emotional distress related to their illness, such as difficulties in adjustment, demoralization, fears from dependency on others, death, and dying. However, many of them feel that their psychosocial needs are not being considered and they are being undertreated.6 The relatively low rate of elderly cancer patients applying and receiving psychological support raises the question, whether it is due to healthcare professionals' ageism and indifference, or owing to the part of the elderly themselves, in responding to psychological means of interventions?
Under treatment may be a result of decision makers, who perceive elderly mental healthcare affairs as inferior among other components of healthcare policy. Also, in an overloaded public healthcare system (including mental healthcare), younger cancer patients tend to receive priority over the elderly, owing to a common assumption, that their psychological needs are more urgent. As for the healthcare providers, although ageism and age phobia are denied, they surely do exist. Many professionals find the field of geriatrics unattractive (both financially) and medical or psychological approaches actually derivate from standard protocols of general population and not from an evidence or practice-based gerontological conception.
The relatively small rates of elderly patients seeking for psychological counseling from their own initiative can be explained in several ways; many of them find emotional expressions very difficult, so they may perceive psychotherapy as potentially intrusive, uncomfortable, and even threatening. Many are still suspicious, carrying stigma and biases against psychological assistance, whereas some would like to receive support, but just don't have any available access to such facilities.
Altogether from both sides, communication between healthcare provider and the elderly patient may be cumbersome, either owing to patient's sensorial or cognitive decline, or owing to gaps of language, culture, and outlook between both sides. These obstacles, too, contribute to the unfortunate outcome of underdetection and undertreatment of emotional distress among elderly patients.2
PSYCHOLOGICAL NEEDS OF ELDERLY CANCER PATIENTS
The definition of “elderly” or “older people” is usually taken to be from age 65 and above. This large life span-when some people live to be 100 years old—is far from being homogenous, and the differences between a 65-year-old person living with cancer and an 88-year-old person living with the same illness are tremendous. Therefore, a more accurate descriptive mapping of the elderly population would be the classification between the younger old (age 65 to 74), mid-old (age 75 to 84) and old-old (age 85 and above).7 The following review is too concise to refer to each group separately, but addresses some issues, which in one way or another, exist throughout the entire spectrum of old age.
As opposed to younger patients, much less emphasis is put on the psychosocial needs of the elderly. It appears both as screening at time of diagnosis or monitoring during the period of treatments and by that, creates a risk for undetected emotional symptoms. The unpaid attention to the psychosocial needs of the elderly somehow stems from a nondeliberate presumption that to them, cancer is a natural, unavoidable part of aging. Assuming that, there should not be any reason for emotional distress.
As mental health is not always apparent as physical health, it frequently tends to hide behind physical, somatic symptoms. The conversion of emotional pain to somatic symptoms is a very common phenomenon among the elderly, who from the outset tend to present a rather limited repertoire of emotional expressions.8
Most of the psychological needs of elderly cancer patients stem from the fact, that their missions of adjustment are much more complex than in younger ages: Recent theories of psychological development (eg, Baltes,9) claim that the human personality develops throughout the entire life span, even more so in older ages, when many adjustments to life changes occur. However, the ability to cope with aging-related losses has a significant impact on the direction of adjustment—whether toward decrease in abilities and functions or toward personal growth.
Coping with a changing reality, or in other words, adjusting, is twice as hard for a cancer patient who is also old and frequently suffers from comorbidities, losses which are sometimes permanent. Lack of satisfactory supportive system may also contribute to complex adjustment; older people have usually retired from work, have experience loss of friends or relatives, and tend to be less involved in society. In addition, financial difficulties might have a destructive influence, both on physical and mental status.
However, altogether with certain difficulties, elderly cancer patients do have unique advantages, being derived from their age and accumulated experience in life; along the process of aging, psycho-developmental processes, such as ego integration, development of wisdom, and mature evaluation of importance versus unimportance.10
AGE-RELATED COPING MECHANISMS
Whereas the biomedical approach tends to focus on losses and disabilities occurring in older ages, the bio-psychosocial approach tries to balance the image, by pointing out considerable virtues older people may achieve while growing older. In fact, the psychological impact of cancer is less negative in the elderly compared with younger patients.6 There was strong evidence to better adjustment reactions among elderly people and better management of illness, despite the mentioned complex missions of adjustment.11 Providing explanations to those findings would be based on the examination of the unique psychological resources older people generally have, which distinguish their ways of coping from younger adults.
