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This is to certify that the

thesis entitled
The Relationship Between the Level
of Depression, Symptoms, and Physical
Function Among a Group of Newly
Diagnosed Elderly Patients With Cancer

of the Lung
presented by

Janice Lynn Cooper

has been accepted towards fulfillment
of the requirements for

MasteL—degree in m

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MSU In An Afflnnotivo Action/Equal Opportunity Instituion

 

THE RELATIONSHIP BETWEEN THE LEVEL OF DEPRESSION, SYMPTOMS,
AND PHYSICAL FUNCTION AMONG A GROUP OF NEWLY DIAGNOSED
ELDERLY PATIENTS WITH CANCER OF THE LUNG
BY

Janice Lynn Cooper

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1997

ABSTRACT
THE RELATIONSHIP BETWEEN THE LEVEL OF DEPRESSION, SYMPTOMS,
AND PHYSICAL FUNCTION AMONG A GROUP OF NEWLY DIAGNOSED
ELDERLY PATIENTS WITH CANCER OF THE LUNG
BY

Janice Lynn Cooper

The focus of this study was to search for relationships between level of
depression, the level Of symptoms, and physical functioning of elderly people
recently diagnosed with lung cancer. It was a secondary analysis of data from a
longitudinal study Of people 65 years of age and Older newly diagnosed with
breast, lung, cola-rectal and prostate cancer conducted at Michigan State
University by Barbara A. Given, R.N., Ph.D., F.A.A.N., Principal Investigator.
The sample included 78 patients age 65 and Older who were newly diagnosed
with lung cancer. The levels were measured with the CES—D, Given and Given
Symptom Experience Scale, and the Physical Function Concept Scale from the
Medical Outcome Studies Short Form-36. A Significant relationship was found
between the level of symptoms and the level physical functioning. Implications

of the findings for research and practice are presented.

To my Father and brother Mark, who fought courageous battles with cancer.

ACKNOWLEDGMENTS

I would like to extend my appreciation to my thesis chair Sharon King
for her support Of my efforts throughout the thesis process. In addition, I
would like to thank Barbara Given and Mannered Stommel for their time and
efforts as members of my committee.

Thank you to my family for their support, and patience throughout the
course of my graduate study.

Special thanks to my thesis study group. I would never have
completed my thesis without the support and encouragement of Debbie,
Andi, Luanne, Kathy, and Sandy. Thank you also to Betty Marshall for her

expert assistance in searching for literature and obtaining copies for me.

TABLE OF CONTENTS

LIST OF TABLES .........................................................................................
LIST OF FIGURES .......................................................................................
INTRODUCTION ..........................................................................................

CONCEPT DEFINITIONS .............................................................................
Elderly ......................................................................................................
Lung Cancer ............................................................................................
Newly Diagnosed .....................................................................................
Level Of Depression ................................................................................
Symptoms ................................................................................................
Physical Function .....................................................................................

THEORETICAL FRAMEWORK ...................................................................
Background Of Family/Patient ..................................................................
Patient Characteristics .............................................................................
Nature of the Cancer and Care Situation .................................................
Demands on the Patient ..........................................................................
Depression as a Patient Outcome ...........................................................

LITERATURE REVIEW ................................................................................

METHODS
Research Question ..................................................................................
Hypotheses ..............................................................................................
Research Design .....................................................................................
Sample Procedure ...................................................................................
Data Collection Procedures .....................................................................
Operational Definition of Variables and Instrumentation ..........................
Elderly ......................................................................................................
Lung Cancer ............................................................................................
Newly Diagnosed .....................................................................................
Level Of Depression ................................................................................
Level of Symptoms ..................................................................................
Level of Physical Function ......................................................................
Data Analysis ...........................................................................................
Procuedures for Protection of Human Subjects .......................................

V

vii

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10
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21
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25
26
28
29

RESULTS ................................................................................................... 29

Sample ................................................................................................... 29
Symptoms .............................................................................................. 30
Physical Function ................................................................................... 33
Depression ............................................................................................. 35
Relationships Between Levels of Depression, Symptoms,
and Physical Function ....................................................................... 38
DISCUSSION .............................................................................................. 39
Interpretations Relative to Framework .................................................... 41
Limitations of the Study .......................................................................... 46
Recommendations for Future Research ................................................. 47
Implications for Advanced Nursing Practice ............................................ 50
APPENDICES
Appendix A: CES—D Items Divided Into the Four Factors ....................... 55
Appendix B: UCRIHS Approval for Original Study .................................. 56
Appendix C: UCRIHS Approval .............................................................. 57
LIST OF REFERENCES ............................................................................... 58

vi

LIST OF TABLES

Table 1 - Sample Characteristics ................................................................. 31
Table 2 - Most Frequently Reported Symptoms ................................................ 32
Table 3 - Symptoms With the Highest Severity ................................................. 32
Table 4 - Physical Function Scores Ranked from Highest to Lowest ................ 34
Table 5 - Range Of Physical Function Scores from Best Function to Worse ..... 36
Table 6 - Mean Scores of CES~D Ranked Highest to Lowest ........................... 37
Table 7 - Correlation Coefficients ................................................................ 38

vii

LIST OF FIGURES

Figure 1- Continuing Cancer Care Demands and Family Caregiver Burden 8

Figure 2- Adaptation Of Cancer Care Demands from Figure 1 ................... 9

viii

INTRODUCTION

The incidence of death from lung cancer has markedly increased in recent
decades until lung cancer has become the leading cause of death from cancer in
both men and women. Although the incidence is now decreasing for men,
approximately 14% of the 640,000 men who will be diagnosed with cancer in
1995 are expected to have lung cancer while 13% of 575,000 newly diagnosed
female cancer patients are expected to have lung cancer (SEER Cancer
Statistics Review, 1973-1991).

The incidence of lung cancer increases after the age Of fifty peaking at
ages 75 to 79 and then declines (SEER Cancer Statistics Review, 1973-1991).
The average age of onset is 60 (Faber, 1991). In 1996 an estimated 158,700
people in the United States will die from lung cancer. (Parker, Tong, Bolden, &
Wingo, 1996). Cancer of the lung interferes with the quality of the patient's life.
For this reason, this study searches for relationships between symptom distress,
physical functioning, and depression for the elderly person newly diagnosed with
lung cancer.

Only 21% of newly diagnosed lung cancer patients have localized
disease and only 12% Of them are asymptomatic (Faber, 1991). Common

symptoms for people with lung cancer include cough, hemoptysis, pain, poor

appetite, weight loss, trouble sleeping, fatigue, and dry mouth. The majority of
people with lung cancer do not need to stay indoors or need assistance with
functions such as taking medicine, money management, driving, or climbing
stairs. However, up to 50% of people newly diagnosed with lung cancer are
unable to walk several blocks, need assistance with housework, and have
difficulty bending, lifting, and stooping. Approximately 30% need assistance
making meals and have difficulty climbing stairs (Given, Given, & Stommel,
1994). These dependencies may be caused by symptoms, age, or comorbid
diseases.

Elderly persons with may be diagnosed with late stage lung cancer or may
already have other chronic illnesses and disabilities impacting on their life. For
people over 75 years Of age, approximately 40% will have multiple chronic
illnesses and/or dementia. People over 85 years of age are at the greatest risk
for disability and chronic illness (Knobf, F ulmer, & Mion, 1993). These chronic
illnesses and disabilities may decrease independent function and emotional well-
being Of the elderly person. The symptoms caused by the lung cancer, along
with the symptoms caused by comorbid diseases, can cause symptom distress
for the elderly person newly diagnosed with cancer. The distress from symptoms
can severely interfere with their physical function, decrease their quality of life,
decrease compliance with the treatment plan, and increase their need for

assistance from others.

The aging process, cancer, and comorbid diseases when combined may
seriously impair the physical functioning of the elderly person diagnosed with
cancer. lmpairrnents in physical functioning may interfere with the person’s
ability to comply with their treatment plan and/or further jeopardize their health
status (Mor, Masterson-Allen, Houts, & Siegel, 1992).

Treatment options for lung cancer vary depending on the stage and type
Of cancer. Treatment options may include surgery, radiation therapy, and
chemotherapy. The treatments may cause side effects and symptoms which
further disrupt physical function abilities. Physical function impairments in people
with cancer may reduce quality of life and increase need for dependence on
others (Greene, Nail, Fieler, Didgeon, & Jones, 1994).

