The Catholic University of Korea College of Medicine, 224 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
Research Institute for Hospice/Palliative Care, The Catholic University of Korea College of Nursing, Arizona State University College of Nursing and Health
Innovation, 224 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
c
Kyungbok University Department of Nursing, Sinbuk-myeon, Pocheon, Gyeonggi-do, 487-717, Republic of Korea
b
a b s t r a c t
Keywords:
Mobility limitation
Aged
Koreans
Palliative care
Oncology nursing
Purpose: to describe the levels of mobility in older cancer patients receiving palliative care in Korea, and
to examine the associations of their mobility with lifestyle factors (sleep disturbance, physical activity)
and physical symptoms (pain, fatigue).
Methods: In this cross-sectional descriptive study, 91 older cancer patients receiving palliative care were
interviewed using a semi-structured survey questionnaire. Mobility was measured using the 6MWT.
Physical activity behavior was measured using the classication of the ACSM. Sleep disturbance was
assessed using the frequency sub-category of the SHQ. Both pain and fatigue were measured using a VAS.
Results: The mean 6MWT distance was 220.38 m. Participants in their 60 s, 70 s, and 80 s walked, on
average, 260.93 m, 205.31 m, and 157.05 m, respectively. Approximately 73% of the participants engaged
in regular physical activity. Those engaged in regular physical activity were signicantly more mobile
than those who were not (t 2.44; p .017). Higher levels of mobility were correlated with lower levels
of sleep disturbance (r .37), fatigue (r .23), and pain (r .27). Signicant predictors for mobility
included levels of sleep disturbance, medication status, age, number of family members and monthly
income, accounting for 34.7% of the variance in mobility.
Conclusions: Korean cancer patients have relatively low levels of mobility. Cancer patients aged over 80
years are a vulnerable group at risk for impaired mobility. Older palliative care patients are more active
than one might expect. Levels of mobility are inversely associated with pain, fatigue, and sleep-related
symptoms.
2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
Introduction
The goal of palliative care is to increase the physical and psychosocial wellbeing of terminally ill patients in an effort to enhance
the quality of life of patients and their families (Morrison and Meier,
2004, World Health Organization, 2010). Preservation of function is
important for quality palliative care and is critical in the clinical
assessment of palliative care patients (Ferrell et al., 2007). Patients
with cancer often report low levels of independence in daily living
because of functional impairment, physical and psychological
symptoms, and the nancial burden associated with the cost of
treatment (Baker et al., 2003, Hewitt et al., 2003, Stafford and Cry,
1997, Torvinen et al., 2013). They are also known to be frailer and
their activities of daily living are more limited than those of noncancer patients (Mohile et al., 2009).
Approximately two-thirds of newly diagnosed cancer patients
are older adults (Balducci, 2005) and it is particularly important to
institute measures that would preserve the physical function of
these patients. While young cancer patients can experience progressive but reversible functional limitation during the course of
their diseases, older cancer patients often undergo a slow and
permanent decline in function (Ganz et al., 2003). This reduces the
older patient's chance of recovery and leads to high levels of frailty
in those who become terminally ill (Baker et al., 2003). Considering
that frailty is a signicant predictor of mortality in elderly cancer
patients receiving palliative chemotherapy (Aaldriks et al., 2013),
considerations for palliative care that focus on preserving function
are clearly necessary.
Mobility is an essential component of physical function as it can
ensure the independence of older adults. It is well known that
http://dx.doi.org/10.1016/j.ejon.2014.06.005
1462-3889/ 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
614
615
Table 1
Mobility in relation to general characteristics of subject. (n 91).
