Through Case Presentation and Dydactics, participants will gain an understanding of the psychological and behavioral impact cancer has on older adults.

1. Psychiatry & Behavioral Medicine Symposium

2. Psychological and Behavioral
Implications of Cancer in Older Adults
Sherry Romero, LMSW
Kimberly Reynolds, LMSW
October 9, 2019

3. Disclosures
There are no financial or other conflicts of interest.
3

4. Cancer can be devastating and stressful for
anyone, but older adults have a unique set of
stressors that can make navigating cancer even
more complicated. The purpose of this presentation
is to identify what those stressors are and to
integrate meaningful treatment approaches that
acknowledge and address the psychological and
behavioral implications for older adults with cancer.
4

5. Objectives
• Participants will be able to identify common stressors faced by older
adults with cancer.
• Participants will understand the basics of using CBT and ACT as
evidence based methods of treating psychological and behavioral
concerns in older adults with cancer.
• Participants will be able to identify resources for psychological and
behavioral concerns in older adults with cancer.
5

6. Characteristics of Older Adults with Cancer
6

7. Who Are We Talking About?
For the purpose of this presentation, Older Adults are defined as
individuals age 60 years and older.
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8. Why Is This Topic Important?
“About 60% of cancers occur in people 65 years of age or older.
Furthermore, about 70% of the deaths caused by cancers occur in this
stage.”
Cancer of the elderly frequently exhibits slower growth, because their
bodies already have a slower rate of cell development. However, older
people have a lower health literacy and tend to see health concerns or
discomfort as age related, which can lead to a delayed diagnosis.
Estape, T., (2017). Cancer in the Elderly, Challenges and Barriers. Asia-Pacific Journal of Oncology Nursing https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5763438/
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9. A Reluctant Member of the Care Team
Our older generation comes from a time when Doctors sometimes made
decisions without talking with patients, or determined how much
information to share with them. The older patients now look to
physicians, and sometimes family members, to make treatment decisions
for them. Fear, lack of knowledge, lack of confidence, etc. contribute to
this insecurity however the importance of including patients (with support
from family and medical providers) in treatment decisions cannot be
understated.
9

10. Signs and symptoms of fear and anxiety include:
• Anxious facial expressions
• Uncontrolled worry
• Trouble solving problems and focusing thoughts
• Muscle tension (the person may also look tense or tight)
• Trembling or shaking
• Restlessness, may feel keyed up or on edge
• Dry mouth
• Irritability or angry outbursts (grouchy or short-tempered)
https://www.cancer.org/treatment/treatments-and-side-effects/emotional-side-effects/anxiety-fear-depression.html
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Depression, Anxiety and Cancer

11. Depression, Anxiety and Cancer Continued
11
Symptoms of clinical depression
• Ongoing sad, hopeless, or “empty” mood for most of the day
• Loss of interest or pleasure in almost all activities most of the time
• Major weight loss (when not dieting) or weight gain
• Being slowed down or restless and agitated almost every day, enough for others
to notice
• Extreme tiredness (fatigue) or loss of energy
• Trouble sleeping with early waking, sleeping too much, or not being able to sleep
• Trouble focusing thoughts, remembering, or making decisions
• Feeling guilty, worthless, or helpless
• Frequent thoughts of death or suicide (not just fear of death), suicide plans or
attempts

12. Suicide Risk Factors
12
https://www.cancernetwork.com/article/suicide-patients-cancer-identifying-risk-factors

13. Suicide Risk Factors continued
• Depression
• Hopelessness
• Demoralization – similar to hopelessness, but denotes a perceived
inability to cope and is associated with a loss of meaning and a sense
of disheartenment. *Stronger predictor than depression.
• Pain
• Lack of Social Support
https://www.cancernetwork.com/article/suicide-patients-cancer-identifying-risk-factors
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14. Suicide Risk Factors continued
• Perceived Burden to Others
• Personality Traits
• Psychiatric History
• Existential Concerns – loss of meaning, purpose, dignity. Regrets,
Spiritual concerns…
https://www.cancernetwork.com/article/suicide-patients-cancer-identifying-risk-factors
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15. Interventions
• Normalize conversations about suicide
• Screening – PHQ-9, Columbia Suicide Severity Rating Scale,
Distress Screening (LHCP)
• Safety Planning
• Coping Strategies
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16. Interventions continued
• Mental Health Treatment
• ACT Strategies
• Values – Identifying what is important to you, to make a
meaningful life.
• Committed Action – Taking the steps to live according to our
values.
• CBT Strategies
• Cognitive Restructuring
16

17. Interventions continued
• DBT Strategies
• Distress Tolerance
• Mindfulness
• Increase supports to patient and family
• Homecare
• Support Groups
• Religious/Spiritual
17

