Archives of Gerontology and Geriatrics 51 (2010) e57–e61

Assessment of pain, fatigue, sleep and quality of life (QoL) in elderly hospitalizedcancer patients

Sibel Eyigor a,*, Can Eyigor b, Ruchan Uslu c

a Ege University, Faculty of Medicine, Physical Therapy and Rehabilitation Department, Tulay Aktas Oncology Hospital, Supportive Care Unit, 35100 Bornova-Izmir, Turkeyb Ege University, Faculty of Medicine, Anesthesiology Department, Pain Clinic, 35100 Bornova-Izmir, Turkeyc Ege University, Faculty of Medicine, Medical Oncology Department, Tulay Aktas Oncology Hospital, Supportive Care Unit, 35100 Bornova-Izmir, Turkey

A R T I C L E I N F O

Article history:

Received 9 September 2009

Received in revised form 24 November 2009

Accepted 25 November 2009

Available online 30 December 2009

Keywords:

Cancer

Elderly

Pain

Fatigue

Sleep

Quality of life

A B S T R A C T

As the proportion of older adults in the population continues to grow, the number of patients with cancer

is expected to increase proportionally. In the previously conducted studies, data on elderly cancer

patients were generally compared with the QoL scores of elderly patient group and with the data of non-

cancer individuals. The purpose of this study was to examine differences in reported pain, fatigue, sleep

problems and QoL between middle-aged and elderly hospitalized patients with cancer. We included 53

middle-aged (between 18 and 50 years) hospitalized cancer patients and 47 elderly (>60 years)

hospitalized cancer patients in this study. Pain (visual analog scale = VAS, verbal pain rating), fatigue

(brief fatigue inventory = BFI), sleep problems, QoL (Short Form 36 = SF36), and European Organization

for Research and Treatment of Cancer (EORTC)-QoL-C30 data were gathered using standardized

measures. In the elderly group, no significant difference was detected in terms of VAS, verbal pain rating,

fatigue, fatigue type, sleep problems and QoL scores (p > 0.05). When the two age groups were

compared, BFI scores were found to be significantly high among the elderly patients (p < 0.05). A

significant relationship was observed in both age groups between the scores of pain, fatigue and sleep

problems, and QoL (p < 0.05). Elderly hospitalized cancer patients did not demonstrate a distinctive

difference in terms of pain, sleep and QoL compared to the younger group. The relationship between

pain, fatigue, sleep and QoL should be definitely kept in mind in clinical practice.

� 2009 Elsevier Ireland Ltd. All rights reserved.

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1. Introduction

Cancer is observed to be the most common disease all over theworld, and for most types of cancer, incidence rates increase withadvancing age (Wedding et al., 2007). As the proportion of olderadults in the population continues to grow, the number of patientswith cancer is expected to increase proportionally. Therefore, thepoints to be taken into consideration, such as the multi-perspectiveevaluation of the patient and expectations from the treatment,differ for elderly patients. The significance of this issue has recentlyincreased among geriatrists and oncologists (Gosney, 2007; Maaset al., 2007). Although young cancer patients reach the maximumphysical and psychological function approximately 1 year after theprimary treatment, older adult cancer survivors face with severalproblems (Robb et al., 2007). The prevalence of chronic diseases ishigh in the elderly group and co-morbidities add to the existingstress in these patients. The incidence of functional, physical andpsychological problems increases with age. Besides, the two agegroups show differences in terms of response to treatment, side

* Corresponding author. Tel.: +90 232 3903 6887; fax: +90 232 3881 953.

E-mail address: eyigor@hotmail.com (S. Eyigor).

0167-4943/$ – see front matter � 2009 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.archger.2009.11.018

effects and treatment expectations (e.g., relatively shorter lifeexpectancy, side effects) (Mandelblatt et al., 2003; Robb et al.,2007). However, few studies have focused solely on elderly peoplewith cancer (Thome et al., 2004).

