https://doi.org/10.33698/NRF0286-C Sam Ila Kyndiah, Sukhpal Kaur, NeenaVir Singh, Rakesh Kapoor, Kamal Kishore
ABSTRACT:
Background: Cancer patients frequently experience disease or treatment-related symptoms and functional morbidities that often go unnoticed and seldom managed. Objective: To investigate the functional loss related to the activities of daily living (ADLs) in cancer patients receiving neurotoxic chemotherapeutic drugs. Material and method: A prospective study was conducted at the Day Care Centre, Department of Radiotherapy, PGIMER, Chandigarh. Cancer patients undergoing rst cycle of chemotherapy treatment and willing to participate in the study were enrolled from June to August 2018. Data was collected by a prevalidated interview schedule comprising of the sociodemographic and personal prole, clinical prole, Katz Index of Independence in Activities of Daily Living (ADL) and Lawton – Brody Instrumental Activities of Daily Living Scale (IADL). Eighty participants were interviewed and followed up in midline (3rd cycle) and endline (6th cycle) of the chemotherapy cycle. Results: The functional dependency throughout the course of chemotherapy was 1.25%, partially dependent as 3.75% and independent in 95% as assessed by the Katz Index of Independence in Activities of Daily Living (ADL). The instrumental activities of daily living as assessed by the Lawton – Brody instrumental activities of daily living deteriorates throughout the course of chemotherapy. At the baseline, 86.84% males and 71.43% females were high functioned. At endline, 34.22% males and 11.91% females were high functioned. Conclusion: The study shows that there is a deterioration in the instrumental activities of daily living (IADL) whereas the basic activities remain unchanged as the course of chemotherapy progresses.
Keywords: Activities of daily living; Functional loss; Neurotoxic chemotherapeutic drugs.
Address for correspondence :
Dr. Sukhpal Kaur Lecturer
NINE, PGIMER, Chandigarh.
Introduction
Chemotherapy-induced peripheral neuropathy (CIPN) is a disabling condition occurring as a side effect of cancer treatment. Few neoplastic drugs which are responsible for causing CIPN include platinum drugs such as cisplatin, carboplatin, and oxaliplatin; taxanes including paclitaxel, docetaxel; plant alkaloids, such as vinblastine, vincristine, and etoposide1. Improving the quality of life (QOL) of cancer patients including the function in daily activities during the clinical trajectory after diagnosis has become a new task2.Objective assessment and timely management of physical health and function are needed to promote improved health-related quality of life of cancer patients under treatment3- 5. There are scarcity of studies on detailed assessment of functional loss in activities of daily living (ADLs) and treatment-related symptoms. Although most cancer survivors experience cancer treatment-related functional morbidities that can be mediated through rehabilitation services, this functional loss often goes unnoticed and is seldom managed due to the lack of comprehensive cancer care. Hence the aim of this present study is to investigate the functional loss related to the activities of daily living (ADLs) in cancer patients receiving neurotoxic chemotherapeutic drugs during chemotherapy.
Material and method
This prospective study was carried out in the Day Care Centre, Department of Radiotherapy, PGIMER,Chandigarh. The participants were patients coming for the rst cycle of chemotherapy enrolled between June to August, 2018, for c h e m o t h e r a p y w i t h n e u r o t o x i c chemotherapeutic drugs.
A total of 80 participants were included in the study. The inclusive criteria were diagnosed cancer patients above 18 years of age who came for 1st cycle of chemotherapy with neuro-toxic drugs. Exclusion criteria were known case of Peripheral neuropathy, patients who are unable to report paraesthesia and pain and patients undergoing palliative chemotherapy. The tool used for data collection was a p r e v a l i d a t e d i n t e r v i e w s c h e d u l e comprising of Sociodemographic and personal prole, clinical prole, the Katz Index of Independence in Activities of Daily Living (ADL) and Lawton – Brody instrumental activities of daily living scale (IADL).
The Katz index of independence in activities of daily living is a dichotomous scale used to assess the independence of patients in ADLs. The index includes performance in six functions (bathing, d r e s s i n g , t o i l e t i n g , t r a n s f e r r i n g , continence, and feeding) with a total score of six points. A score of six indicates full function, 3 – 5 indicates moderate impairment, and two or less indicates severe functional impairment6-7.
The Lawton Instrumental Activities of Daily Living Scale ( IADL) i s an appropriate i nstrument t o assess independent living skills (Lawton & Brody, 1969). These skills are considered more complex than the basic activities of daily living as measured by the Katz index of ADLs. The instrument is most useful for identifying how a person is functioning at the present t ime, and to identify improvement or deterioration over time. There are eight domains of function measured with the Lawton IADL scale. Women are scored on all 8 areas of function; historically, for men, the areas of f o o d p r e p a r a t i o n , h o u s e k e e p i n g , laundering are excluded. Patients are scored according to their highest level of functioning in that category. A summary score ranges from 0 (low function, d e p e n d e n t ) t o 8 ( h i g h f u n c t i o n , independent) for women, and 0 through 5 for men8.