Assuming that older people may have started coming to terms with their own mortality provides a rather reasonable explanation to these findings.12 In other words, preoccupation with an imminent death is a rather natural process followed by aging itself and doesn't have to do necessarily with cancer. Elderly people’s levels of death anxiety are substantially lower than of younger people,13 and the recognition of having lived a good life decreases fear of death even more.14
Another important predictive factor for positive coping would be emotional resilience. Being derived from accumulated experience in life, especially of stressful life events, it provides a technical advantage for people who have lived longer. Being diagnosed with a life-threatening illness is much more easily taken in proportional perspective when current illness is defined as another—difficult—though manageable challenge, such as other obstacles, which had been overcome along one's personal history.
Owing to previous experiences of coping with illnesses and their management, apprehension of cancer may seem to be less fatalistic. Reflective reconstruction of idiosyncratic coping resources, which proved to be effective in the past, provide a sense of mastery and self-efficacy to deal with present. Self-efficacy, defined as belief system of one's own abilities to fulfill its own expectations, goals, or missions, was proven to be an extremely important psychosocial predictor of effective coping in the elderly cancer patient.14 However, emotional well-being is much more derived from one's sense of meaning in life rather than any of its coping mechanisms.15 Sense of purpose and meaning in life create the foundations of the will and reason for living. Passive and emotional-focused coping strategies are also useful adaptive mechanisms, common among the elderly,4 which assist in maintaining some sense of control over their emotional and cognitive reaction.
Even if secular, many elderly people are likely to take part—mostly before illness—in traditional, communal, and/or spiritual rituals. Cultural reliance, too, plays a major protective role, by preventing sense of identity from coming apart, especially owing to illness-related losses.4 Rituals and community involvement may prevent social isolation, maintain relevance and participation in life, and most important, may exist unconditionally to any physical state.
As for the body-mind connection, chronic illnesses generally serve as a major cause for physical deterioration of the elderly. Cancer, however, was interestingly found to be much less harmful to the performance status.16 If physical adjustment to cancer is not so bothersome, then the accompanied psychological distress would be rather minor.
Aiming to treat psychopathologies or personality weaknesses is not only irrelevant while working with elderly patients, but might also be harmful. For an elderly patient, to whom sometimes the first encounter with psychological counseling, support and comfort are required. Legitimizing and encouraging varied emotional expressions would be a major focus of discussion, since elderly, in general, are used to expressing themselves in a somatic language rather than an emotional one. It is the patient's unique opportunity to be listened, absorb his thoughts deeply and seriously, with no particular intention of changing his character, behavior or manner. Extra modesty of the therapist is required due to that, especially when the age differences between him and the patient are significant.8
Furthermore, emphasizing their personal strengths and inner resources for optimal coping is what they need. Psychotherapy with the elderly ought to highlight what there still is, and not on what there isn't any longer, or will never be.
Considering therapeutic approaches, suitable to the world of contents of the elderly, would increase probability for effective outcomes and empowerment, as opposed to irrelevant approaches, which might cause frustration or even increase existing distress. Hence, existential approaches, life review, and meaning focused techniques are usually considered the treatments of choice for elderly people, moreover when life is under threat. If depression is suspected, psycho-geriatrician's assessment is highly recommended, both for ruling out mental deteriorations, which frequently seems as depression, and also for considering pharmacological interventions, for alleviating severe distress, in addition to psychotherapeutic interventions.
Finally, one must not forget the patients' support system and its crucial importance in maintaining emotional well-being. Unlike younger cancer patients, who are usually embraced and cared all over, the elderly patient many times has to cope more or less alone. Promoting family and/or caregivers' involvement on a regular basis may alleviate loneliness-related emotional distress, intensify patient's involvement in daily life, and increase positive self esteem.
The ability to choose one’s coping style to living with cancer was proven to be crucial for effective coping.14 Elderly people frequently don't receive the freedom of choice, either owing to family members who take upon themselves the role of decision-making; lack of medical information disclosure; and most of all—lack of attention to their functional, psychological, social, and spiritual needs.
Therefore, supporting older patients with cancer would mean respecting their choices, not only in the medical aspect, but also in the way they decide to cope and express themselves. Preserving dignity may alleviate feelings of helplessness and alienation and most certainly maintain the individual's will to live, for the sake of a meaningful tomorrow.