Many adverse events can be observed in cancer patients, eitherdue to the disease itself or the treatment. Pain is one of the majorproblems faced by cancer patients (Yates et al., 2002; McBeth et al.,2003). It has been argued that pain is present in 30% of the patientsat the time of diagnosis, increasing to 65–85% as the diseaseprogress (Yates et al., 2002). Data also exist showing thatwidespread pain decreases cancer survival (McBeth et al., 2003).Pain is also present in 90% of all hospitalized cancer patients(McMillan et al., 2000). Despite its prevalence, our knowledge onpain among elderly hospitalized cancer patients is limited (Torviket al., 2008). Meanwhile, fatigue, observed in some 61% of cancerpatients, is the most common complaint (Moore and Dimsdale,2002). Pain and fatigue are important because they stand at theforefront of factors adversely affecting these patients with regardto general health, function and QoL (Schag et al., 1993).

As another important symptom, research in cancer survivors ingeneral has shown that sleep difficulties are a common concernwith 36.9–58.7% of cancer survivors reporting sleep symptoms an

Table 1Demographic variables of hospitalized cancer patients, mean� S.D. or n (%).

Middle-aged Elderly

Number 53 47

Age 36.72�10.74 65.77�4.97

Range (17–50) (60–78)

Gender (female/male) 27 (50.9)/26 (49.1) 23 (48.9)/24 (51.1)

Occupation*

House working 19 (35.8) 20 (42.6)

Retired 9 (17) 27 (57.4)

Employee 5 (9.4)

Workman 7 (13.2)

Other 13 (24.5)

Marital status*

Married 33 (62.3) 39 (83)

Single 20 (37.7) 8 (17)

Education level

Primary 22 (41.5) 18 (38.3)

High school 21 (39.6) 18 (38.3)

University 9 (17) 9 (19.1)

No school 1 (1.9) 2 (4.3)

* p<0.05.

S. Eyigor et al. / Archives of Gerontology and Geriatrics 51 (2010) e57–e61e58

average of 1 year after diagnosis (Gooneratne et al., 2007). Fatigueand insomnia have previously been found as predictors of changein elderly cancer patients’ functioning (Given et al., 2001; Esbensenet al., 2006). Nevertheless, there are no available data about fatigueand sleep problems in hospitalized elderly cancer patients.

Elderly cancer patients tend to weight their QoL as moreimportant than gain in survival, when compared to younger patients(Wedding et al., 2007). QoL data are of prognostic importance forsurvival in a hospitalized elderly population in general in a variety oftypes of cancer. Therefore, QoL is a major area of concern in thetreatment of patients with cancer, especially in elderly patients andthose treated within a non-curative approach (Wedding et al., 2007).Cancer survivors tend to have significantly lower scores in QoL thanage-matched non-cancer individuals (Baker et al., 2003). In thepreviously conducted studies, data on elderly cancer patients weregenerally compared with the QoL scores of elderly patient group andwith the data of non-cancer individuals (Gooneratne et al., 2007;Robb et al., 2007; Baumann et al., 2009).

Thus, in our study, the characteristics of elderly hospitalizedcancer patients such as pain, fatigue, sleep symptoms and QoLwere compared with the results of middle-aged hospitalizedcancer patients.

2. Subjects and methods

2.1. Study participants

This study has been designed to be a descriptive study andincluded 85 patients between 18 and 50 years of age and 75patients above 60 years of age who were admitted to Tulay AktasOncology Hospital for treatment and followed by the SupportiveCare Unit. Inclusion criteria were: being 18 years of age and over,hospitalized cancer patients, consenting to participate in the study,having general status and cognitive functions good enough tounderstand and answer the questions. Among these patients, 2patients between 18 and 50 years of age died, 20 patients could notbe contacted and 10 patients refused to participate in the study;while 5 patients in the group over 60 years of age died, 15 patientscould not be contacted and 8 patients refused to participate in thestudy. Patients were given information about the study and thosewho agreed to participate were included in the study.

2.2. Evaluation of demographical and clinical data

Patient query form was used to obtain demographical data.Disease histories were extracted from the patient records. Pain,fatigue and sleep statuses were explored with short-answerquestions.

Short-answer questions such as the localization of pain(widespread pain-local pain-no pain), fatigue, type of fatigue(morning fatigue-getting tired easily during the day), sleep disorder,were answered as ‘‘present’’ or ‘‘absent’’. Pain was assessed using avisual analog scale (VAS) and verbal pain rating (0: no pain, 1: mild,2: moderate, 3: severe, 4: unbearable).