Permission was obtained from the Head, Department of Radiotherapy, PGIMER, Chandigarh. The study was approved by Institute Ethics Committee ( IEC), PGIMER, Chandigarh. The participants were given full explanation about the procedure of data collection. A written informed consent was taken from each patient. They were assured of the information obtained from them. Data was chemotherapy was 21% [Table 2]
The Katz Index of Independence in Activities of Daily Living (ADL) and dependence of each domain function are depicted in Table 3. The domains assessed by the Katz Index of Independence in Activities of Daily Living (ADL) remained unchanged as the course of chemotherapy collected between 24th June till 10th progressed.
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December, 2018. Patients were interviewed at bedside during the chemotherapy administration time as per the interview
Table 1. Sociodemographic and personal profile of the participants (N= 80)
s c h e d u l e d u r i n g t h e 1 s t c y c l e o f chemotherapy. Time taken for the interview was 30-35 minutes for each participant. They were further followed up and interviewed at midline (3rd cycle) and endline (6th cycle). Data was analyzed in SPSS v20.
Results
Of the total 80 participants included in the study, 42 (52.5 %) were females and 38 (47.5%) were males. The age range in the study was 18-72 years. Majority, (77.5%) of the participants in the study were in the age group 40-69 years. Nearly half (42.5%), of the participants had completed their secondary level and above education while 27.5 % were illiterate. 42.5% were labourer by occupation and 72.5% hailed from the urban area. The study shows that 11.25% and 15% were alcoholics and smokers respectively. [Table 1] Ovarian cancer (40%) was the most common diagnosis among females and Oesophageal cancer (12%) was the second most common among males.[Table 2] Paclitaxel and carboplatin combined chemotherapy regime accounted for 20% and the percentage of others single agent ¶Ca Gall Bladder, Ewing’ sarcoma retroperitoneum, Malignant peritoneal mesothelioma, Ca stomach, Neuroendocrine tumor, Germ cell tumor, Ca Penis, Ca UB metastatic, Ca Anus, Ca oral cavity, Ca Base of tongue, Ca nasopharynx, Ca bladder, Leiomyosarcoma, Ca urinary bladder, Sex cord stromal tumor, Recurrent squamous cell carcinoma, Ca colon, adenocarcinoma ca rectum, chondrosarcoma with lung mets, Metastatic osteosarcoma with secondary mets
- Cisplatin & Etoposide, Bleomycin, Etoposide & Cisplatin, Vinblastine, Methotrexate, Docetaxel & Cisplatin, Docetaxel & Cisplatin, Carboplatin & Gemcitabine, Pemetrexed & Cisplatin,
The Lawton’s instrumental activity of daily living (IADL) score and dependence of each domain function are shown in Table 4.
The score was very much affected as the course of chemotherapy progressed.
Discussion
Advances in medicine have led to the early diagnosis of cancer and increased life expectancy after initial cancer diagnosis. An awful consequence of chemotherapy treatment is the chemotherapy induced peripheral neuropathy (CIPN). It restricts daily activities and thereby impairs the physical and role functioning and quality of life of the patients. Due to this prolongation of the cancer care continuum, patients’ quality of life has become an important area of cancer care as activities of daily living is directly contributing to quality of daily living. Hence a need was felt to assess the functional loss of patients undergoing chemotherapy with neurotoxic drugs.
