The Impact of Exercise on Activities of Daily Living and Quality of Life: A Primary Care Physician's Perspective

Abstract

Evaluation of the environment of patients is an important function of the primary care physician and assists the caregiver in providing an improved quality of life for one's patients. In addition to data collection and therapy, assessment of both the basic and instrumental activities of daily living is a primary concern, especially in patients with chronic diseases such as chronic obstructive pulmonary disease. This article presents the perspective and observation of a primary care physician's management of chronic obstructive pulmonary disease and will give examples of how combined pulmonary rehabilitation and medication improved the quality of life for three patients and show how activities of daily living and quality of life may be seen as a continuum in chronic obstructive pulmonary disease.

Keywords::

• COPD
• Exercise
• Anxiety
• Activities of daily living
• Quality of life

INTRODUCTION

One of the most important functions of the primary care physician (PCP) is the evaluation of the physical and social environment of our patients. This evaluation includes Activities of Daily Living (ADLs) ([1]) as well as Instrumental Activities of Daily Living (IADLs) ([2]). This assessment is particularly important for patients who are being evaluated for chronic obstructive pulmonary disease (COPD). Several studies have examined the association between measures of exercise and activities of daily living and health-related quality of life with varying levels of correlation found ([3]). Quality of life has a direct relationship to activities of daily living in all people; depression and social isolation may be present secondary to a person's inability to perform even the simplest of activities ([4]). Thus, the PCP is in a great position to impact quality of life in our patients. There are several questions utilized in the patient's history that assists the PCP in evaluating function and quality of life. In addition, our patient's exercise capability has a direct effect upon their quality of life as it relates to their own activities of daily living.

BASIC ACTIVITIES OF DAILY LIVING (BADL)

Table 1 suggests simple questions that may be utilized in assessing the basic ADLs and may be posed to the patient or their caregiver. These instrumental ADLs may be thought of using the simple mnemonic SHAFT: Shopping, Housekeeping, Accounting, Food preparation, and Transportation ([5]).

Table 1 Simple questions to assess basic ADLs

“Are you able to wash and bathe yourself?”

“Are you able to climb stairs?”

“Are you able to move (i.e. transfer) from a bed to a chair on your own?”

“Can you walk (and if so, how far)?”

“Are you able to feed yourself?”

“Do you have difficulty using the toilet for either bladder or

bowel functions?”

“Are you able to groom yourself?”

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLS)

Table 2 contains example questions used to assess instrumental ADLs, evaluating the higher capabilities of patients.

Table 2

“Are you able to travel via car or public transportation?”

“Do you shop for your own food and clothes?”

“Who prepares your food for you?”

“How much of your own housework do you perform?”

“Can you make your bed?”

“Who ensures you take your medication on time and in the

correct dose?”

“Do you manage your own money?”

“Are you able to engage in sexual activity?”

“Do you care for others?”

“Do you care for a pet?”

“Are you caring for children?”

“How do you get around?”

“Do you require a device to communicate with others?”

PRODUCTIVE ACTIVITIES

People with chronic, but stable illnesses who remain productive are usually able to perform all or most of the above activities and are also able to engage in many of the following activities: employment; volunteer work; gardening; social activities; going to movies; sporting or recreational activities; recreational travel; and group participation.

Clinical studies have demonstrated that pharmacologic treatment with long-acting bronchodilator therapy ([6], [7], [8]) and pulmonary rehabilitation ([9], [10]) can increase exercise tolerance of COPD patients. Although the impact of this improved exercise endurance on patient ADL and IADL has not yet been specifically defined, the following three patients may serve as examples of what even a few extra minutes of endurance may mean to a patient with moderately severe to severe COPD.

PATIENT 1: JOHN H

John H. is a 78 year-old white retired and widowed male who currently lives alone. He has a 30-plus pack-year smoking history, but quit in 1970. In the past, he was an avid golfer, although he was forced to ride in a golf cart over the final 3 years due to his increasing dyspnea. He had to give up golfing completely due to this breathlessness in 2003. COPD was first diagnosed in 1997 when spirometry showed an FEV₁: 2.26L (87% predicted); FVC: 3.90L (113% predicted); FEV₁/FVC: 58%. Mr. H. has been on continuous supplemental oxygen at 3 L/min since 2002. He complained of dyspnea at rest and this was exacerbated by minimal activity. His pulse oximetry showed desaturation to 84% without oxygen. He became increasingly depressed due to the lack of social interaction, eg, golf. In 2006 his spirometry showed an FEV₁: 1.57L (67% predicted); FVC: 2.68L (87% predicted); FEV₁/FVC: 59%. His medications have been maximized with tiotropium (Spiriva®, Boehringer Ingelheim) and (rescue) albuterol (generic) inhalers as well as fluticasone/salmeterol 500 mcg/50 mcg inhaler (Advair Diskus®, GlaxoSmithKline) and he has undertaken a course of pulmonary rehabilitation. To John H., increased endurance has meant the ability to travel to the golf course and riding in a golf cart with his friends. He hopes to be able to once again hit golf balls in the near future.