For sleep disorders, patients were asked questions regardingthe number of nights with difficulty falling asleep, the frequency ofwaking up at night during the previous week (0: did not wake up atall, 1: woke up some nights, 2: woke up every night), mean lengthof sleep in the previous week, and un-refreshing sleep (0: wakingup refreshed, 1: sometimes waking up refreshed, 2: never wakingup refreshed).

2.3. Study variables

Fatigue, QoL and health statuses were assessed using thefollowing measures: the BFI assesses the severity of fatigue and the

impact of fatigue on daily routine activities. Zero point denotes nofatigue, while 1–3, 4–6, and 7–10 points indicate mild, moderateand severe fatigue, respectively (Mendoza et al., 1999). The ShortForm 36 – SF36: on this widely used index, there are 36 questionsevaluating the QoL. The SF36 explores eight dimensions of the QoL,labeled as ‘‘physical function’’, ‘‘role physical’’, ‘‘bodily pain’’,‘‘general health’’, ‘‘vitality’’, ‘‘social function’’, ‘‘role emotional’’, and‘‘mental health’’. Higher scores indicate better health (Ware et al.,2000).

The EORTC-QoL-C30 is a 30-item scale that measures the QoL ofcancer patients in which respondents receive scores for functionalscale, symptom scale and global health scale. High scores forfunctional and global health scales indicate a good QoL while highscores in symptom scale represent a high level of problems(Aaronson et al., 1993).

2.4. Statistical methods

All data were analyzed using SPSS version 14 statisticalsoftware package for Windows. Descriptive statistics were usedto characterize the sample. Preliminary inferences were madeusing t-tests for two independent samples and Chi-square forproportions. For statistical methods we preferred using non-parametric tests. The p < 0.05 were considered statisticallysignificant.

3. Results

Fifty-three patients from the 18–50 age group and 47 patientsfrom the group over 60 years of age were included in theassessment. Demographical, medical and clinical characteristics ofthe patients are presented in Tables 1 and 2.

When the two age groups were compared, no significantdifference was detected between VAS, verbal rating scale, fatiguestatus and fatigue type, sleep problems, SF36 (excluding vital sub-score) and EORTC-QoL-C30 scores (p > 0.05) (Tables 2 and 3). BFIscore was found to be significantly higher in the elderly group(p < 0.05) (Table 3).

When the patients were compared according to the extent ofpain (widespread pain-local pain-no pain), there were nostatistically significant differences between the two age groups(p > 0.05) (Table 2).

Table 2Medical and clinical variables of hospitalized cancer patients, n (%), or mean� S.D.

Middle-aged Elderly

Number 53 47

Chemotherapy (Yes/No)* 50 (94.3)/3 (5.7) 37 (78.7)/10 (21.3)

Radiation therapy (Yes/No) 24 (45.3)/29 (54.7) 17 (36.2)/30 (63.8)

Co-morbidites (Yes/No)* 11 (20.8)/42 (79.2) 24 (51.1)/23 (48.9)

Metastasis (Yes/No) 25 (47.2)/28 (52.8) 27 (57.4)/20 (42.6)

Living alone (Yes/No) 3 (5.7)/50 (94.3) 6 (12.8)/41 (87.2)

VAS 3.75�3.63 2.83�3.04

Pain

Widespread pain 16 (30.2) 15 (31.9)

Local pain 23 (43.4) 16 (34)

No pain 14 (26.4) 16 (34)

Fatigue (Yes/No) 45 (84.9)/8 (15.1) 42 (89.4)/5 (10.6)

Sleep problems (Yes/No) 35 (66.0)/18 (34.0) 28 (59.6)/19 (40.4)

The number of nights with

difficulty falling asleep

3.09�2.21 2.89�2.51

Mean length of sleep 7.17�2.50 6.91�1.60

* p<0.05.

Table 3QoL and fatigue scores of hospitalized cancer patients.