Characteristics
n (%)
Sex
Male
58
Female
33
Age
65e69
29
70e79
57
80
5
Religion
Roman catholic
24
Protestant
27
Buddhism
16
Others
23
Education
Primary school
26
Middle school
12
High school
25
Over college
28
Monthly income
Less than $900
68
Over $900
20
Number of family
1
14
2
41
3
18
4
18
Taking medication
Yes
84
No
7
Regular physical activity
Yes
67
No
24
Mobility
Mean SD
t/F
(63.7)
(36.3)
246.22 115.89
174.98 82.67
3.11a
.003**
(31.9)
(62.6)
(5.5)
260.93 140.66A
205.31 84.45AB
157.05 119.33B
3.51
a>b
.034*
(26.7)
(30.0)
(17.8)
(25.6)
212.89
235.55
199.13
220.39
80.35
100.17
169.46
110.72
.41
.747
(28.6)
(13.2)
(27.5)
(30.8)
166.96
234.34
248.53
238.88
90.70A
107.12B
80.65B
135.69B
3.12
a<b
.030*
(77.3)
(22.7)
206.31 110.94
261.88 105.40
1.99a
.050*
(15.4)
(45.1)
(19.8)
(19.8)
213.21
239.45
245.73
157.18
2.90
a<b
.040*
(92.3)
(7.7)
208.62 95.46
361.49 174.95
3.78a
.000**
(73.6)
(26.4)
236.76 107.73
174.67 105.67
2.44a
.017*
65.57AB
131.31B
76.75B
91.63A
Table 2
Scores for mobility and physical symptoms.
Characteristics
Mean SD
220.38
39.22
540.48
.51
3.53
4.86
110.10
9.10
207.96
.30
3.53
2.37
Range
9.72e737.44
20e64
36e900
0e2.17
0e10
0e10
616
were signicantly more mobile than those who were not (t 2.44;
p .017) (Table 1).
Levels of mobility were signicantly correlated with sleep
disturbance, fatigue, and pain. Higher levels of mobility was
correlated with lower levels of sleep disturbance (r .37;
p < .001), fatigue (r .23; p .031), and pain (r .27; p .010)
(Table 3).
Signicant correlates of mobility identied in the primary
analysis were entered as potential predictors of mobility in the
regression model. These variables included age, sex, education,
income, number of family members, medication status, regular
physical activity, sleep disturbance, fatigue and pain. Assumptions
for the regression technique were met as Variance Ination Factor
was not larger than 10, showing that multicollinearity of all variables was not problematic. Linearity, normality, and equal variance
of the equation model were supported at residual analysis. The
regression model was signicant (F 10.05, p < .001) with 34.7% of
explanatory power. Signicant predictors for mobility included
lower levels of sleep disturbance (b .34), not taking medication
(b .29), younger age (b .23), fewer family members
(b .20) and monthly income over $ 900 (b .18) (Table 4).
Discussion
This study aimed to report levels of mobility in older cancer
outpatients receiving palliative care, and to examine lifestyle and
symptom correlates of their mobility. The mean 6MWT distance of
our group of patients (220 m) was considerably less than that of
older cancer patients in the United States (440 m) (Bean et al., 2002,
Steffen et al., 2002) and Finland (359 m) (Mutikainen et al., 2011). It
therefore seems as if older Koreans, in general, have lower levels of
mobility than their Western cohorts, which might be due to genetic
differences in gait speed and stride length of different racial groups.
The patterns of functional decline at the end of life are known to
vary among individuals with different types of illness trajectories,
e.g., sudden death, cancer, frailty (Lunney et al., 2003).
In the present study, participants were not classied according
to the palliation stage; future studies should examine the level of
mobility of cancer patients, stratied according to the palliative
care stage and cancer type, as this could contribute to individuallytailored mobility intervention programs for older cancer patients.
Our study also showed that Korean men receiving palliative care
had higher levels of mobility than women receiving palliative care.
This nding is consistent with the results of previous studies that
men report longer walk distance than women (Shumway-Cook
et al., 2005, Steffen et al., 2002). The men in our study had longer
walk strides than the women, and this could account for the sex
difference in mobility that we observed. Further, mobility
decreased with an increase in age: patients in their 60 s could walk
260 m, while those in their 80 s could walk 156 m on average. This
nding supports the view that mobility decreases with age
(Shumway-Cook et al., 2005, Steffen et al., 2002) and it suggests
that cancer patients aged over 80 years are a vulnerable palliative
care group at risk for impaired mobility.