18. Stigma About Mental Health Treatment
• Generational attitudes.
• Denial of mental health issues
• May chose to deal with it privately
• Stoicism
• Shame
• Reluctant to take medications
• Distrust of medical system
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19. Identifying and Overcoming Psychosocial Barriers
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20. Decreased Support System/Loneliness
▪ Loss of same age friends and family to death.
▪ Family living out of town.
▪ Loss of mobility, unable to attend social gatherings.
▪ Living with chronic diseases.
▪ Isolation due to depression and lack of confidence in abilities.
▪ Lower computer literacy makes finding resources more difficult.
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21. Interventions
• Cognitive Behavioral Therapy Strategies
• Behavioral Activation
• Increase engagement in adaptive activities (reinforcing pleasure
and/or mastery).
• Decrease engagement in activities that support depression (i.e.,
isolation).
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22. Behavioral Activation in Action
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23. 23

24. Interventions continued
• Increase support system
• Support Groups
• Area Agency on Aging/Senior Neighbors (i.e., Friendly Visitor
program)
• Congregate Lunches
• Access resources (i.e., transportation) to decrease isolation
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25. Cognitive Changes
Medical causes may mimic symptoms of dementia and/or age related
memory changes and are important to rule out.
• UTI
• Metastases
• Medication Interactions
• Side effects of treatment (“Chemo Brain”)
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26. Implications and Interventions
• Is patient able to make informed medical decisions?
• Referral to Psychiatry/Neuropsychiatry for evaluation
• Does patient need help with medication administration?
• Medication Box set up, reminder calls/alarms, Visiting Nurse, etc.
• Can the patient participate in, and benefit from, Psychotherapy?
• Refer to Supportive Care Medicine
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27. Behavioral Interventions
• Cue cards placed around the home.
• Check lists, Calendars, etc.
• Exercise can help with depression and fatigue that can accompany
“chemobrain.”
• Mental stimulation, such as working puzzles, games, etc.
• Establish a routine. Simple things such as putting your keys in the
same place every day, sticking to a normal schedule, etc. can help
patients keep on track.
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28. Interventions continued
• Take a friend/family member to appointments and ask them to take
notes.
• Get plenty of rest.
• Follow good nutrition. Eating well and drinking plenty of fluids helps
restore energy levels and helps maintain cognitive function.
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29. Intimacy
• Body Changes/Body Image
• Fear
• Fatigue
• Role changes
29

30. Interventions
• Normalize and encourage open communication with partner.
• Explore other ways of being intimate.
• Couple’s Therapy.
• Sex Therapy
• Encourage patient (and partner) to discuss concerns with Doctor.
30

31. Changes in Family Dynamics
• Challenges of an over-involved, or under-involved, family.
• Conflict between family members over treatment decisions, care,
etc.
• Lack of support, regrets, rumination, comparisons to other families.
• Role changes – caregiver now needs care.
31

32. Changes in Family Dynamics, continued
• Tendency to minimize need for help
• Don’t want to be a burden
• Don’t see, or want to admit to, physical or cognitive decline
• Fight to maintain independence
32

33. Interventions
• Focus on value and relevancy.
• Identify spheres of control.
• Facilitate process of adjustment to loss and setting new goals.
• Family Therapy
• Effective communication
• Role identification
• Transition
33

34. Caregiver Fatigue
Cancer is a family disease, and caregivers also experience the
emotional, social and spiritual aspects of the disease.
“Family members who care for a loved one with cancer during the last
months of life are 5 to 7 times more likely to have mental health
problems, compared with the general population, according to a study
published online in the journal Palliative Medicine.”
https://www.psychcongress.com/article/caring-relative-cancer-spikes-risk-mental-distress
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35. Challenges of Caregiving
“If we can ensure that carers feel better supported, we are likely to
reduce some of the more extreme stresses of caregiving,” Dr. Grande
said, “so that carers are more able to carry on their valuable work without
being ‘broken’ by the experience.”
https://www.psychcongress.com/article/caring-relative-cancer-spikes-risk-mental-distress
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36. Challenges of Caregiving
• Patient may over-identify with the sick role.
• Caregiver not taking care of self.
• Anticipatory grieving.
• Caregiver loses their own activities due to care needs.
• Loss of identity due to role change.
• Feelings of guilt, resentment.
• Feelings of depression and anxiety.
36

37. Interventions
• Identify and Examine your thoughts (Cognitive Restructuring)
• Identify the thought that is making you feel anxious, sad, angry, etc.
• What evidence supports this thought?
• What evidence suggests this thought is NOT true?
• Are there other possibilities or explanations?
• What is a more realistic thought?
37

38. Interventions continued
• Make sure your own questions get answered.
• Simplify – when possible, cut back or delegate lesser responsibilities,
set limits.
• Take care of yourself!
• Strengthen your support system.
38

