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European Journal of Oncology Nursing 18 (2014) 613e618

Contents lists available at ScienceDirect

European Journal of Oncology Nursing


journal homepage: www.elsevier.com/locate/ejon

Mobility of older palliative care patients with advanced cancer:


A Korean study
Sang-Young Roh a, Hye-A. Yeom b, *, Myung-Ah Lee a, In Young Hwang c
a

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

* Corresponding author. Tel.: 82 2 2258 7402.


E-mail address: yha@catholic.ac.kr (H.-A. Yeom).

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

S.-Y. Roh et al. / European Journal of Oncology Nursing 18 (2014) 613e618

impaired mobility in older adults is associated with a variety of


negative health outcomes, including depression, institutionalization, and mortality (Lyyra et al., 2005, Mutikainen et al., 2011, von
Bonsdorff et al., 2006). Whereas previous research has focused on
risk factors that limit mobility and interventions for enhancing
mobility in well functioning, community dwelling older adults with
or without chronic illnesses (Yeom et al., 2008, 2009), there have
been limited studies on the mobility of older palliative care patients
with advanced cancer. This may well be because studies examining
the mobility of older palliative care patients are relatively novel and
older cancer patients are often excluded from research studies,
although they do not consider their age as a barrier to participation
in clinical studies (Townsley et al., 2005).
The 6-minute walk test (6MWT), a performance-based assessment that evaluates mobility, measures the maximum distance that
an individual can walk in 6 min at a usual gait speed. Incorporating
both gait speed and step length into the assessment, the 6MWT has
been shown to be reliable and valid in assessing the level of
mobility in older adults (Bean et al., 2002, Morley et al., 2011,
Steffen et al., 2002). Results of a 6MWT can be used to assess the
actual walking capacity of older palliative care patients and might
be useful in guiding healthcare professionals in clinical decisionmaking and in providing appropriate palliative care, based on the
degree of frailty of individual patients.
An in-depth understanding of the correlates of mobility of older
cancer patients is necessary to develop effective strategies that
would improve the mobility of these patients. Further, recent international trends in palliative care reect the importance of
assessing the palliative care needs of culturally-diverse racial
groups (Ahmedzai et al., 2004). Specically for Koreans, previous
studies on mobility have focused on patients with chronic illnesses
such as renal failure and stroke (Lee et al., 2005, Park et al., 2001);
however, there has been sparse research on mobility of older cancer
patients. Therefore, the present study aimed to describe the levels
of mobility in older cancer outpatients 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
Design and sample
This was a cross-sectional descriptive study in which 94 cancer
patients 65 years of age or older were recruited; all were outpatients of the oncology clinic of a university hospital in Seoul,
Korea. Sample size was estimated based on a signicance level of
.05, a power of .80, and a medium effect size of .30 (Polit and
Hungler, 1999). The sample was one of convenience, for which
two of the research team members who are oncologists recruited
subjects on a voluntary basis during their regular outpatient
clinics. Patients were eligible for enrollment if they were (a)
receiving palliative care following a diagnosis of advanced cancer
(i.e., terminal stage of local cancer or metastatic cancer that
involved more than two solid organs), (b) able to walk without
assistive devices, (c) living in the community independently, and
(d) able to communicate verbally in Korean. The nal data
included a total of 91 participants after excluding three incomplete
surveys (Fig. 1).
Measurements
General characteristics included age, gender, religion, education,
monthly income, medication status, and number of co-morbid
diseases.

109 Invited for participation


15 rejected for participation
94 Included for participation
3 excluded for incomplete
survey

94 Included for participation


Fig. 1. Flow diagram for subject recruitment.

Mobility was measured using the 6MWT (Guyatt et al., 1985).