Major depression affects between one to two percent of people 65 and
Older in the community. More than ten percent of elderly people in the
community have significant symptoms of depression (Blazer, 1989). Blazer
(1989) describes that for the majority of elderly people with depressive
symptoms, the symptoms occur associated with physical illness, adjustment to
life stresses, or mild but biologically derived depressive episodes. Diagnosis with
lung cancer would be associated with both physical illness and adjustment to life
stressors which could precipitate depression.

Ell, Mantell, Hamovitch (1988) measured levels of psychologic distress in
patients with breast, colorectal, and lung cancer and found psychologic distress

decreased with advancing age until age 75 when distress started increasing

again. Godding, McAnUlty, Wittrock, Britt, and Khansur (1995) studied a group
of 69 male patients with an average age Of 64.3 years who had lung, head/neck,
prostate, lymphoma, melanoma, or gastrointestinal cancers. Thirty-nine percent
Of the men reported symptoms of moderate-to-severe depression with 13% of
the men reporting severe depressive symptomatology.

Cassileth, et al. (1984) found lower psychological distress in people older
than 60 than for those younger than 40 and 40 to 60 during a study of 758
patients with chronic physical illness including arthritis, diabetes, cancer, renal
disease, and dennatologic disorder. The study also indicated that cancer
patients able to maintain normal activity had better mental health scores than
those who were experiencing symptoms or were confined to bed.

The rate of depression is higher in cancer patients than in the elderly
community as a whole. Depression occurs in approximately 20% to 25% of all
cancer patients and increases as illness advances with increasing pain and
disability (Breitbart, 1994). Depression can contribute to decreased self-esteem,
decreased quality of life, and impaired social functioning (Badger, 1993).

Since the greatest share Of cancer treatment occurs in out-patient
settings, assessments of clients must be thoroughly, but quickly completed.
Assessments Of the client’s physical function needs to be done easily with results
that will assist the health professional to help the elderly maintain their function
and independence and manage on an out-patient basis. The health care

professional needs to understand that the diagnosis of lung cancer is a stressful

event in the person’s life that may be accompanied by feelings of depression. In
addition, the person with cancer may already be experiencing symptom distress
and physical function impairment. An understanding Of any relationship between
the level Of depression, symptoms, and physical function will help the health
professional better understand the needs Of the person with cancer. Therefore,
the focus of this study was to search for relationships between level of
depression, the level of symptoms, and physical functioning of elderly
people recently diagnosed with lung cancer.
Concept Definitions

m

For the purposes of this study, elderly were defined as people 65 years of
age and older. Sixty-five and Older is commonly used to describe elderly in
research studies and position papers (Boyle, et al., 1992; Knobf, Fulmer, &
Mion, 1993).
Lung Cancer

For this study, lung cancer included both small cell tumors and non-small
cell tumors. This study included elderly people with a new primary diagnosis of
lung cancer including all stages whether or not they chose to have treatment.
Newly Diagnosed

This study included the first eight weeks after the diagnosis Of cancer as
the period considered newly diagnosed. During the initial eight weeks, the

person may undergo many tests and procedures and consultations with

specialists. Treatment Options are usually discussed, decisions are made about
treatment plans and the plan may have been initiated and completed. This initial
stage of illness has been identified as being especially important in the process
of adapting to cancer (Northouse, 1989).
Level Of Depression

A sad or depressed mood is a normal response to feelings of loss and
stressful situations. The degree of depression varies from person to person, and
some people may even develop a major depression requiring treatment (Valente,
Saunders, & Cohen, 1994). Depressed or sad moods may affect a person’s
appetite, tolerance of situations, self-concept, concentration, feelings Of
hopefulness, energy level, degree of fear, feelings of loneliness, and enjoyment
Of life.
Symptoms

Rhodes and Watson (1987) define symptoms as “distinctive features
interpretive of a disease category used to diagnose a patient’s condition” (p. 242)
and state symptoms “have Often included signs or objective clinical
manifestations” (p. 242). Symptom distress is described by Rhodes and Watson
as physical and mental anguish or suffering resulting from experiencing the
occurrence Of symptoms and/or the perceiving Of feeling states. The University
Of California, San Francisco School of Nursing Symptom Management Faculty
(1994) proposes that a person’s experience with symptoms is dynamic and

involves their perception of the symptoms, evaluation, and response.

Physical anction

Physical function includes the patient’s mobility and ability to perform
certain physical tasks including vigorous activities such as running, lifting heavy
Objects, and strenuous activities. The level of physical function was assessed by
the Physical Function Concept Scale from the Medical Outcome Studies Short
Form-36 (MOS SF-36).

In summary, this study included people 65 years of age and Older within
eight weeks of diagnosis with lung cancer. The study assessed levels of
depression, symptoms, and physical function.

Theoretical Framework

Given and Given (1996) have proposed a conceptual model for family

caregiver burden from cancer care (See Figure 1). The model describes factors

contributing to the responses and outcome Of the caregiver to the care of family

members with cancer. The model was adapted to show the relationships

between symptoms, physical function and depression (See Figure 2).

Given and Given (1996) propose that the background Of both cancer
patients and their families along with their characteristics are factors which
influence the nature of the cancer and care situation. Formal and informal care
systems also influence the nature of the cancer and care situation. The nature

of the cancer and care situation influences the demands on the caregiver and

 

Background of Family
Prior Family Relationships
Family Networks
Family Development Stage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Socioeconomic Status
Living Arrangement
fluent Cha_ractenstIcs Age
Age Gender
Gender Marital Status
Mental Slat"? <I 9 Role Obligations
Role Oblrgatrons Resources
Resources
Co—morbid Conditions
Formal Care M
System _S_y_s_t_efl
Acute Care | I Family
VNS Friends
Home Care
Hospice Nature of the Cflerm
M911
Site of Cancer
Type of Cancer
Stage
Treatment and Side Effects
Care Requirements

 

 

 

l

Dema_nds on Caregiver and Patient
Patient Symptom Experience
Patient Dependencies
Other Patient Role Dependencies
Medical Care Tasks

 

 

 

 

 

Caregiver Outcomes
Caregiver Burdens
Depression
Anxiety
Role Burdens
Economic Burdens

 

 

 

Figure 1 Continuing Cancer Care Demands and Family Caregiver Burden (Given 8 Given, 1996)

 

Demands on Patient
Symptoms

Physical Function

 

 

 

 

Egtjent (incomes

Depression

 

 

 

Figure 2 Adaptation of Cancer Care Demands from Figure 1 (Given 8 Given, 1996)

10

patient. These demands in turn result in multidimensional responses from the
patient.
Background Of Family/PaLient

The background of the family and patient affects how they react to the
stress of the new diagnosis of cancer. Given and Given (1996) indicate that the
patient and family bring a history of interactions to the cancer experience that
may strengthen or complicate the experience. Factors include the closeness,
intensity, and quality of the prior relationships.

The developmental stage Of the patient has an impact on how the patient
responds to the cancer experience. Havighurst (1972) describes people 60
years of age until death as in the developmental stage Of later maturity.
Developmental tasks for later maturity include: adjusting to decreasing physical
strength and health, adjusting to retirement and a reduced income; establishing
an explicit affiliation with one’s age group; adjusting to death Of spouse or
partner; adopting and adapting social roles in a flexible way; and establishing
satisfactory physical living arrangements (Kopac, 1993; Matteson, 1990).
Patient Characteristics

Characteristics that affect the patient’s response to the cancer experience
include age, gender, marital status, role Obligations, resources, co-morbid
conditions. The Older the patient, the greater the chance that the person has

already experienced loss of physical strength, loss of health and vigor, and

ll

sensory losses. Age may affect the physiological response to the cancer
experience.

The older person is also more likely to have experienced the loss Of their
spouse, brothers, sisters, other relatives, and friends and this narrows the
number of people available for caregiving and emotional support. Older people
may have already suffered material losses including income, reduced living
circumstances and opportunities resulting in less financial resources for medical
bills and home care (Kane, 1991). Through their history Of losses the older
person may have developed patterns for coping with losses. These patterns
may include effective coping mechanisms or ineffective coping mechanisms
including depression.

