Mr. B is a 73-year-old retired mechanical engineer. He enjoys flying model airplanes, playing golf, and woodworking, and he walks with his wife three to four times a week. Other than a few chronic health issues, including osteoarthritis, hypertension, and peripheral vascular disease, managed with exercise, diet, and medication, Mr. B has been in excellent health.
About 6 months ago, Mr. B experienced a noticeable change in energy level. A comprehensive cardiac evaluation, including renal function tests, was completed—all of which were negative. Three months passed with no improvement. As time progressed, Mr. B complained of back pain and being unable to “make his legs work.” Gradually, he gave up all leisure activities because he was unable to walk even a few feet or stand for any period of time without monumental effort. Even walks in the mall or a grocery store resulted in rest periods every 50 feet or so. Mr. B's appetite diminished, but he forced himself to eat, adding nutrient shakes to his diet.
His physician completed even more diagnostic tests and blood work, but the results were unremarkable except for an abnormally low hemoglobin level. The physician suggested a blood transfusion, which gave Mr. B energy for a couple of days. However, the frequency of the transfusions increased and the energy provided from each transfusion decreased. Still there was no confirmed diagnosis almost 4 months after the first energy changes.
Mr. B began needing help with activities of daily living (ADLs), turned away favorite foods, and had to plan rest periods around visits with family. He was admitted to the hospital for further evaluation and transfusions. Within 24 hours of admission, he was confused and jaundiced, with elevated liver enzymes and an increased white blood cell (WBC) count. He was diagnosis with acute myeloid leukemia (AML) and died the same week—only 6 months after his initial complaint.
What's happening with the cells?
Leukemia is a malignancy involving the bone marrow—the site where blood cells are formed. Leukemia specifically affects WBCs, causing abnormal cell growth and production. The American Cancer Society estimated that about 43,000 new cases of leukemia were diagnosed in the United States in 2010; close to 22,000 people died from leukemia in that same year. Leukemia is diagnosed 10 times more often in older adults than in children or younger adults.
The production of blood cells by the bone marrow is usually an efficient and balanced process. In leukemia, the balanced proliferation and maturation is altered, and normal bone marrow is ultimately replaced by abnormal, immature cells (see Picturing leukemia). These leukemia cells circulate in the body and invade organs responsible for blood formation, such as the liver, spleen, and lymph nodes, along with other sites. The leukemia cells compete with normal cellular processes in the body.
There are four basic types of leukemia, categorized by the speed of disease progression—acute or chronic—and the type of WBCs affected—lymphoid or myeloid cells (see Types of leukemia). In acute leukemia, fast-growing leukemia cells are unable to do the work of normal WBCs, and the disease worsens quickly. In chronic leukemia, the leukemia cells are able to function like normal WBCs at first. As the disease progresses, the leukemia cells are unable to compensate for normal WBCs.
Risk factors ahead
The risk factors for each type of leukemia vary to some degree, but some common risk factors do exist. One risk factor is age; about 70% of leukemia cases occur in individuals over age 60. The National Institutes of Health has identified older, White men as a high-risk population. Nutrition is another risk factor. Diets rich in fruits and vegetables help prevent changes to DNA that might be precursors to leukemia cell development. Deficiencies of folic acid and vitamins B12 and B6 are also risk factors.
Chronic exposure to some chemicals, such as benzene, increases the risk of AML and acute lymphocytic leukemia, especially in older adults. Before current regulations, benzene was found in some work areas and gasoline-related industries. It's also found in cigarette smoke. Chemotherapy used to treat other cancers may damage healthy cells and predispose the individual to leukemia. Exposure to radiation, including radiation therapy, has similar effects. People exposed to high levels of radiation, such as survivors of atomic bomb explosions in the 1940s or the recent nuclear accidents in Japan, are at increased risk as well. Researchers are investigating whether the accumulated effects of low levels of radiation, such as levels received in diagnostic X-rays, are also a risk factor.