39. Interventions continued
• Consider counseling or a support group.
• Supportive Care Medicine
• Gilda’s Club
• Belong – Beating Cancer Together app (American Cancer Society)
• Online Cancer Chat/Support Groups
• Delegate/Access Resources
39

40. 40

41. Economic Challenges
• Fixed income
• Savings wiped out by medical bills
• Assets may prevent meeting criteria of assistance programs
• Reticent to spend savings earmarked for family/children
• Loving couples may consider divorce to protect assets
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42. Economic Challenges
• Housing
• Struggle with upkeep of home
• Difficulty making decisions about changing living arrangements
• Adjustment difficulty when accepting the need for, or transitioning
to, a different level of care
42

43. Interventions
• CBT
• Decatastrophizing.
43

44. 44

45. 45

46. What Patients Can Do
• Get organized.
• Disorganization costs money: you buy things you forgot or can’t
find, you think a bill is wrong but don’t have the receipt, etc.
• Accept help.
• Create a list of things that would be useful such as meals, rides to
chemotherapy, grocery shopping, etc.
• Accept financial help.
• Go Fund Me, Amazon Wishlist
46

47. What Patients Can Do continued
• Explore Assistance Programs
• Pharmacy
• Cancer Funding
See Handouts for resources.
47

48. Increased Health Issues
People age 60 and older are more likely to have one or more long-lasting health
problems in addition to cancer. These may include:
•High blood pressure
•Heart disease
•Lung disease
•Diabetes
•Kidney disease
•Arthritis
48

49. Increased Health Issues continued
It is important to know how a chronic health problem can affect cancer
treatment. Risks can include:
• Reactions between your cancer drugs and other medications.
• Cancer or its treatment making your chronic health problems worse.
This could make it harder to finish cancer treatment as planned.
• Slower recovery from cancer treatment because of other health
problems.
“When Cancer is Not Your Only Health Concern.” Cancer.Net, 05/2019. https://www.cancer.net/navigating-cancer-care/older-adults/when-cancer-not-your-only-health-concern
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50. Increased Health Issues continued
• Pain related and/or unrelated to cancer
• Decreased stamina
• Side effects of treatment
• Normal aging process
50

51. 51
Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.,D., & Karlin, B.E. (2014) Cognitive Behavioral Therapy for Chronic Pain Among Veterans: Therapist Manual. Washington,
DC: U.S. Department of Veterans Affairs.

52. Interventions
• Activity pacing to manage pain and fatigue
• Pain Cycle vs Activity-Rest Cycle
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https://www.mentalhealth.va.gov/coe/cesamh/docs/Activity_Pacing-patients.pdf

53. Intervention continued
Pain changes a person. Sometimes the task for the
day is just surviving, and that’s enough.
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54. Interventions continued
• ACT strategies for pain Management - ACT believes that while pain
hurts, it is the “struggle” with pain that causes suffering.
• Psychological flexibility encourages patients to stop trying to control
their pain and to accept the face that unpleasant experiences are a
part of life.
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55. Interventions continued
• The ACT strategy of Cognitive Defusion teaches patients to notice
thoughts as they occur without attaching any significance to them.
• The patient chooses to not allow their thoughts about pain to
influence or control their thoughts and behavior.
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56. Interventions continued
• Mindfulness
• Bringing your attention and awareness to the moment.
• Grounding strategies.
• A way to refocus. If your focus is on the pain, the pain feels worse.
By bringing your focus to something else, the pain feels less
intense.
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57. 57
S Stop!
T Take a deep breath!
O Observe
P Proceed mindfully