The gender Of the cancer patients may affect their response to the cancer
experience. Gender may affect marital status, financial income, and types Of
daily chores. Seventy-seven percent of elderly men are married compared to
41% of elderly women (Kopac, 1993). This may mean that the single woman will
find it more difficult to find a caregiver. In 1991 the median income for elderly
men was $14,357 while the median income for elderly women was only $8,189
(Kopac, 1993). Gender affects the different types Of daily tasks that may need to
be reassigned to others while patients are experiencing any ill effects from
cancer (Given & Given, 1996). Gender may also affect how the body responds

to the cancer experience. For example, men may experience greater cancer-

12

related weight loss than women, despite the fact that men may consume more
food (Brown, 1993).

Mar, Allen, and Malin (1994) argue that elderly people have fewer
competing role Obligations and demands in their lives during their coping with
cancer than younger people. They hypothesize that fewer role Obligations may
lead to less disruption in the lives of older people resulting from the cancer
experience interfering with role Obligations. If this is true, it could explain why
elderly people report less psychological distress than younger people.

The risk of comorbid conditions increases with age. Comorbid diseases
may negatively affect or complicate the cancer treatment and prognosis,
influence treatment choices, decrease the patient’s independent function and
emotional well-being, and will influence the intensity of symptom distress and
physical impairment caused by the lung cancer (Given, McCorkle, 8. Given,
1993; Knobf, Fulmer, & Mion, 1993; Silliman, Schonwetter, & Burns, 1994). Age,
gender, marital status, role Obligations, resources, and co-morbid diseases have
physiological, emotional, and economical impacts on the person’s response to
cancer.

We Of the Cancer and Care Situation

Factors that influence the nature of the cancer and care situation include:
the site of the cancer, the type Of cancer, the stage, any treatment and side
effects produced by the treatment, and care requirements (Given & Given,

1996). The site, cell type, and stage at diagnosis will influence the treatment

13

options and the amount, type, and intensity of the symptom distress and physical
impairment experienced by the patient (Given, McCorkle, & Given, 1993).

The stage Of the cancer also affects the symptom distress. Patients may
be asymptomatic from their tumor site in the lung but experience symptom
distress from distant metastasis (Choi, Mathisen, Huberrnan, & Mark, 1990).
Comis and Martin (1987) describe the stage of small Cell lung cancer and
performance status as the most important disease-related prognostic factors.
The type of treatment that the patient receives will influence the Side effects
experienced and this affects performance.

Demands on Patient

Given and Given (1996) report that patient symptom experience,
dependencies, other patient role dependencies, and medical care tasks combine
and increase demands on the caregiver. This writer suggests that these same
experiences can increase the emotional and physical difficulty for the patient
making life more difficult for the patient as well as the caregiver. This added
difficulty on the patient creates demands on the patient's life.

As previously discussed, the nature Of the cancer, treatment, and
comorbid diseases result in symptoms. The symptoms experienced may have
profound functional and emotional consequences (Sarna, 1993). Sarna (1993)
found that fatigue, pain and insomnia were reported with the highest frequency
of occurrence in women with lung cancer. Fatigue, pain and insomnia were also

ranked as the most severe symptoms. The symptom experience increases the

I4

difficulty for the patients to accomplish their usual tasks and roles increasing the
demands and changes that the cancer experience places on their lives.

Newly diagnosed patients usually have lower functional needs than
terminal patients (Mor, Guadagnoli, 8 Wool, 1988). However, newly diagnosed
elderly patients may already have physical function impairment needs resultant
from comorbid diseases and age. Faber (1991) reports that at the time Of
diagnosis only 12% of lung cancer patients are asymptomatic and only 21%
have localized disease, therefore the elderly person newly diagnosed with lung
cancer may already have more functional impairment than other newly
diagnosed cancer patients. The physical and emotional needs caused by the
cancer experience or comorbid diseases become areas Of demand on the
patient as well as on the caregiver.

Depression as a Pat_ient Outcome

Given and Given (1996) propose caregiver outcomes in their model.
However, this study will adapt the model to address patient outcomes. Given
and Given propose that depression is a characteristic of care giver outcome.
This study focuses on depression as a characteristic Of patient outcome.
Depression has been found to be highly correlated with cancer patient’s
immobility and symptom distress (Given 8 Given, 1996; Kurtz, Kurtz, Given, 8
Given, 1995). Given and Given (1992) report that functional status and symptom
distress add to the variation in depression. Cassileth, et al. (1984) found that

cancer patients with normal physical performance had less depressive scores

I5

than patients who had more symptom distress or were bedridden. Godding,
McAnulty, Wittrock, Britt, and Khansur (1995) found that quality Of life was the
single most important predictor Of depression. This study suggests that
increased symptoms and increased functional impairment interferes with quality
Of life for lung cancer patients and may increase the patient’s depression.
Therefore, this study proposes that the level of symptoms and level of physical
function influences the level of depression of the patient with lung cancer.
Individuals with lung cancer undergoing cancer treatments frequently
experience poor appetite, weightless, trouble sleeping, and fatigue. Symptoms
of depression include appetite disturbance, weight loss, and sleep disturbance
(Blazer, 1990). This researcher questions whether the lung cancer patient can
make the distinction between the cause Of their symptoms. The similarity
between the symptoms of lung cancer and depression may lead the patient to
believe their weight loss and fatigue mean their disease is worse rather than that
the symptoms are at least partially caused by depression. Another factor
influencing a patient’s physical functional level may be fatigue resulting from
depression. This researcher proposes that depression is a characteristic Of the
patient outcome from the cancer experience. However, the symptoms of
depression may also influence the symptom level and physical function level.
Therefore, this researcher proposes that the arrow in the conceptual framework
between Demands on Patient and Patient Outcomes should point both directions

(see Figure 2). In summary, this study proposes that there is a positive

16

relationship between the levels of symptoms, physical function, and depression.
An increase in the levels Of symptoms, physical function or depression would
increase the other levels. A decrease in the levels Of symptoms, physical
function or depression would decrease the other levels.
Literature Review

The focus of this review will be on what is known about the relationships
between symptoms, physical function, and depression in individuals with cancer.
Kurtz, Given, Kurtz, and Given (1994) found that symptoms were a significant
predictor of dependencies in ADLs and that there were significant correlations
between depression, immobility, and dependencies in ADLs. Kurtz, Kurtz,
Given, and Given (1995) found that patient immobility and symptom distress
were highly correlated with levels Of depression for 150 adult cancer patients.
The patients were interviewed again six months later and the change in
depression was positively correlated with Changes in immobility and symptoms.

Kurtz, Kurtz, Given, and Given (1993) found a significant correlation
between symptoms and loss of physical functioning in 279 adult cancer patients.
Symptoms, most specifically poor appetite, were a significant predictor of loss Of
physical functioning in the patients with lung cancer. Sarna, Lindsey, Dean,
Brecht, and McCorkle (1994) found that weight loss with advanced lung cancer
was associated with decreased functional status.

Given, Stommel, Given, Osuch, Kurtz, and Kurtz (1993) found that

patients” immobility, symptom distress, and the number of dependencies in ADLs

17

were moderately to highly correlated with levels Of depression reported by the
patients. Patient symptom experience had a statistically significant impact on
both physical function and depression in a study of 111 cancer patients 50 years
of age and older reported by Given, Given, and Stommel (1994). In the same
study, physical function did not significantly help predict the level of depression.

Donaldson, McCorkle, Georgiandou, and Benoliel (1986) report that
psychological distress decreased by the second month after diagnosis for lung
cancer even though the patients did not report a change in the level of symptom
distress. Cassileth, et al. (1984) found that cancer patients with normal physical
function had better levels Of mental health than cancer patients who had higher
levels Of symptom distress or were bedridden.

In summary, correlations have been found between the level of
depression, symptoms, and physical function in adult cancer patients. This
leads to the following hypotheses for this study: 1) There is a positive
relationship between the level of depression and level of symptoms in the newly
diagnosed elderly person with lung cancer; 2) There is a positive relationship
between the level Of depression and level Of physical function in the newly
diagnosed elderly person with lung cancer; and 3) There is a positive
relationship between the level Of symptoms and level Of physical function in the
newly diagnosed elderly person with lung cancer.