PATIENT 2: MARY H

Mary H. is a 49 year-old African-American, married homemaker. She was diagnosed with “asthma” until 2003 when COPD was then diagnosed. She finally quit smoking cigarettes in 2005 after 28 pack-years. Mary H. cares for her 3 young grandchildren at home and works part-time as a “materials handler.” After being seen by the author in late 2004, office spirometry in early 2005 showed an FEV₁: 1.24L (44% predicted), FVC: 2.51L (73% predicted); FEV₁/FVC: 49%. She was very depressed due to her increasing breathlessness when caring for her grandchildren and has complained about significant dyspnea during sexual activity. She has required psychological counseling and has undertaken three phases of pulmonary rehabilitation successfully. She has seen an increase in exertional tolerance, decrease in dyspnea, is able to now work an entire day, and has had fewer exacerbations. Her current medications include tiotropium (Spiriva®) and (rescue) albuterol inhalers as well as fluticasone/ salmeterol 250 mcg/50 mcg inhaler (Advair Diskus®). To Mary H, increased endurance means the ability to enjoy caring for her grandchildren and return to sexual relations with her husband with less dyspnea.

PATIENT 3: MICHAEL M

Michael M. is a 68 year-old retired and divorced white male who currently lives alone. He was an avid hunter and fisherman until 2004, but had to give it up due to severe dyspnea. He quit smoking cigarettes in 2001 after 62 pack-years. His history is also significant for exposure to silicon dioxide dust at work for many years. COPD was first diagnosed in 2000 after several years carrying the diagnosis of “asthma.” Upon seeing the author for the first time in 2004, spirometry showed an FEV₁: 1.47L (46% predicted); FVC: 2.38L (59% predicted); FEV₁/FVC: 62%. He was depressed due to his inability to walk up a flight of stairs without stopping and increasing difficulty dressing due to the dyspnea. Walking through the woods or fishing was almost impossible. He had a new sexual partner, but was too dyspneic to enjoy sexual activity. He has now undergone pulmonary rehabilitation and is stabilized with tiotropium (Spiriva®) and (rescue) albuterol inhalers as well as fluticasone/salmeterol 250 mcg/50 mcg inhaler (Advair Diskus®). For Michael M., increased endurance means the ability to care for himself at home, and enjoy occasional sexual activity with his partner. He now has returned to his fishing hobby and hopes to again have the ability to go hunting.

ADLS AND QUALITY OF LIFE AS A CONTINUUM IN COPD

Activities of daily living and quality of life may be seen as a continuum in COPD and the PCP should be able to ascertain an approximate level of severity by assessing the ability to perform basic and instrumental ADLs as well as querying about “productive” activities. In early COPD, with only mild dyspnea on exertion, the patient should be able to perform most “productive” activities. In “stable” COPD, with moderate dyspnea on exertion, patients should be able to perform at least most of the instrumental ADLs. Finally, in severe COPD, patients may be able to perform only the most basic of the ADLs or may need assistance with these.

DATA COLLECTION AND THE NEED FOR SPIROMETRY

Primary care physicians increasingly need to have data (i.e. numbers) when caring for patients and preventing future disease or debilitation. Patients are also increasingly inquisitive regarding their own numbers. These tests include: blood pressure; blood sugar; lipid panel (total cholesterol/ HDL-cholesterol/LDL-cholesterol/triglycerides); body mass index (BMI); and 10-year National Cholesterol Education Program/Adult Treatment Panel III risk evaluation for developing coronary heart disease. Physicians in primary care are still obtaining spirometry in dismally small numbers. The FEV₁, FVC, and the FEV₁/FVC ratio should be obtained early as a routine, especially in patients most at risk for developing COPD (eg, every smoker, past and present) ([11]). Office spirometry is an easy, inexpensive procedure that is reimbursable and may enable PCPs to find patients at risk early.

SUMMARY

The primary care physician needs to ask questions that may give clues for the early diagnosis of COPD. One of the most important questions is, “Have you given up any activities due to shortness of breath?” With the rigors of having to evaluate patients in a reasonably short, efficient manner, gauging the efficacy of therapy in a typical primary care practice can be summed-up with the simplistic “thumbs-up” or “thumbs-down sign.” Perhaps the easiest way to gauge new treatment is to just ask, “Did the new medication make you feel better?” If the answer is “Yes,” this would elicit the “thumbs-up” sign. If the answer is “No,” the “thumbs-down” sign would be utilized. The diminished ability to perform activities of daily living is an important key to help the PCP differentiate between mild versus more advanced and uncompensated disease. It is imperative that spirometry is obtained early in the process. Also, pulmonary rehabilitation should be started early in the course of therapy, but currently is underutilized ([11]). Finally, to our patients, a few minutes of increased “endurance” may mean the difference between depression and social isolation and a “re-energized” quality of life.

SUGGESTED READING

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6. National Center for Health Statistics: Health, United States, 2005 With Chartbook on Trends in the Health of Americans With Special Feature on Adults 55-64 Years. Hyattsville, Maryland: 2005. Available at: http://www.cdc.gov/nchs/hus.htm Accessed on: June 4, 2006.

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