Middle-aged Elderly p

Number 53 47

BFI 5.21�3.33 7.30�1.30 0.046*

SF36

Physical functioning 42.30�29.99 30.77�18.60 0.134

Physical role 6.13�23.46 0 0.056

Bodily pain 57.56�35.41 63.74�30.70 0.465

General health 41.08�23.29 38.40�16.02 0.753

Vitality 47.83�11.16 43.09�8.11 0.027*

Social functioning 28.77�29.98 19.15�17.84 0.261

Emotional role 44.22�39.97 57.42�40.37 0.077

Mental health 46.06�16.72 43.85�12.99 0.776

EORTC-QoL-C30

Function scales 52.49�21.46 44.70�13.49 0.058

Symptom scales 32.67�17.80 36.80�10.53 0.169

Global health scale 35.07�30.73 22.64�20.51 0.076

* p<0.05.

S. Eyigor et al. / Archives of Gerontology and Geriatrics 51 (2010) e57–e61 e59

3.1. In middle-aged group

Significant correlations were found between VAS score and thescores of SF36 subgroups like physical functioning (r = �0.440**),bodily pain (r = �0.953**), general health (r = �0.460**), vitality(�0.384**), social functioning (r = �0.398), mental health(r = �0.293*) and EORTC-QoL-C30 function scale (�0.460**),EORTC-QoL-C30 symptom scales (r = 0.721**) and EORTC-QoL-C30 global health scale (�0.362*) (*p < 0.05, **p < 0.01). Signifi-cant correlations were detected between verbal rating scale andthe scores of SF36 subgroups like physical functioning(r = �0.421**), bodily pain (r = �0.936**), general health(r = �0.451**), vitality (�0.368**), social functioning (r = �0.400),mental health (r = �0.324*) and EORTC-QoL-C30 function scale(�0.482**), EORTC-QoL-C30 symptom scales (r = 0.745**), EORTC-QoL-C30 global health scale (�0.362*) (*p < 0.05, **p < 0.01).

Significant correlations were detected between mean length ofsleep and the scores of SF36 subgroups like mental health(r = 0.303*) and EORTC-QoL-C30 symptom scales (r = �0.304**)(*p < 0.05, **p < 0.01).

Significant correlations were detected between the number ofnights with difficulty falling asleep and the scores of SF36 subgroupslike bodily pain (r = �0.330*), emotional role (r = �0.371**) andEORTC-QoL-C30 symptom scales (r = 0.510**), VAS (r = 0.294*),verbal rating scale (r = 0.323**) (*p < 0.05, **p < 0.01).

Significant correlations were detected between BFI and thescores of SF36 subgroups like physical functioning (r = �0.604**),general health (r = �0.743**), vitality (r = �0.749**), social func-tioning (r = �0.766**), emotional role (r = �0.501**), mental health(r = �0.760**), VAS (r = 0.405*), verbal rating scale (r = 0.420*)(*p < 0.05, **p < 0.01).

Significant correlations were detected between EORTC-QoL-C30function scale and the scores of SF36 subgroups like physicalfunctioning (r = 0.784**), physical role (r = 0.330*), bodily pain(r = 0.406**), general health (r = 0.657**), vitality (r = 0.743**), socialfunctioning (r = 0.768**), emotional role (r = 0.449**), mental(r = 0.808**) scores (*p < 0.05, **p < 0.01). Significant correlationswere detected between EORTC-QoL-C30 symptom scales and thescores of SF36 subgroups like physical functioning (r =�0.458**),physical role (r = �0.317*), bodily pain (r = �0.712**), general health(r = �0.640**), vitality (r = �0.649*), social functioning(r = �0.487**), emotional role (r = �0.596**) and mental health(r = �0.574*) scores (*p < 0.05, **p < 0.01). Significant correlationswere detected between EORTC-QoL-C30 global health scale and thescores of SF36 subgroups like physical functioning (r = 0.516**),bodily pain (r = 0.316**), general health (r = 0.679**), vitality(r = 0.628**), social functioning (r = 0.620**), emotional role(r = 0.508**) scores (*p < 0.05, **p < 0.01).

3.2. In elderly group

Significant correlations were detected between VAS and thescores of SF36 subgroups like bodily pain (r = �0.951**) andEORTC-QoL-C30 symptom scales (r = 0.418**) (*p < 0.05,**p < 0.01).