Interestingly, those living with 1 or 2 other family members had
higher levels of mobility than those living alone or with 3 or more
Table 3
Correlation among mobility and other continuous variables. r(p).
Mobility
Age
Fatigue
Pain
* *
Age
Fatigue
Pain
Sleep disturbance
.298** (.004)
.226* (.031)
.089 (.402)
.269** (.010)
.037 (.729)
.402** (<.001)
.370**
.007
.285**
.291**
(<.001)
(.950)
(.007)
(.006)
Table 4
Regression model for mobility in older cancer patients. (n 91).
Variables
S.E.
Sig.
Adj R2 F(p)
(Constant)
782.845 140.411
5.575 .000 .347
Medication status 117.697 37.073 .286 3.175 .002
Sleep disturbance 121.643 32.708 .337 3.719 .000
Age
5.004
1.943 .230 2.576 .012
Number of family 15.805
7.258 .199 2.178 .032
members
Monthly income
46.927 23.145
.180
2.028 .046
over $900
10.05
(<.001)
family members. Although information on the relationship between family structure and the mobility of older adults is sparse,
the relation between social support and physical health outcomes
is well documented (Uchino, 2006). Social support is known to be
health-promoting, as it aids patients to engage in healthy lifestyles,
including physical activity, optimal diet, and medication compliance (DiMatteo, 2004, Uchino, 2006). Family members are often an
important source of social support and they fulll a valuable role in
the care of patients with advanced cancer (Given et al., 2001).
Considering our results, it seems plausible that older cancer patients in larger families do not receive as much individualized
attention than those living with their spouses only, or in small
families with only 2 additional family members. However, in-depth
knowledge regarding the role of family structure in the mobility of
older cancer patients receiving palliative care is lacking, and future
studies investigating the relationship between family structure and
mobility are clearly needed.
Participants in our study who engaged in regular physical activity walked a greater distance on the 6MWT than those who did
not engage in such activities. Our results support the current view
that regular physical activity improves the mobility of older adults
(Yeom et al., 2009). The ACSM recommends that older adults with
chronic illnesses partake in physical activity for 150e300 min per
week (Chodzko-Zajko et al., 2009). The proportion of participants in
the present study who engaged in regular physical activity (76%)
was higher than that reported in a study conducted in the United
States (60%) (Sprod et al., 2012) even though that study included
patients who were newly diagnosed with cancer had completed
either chemotherapy or radiation therapy. It is worth noting that
older palliative care patients are more active than one might
expect, possible because cancer patients in palliative care are
strongly motivated to preserve their physical function through
regular physical activity. However, the optimal amount of exercise
for patients with metastatic cancer has not been clearly established
(Beaton et al., 2009). Future studies should therefore assess the
relationship between the amount as well as the frequency of
physical activity and the mobility of older patients with advanced
cancer.
In our cohort, levels of mobility were inversely related to
physical symptoms including pain, fatigue, and sleep-related
symptoms. This nding corresponds with a previous view that
patients with few physical symptoms have better mobility than
those with many physical symptoms (Whitson et al., 2009). It is
reasonable to expect that the effective management of pain, fatigue,
and symptoms, which disturb night-time sleep, would reduce daytime frailty and inactivity, thereby improving the mobility of these
patients. Although the impact of fatigue and pain on the physical
function of older adults has been well documented (Dawson et al.,
2004, Enright, 2003, Whitson et al., 2009. Zhu et al., 2007), there is
currently little empirical evidence to link sleep disturbances and
the mobility of older cancer patients. Further studies to examine
the association between sleep patterns and the level of mobility of
older cancer patients in palliative care are warranted.
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