The 6MWT is an indirect measure of aerobic capacity required to
maintain mobility in older adults. The 6MWT evaluates the total
distance one can walk for 6 min at a usual gait speed. In the current
study, a participant's 6-min walk distance was determined by
multiplying the person's stride length and number of walking steps.
A stride length was determined by instructing the patient to take 5
steps, measuring the distance from the start to nish lines, and
dividing it by 5. A walking step was counted using a pedometer.
Each participant was instructed to perform the 6MWT in the at
hallway of the oncology clinic, which is located on the third oor of
the 22-story, 1332-bed hospital. The participants were allowed to
rest or terminate the test at any time, and chairs were available for
rest in the hall-way. There were no seasonal or environmental
variations in the participants' responses and performance as the
entire data collection was conducted in an indoor setting with an
identical physical environment.
Physical activity behavior was measured using a self-reported,
single question: Do you currently do any type of regular physical
activity for a minimum of 30 min at least three times a week?
Based on the criteria proposed by the American College of Sports
Medicine (ACSM) (Haskell et al., 2007), those who responded yes
were categorized as engaging in regular physical activity and those
who responded no were categorized as sedentary. In this study,
physical activity was measured as a dichotomous response because
the authors were interested more in exploring the engagement
status of physical activity, a behavioral outcome, than the intensity
of physical activity levels. The validity of the ACSM criteria as a
measure for physical activity behavior has also been supported in
the literature (Nelson et al., 2007; Pinto et al., 2005).
Sleep disturbance was assessed according to the frequency of
sleep symptoms, which was evaluated using the frequency subcategory of the Sleep Habit Questionnaire (Baldwin et al., 2010).
This questionnaire consists of 9 items, rated on a 5-point scale from
0 (never) to 4 (almost always, i.e., 4 nights a week). The possible
total score for the Sleep Habit Questionnaire used in this study was
36. A higher score indicates a greater level of sleep disturbance. In
the present study, Cronbach's alpha reliability of the scale was .72.
Both pain and fatigue were measured using a visual analoge
scale (VAS) (Cline et al., 1992), which ranged from 0 (no pain or
fatigue at all) to 10 (the highest level of pain or fatigue that an individual can experience).
Data collection procedure
This study was approved by the Institutional Review Board of the
Catholic University of Korea (IRB approval number MC12QISI0105),
and participants were recruited from the oncology outpatient clinic
of C University Hospital in Seoul, Korea. The research team reviewed
the outpatient register and identied 109 potential patients who

S.-Y. Roh et al. / European Journal of Oncology Nursing 18 (2014) 613e618

were eligible for enrollment, 15 of whom rejected participation,


resulting in 94 patients recruited on a voluntary basis at the
outpatient oncology clinic. These patients were verbally invited to
participate in the study after the purpose and the data collection
process of the study were explained to them. Individual interview
schedules were arranged for those interested in participating in the
study. Before the interviews, subject protection and data condentiality were reviewed with each participant. Researchers assured
participants that their refusal to participate in the study would not
affect the care they received and that the content of the interview
would be used solely for research purposes. After the patient signed
the informed consent form, a research assistant conducted a face-toface interview at the outpatient clinic with the participant.
The research assistant was trained in implementing the 6MWT
based on previously published guidelines (Guyatt et al., 1985). In
addition, to avoid potential bias in data collection by using a single
data collector, for the rst three participants, a research team made
simultaneous observations along with the research assistant's
6MWT evaluations. The agreement between the two raters on the
6MWT evaluations was 100%. The interview was based on a semistructured survey questionnaire. The data were collected from
July 2012 to January 2013. Each participant spent approximately
30 min to complete the survey and the 6MWT and was compensated the equivalent of V4 for their participation in the study.
Data analysis
The data were analyzed using PASW 18.0. Socio-demographic
characteristics, mobility, physical activity behavior, sleep disturbance, fatigue and pain were described using descriptive statistics.
Associations of mobility with demographic characteristics and
physical activity were examined using t-test and ANOVA with
 test as a post-hoc test. Correlations of mobility with sleep
Scheffe
disturbance, fatigue and pain were tested using Pearson's correlation coefcients. A prediction model for mobility was examined
using multiple stepwise regression techniques.
Results
General characteristics
Baseline characteristics of the participants are shown in Table 1.
The mean age of the participants was 72 years (SD 5.07), ranging
from 65 to 95 years. Of the 91 participants, 36.3% (n 33) were
women, 30% (n 27) were Protestants, and 77.3% (n 68) had a
monthly income of less than $900 based on the exchange rate of
Korean won to US dollar in December 2013. Almost one-third of the
participants (n 28; 30.8%) were college graduates. The average
number of family members in the participants' families was 2.65,
ranging from 1 to 6 members. Participants had, on average, three
co-morbid diseases (range, 1e9), and the majority of them (n 84;
92.3%) were taking, on average, two classes of drugs (range, 1e6).
Approximately 73% of the participants (n 67) engaged in regular
physical activity at least 3 times a week. The most common type of
physical activity was walking (n 58; 63.7%), followed by mountain climbing (8.8%, n 8) and yoga (8.8%, n 8).
The mean score for the frequency of sleep symptoms was .51
(SD .30) out of 4.0, with a range from 0 to 2.17. The mean VAS
scores for pain and fatigue were 3.53 (SD 3.53) and 4.86
(SD 2.37) out of 10, respectively (Table 2).
Mobility
The mean 6MWT distance was 220.38 m (SD 110.10), with a
range from 9.72 m to 737.44 m (Table 2). The mean 6MWT distance