Significant correlations were detected between verbal ratingscale and SF36 subgroups of bodily pain (r = �0.948**), EORTC-QoL-C30 symptom scales (r = 0.456**) and EORTC-QoL-C30 globalhealth scale (r = �0.322**) scores (*p < 0.05, **p < 0.01).

Significant correlations were detected between the meanlength of sleep and SF36 subgroups of physical functioning(r = 0.316*), bodily pain (r = 0.302*) and EORTC-QoL-C30 globalhealth scale (r = 0.430**) scores (*p < 0.05, **p < 0.01).

Significant correlations were detected between BFI and theEORTC-QoL-C30 symptom scales (r = 0.693**), EORTC-QoL-C30global health scale (r = �0.444*) scores (*p < 0.05, **p < 0.01).

Significant correlations were detected between EORTC-QoL-C30 function scale and the scores of SF36 subgroups of physicalfunctioning (r = 0.633**), social functioning (r = 0.667**), emotion-al role (r = 0.394**), mental health (r = 0.481**) and the number ofnights with difficulty of falling asleep (r = �0.373*) (*p < 0.05,**p < 0.01).

Significant correlations were detected between EORTC-QoL-C30 symptom scales and SF36 subgroups of physical functioning(r = �0.409**), bodily pain (r = �0.515**), social functioning(�0.418**) and mental health (r = �0.414**) scores (*p < 0.05,**p < 0.01).

4. Discussion

According to the results of our study, no difference wasobserved between the age groups in terms of pain, sleep problemsand QoL scores, and fatigue scores were found to be higher in theelderly group. In both age groups, a relationship was foundbetween pain, fatigue and sleep symptoms, and QoL in elderlyhospitalized cancer patients.

Cancer-related symptoms may affect the biological behavior ofthe tumor and therefore may be important for prognosis (Chen andChang, 2004; Hwang et al., 2004; Hauser et al., 2006). It should bekept in mind that if the clinicians do not have the knowledge onQoL and symptoms such as pain and fatigue, they may be mistaken

S. Eyigor et al. / Archives of Gerontology and Geriatrics 51 (2010) e57–e61e60

in their choice of appropriate and realistic treatment andestimation of survival (Hwang et al., 2004; Hauser et al., 2006).It has been reported that pain (Chen and Chang, 2004) and fatigue(Herndon et al., 1999) are particularly important for survival. Inanother study, prevalence of pain in hospitalized cancer patientshas been found to be higher than for patients with other chronicdiseases and it has been argued that it is related to distress incancer patients (Tranmer et al., 2003). Cancer, as well as factorscaused by cancer treatment, may have increased the percentage ofpain in that study. When the middle-aged and elderly groups werecompared in patients with bone metastases, the results havedemonstrated that pain severity and pain percentages are higher inthe elderly group (Torvik et al., 2008). On the other hand, anotherstudy has shown that older adults with cancer may experience lessintense pain than their younger counterparts (McMillan, 1989).Contrary to these results, our study has not revealed any differencebetween the two age groups in terms of pain scores. There are notmany available studies with which we can compare the pain levelin hospitalized cancer patients. This result may be due to the factthat the two age groups were assessed during the period in whichthey were hospitalized. Further studies are needed in order todemonstrate the relationship between pain and hospitalization inelderly cancer patients. It is emphasized in literature that therelationship between pain and QoL should also be taken intoaccount (Tavoli et al., 2008). Our study has also shown that painand QoL scores are related in both age groups. The effect ofeffective pain treatment on patient’s QoL should be taken intoconsideration in clinical practice.

Cancer-related fatigue is one of the most common anddisabling symptoms experienced by elderly cancer patients andby cancer survivors. However, this has not led to an increase inclinical trials for assessment and therapy of fatigue in thispopulation. The early recognition and formal assessment of thissymptom is important in order to be able to treat it before itnegatively impacts the patient’s QoL (Rao and Cohen, 2008).Emotional distress, sleep disorders, and the physical effects of thedisease have been implicated in development of fatigue (Rao andCohen, 2008). It is known that it has a negative impact on the QoLand functional capacity (Tranmer et al., 2003). In our study,although no difference was found between the two age groups interms of fatigue status and type, it was observed that BFI scoreassessing the effect of fatigue was higher in the elderly group. Asreported in literature (Reiner and Lacasse, 2006), the higher rate ofco-morbidities in the elderly group may account for this resultobtained in our study. We are of the opinion that necessaryattention should be paid also to this symptom regarding therelationship between fatigue and QoL.