The Oncology Nursing Society released a Position Paper on Cancer and

Aging that addresses the importance Of meeting the needs Of the elderly person

18

with cancer (Boyle, Engelking, Blesch, Dodge, Sarna and Weinrich, 1992). The
Oncology Nursing Society advocates determining whether research findings can
be generalized to the elderly and performing comprehensive gerontological
assessments. This study will explore whether the relationships that have been
found between the levels of depression, symptoms, and physical function might
be found in elderly patients with lung cancer. The results will help health care
providers determine if their comprehensive assessment of the elderly person
newly diagnosed with lung cancer indicates that the person is at risk for
problems with increased levels of depression, symptoms, and difficulties with
mobility.
Methods

The purpose Of this study was to search for relationships between level
of depression, level of symptoms, and level of physical functioning of
elderly people recently diagnosed with lung cancer. The following section
will present the methods and procedures proposed for this study.
Research Question

What is the relationship between the level Of depression, level of
symptoms, and physical functioning of elderly people recently diagnosed with

lung cancer?

l9

Hypotheses

The three hypotheses include:

1) There is a positive relationship between the level of depression and
level of symptoms in the newly diagnosed elderly person with lung cancer.

2) There is a positive relationship between the level of depression and
level of physical function in the newly diagnosed elderly person with lung cancer.

3) There is a positive relationship between the level of symptoms and
level of physical function in the newly diagnosed elderly person with lung cancer.
Research Design

This study was cross-sectional using data from the first wave of a panel
study Of people 65 years of age and older newly diagnosed with breast, lung,
cola-rectal and prostate cancer (Grant #2 R01 NR/CA01915-05, “Family Home
care for Cancer - A Community-Based Model”, Principal Investigator - Barbara A.
Given, R.N., Ph.D., F.A.A.N.). The study was funded jointly by the National
Institute Of Nursing Research and the National Cancer Institute (Given, 1991).
Sample Procedure

The longitudinal study included people 65 years Of age and Older admitted
into community-based hospitals affiliated with the Human Health Programs at
Michigan State University. The people were admitted for a new diagnosis of
lung, breast, cola-rectal, or prostate cancer and planned continuing cancer

treatment (Given, 1991). Only people from the original study who were 65 years

20

Of age and older and diagnosed with lung cancer within eight weeks Of their
intake into the study were selected for this study.

The longitudinal study recruited patients from community based hospitals
affiliated with the Human Health Programs at Michigan State University. The
hospitals were from Lower Michigan and included Saginaw, Grand Rapids, Flint,
and Kalamazoo (Given, 1991).

Patients were recruited for the longitudinal study by recruiters at the
participating community-based hospitals. The recruiters, who were hired by the
agency, reviewed medical records, surgery schedules, and admission records to
identify patients who would meet the criteria for inclusion in the study. After the
patient was identified as appropriate for the study, the patient was approached
and the study details and expectations for participation explained to the patient.
If consent was Obtained, the information was sent to Michigan State University
and the patient enrolled in the study (Given, 1991).

The criteria for entry into this study were: 1) 65 years of age or older,

2) diagnosis Of lung cancer within the last six to eight weeks, 3) no diagnosis of
cancer or hospitalization for cancer within the last two years, 4) cognitively intact,
5) English speaking, and 6) able to read.

DaiCollection Procedfl

Trained recruiters identified patients who met the panel study criteria by
reviewing medical records. After the patient was identified, the recruiter

explained the study and Obtained patient consent. The recruiters Obtained

21

information from the oncologist, pathology, and the out-patient setting where the
patient planned to receive continuing treatment (Given, 1991).

After the data was fowvarded to Michigan State University and enrollment
completed, trained data collectors contacted the patient for interviews. Self-
administered questionnaires were also mailed to the patients. Patients were
interviewed at intake and then in six to eight weeks, three months, six months,
and twelve months (Given, 1991). This study used data collected from Wave l
Patient Self Administered Booklet and Wave l Patient Telephone Interview at six
to eight weeks after enrollment in the study.

Data collectors were carefully trained to ensure inter and intra data
collector reliability. Training included videotaping mock interviews and taping
and listening to interviews during the first three months. The data collectors
were retrained each time a new Observation period was begun. Group meetings
of all data collectors were held three times a year. In addition, quality assurance
included monthly taping and auditing of ten percent Of the interviews.
Qfltiongl Definition of Variables and Instrumentation

mm

For the purposes Of this study, elderly were defined as people 65 years of
age and older. Age was Obtained from the medical record and by asking the

patient their birth date (Given, 1991).

22

Lung cancer

Lung cancer was defined for this study as primary tumors in the lung,
including both small and non-small cell tumors. This information is Obtained from
the pathology reports and from medical record audits and enrollment data.

Newly diagnosed

Newly diagnosed included people diagnosed with cancer within eight
weeks of intake into the panel study. The time of diagnosis was Obtained from
the medical records and enrollment data. Patients cannot have had treatment
for this cancer or any other cancer within the last two years.

Level Ldepression

Depression was defined in this study as a depressed or sad mood. The
level of depression was measured by the Center for Epidemiological Studies-
Depression Scale (CES-D), a 20 item self-report questionnaire that includes
assessments of frequency and severity of depressed moods feelings Of guilt and
worthlessness, feelings of hopelessness and helplessness, loss of energy, and
disturbances of sleep and appetite (Badger, 1993; Given, 1991). This is a widely
used scale for studies focusing on levels of depression within clinical and general
populations.

The CES-D was designed by several researchers including Myers and
Weissman (1980) and Roberts and Vernon (1983) from the Center for
Epidemiologic Studies, National Institute Of Mental Health to measure

depression in studies comparing the relationship Of depression to other variables

23

(Radloff, 1977). Items for the CES-D were selected from scales already
developed to depict multidimensional major symptoms found in the clinical
syndrome of depression. Major contributors included the Minnesota Multiphasic,
Beck Depression Inventory, and the Schedule for Affective Disorders (Callahan
8 Wolinsky, 1994; Myers 8 Weissman, 1980; Roberts 8 Vernon, 1983).

The CES-D is divided into four separate, correlated domains or factors:
Depressive Affect, Somatic Symptoms, Well-being, and Interpersonal Relations.
Depressive Affect and Somatic Symptoms are both represented by seven items,
Well-being is represented by four items while the Interpersonal Relations is
represented by two items. Refer to Appendix A to view the division Of items into
the four factors (Callahan 8 Wolinsky, 1994; McCallum, Mackinnon, Simons, and
Simons, 1995).

The CES-D has a correlation of .90 with a tOOl developed by Zung (1965)
and a correlation Of .81 with the Beck Depression Inventory (Weissman, Prusoff,
8 Newberry, 1975). Badger (1993) reports an internal consistency coefficient of
.93. Callahan and Wolinsky (1994) report Cronbach's alpha results ranging from
.80 to .87 when subjects were divided into groups by race and sex.

The content of the CES-D is valid for this study in that the four dimensions
include the areas Of a person’s life described earlier in this proposal which can
be affected by depressed or sad moods. The CES-D is more sensitive for
identifying current depressive symptomotology than a lifetime of depressive

illness (Roberts and Vernon, 1983). The CES-D can identify 78% of clinically

24

depressed elderly subjects when a score of 16 is used to determine depression;
increasing the score to 20 to determine depression increases the percentage Of
identification of clinically depressed elderly to 82% (Himmelfarb 8 Murrell, 1983).

Factor analysis usually supports the four factor solution (Callahan 8
Wolinsky, 1994; Hertzog, VanAlstine, Usala, Hultsch, 8 Dixon, 1990; Stommel,
Given, Given, Kalaian, Schulz, 8 McCorkle, 1993). Stommel, Given, Given,
Kalaian, Schulz, and McCorkle (1993) found that a gender-bias free model can
be constructed when the interpersonal factor is left out and the remaining items
are grouped into three factors: depressive mood, well-being, and somatic
symptoms. This reduces the tool to a 15 item tool that correlates highly with the
20 item tool (0.98). The Cronbach's alpha for the 15 item tool is 0.88 and 0.89
for the 20 item tool.