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

* Signicant at .05; ** Signicant at .01.


Bonferroni test: means with the different uppercase letter are signicantly
different.
a
t-value.
AB

Table 2
Scores for mobility and physical symptoms.
Characteristics

Mean SD

6-Minute walk (m)


Stride length (cm)
Steps
Sleep symptoms
Pain
Fatigue

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

was 174.98 m in women and 246.22 m in men, indicating that older


men walked signicantly further than older women (t 3.11;
p .003). There was also a signicant decrease in the mean distance that participants in different age groups could walk during
the 6MWT: participants in their 60 s, 70 s, and 80 s walked, on
average, 260.93 m, 205.31 m, and 157.05 m, respectively (F 3.51;
p .034).
The mobility of participants differed signicantly based on their
level of education and monthly income: those with relatively high
level of education and with a monthly income of more than $900
were signicantly more mobile than those with a primary school
education and (F 3.12; p .030) and with an income of less than
$900 per month (t 2.02; p .047). Participants who had families
consisting of 2e3 members showed signicantly higher levels of
mobility than those who lived on their own or had families consisting of 4 members (F 2.90; p .040). Participants who were
taking medications at the time of the study showed higher levels of
mobility than those who were not taking any medication (t 3.78;
p .000). Those who were engaged in regular physical activity

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S.-Y. Roh et al. / European Journal of Oncology Nursing 18 (2014) 613e618

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**

Signicant at .01; *Signicant at .05.

(<.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.

S.-Y. Roh et al. / European Journal of Oncology Nursing 18 (2014) 613e618

Age, monthly income, number of family members, medication


status, and sleep disturbances accounted for only 34% of the variance in mobility measured using the 6MWT. This nding supports
the need for ongoing exploration of alternative lifestyle and
symptom-related factors that could affect and predict the mobility
of older cancer patients. If such predictors can be identied, then it
would be possible to design more specic interventions for the
improvement of mobility in this patient population.
This study has several limitations. The cross-sectional nature of
this descriptive study limits identication of specic causal-effect
relationships between predictors and the mobility of older cancer
patients. Further, as the participants for this study were recruited
from the oncology outpatient clinic of a single university hospital in
Korea, the ndings might not accurately reect the circumstances
of all older cancer patients. Additionally, we measured physical
activity as a dichotomous variable (regular physical activity or
sedentary behavior), focusing on the regularity rather than on the
intensity of the physical activity. Use of a continuous variable in
measuring physical activity behavior in future studies may produce
a more accurate assessment of physical activity intensity in older
adults. Dening the difference between moderate- and vigorousintensity physical activity can also help researchers design a
dose-specic physical activity intervention for enhancing mobility
in older cancer patients in future research. Nonetheless, this study
contributes critical information regarding lifestyle correlates of
mobility of older cancer patients receiving palliative care- a topic
that has not been well researched. Further studies that examine
mobility levels according to the palliation stage are necessary to
ensure the design of appropriate intervention strategies that would
improve the functional mobility of older cancer patients.
Conict of interest statement
None declared.
Acknowledgments
This research was supported by Basic Science Research Program
through the National Research Foundation of Korea (NRF) funded by
the Ministry of Science, ICT & Future Planning (2013R1A1A3005236)
and the Catholic Medical Center Research Foundation made in the
program year of 2011 (5-2012-B0001-00004). These sponsors had no
involvement in the research process.
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