Spécificités de la psycho-oncologie du sujet âgé

The specificity of cancer is at the origin of emotional, cognitive and behavioural reactions in old age as well as in other stages of life. It is important to understand the particularities due to ageing to be able to listen to, to help express emotions, to inform and to better support patients. That is why in this paper the authors envisage the psychological vulnerability of elderly persons, the psychological processes at work from the first symptom of cancer to the treatment phase via investigations and announcing the diagnosis. Finally they evoke the psychopathological disorders that arise with elderly patients with cancer and the specificities of the diagnosis approach.     

Intérêt d'une approche multidisciplinaire en psycho-oncologie des personnes âgées

Old age is not an illness. However the incidence of cancer increases with age. The care of elderly persons with cancer has its own “technical” specificities that will lead to decide whether to apply or not, to adjust or not, cancer treatments in the most individual way possible. This implies a global and pluri-disciplinary approach of the elderly cancer patient. Among the actors of care, psycho-oncologists will have to explore the vast and little-known world of the behaviour of elderly cancer patients, their repercussions on the illness and the results of the treatments on the quality of life of the patients. That is what the “onco-more or less psychologist” expects from the “psycho-more or less oncologist”…     

Acute STEMI in old and very old patients. The real life

OBJECTIVES: From a prospective multicenter registry, we evaluated in three non-academic interventional cardiologic centers (Alsace/France), the coverage and the feasibility of the percutaneous coronary angioplasty (PTCA) in the acute phase of STEMI in the elderly (patients 75-years old and more). METHODS: We studied clinical characteristics and angiographic data of patients older than 75 years, and the PTCA results: the revascularisation rates and the intrahospital events were analysed. These data were compared with those of the younger patients and confronted with the literature data. RESULTS: Of a total of 1672 patients admitted for a STEMI, 342 (20.45%) were older than 75 years. These patients represented a high-risk group with a high proportion of women (50%), and many co-morbidities (e.g.: hypertension and diabetes mellitus), and three-vessel disease was found more often than in younger patients. Mortality rate was high in this subgroup and always more severe as compared to younger subjects, but remains variable according to the initial clinical profile. The global mortality was 20.47% but fell to 5.41% if we excluded the patients with cardiogenic shock, in Killip III and after resuscitation. PTCA is a coronary reperfusion technique particularly indicated in the management of the elderly presenting a STEMI. It is an effective technique in term of revascularisation, the reperfusion success (exclusively TIMI III flow) was indeed raised in the elderly even though it is lower than in younger patients (93.88 vs 97.18%). It is a quickly accessible technique, cath-lab accessibility provided, allowing a fast reperfusion and reducing hospitalization to a minimum. The management of the elderly presenting a STEMI has to focus on reducing the preadmission delay since this subgroup of patients hesitates to call the emergency (SMUR) when presenting an acute coronary symptomatology. The shorter the delay till admittance, the better the outcome. CONCLUSION: PTCA is a technique particularly indicated in the elderly in Alsace because of regional specificities: first of all geographic (proximity of the SMUR for virtually all the population of Alsace), and secondly the medical infrastructure since the strategy of exclusive primary PTCA is granted by numerous interventional cardiologic teams. In Alsace, the proportion of elderly patients (> or = 75 years) is going to increase significantly with a parallel rise of STEMI--"a frightening perspective". We have to take into account this evolution, this reperfusion technique presenting numerous advantages and very few complications.     

Le centre de jour interne d’un service de gérontologie

In this article is reported the experience of a Gerontology department in the treatment of psychological and behavioral disorders, by means of an internal day care center. Historically, the creation of a day care center, within the Gerontology departement of the Bicêtre hospital (France), was the result of a reflection and experiences carried out for several years, about the difficult care of inpatients with psychological and behavioral disorders. The project was designed to meet the need of creating a place where these disorders might be more completely understood and treated. Given the previous experiences in this department and in others, the day care center had to reach several aims:

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to be comforting and to allow affective relations, pleasure and meaning;

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to protect and give the desire of being;

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to enable analysis and care of behavioral disorders;

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to keep or better the cognitive state;

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to strengthen the autonomy;

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to propose individual care;

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to reduce the use of psychotropic medications.