The CES-D has been found to be a useful instrument for measuring
depression in the elderly (Badger, 1993, McCallum, Mackinnon, Simons, 8
Simons, 1995). Davidson, Feldman, and Crawford (1994) report the four-factor
model fit well for frail elderly. Radloff and Teri (1986) and Reed (1989)
established adequate reliability and validity for use Of the CES-D with elderly
persons. MacCallum, Mackinnon, Simons, and Simone (1995) argue that the
relative stability of the CES-D across age groups is related tO the fact that
depression symptoms are similar across age groups. Davidson, Feldman, and
Crawford (1994) studied the use of the CES-D for measuring depression

symptoms in elderly with poor health and/or high levels Of functional limitations

25

and report that scores were not distorted by a disproportionate influence Of
somatic items although functional limitations were associated with higher somatic
scores. Foelker and Shewchuk (1992) evaluated the use Of the CES-D for false
positives resulting from somatic complaints not related to depression and
concluded that the CES-D is a valid measurement. The CES-D has been used
to measure emotional distress and depressive symptoms in several studies on
individuals with cancer (Given 8 Given, 1992; Given, Given, 8 Stommel, 1994;
Given, Stommel, Given, Osuch, Kurtz, and Kurtz, 1993; Mar, 1992; Mar, Allen,
and Malin, 1994).

This study will use the entire 20 item scale for a single measure Of level Of
depression. McCallum, Mackinnon, Simons, and Simons (1995) report that the
CES-D has good validity as a single depression scale. Subjects answer each
item on a four point scale which ranges from a score of zero for “Rarely or None
of the Time” to a score of three for “Almost All Of the Time”. The scores for the
four positive affect items will be reverse coded. The score Of each item is added
together and the sum becomes the score for each patient. The summated score
can range from zero to sixty; a score of sixteen or above is indicative of clinical
depression (Callahan 8 Wolinsky, 1994; Given, Given, 8 Stommel, 1994).

Lfievel Of symptoms

Rhodes and Watson’s (1987) definition for symptoms is “distinctive
features interpretive of a disease category used to diagnose a patient’s

condition” (p. 242) was used in this study. In addition, Rhodes and Watson

26

(1987) state symptoms “have Often included signs or objective clinical
manifestations” (p. 242). The level Of symptoms was measured by the Given
and Given Symptom Experience Scale (SEI). The Given and Given Scale
assesses for the presence of 34 symptoms including: pain, anorexia, weight loss,
insomnia, fatigue, constipation, diarrhea, and vomiting (Kurtz, Given, Kurtz, 8
Given, 1994). The symptoms in the SEI include the symptoms most commonly
found in patients with cancer and undergoing cancer therapy (Donehower, 1991;
Faber, 1991).

The patients were asked if they have had the symptom within the last two
weeks. If no, the answer was coded zero points. If yes, the answer received
one point and the patient was asked the severity Of the symptom. The answers
are on a three point scale with one representing mild, two representing
moderate, and three representing severe. If they had not experienced the
symptom, their score was zero. The score for the presence of the symptom was
multiplied by the score for the severity of the symptom. This score was then
added for each symptom to determine the total symptom score. If the patient
indicated the presence of a symptom but the subsequent severity score was
missing, the presence Of the symptom score was multiplied by the mean severity
for that symptom.

Level cflhvsical fpnction

Physical function included the patient’s mobility and ability to perform

certain physical tasks including vigorous activities such as running, lifting heavy

27

Objects, and strenuous activities. The level Of physical function was assessed by
the patient’s responses to the Physical Function Concept Scale from the Medical
Outcome Studies Short Form-36 (MOS SF-36).

The MOS SF-36 was developed to be a comprehensive, psychometrically
sound, and brief standardized health status survey (Ware 8 Sherbourne, 1992).
The Physical Function Concept Scale is one Of the eight multi-item health
concepts scales which are part Of the MOS SF-36. The physical function
concept contains ten items measuring both the presence and extent of physical
limitations with a three-level response continuum (Ware 8 Sherbourne, 1992). In
the primary study, one item assessing bathing and dressing, was inadvertently
omitted resulting in a nine item physical function scale.

McHorney, Ware, Lu, and Sherbourne (1994) report inter item correlations
scores ranged from 0.49 to 0.80 for the physical function scale items with a
Cronbach’s alpha Of 0.93 . McHorney, Ware, Lu, and Sherbourne divided
patients into 24 subgroups which differed in sociodemographic characteristics,
diagnosis, and disease severity. The internal consistency reliability coefficients
for the physical function scale ranged from .90 for patients with uncomplicated
medical diseases to 0.94 for the subgroups Of less than eight years Of education,
nine to eleven years of education, poverty, and symptomatic depression. The
intemal-consistency reliability coefficient was 0.92 for subgroups of people 65 to

74 years of age and 75 years Old and Older.

28

Reuben, Valle, Hays, and Siu (1995) compared the physical function
concept scale from the MOS SF-36 with three other tools measuring physical
function in community-based elderly people. The internal consistency reliability
for the physical function concept scale was 0.90. Correlations between the four
tools compared were highest between the SF-36 physical functioning scale and
the F80 lnterrnediate Activities Of Daily Living (0.76).

McHorney, Ware, and Raczek (1993) tested the validity of the SF-36.
Correlation with the principal component of physical health was highest for the
physical functioning concept scale (0.88). McHorney, Ware, and Raczek found
that physical functioning (RV = 1.00) was the scale which performed best in
differentiating the severity Of chronic medical problems.

Patients rate their current limitations in performing specific physical
activities. Each activity limitation is rated on a three-point scale ( “yes, limited a
lot” = 3, “yes limited a little” = 2, and “no, not limited at all” = 1). The score was
summed for a composite scores of limitations ranging from 10 to 30. The scale
score is then transformed to a standardized zero to 100 scale using a scoring
algorithm. A score Of zero indicates worst function and 100 indicates best
function (Reuben, Valle, Hays, 8 Siu, 1995).

Data Analysis

The data included descriptive information on the sample demographic

data. Descriptive statistics are also included for the number Of symptoms

experienced by patients, and the average severity. Measures Of central

29

tendency, including the mean, are used to describe the CES-D scores, number
Of symptoms, severity Of symptoms, and Physical Functioning Concept Scale.

The data were analyzed to determine the significance of the relationships
between the scores for the CES-D, SEI, and SF-36. The statistical relationships
between the levels of depression, symptoms, and physical function were
calculated using a Pearson’s r. The relationships examined include the level Of
depression and the level of physical function; the level of depression and the
level Of symptoms; and the level Of symptoms and the level Of physical function.
The data results are presented in table format to promote ease of understanding
of the relationships between depression, symptoms, and physical function.
Proced_ures for Protection Of Human Subjects

Prior to any secondary data analysis, permission was Obtained from the
University Committee on Research Involving Human Subjects at Michigan State
University. The original study procedure was approved by the University
Committee on Research Involving Human Subjects at Michigan State University.
A copy of of the original approval is available in Appendix B and a copy for the
approval for this study in Appendix C.

Results

M

The sample is a subset Of 47 people Of age 64 and Older with lung cancer.

The patients range in age from 64 to 86 years of age with a mean age of 72

30

years. The sample was evenly divided between male and female. Refer to
Table 1 for Sample Characteristics.
Symptoms

Patients (N=47) were asked whether they experienced a variety Of 37
symptoms, up to 20 symptoms were reported. The average number of symptoms
experienced was 10.8 symptoms. The patients were asked to rank the severity
Of each symptom they experienced. Severity was ranked as mild (one point),
moderate (two), or severe (three). The mean severity of a symptom ranged from
1.0 to 2.3. Severe fatigue was reported by the highest number of patients (76%)
and received a mean severity of 1.8. The need to void at night was the symptom
reported second most frequently by 68% of the patients and had a mean severity
score of 1.4. Severe cough, reported by 62% of the patients, was the next most
frequently reported symptom and received an mean severity of 1.4. Refer to
Table 2 for the most frequently reported symptoms. The highest mean severity
for an individual symptom was 2.3 for lack of sexual interest but this was only
reported by 12 of the patients. The second highest mean severity was 2.0 for
constipation and difficulty swallowing. However, constipation was only reported
by 10 patients and difficulty swallowing was reported by 16 patients. Refer to
Table 3 for the seven symptoms with the highest mean severity ranking.