58. Interventions continued
• Relaxation
• Paced breathing.
• Imagery.
• Self-Soothing (Candles, warm bath/shower, etc.).
• Five Senses
• Meditation (apps, guided meditation, prayer)
• Movement: Yoga, Tai Chi, walking
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59. Survivorship – Now What?
• Transition from fighting for life to living again.
• May have spent/given away assets.
• Finding their “New Normal.”
• Increased symptoms of depression/anxiety post treatment.
• Learning to cope with anxiety related to possible recurrence.
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60. Interventions
• ACT
• Values and Committed Action
• Connecting with the present moment.
• Self as Context
• Radical Acceptance that cancer has changed life. Finding the
blessing from cancer.
• Mindfulness
• CBT
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61. End of Life Issues - Patient
• Grief
• Patient’s “need” to make sure everyone else is alright.
• Fear
• Spiritual
• Physical
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62. End of Life Issues – Patient continued
• Anger
• Why me?
• Blame - towards medical community, self, environmental factors.
• Can trigger Spiritual Crisis.
• Mad at God
• Guilt
• Questions about the After life
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63. Interventions continued
• End of Life Planning
• Advance Directives.
• Funeral Planning.
• Writing a will.
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64. Interventions
• Legacy Work
• Life Review
• CBT – Cognitive Restructuring – Thoughts based in fact, opinion,
fear?
• Acceptance
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65. End of Life Issues- Family
• Family feelings of guilt
• Hospice
• Unresolved relationship issues - regrets
• Anger
• Grief
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66. Interventions
• CBT
• Cognitive Restructuring – Thoughts based in fact, opinion?
• Gratitude
• Mindfulness
• ACT
• Connecting with the present moment
• Acceptance
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67. Interventions continued
Grief Counseling - Psychologist J. W. Worden created a stage-based
model for coping with the death of a loved one. He divided the
bereavement process into Four Tasks of Mourning:
• To accept the reality of the loss
• To work through the pain of grief
• To adjust to life without the deceased
• To maintain a connection to the deceased while moving on with life
https://www.goodtherapy.org/learn-about-therapy/issues/grief
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68. Interventions continued
• Accept your feelings. Sadness, loneliness, fear, confusion, regret,
anger—these are among the many feelings that may occur, and are
completely normal. It is important to express your feelings, without
judgement of them.
• Be patient with yourself. Grief is an individual process and is not
linear but comes and goes in waves.
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69. Interventions continued
• Pay attention to physical needs. It is important to get adequate
sleep, eat nutritionally balanced meals, get physical activity and
make time for relaxation.
• Accept the help of others. Understand that grief takes a great deal
of energy and can be exhausting. Accept offers of help and
support, and don’t be afraid to reach out. Many times our family
and friends want to help, but don’t know what to do.
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70. Interventions continued
• Limit your responsibilities. When possible, limit your
responsibilities and take this time to regain your balance. Grief
takes time and energy. Pace yourself.
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71. Other Considerations…
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72. Safety Concerns
• Mobility concerns (pain, weakness, etc.).
• Memory/Cognition.
• Environment.
• Is home safe?
• Difficulty maintaining home
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73. Interventions
• Social Work Referral.
• Physical Therapy Consult.
• Increase Supports (family, homecare).
• Community Resources.
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74. Resources
See handouts
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75. References
“Activity Pacing.” Veteran’s Association. https://www.mentalhealth.va.gov/coe/cesamh/docs/Activity_Pacing-patients.pdf
“Anxiety, Fear and Depression. Having Cancer Affects Your Emotional Health.” American Cancer Society, 04/2016.
https://www.cancer.org/treatment/treatments-and-side-effects/emotional-side-effects/anxiety-fear-depression.html
Bach, P. and Moran, D. (2008). ACT In Practice: Case Conceptualization in Acceptance & Commitment Therapy.
Oakland, CA: New Harbinger Publications, Inc.
Beck J. S. (2011). Cognitive Behavior Therapy: Basics and Beyond. New York, NY: Guilford Press.
“Decatastrophizing.” Retrieved 9/28/19 from TherapistAid.com. https://www.therapistaid.com/therapy-
worksheet/decatastrophizing
Estape, T., (2017). Cancer in the Elderly, Challenges and Barriers. Asia-Pacific Journal of Oncology Nursing
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5763438/
Gordon, T., Borushok, J. (2017). The Act Approach, A Comprehensive Guide for Acceptance and Commitment Therapy.
Eau Claire, WI: PESI Publishing & Media
75

76. References continued
“Grief, Loss and Bereavement,” June 21, 2018. Good Therapy.org. https://www.goodtherapy.org/learn-about-
therapy/issues/grief
Harris, R. (2009). ACT Made Simple. Oakland, CA: New Harbinger Publications.
Harris, R. (2008). The Happiness Trap: How to stop struggling and start living. Boston, MA: Trumpeter.
McFarland, D., Walsh, L., Napolitano, S., Morita, J. and Jaiswal, R. (2019) Suicide in Patients With Cancer: Identifying
The Risk Factors. CancerNetwork. https://www.cancernetwork.com/article/suicide-patients-cancer-identifying-risk-
factors/page/0/1
Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.,D., & Karlin, B.E. (2014) Cognitive Behavioral Therapy for
Chronic Pain Among Veterans: Therapist Manual. Washington, DC: U.S. Department of Veterans Affairs.
Sears, R. (2017). Cognitive Behavioral Therapy & Mindfulness Toolbox. Eau Claire, WI: PESI Publishing & Media.
Tumolo, J. (2018) Caring for Relatives With Cancer Spikes Risk of Mental Distress. Psychiatry & Behavioral Health
Learning Network. https://www.psychcongress.com/article/caring-relative-cancer-spikes-risk-mental-distress
76

77. References continued
Weekly Activity Diary. Retrieved November 12, 2015 from GET.gg Web Site:
https://www.getselfhelp.co.uk//docs/BACEdiary-weekly.pdf
“When Cancer is Not Your Only Health Concern.” Cancer.Net, 05/2019. https://www.cancer.net/navigating-cancer-
care/older-adults/when-cancer-not-your-only-health-concern
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