The main indications of the day care center are the psychological and behavioral disorders in dementia; these disorders are bound directly to dementia or are symptoms of anxiety, depression or delusion. Limits are imposed by the patient condition, particularly if there is a very severe cognitive impairment, an apathy or certain personality disorders. In the day care center, several therapeutic approaches may be gathered:

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psychotherapy techniques individually or in a group;

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re-education or re-learning of cognitive functions that is rather a play activity than a school class;

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social activities : meetings, meals, outside visits;

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body care : massage, relaxation, esthetics;

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work therapy, artistic activities : music, cooking…

Whatever kind of therapy is used, the affective dimension is the most important. A study of the effectiveness of the day care center had been carried out during the first year of activity (2000-2001). Twenty one patients had been included and they had stayed in the center for six months on average; 11 with Alzheimer dementia, 2 vascular dementia, 2 fronto-temporal dementia, 3 with old psychiatric pathologies and 3 somatic pathologies. The patients state had been assessed by several scales: Mini Mental State Examination, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression, Activities of Daily Living, Instrumental Activities of Daily Living. The findings of the study were that the condition of certain patients was clearly bettered by the stay in the day care center; these patients had a mild or average cognitive impairment (MMS > 10) or were depressed (Cornell > 10). But the assessment of severe dementia is very difficult, and some psychological improvements in the condition of these patients can't be taken into account by scales. Thus, this day center can take care of many patients including those with severe cognitive impairment and associated disorders; in addition, it must play a role of observation, analysis and research in order to optimize care in the whole department.     

Acceptability of Elderly Cancer Patients and Tolerance to COVID-19 Vaccination in the Brittany Region<br/>L’acceptabilité du Patient Âgé Porteur de Cancer et la Tolérance à la Vaccination Anti-COVID-19 dans la Région Bretagne

Context: Since January 2021, vaccination for COVID-19 has been made possible in France for people aged 75 and over. Patients suffering from a cancer disease are part of a group at risk to develop severe complications to COVID-19. Method: The « Unité de coordination en Onco-Gériatrie région Bretagne » (the Brittany This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Coordinating Unit in Onco-Geriatrics) has wished to set up an inquest about the acceptability and the tolerance to COVID-19 vaccination by old-aged patients suffering from cancer in the Brittany region. Results: The study has been carried out between May 1, 2021 and August 31, 2021 in 7 Breton centers. 50 patients have been included in the study with an average age of 84 (72-93). At the time of inclusion, 43 patients had already been vaccinated (80% having had 2 injections and 8% only one). Among them, 86% have declared they had had a very good tolerance to the first injection of the vaccine, and 90% to the second injection. 12% of the patients had not been vaccinated. Conclusion: Overall, in our study, old-aged patients suffering from cancer haven’t been reluctant to the antiCOVID-19 vaccination and have shown a very good tolerance to these vaccines. However, seen the profile of these patients and the period of inclusion, the number of patients showing a complete vaccinal outline should have been more consistent, indeed even total.

RÉSUMÉ
Contexte: Depuis le 25 janvier 2021, la vaccination de la COVID-19 a pu être réalisée en France auprès des personnes âgées de 75 ans et plus. Les patients souffrant d’une maladie cancéreuse font partie des groupes à risque de développer des complications sévères à la COVID-19. Méthode: L’Unité de Coordination en Onco-Gériatrie région Bretagne a souhaité mettre en place une enquête sur l’acceptabilité du patient âgé porteur de cancer et sur la tolérance à la vaccination anti-COVID 19 dans la région Bretagne. Résultats: L’étude a été réalisée entre le 1^er mai 2021 et le 31 août 2021 dans 7 centres bretons. 50 patients ont été inclus avec un âge médian de 84 ans (72–93). 43 patients au moment de l’inclusion avaient été vaccinés (80% ayant eu 2 injections et 8% une seule injection). Parmi eux, 86% ont déclaré avoir eu une très bonne tolérance à la première injection du vaccin et 90 % à la seconde injection. 12% des patients n’étaient pas vaccinés. Conclusion: Globalement, dans notre étude, les patients âgés porteurs de cancer ne présentaient pas de réticence à lavaccination anti-COVID19 et ont eu une très bonne tolérance à ces vaccins. Cependant, au vu du profil de ces patients et de la période d’inclusion, le nombre de patients présentant un schéma vaccinal complet aurait pu être plus conséquent.