People with some blood disorders may be at increased risk. In a small number of cases, genetics plays a role. Children with Down syndrome have a 10 to 20 times greater risk of developing leukemia compared with other individuals. A family history of leukemia can increase a person's risk, particularly for chronic lymphocytic leukemia (CLL). Infection with human T-cell leukemia virus type 1 is another risk factor that can cause a rare form of CLL. This virus is most commonly found in southern Japan and the Caribbean. Individuals in the United States infected with this virus are usually descendants of people in these regions or immigrants from these areas.
Signs and symptoms to look for
Leukemia symptoms vary by type (see What to look for). In chronic leukemia, the symptoms develop gradually and are unnoticeable at first. However, as the disease progress, the symptoms worsen. In some cases, an individual can have the disease for years without any obvious symptoms. In acute leukemia, the person usually feels sick enough to visit the healthcare provider.
Common symptoms of acute leukemia include:
- joint or bone pain
- fever and night sweats
- weight loss for unknown reasons
- weakness or tiredness
- frequent infections
- swollen lymph nodes in the neck and armpit
- bruising easily
- bleeding from the gums or under the skin layers.
Some people experience abdominal discomfort, especially if the spleen or liver is swollen. Some symptoms depend on where the leukemia cells collect. For example, cell accumulation in or near the brain may cause headaches, confusion, and loss of muscle control or even seizures. Other systems that may be affected are the digestive tract, kidneys, eyes, heart, and testes.
The basics of diagnosis
Diagnosis begins with a comprehensive history and physical exam, including chest X-rays and lab studies with a focus on WBCs, red blood cells (RBCs), platelet counts, and the presence of leukemia cells. WBC counts are usually very high, with platelet and hemoglobin levels low. However, in some cases, the WBC count may be normal or even abnormally low. Bone marrow aspiration or biopsy may also be performed to confirm the diagnosis. Typically, the aspirant or biopsy shows an increase in the number of bone marrow cells and the proportion of immature cells. A spinal tap may determine how the leukemia cells have spread.
Older adults: The differences
Although other cancers are more prevalent in the older adult population, older adults with leukemia are less likely to achieve remission. AML is the most common type of leukemia in older adults, and prevalence increases progressively after age 50. It's more common in men than in women. With the demographic shift and people living longer, increasing numbers of cases are expected in the future. Currently, older adults diagnosed with AML in their 60s have an 8% survival rate over 5 years; adults over age 80 when diagnosed have a 0% survival rate for the same period.
Why does leukemia, particularly AML, have such devastating outcomes? Age itself is one factor that significantly lowers the survival rate. Older adults are more likely to have comorbidities, such as diabetes and kidney, lung, and heart disease, that increase the risk of treatment complications. In addition, age-related changes may affect the patient's ability to tolerate the pathophysiologic changes of leukemia and aggressive treatments such as chemotherapy. Comor bidities may also limit the patient's ability to tolerate the potential adverse reactions of chemotherapy.
Tumor biology is another factor associated with poor outcomes; some older patients have a higher percentage of cytogenetic abnormalities, such as chromosomal or karyotype abnormalities. For some, the cytogenic changes enhance the production of leukemia cells and treatment resistance. Even with a more favorable cytogenetic picture, treatment outcomes are inferior to younger patients. Traditional chemotherapy or combination therapies are ineffective in older adults with AML. If chemotherapy is used, older adults are less able to tolerate the treatment or its adverse reactions. Lower functional status also predisposes the older patient to poor outcomes.
Treatment for older adults with leukemia
There's no agreement about the overall medical treatment plan for older adults with leukemia. Treatment modalities range from palliative care to aggressive therapies. The debate centers on whether it's beneficial to the patient to use standard chemotherapies, knowing the impact of treatment is often minimal and can have negative effects on overall quality of life.
Even the management plan for older patients in remission is controversial. Induction therapy is a common chemotherapy plan that involves a combination of drugs. Research suggests that patients over age 65 who are treated with induction therapy have a longer survival time than those who receive supportive care alone. However, no specific drugs have been identified for the induction plan. Decisions are made on a case-by-case basis.