Sleep disorders is a common complaint in cancer patients thatis often neglected during clinical oncology practice (Moore andDimsdale, 2002). The insomnia complaints noted by Davidson etal. (2002) in their study of predominantly older patients withvarious types of cancer tended primarily to be difficultymaintaining sleep (76%), followed by difficulty falling asleep(44%) and early morning awakenings (33%). Despite the effects ofsleep difficulties on QoL, these sleep disorders are often notevaluated or treated. In part this is because health care providersdo not inquire about sleep, but the patients themselves do notreport it as well in many cases (Gooneratne et al., 2007). In ourstudy, no difference was found between the middle-aged andelderly patient groups in terms of sleep problems. In the literature,these complaints are especially common in patients with chronicpain (88%) (Moore and Dimsdale, 2002). Results of the presentstudy demonstrate a relationship between sleep status and pain.Considering the relationship observed in our study between pain,fatigue, sleep and QoL, the necessity of treating these symptomscollectively should be noted.

Cancer is a serious health problem that affects the patients’ QoLconsiderably (Peters and Sellick, 2006). QoL has been recom-mended as one of the hard end-points for clinical cancer research(Di Maio and Perrone, 2003). As a conclusion, no distinctivedifference was found between elderly patients and their youngercounterparts in terms of QoL scores. Contrary to our results,Fehlauer et al. (2005) noticed that older breast cancer survivors(>65 years versus <65 years) had decreased physical functioning,role functioning, and sexual functioning compared to their youngercounterparts. Furthermore, QoL scores were determined to behigher in cancer patients compared to young patients living alone(Rustoen et al., 1999). Yet, literature includes results that supportour study on breast cancer patients and non-small-cell lung cancerpatients (Crivellari et al., 2000; Langer et al., 2002). This findingwas explained by the authors with the tendency of elderly patientsto complain less and endure symptoms better. In the study carriedout by Torvik et al. (2008), no difference was observed betweenmiddle-aged and elderly cancer patients in terms of QoL in patientswith bone metastases. In a study carried out in Germany (Baumannet al., 2009), hospitalized cancer patients of 60 years and over werecompared with patients hospitalized for other medical reasons andwith the normal population in terms of QoL. QoL scores were foundto be low in cancer patients and the patients hospitalized for othermedical reasons compared to the general population. As a result, itwas reported that the low QoL in elderly patient group cannot beassociated only with cancer diagnosis, and similar deteriorationmay be seen in other medical diseases (Baumann et al., 2009). If theresults of elderly cancer patients are not different from the resultsof younger population and show similarity with the results ofpatients with other medical problems, the observed changes maybe related to the disease rather than old age. Besides, it should bekept in mind that QoL is multi-faceted.

Powerful aspect of our study is that it is the first study in whichpain, fatigue, sleep and QoL were assessed together in elderlyhospitalized cancer patients and the results of these assessmentswere compared with the data obtained from younger generation.This study also has certain limitations. Assessment could havebeen made for only one type of cancer. Yet, probably due to thedifficulty of performing a study on cancer patients, similar studiesalso included different cancer types. It has been demonstrated thatpain management in hospitalized cancer patients is not wellknown and adequately carried out. In our study, the assessmentand follow up of pain treatments could have been valuable.Besides, anxiety and depression status should also be evaluated infuture studies.

In a conclusion, elderly hospitalized cancer patients did notdemonstrate a distinctive difference in terms of pain, sleep and QoLcompared to the younger group. The relationship between pain,fatigue, sleep and QoL should be definitely kept in mind in clinicalpractice. By all means, special attention should be paid to elderlypatients in terms of assessment and treatment. Yet, if the results ofcancer patients are not different from those of younger populationand show similarities with the results of patients with othermedical problems, the differences in QoL and associated factorsmay be due to cancer diagnosis rather than old age. We think thatour study results sand hypothesis should be supported also withother studies.

Conflict of interest statement

None.

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