The level Of symptoms was calculated by multiplying the score for the

presence of the symptom by the score for the severity Of the associated

31

Table 1 Sample Characteristics

 

 

 

 

 

 

 

 

 

(N=47) (Percent)
§e_x: Males 23 50%
Females 23 50%
Patient Race: Caucasian 41 91.1%
African American 3 6.7%
Native American 1 2.2%
App: 6474 31 69%
75-84 13 29%
z 85 1 2%
Marital Status: Married 23 62.2%
Divorced/Separated 3 8.1%
Widowed 1 1 29.7%
Lives With: Spouse 23 62.2%
Other 4 10.8%
Alone 10 27.0%
Educational Level: completed grade school 6 16.2%
completed some high school 14 37.8%
completed high school 10 27.0%
completed some college 5 13.5%
completed college 2 5.4%
Treatment: Surgery only 8 17.8%
Chemotherapy only 5 11.1%
Radiation therapy only 22 48.9%
Surgery and chemotherapy 3 6.7%
Surgery and radiation therapy 3 6.7%
Chemotherapy and radiation therapy 1 2.2%
None 3 6.7%

 

 

 

 

32

Table 2 Most Frequently Reported Symptoms (N=47)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Symptom Reporting Symptom Mean Severity
# %

Fatigue 28 76 1.8

Up at night to void 25 68 1.4

Cough 23 62 1.4

Poor appetite 21 57 1.7

Weakness 21 56 1 .6

Difficulty breathing 19 51 1.9

Weight loss 1 8 49 1 .7

Table 3 Symptoms With the Highest Severity (N=47)

Symptom Mean Severity Mild Moderate Sev'fre

Lack Of sexual interest 2.3 g g 7

Difficulty swallowing 2.0 5 6 5

Constipation 2.0 2 6 2

Difficulty breathing 1.9 6 9 4

Fatigue 1 .8 1 0 14 4

Pain 1.8 9 3 5

Diarrhea 1.8 2 3 1

 

 

 

 

 

 

 

33

symptom. This score was then added for each symptom for the level Of
symptom score. If the patient indicated the presence of a symptom but the
subsequent severity score was missing, the presence of the symptom score was
multiplied by the mean severity for that symptom. The score for the level of
symptoms could range from zero to 111 with higher scores indicating a higher
number Of symptoms and severity. The actual scores ranged from one to 35
with a mean score Of 17.4 which is low for a scale with a possible score of 111.
Physical Function

The scores for the nine physical function items ranged from one (limited a
lot) to three (not limited at all). The mean score for each item was calculated by
dividing by the number Of patients answering the item. The mean scores ranged
from 1.4 to 2.1. This indicates that the responses were located somewhere
between “limited 3 lot” and “limited a little”. The lowest mean score indicating the
highest degree Of limitation was for vigorous activities (1.4). Thirty-one patients
(72%) reported “limited a lot” for vigorous activities while six patients (14%)
reported no limitation. Walking more than one mile was the activity with next
lowest mean (1.6). Moderate activities received the next lowest mean score
(1.7). Refer to Table 4 for the results Of the Physical Function Sub Scale from
the Medical Outcome Studies Short Form-36 (MOS SF-36).

If an item was not answered by the patient, the mean response was
substituted. The total score for the physical function scale was standardized

using the algorithm Of John E. Ware (1994). The final standardized scores range

Table 4

34

Physical Function Scores Ranked from Highest to Lowest Limitation (n=47)

 

 

 

 

 

 

 

 

 

 

 

Item Not limited Limited a little Limited a lot Mean
n % n % n %

Vigorous activities 6 14 6 14 31 72 1.4
Walk >1 mile 11 26 3 7 28 67 1.6
Moderate activities 11 27 6 14 26 61 1.7
Climb several stairs 11 26 6 14 25 60 1.7
Lift, carry groceries 14 33 7 16 22 51 1.8
Walk several 13 30 10 23 20 47 1.8
blocks

Walk one block 20 47 5 12 18 42 2.1
Bend, kneel, stoop 18 42 9 21 16 37 2.1
Climb one stair 18 43 8 19 16 38 2.1

 

 

 

 

 

 

35

from five to 100 with a mean score of 43.2 (N=47). Table 5 shows the
distribution of the standardized scores. The standardized score could range
from zero (worst functioning) to 100 (best functioning) so a mean of 43.2
indicates that the majority had substantial limitations in physical function.
Depression

The four items of the depression scale with the highest mean scores
included two Of the somatic symptom items and two of the four positive affect
items. Restless sleep, a somatic symptom item, received the highest mean score
(1.4 on a response scale Of 0 to 3). Another somatic symptom item, “felt that
everything was an effort” received the third highest mean score (1.1). The
positive affect items were reversed scored. The item “was happy” received the
second highest mean score (1.5) while hopeful about future received the fourth
highest mean score Of 1.1. The mean scores of the four positive affect items
were among the seven highest mean scores. The mean scores for the somatic
symptom items were in the highest thirteen mean scores. The mean scores for
the depressive affect items were within the lowest eleven mean scores. The
interpersonal distress items received the two lowest mean scores. Refer to
Table 6 for mean scores of the CES-D.

Overall depression is indicated by the summated score of the depression
items that could range from zero to sixty. If an item of the CES-D was missing,
the mean from the available items was substituted for that case. Scores of 16 or
above are indicative of clinical depression (Callahan 8 Wolinsky, 1994; Given,

Given, 8 Stommel, 1994). Results ranged from one to 38 with a mean score Of

36

Table 5

Range of Physical Function Scores From Best Function to Worse (n=47)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Score Frequency Percent
(0-100) Mean = 43
100 5 12
95 1 2
89 1 2
80 1 2
75 3 7
65 2 5
60 1 2
55 2 5
50 2 5
35 3 7
33 1 4
30 3 7
25 2 5
20 1 2
1 7 1 2
1 5 3 7
10 3 7
5 7 17

 

 

 

 

Table 6

37

Mean Scores Of CES-D Ranked Highest to Lowest (n=47)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mean Score Item Factor
1.4 My sleep was restless. Somatic
1.3 l was happy. Positive
1.1 I felt that everything I did was an effort. Somatic
1.0 I felt hopeful about the future. Positive
.91 I had trouble keeping my mind on what I was doing. Somatic
.91 I enjoyed life. Positive
.89 I felt that I was just as good as other people. Positive
.85 I could not get “going.” Somatic
.85 I felt depressed. Depressive
.85 I did not feel like eating; my appetite was poor. Somatic
.85 l was bothered by things that usually don't bother me. Somatic
.76 I felt sad. Depressive
.74 I talked less than usual. Somatic
.70 I felt fearful Depressive
.68 I felt that I could not shake off the blues even with the Depressive

help of my family and friends.
.57 I felt lonely. Depressive
.40 I had crying spells. Depressive
.30 I thought my life had been a failure Depressive
.23 People were unfriendly. Interpersonal
.19 I felt that people disliked me. Interpersonal

 

 

 

 

38

15.5 (N=47). Forty-six percent of the patients (N=47) reported scores indicative Of

clinical depression.

Relationships Between Levels Of @pression. Symptoms. m
Physical Function

Pearson’s r correlation coefficients indicate that there was a moderate
negative statistically significant relationship between the levels of symptoms and
physical function (r = -.47, p = .004). However, using the standardized scoring
for the physical function scale means that higher values indicate better
functioning. Therefore the negative correlation confirms the hypothesis that the
greater the functional limitations, the greater the reported level of symptoms.
The negative relationship between the levels Of physical function and depression
(r = -.05, p = .76) is also a positive relationship but it is not statistically significant.
The relationship between the levels of symptoms and depression (r = -.02, p =
.92) was negibibly negative and not statistically significant. Refer to Table 7 for

the correlation coefficients.

Table 7 Correlation Coefficients

 

 

 

 

Level of Physical Function Level of Depression
All Subjects r= -.47 r= -.02
Level of Symptoms N= 36 N= 37
P= .004 P= .92
Level of Physical Function F -.05
N= 42
P: .76

 

 

 

 

39

Discussion

This study of Wave One included three hypotheses: 1) There is a
positive relationship between the level of depression and level of symptoms in
the newly diagnosed elderly person with lung cancer; 2) There is a positive
relationship between the level of depression and level of physical function in the
newly diagnosed elderly person with lung cancer; and 3) There is a positive
relationship between the level of symptoms and level of physical function in the
newly diagnosed elderly person with lung cancer. Hypotheses one and two
indicated no statistical significance. Hypothesis three did indicate a significant
relationship as a moderate positive relationship between the levels of symptoms
and physical function.