One area of agreement is that treatment for patients in remission must focus on killing any residual leukemia cells to minimize recurrence. But for older patients who achieve remission, the treatment options aren't specific and may be too toxic to tolerate, causing a positive outcome such as maintaining remission to have debilitating health effects.
Making a decision about the best treatment is challenging for older patients. Predicting the prognosis of the disease process and the leukemia cells' toxicity is difficult. Most agree a comprehensive, multidisciplinary assessment will give the most accurate picture of comorbidities, physical and cognitive function, nutritional status, social support, and medication use. Some medical experts worry about the time it takes to complete the comprehensive assessment, knowing the potential speed of AML's devastating consequences.
The primary focus of nursing care for the older patient with leukemia is symptom management. An important nursing-care focus is the patient's functional ability. Assessment of walking ability, endurance, and walking speed outside the home are key characteristics of functional ability. Research suggests that maintaining physical function is an important factor in treatment success. Exercise can improve physical function and minimize the risk of disability. Some research suggests that exercise programs are important before and during treatment to minimize the risk of functional decline. You should assess basic ADLs, as well as instrumental activities such as the ability to cook meals, transport to appointments, and manage medications. You can use standardized scales for this assessment, along with self-reported information from the patient validated by caregivers or family members.
Patients receiving induction therapy may be at risk for tumor lysis syndrome, caused by speedy tumor cell breakdown. To prevent this, patients receive I.V. hydration with diuresis, urinary alkalization, and allopurinol before beginning induction therapy. Some chemotherapy agents also require special nursing care. For example, patients receiving high doses of cytarabine, a chemotherapy agent used mainly for cancers involving WBCs, may need saline or steroid eyedrops because of potential toxicity to the eye.
Chemotherapy produces myeloid suppression, increasing the patient's risk of infection, anemia, thrombocytopenia, and mucositis. Regular monitoring of WBC and RBC counts is imperative. Blood products may be administered to counteract the effects of anemia and thrombocytopenia. Minimizing infection risk is also important. Diligent hand washing, minimizing contact with animals and animal feces, and avoiding contact with people with colds and other infections will help minimize the risk. Optimal oral care will also help manage mucositis.
Another nursing-care consideration in older patients with leukemia is cognitive function. Cognitive function frequently changes in older adults with cancers and ultimately affects the ability to tolerate treatment and adequately accomplish daily functions. Long hospitalizations for treatment of leukemia also increase the older patient's risk of developing delirium.
Medication administration, a complex process for any older adult, may become even more complex with treatment for leukemia. Along with usual medications for preexisting conditions, the patient may also receive chemotherapy. Strategies to coordinate medication administration and minimize the risk of drug error are important.
Patients with leukemia often have a decreased appetite and dietary intake. Promoting good nutrition is an important nursing-care measure. Encourage the patient to eat a diet high in carbohydrates, along with vitamins and minerals. Some research shows that vitamin D is effective against certain leukemia cells, particularly AML cells. Encourage the patient to make food choices that appeal to the taste. Sandwiches, cold foods, and nutritious shakes may be more appealing than hot, spicy food. Encourage frequent, small meals rather than three meals a day. Medication for nausea and vomiting is another consideration. If the patient can't tolerate regular food products, total parental nutrition may be considered as a last resort.
Being tired and lacking energy is a common complaint and may worsen as the disease progresses. Fatigue is also a problem a few days after chemotherapy. Carefully assess the patient's level of fatigue and balance activities with periods of rest.
Remember to emphasize the importance of psychosocial support and emotional care for the older patient and family. A diagnosis of leukemia affects overall quality of life. Patients may be confused by the diagnosis and the available treatment options. Help the patient and family clarify information. Be available to answer the multitude of questions from both patients and families about currently needed care and the prognosis for the future. Patients may deny that this is really happening to them and express fear about the future. Just listening to these concerns is an important nursing measure.