Prospective design is used in the study because the aim is to assess the ongoing status of the participants as the course of chemotherapy progressed because literature says that as the cycle of chemotherapy progresses, the activities of
Table 2. Clinical profile of the participants (N=80)
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)daily living deteriorates4. On this context, as per data given in a systematic review and Paclitaxel, Transtuzumab & Cisplatin, Paclitaxel & Epirubicin, Docetaxel, Fluorouracil, Endoxan, Nabpaclitaxel, Fluorouracil & Irinotecan, Fluorouracil, Adriamycin & Endoxan
Table 3. Functional capability participants as per Katz activity of daily living (ADLs) at different time points
| Katz category | Baseline (1st cycle) n(%) | Midline (3rd cycle) n(%) | Endline (6th cycle) n(%) |
| Independent (6) | 76 (95%) | 76 (95%) | 76 (95%) |
| Partially dependent (3-5) | 3 (3.75%) | 3 (3.75%) | 3 (3.75%) |
| Dependent (≤ 2 ) | 1(1.25%) | 1 (1.25%) | 1 (1.25%) |
| Katz domain | |||
| Bathing | 75 (93.75%) | 75 (93.75%) | 75 (93.75%) |
| Dressing | 79 (98.75%) | 79 (98.75%) | 79 (98.75%) |
| Toileting | 78 (97.5%) | 78 (97.5%) | 78 (97.5%) |
| Transferring | 78 (97.5%) | 78 (97.5%) | 78 (97.5%) |
| Continence | 80 (100%) | 80 (100%) | 80 (100%) |
| Feeding | 80 (100%) | 80 (100%) | 80 (100%) |
Table 4; Functional capability of participants as per Katz activity of daily living (ADLs) at different time points
| Lawton’s category | Baseline (1st cycle) n(%) | Midline (3rd cycle) n(%) | Endline (6th cycle) n(%) | |||||
| M | F | Male | Female | Male | Female | Male | Female | |
| High function | 5 | 8 | 33 (86.84%) | 30 (71.43%) | 15 (39.47%) | 04 (9.53%) | 13 (34.22%) | 05 (11.91%) |
| Partially functional | 1-4 | 1-7 | 5 (13.16%) | 12 (28.57%) | 23 (60.53%) | 38 (90.47%) | 25 (65.78%) | 37 (88.09%) |
| Lawton’s domain | ||||||||
| Telephone use | 38 (100%) | 42 (100%) | 38 (100%) | 38 (100%) | 38 (100%) | 38 (100%) | ||
| Shopping | 34 (89.48%) | 34 (80.95%) | 34 (89.48%) | 34 (89.48%) | 34 (89.48%) | 34 (89.48%) | ||
| Food preparation | – | 35 (83.33%) | – | – | – | – | ||
| Housekeeping | – | 37 (97.3%) | – | – | – | – | ||
| Laundry | – | 40 (95.23%) | – | – | – | – | ||
| Mode of transportation | 36 (94.73%) | 42 (100%) | 36 (94.73%) | 36 (94.73%) | 36 (94.73%) | 36 (94.73%) | ||
| Medications | 38 (100%) | 41 (97.62%) | 38 (100%) | 38 (100%) | 38 (100%) | 38 (100%) | ||
| Finances handling | 37 (97.37%) | 38 (90.47%) | 37 (97.37%) | 37 (97.37%) | 37 (97.37%) | 37 (97.37%) | ||
meta-analysis of cancer patients receiving chemotherapy, chemotherapy induced peripheral neuropathy (CIPN) which affect the functional capability of the patients was 6 8 . 1 % i n t h e r s t m o n t h a f t e r chemotherapy, 60.0% at 3 months and 30.0% at 6 months or more9. Hence, two About 19.05% of total participants showed dependence in activities of daily living with the most affected functions being continence, bathing, transfer, and dressing, in descending order. The inuence of chemotherapy was shown in majority of the functional domains in ADL4 . On the follow ups, upto 6th chemotherapy cycle contrary, the present study shows only 1.25 was carried out in the present study.
A study by Carlson LE, et al shows that majority of patients (80.95%) were independent in their activities of daily life.F u n c t i o n a l i m p a i r m e n t s w e r e measured using the Katz Index of Independence in Activities of Daily Living (ADL) and Lawton – Brody instrumental activities of daily living scale (IADL) as these are standardized, reliable, validated and tested tool used to assess participants functional status and identify patients at risk of functional decline, used in many studies4 % of cancer patients under treatment with neurotoxic chemotherapy had functional dependence in ADLs. The unaffected function was feeding and continence, with all of the participants experiencing independence in performance of the same. On the other hand, the instrumental activities of daily living as assessed by the Lawton-Brody instrumental activities of daily living is very much affected with the cycles of chemotherapy received by the participants. There was a notable deterioration in the Lawton’s category from baseline to midline. At the baseline, 86.84% males and 71.43% females were high functioned, whereas there was a decreased in the high functioned percentage of both the gender in the midline. Similarly, there was deterioration in high functioned percentage of males in the endline. However, females show a minimal increase in high functioned percentage at endline compared to midline. This clearly shows that progress in the course of chemotherapy causes deterioration of functional impairment.
It is concluded that functional impairments in instrumental activities of daily living (IADL) is more affected during the course of chemotherapy. Hence it is recommended that prior to the onset of their anticancer therapy, patients should be informed that chemotherapy induced peripheral neuropathy (CIPN) is a risk factor for functional impairments, and education on how to cope with these functional impairments needs to be provided. Timely recognition of the functional impairment is the key to prevent disability in daily living functions, which directly improves the quality of life of the patients in general. Therefore, Nurses and Doctors are required to be vigilant in this regard.
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