Although Faber (1991) estimates that 12% of patients newly diagnosed
with lung cancer are asymptomatic, no one in this sample identified themselves
as symptom free. Eleven percent of the sample (N=47) reported five or less
symptoms. The patients were approximately six to eight weeks after diagnosis
and 93% Of the patients had experienced some form of treatment. The
symptoms may have been caused or aggravated by the treatment and/or
depression. For example, both fatigue and poor appetite can be signs of
depression and caused by cancer treatments.

Except for nocturia, the seven most frequently reported symptoms are
congruent with common symptoms reported by people newly diagnosed with

lung cancer. Sarna (1993) found that fatigue, pain and insomnia were reported

40

with the highest frequency Of occurrence and ranked the most severe Of
symptoms in women with lung cancer. This sample reported fatigue as number
one in occurrence, pain as the ninth symptom, and trouble sleeping was reported
as the eleventh most frequently occurring symptom. Fatigue and pain ranked
high in the mean severity but insomnia had a lower mean severity within this
sample.

The mean scores for the physical function items ranged from 1.4 to 2.1
indicating the majority experienced a little limitation to a lot of limitation in each of
the items. The greatest limitations were reported in the vigorous activities with
the least limitations reported in the moderate activities. The mean standardized
score (43.2) indicated there were substantial limitations in the functional status
even though the subjects were newly diagnosed within the last six to eight
weeks.

Forty-six percent Of the patients (N=47) reported scores indicative Of
clinical depression. Breitbart (1994) reports that depression occurs in
approximately 20% to 25% of all cancer patients and increases as illness
advances with increasing pain and disability. Therefore, the 46% was higher than
expected considering that only 17% reported pain and the majority did not report
severe physical limitation.

In summary, the study supported only the hypothesis that there was a
positive relationship between the levels Of symptoms and physical function.

Subjects were evenly divided by sex and the majority were young-elderly. The

41

reported symptoms were representative Of symptoms commonly reported by
lung cancer patients. The majority of the patients reported substantial limitation
in their functional status. Forty-six percent Of the patients reported scores
indicative of clinical depression which is close to double the expected percent.
lnte4rpretafions Relative to Framework

The conceptual framework suggests that there should be positive
relationships between the levels of depression, physical function, and symptoms.
This study supported only the positive relationship between symptoms and
physical function. The focus on the relationships was probably too narrow and
did not allow for other contributing variables.

The Given and Given (1996) model suggests many other factors that
could modify the relationships between the levels of symptoms, physical
function, and depression. Age is one of the patient characteristics which could
modify the patient outcomes. Havighurst (1972) describes adjusting tO
decreasing physical strength and health as a developmental task for the elderly.
Seventy-two percent Of the patients reported a lot Of limitation in vigorous
activities. Since the study did not provide information on the pre-existing
functional limitations Of the patients, it is not known what percentage of the
patients already had limitation from other health problems. The relationship
between physical function and depression may have been insignificant because
the patients may have already experienced chronic limitations in their functional

status to which they had adjusted as part Of their developmental task.

42

Patient Characteristics also include resources which may affect the
outcomes. Resources could be a variety of things such as financial, support
network, community, spiritual, and coping skills. Demographic data on patient
resources was not available to this study. The majority Of elderly patients live on
marginally fixed incomes and the impact of out-Of-the pocket expenses
associated with cancer and its treatment can be devastating (Boyle, et al. 1992).
The worries about paying for treatments, home care, and other out-Of-pocket
expenses in addition to their normal living costs, could increase their level of
depression even if their levels of symptoms and physical function were currently
low.

The social support system is an important resource for the elderly cancer
patient. Boyle, et al (1992) reports that the quantity, nature, and quality of
available social support systems are frequently correlated with the sense of well-
being Of the elderly cancer patient. Lack of a social support system may
increase the level of depression independently Of the current level of symptoms
and functional status. The patients living alone (27%) may be experiencing
concerns about how they will be able to manage when they become sicker and
may be fearful of having to make other living arrangements.

Coping skills is another resource for the patients. Coping is a learned skill
which is heavily influenced by intrapersonal strengths and social network
supports. Patterns of coping found in the elderly are fundamentally the same as

their coping abilities in their past (Dugan 8 Scallion, 1987). These learned

43

coping skills would be a personal characteristic which could modify their
response to the cancer experience and fear of death. For example, a history Of
developing depression when coping with stressful events predisposes cancer
patients to develop depressive disorders (Depression Guideline Panel, 1993a;
Nail, 1996). lnforrnation on past history of depressive symptoms was not
available to this study. However, a history of depressive disorder could increase
the level of depression even if the patient is not experiencing symptom distress
or physical function impairment.

Optimism is a concept which should be added to the model. People who
are optimistic have generalized expectations of positive outcomes and usually
deal better with stressors (Lauver 8 Tak, 1995; Carver, et al., 1994). Spiritual
resources may also provide comfort and hope for the cancer patient. Therefore,
one wonders if an optimistic attitude or spiritual resources could lower the level
of depression independently of the levels of symptoms and physical function.

Hardiness has been identified as a motivating factor in resolving stressful
situations and in adapting to health problems (Pollack, 1989). This could
indicate that hardiness is another set of patient characteristics that might have
an effect on the relationships between the levels of depression, symptoms, and
physical function.

Cancer patients age 60 to 74 have been reported to have the lowest
psychological distress (Cassileth, et. al., 1984; Ell, Mantell 8 Hamovitch, 1988).

A surprisingly high percentage (46%) report scores indicative of clinical

44

depression even though the majority Of the subjects (69%) are between the ages
of 64 and 74. The timing of the study may have been a reason for the high
depression scores. The patients were studied within the first six to eight weeks
of diagnosis when they may still be depressed from the receiving the diagnosis
of lung cancer. A diagnosis of lung cancer is Often viewed by patients as more
life threatening than many other types of cancer. The diagnosis of cancer starts
a process of grieving and mourning over multiple actual and potential losses
(Dugan 8 Scallion, 1987). The patients in this study may have been reacting to
the grieving process rather than reacting to their current level of symptoms and
physical function. This study may have captured the levels Of depression,
symptoms and physical function just prior to the decrease in psychological
distress that Donaldson, McCorkle, Georgiandou, and Benoliel (1986) found in
their study Of lung cancer patients in the second month after diagnosis. A
longitudinal study capturing the levels at intervals throughout the cancer
experience would provide interesting insight into the effect of timing on levels of
depression.

The type of lung cancer, stage, treatment and side effects may also
modify the level of symptoms, physical function, and depression. Seven percent
of the patients elected not to have any type of treatment. The 18 percent who
had surgery as their only treatment modality should have been at least two to
four weeks post operative and recovering by the time of the study. Patients

receiving radiation therapy only (49%) or chemotherapy with (9%) or without

45

(11%) other forms Of treatment would probably be experiencing fatigue by this
point in their treatment. Seventy-six percent did report fatigue but the mean
severity (1.8) was close to moderate. The patients would probably experience
more severe fatigue after receiving further radiation therapy and chemotherapy.
Some Of the patients in this study may not have progressed far enough into their
treatments to experience all the side effects Of their treatments. Comparing the
patients by the type of treatment plan and at various times during the treatment
cycles would provide additional insight.

The conceptual framework suggests that patient dependencies have an
effect on the outcome. Mor, Guadagnoli, and Wool (1988) argue that newly
diagnosed patients usually have lower functional needs than terminal patients.
The highest mean scores were for more vigorous activities while many patients
were not reporting limitations in the less strenuous activities important for daily
living. Given, Given, and Stommel (1994) found that physical function did not
significantly help predict the level of depression. However, Given, Stommel,
Given, Osuch, Kurtz, and Kurtz (1993) found that patient’s immobility, symptom
distress, and the number Of dependencies in ADL’S were moderately to highly
correlated with levels of depression reported by the patients. The researcher
wonders if the results of this analysis would have been different if the level Of
physical function had been measured more in terms of immobility and number of

dependencies in ADL’s.

46

In summary, the focus of this study may have been too narrow. The
Given and Given model (1996) suggests several other factors that could interact
and modify the relationships between the levels of depression, symptoms and
physical function.

Limitations Of the Sum

The sample was a secondary analysis Of a convenience sample. The
convenience sample limits the generalizability Of the study. The sample included
31 patients (69%) from the “young-Old” (65-74 years), 13 patients (29%) from the
“middle-old” (75-84 years), and 1 patient (2%) from the “Old-old” (85 and older).
A larger sampling of middle-old and old-Old would have provided more
information about the Older elderly. The sample was biased because it consisted
only of patients motivated to participate in the study. Probability or random
sampling would have been more appropriate methods for Obtaining a sample
because it would have increased the variability within the sample representing
the natural variability among elderly cancer patients. The sample size of 47 was
a limitation. A larger sample size would have increased the variability and
enhanced the potential for statistically significant findings.

The demographic data from the data set was limited. More detailed
demographic data would have been helpful, including stage Of the cancer,
comorbid diseases, history of depression, social support system, previous
functional status, and financial resources. This data would have been useful to

look for comparisons in modifying factors.

47

The interpretation of the results is limited substantially by the inability to
compare the results among elderly patients with other types of cancer. The
survival prognosis for lung cancer is often worse than other types of cancer.
This may make the diagnosis of lung cancer more frightening and influence the
level of depression experienced by the patient. Comparing elderly patients newly
diagnosed with lung cancer with elderly patients newly diagnosed with other
types of cancer would provide a chance to explore for a possible diagnosis
effect.

Recommend_ations for Future Research

This study is an investigation into only a small piece Of the whole picture
Of the cancer experience. Larger samples Obtained from random sampling
should be studied longitudinally over a period of the disease process. This
would provide information on whether there are relationships between variables
and whether these relationships change as the disease progresses. Modifying
factors, including age, sex, gender, social support system, history Of depression,
Optimism, hardiness, spiritual resources, financial resources, spiritual resources,
timing within their cancer experience, and stage of the disease Should be
explored for relationships to depression, symptoms, and physical function.
Comparing the elderly with younger age groups would provide information to
indicate if age is a factor in coping with the diagnosis of lung cancer and

associated symptoms.

48

Fatigue and loss of appetite can be indicators for depression as well as
symptoms of the disease and treatment. Therefore, further analysis could
eliminate these items from the symptom scale and observe for any change in the
relationships. Eliminating fatigue and loss of appetite items from the depression
and symptom scales could help avoid confounding depression indicators with
physical symptom indicators.

Another area of research would be the relationships between symptoms,
physical function and depression among other types of cancer patients. Lung
cancer frequently has a poor survival prognosis while survival prognosis for other
types of cancer may be better. Comparison between types Of cancer diagnosis
would yield important information. Research could also compare cancer
diagnosis with other chronic illness. For example, Chronic Obstructive Lung
Disease also includes symptoms such as coughing, dyspnea, and fatigue.
However, patients may view their illness differently and this may make a
difference in the relationships between symptoms, physical function, and
depression.

Miaskowski (1997) reports that oncology out-patients with unrelieved
cancer pain were significantly more anxious, angry, and depressed than those
without pain. Further research could study whether there are other specific
symptoms or functional impairments which would be more likely to increase

depression.

49

A history of depression is a risk factor for depression in cancer patients
(Depression Guideline Panel, 1993a; Nail, 1996). It would be interesting to
investigate how the relationships between the levels of depression, symptoms,
and physical function vary between groups of cancer patients with a previous
history of depression and cancer patients without a previous history of
depression.

Research should investigate how the relationships between levels Of
symptoms, physical function, and depression change over the progression of
treatment and disease. When choosing between treatment Options patients
Often ask how the treatment will affect them. Patients are interested in how the
treatments will affect their functional status and what side effects or symptoms
they will experience. Evaluation of the levels Of symptoms, physical function,
and depression should be included as treatment plans are researched.
Longitudinal studies could be done on groups Of patients divided by their
treatment choice including surgery, radiation, chemotherapy protocol,
combination treatments, and no treatment. Comparison Of symptoms, physical
function, and depression between the different treatment choices would provide
valuable information to aid patients making decisions on their treatment plan.

Future research could also explore the role Of Optimism, hardiness,
spirituality, and coping mechanisms play on level of depression throughout the
disease process. Research might also investigate whether these concepts play

a role in how the patient view and cope with their current level Of physical

50

function and symptoms. There is a potential for a wealth of research
investigations into the complex experience Of living and coping with cancer.
Implications for Advanced Nursing Practice

The APN can make a significant contribution to increasing the quality Of
life of cancer patients. The primary care APN can serve as a link between the
patient, family members, and other health care team members to ensure the
patient has all their needs met satisfactorily and experience the best quality of
life possible. The APN is active in assessing needs, mutual goal setting, planning
to meet the varied patient needs, and evaluation of the results. Research and
documentation on the effects of the various cancer treatments on the lives of
elderly cancer patients would provide the information to help provide the primary
care APN with necessary information on symptom management, functional
status, and depression.

The results of this study suggest that elderly cancer patients newly
diagnosed with lung cancer will be at risk for experiencing fatigue, coughing,
poor appetite, weakness, dyspnea, nocturia, and weightless. The APN should
anticipate these symptoms and develop management strategies. The patients
and caregivers should be educated to anticipate symptoms, when and how to
call the APN, and measures to cope with the symptoms.

The APN should initiate a nutritional assessment and dietary counseling
for all newly diagnosed lung cancer patients and caregivers. Patients and

caregivers need counseling on anticipating problems that may cause poor

51

appetite and weight loss. The management Of symptoms that could interfere
with appetite is essential. Interventions should include management of
constipation, nausea, vomiting, taste changes, pain, fatigue, and dyspnea, The
APN should work with the patient and caregiver to set mutual goals for dietary
intake. The caregiver should have counseling in how to encourage the patient to
eat without overly zealously pushing the patient to eat which can cause discord
between the patient and caregiver. Interventions for maintaining appetite and
weight may include pharmacological agents for appetite stimulation, oral dietary
supplements, and enteral feedings.

Fatigue was reported by 76 percent of the patients in this study. All
patients and caregivers should receive anticipatory instructions on fatigue and
basic management interventions. Basic interventions include energy
conservation techniques and the need for exercise. Patients and caregivers
should be instructed on a personalized exercise plan to maintain strength and
mobility. Patients Should receive on-going assessment and management of
fatigue. The fatigue in patients with lung cancer can have many different causes
which can make management difficult. The APN should assess the patient
carefully for treatable causes of fatigue, such as anemia, Sleep disturbances,
electrolyte imbalance, malnutrition, cachexia, pain, and infection. Interventions
should be instituted for management of treatable causes.

Poor appetite and fatigue are symptoms that are also found frequently in

patients with depression. It is often difficult to determine whether the symptoms

52

result from the cancer or depression. Nail (1996) suggests guidelines which can
be used for differentiating fatigue and depression in cancer patients. These
guidelines can also be useful for differentiating the poor appetite of disease from
poor appetite caused by depression. The guidelines suggest that the APN should
look first for treatable causes of the poor appetite and fatigue and institute
appropriate management strategies. If unable to find treatable causes of the
symptoms, assess for a pattern in the symptoms which might correspond to the
pattern expected with their treatment cycle. If a pattern is found, the APN Should
institute appropriate management strategies. If no pattern or treatable cause is
found or management strategies fail, treatment strategies for depression should
be considered. The high percentage of clinically depressed in this study suggest
that at times the APN may need to judge whether it would be better to institute
the depression interventions before seeking for a physical cause of the fatigue
and poor appetite. If seriously concerned, the APN should treat the patient for
depression, evaluate for suicidal risk, and then look for other treatable causes of
the fatigue and poor appetite.

Research results suggest that the elderly lung cancer patient is
experiencing significant functional impairment. The elderly cancer patient may
have difficulty with vigorous activities necessitating help with grocery shopping,
yard work, running errands, and other active chores. Assessment Of financial
and social support resources is vital. It is important for the APN to explore with

the patient creative ways to adjust to limitations in vigorous activities and to help

53

organize different ways for assistance for vigorous activities. Many elderly
patients do not qualify to receive assistance with grocery shopping, yard work, or
mnning errands and cannot afford to pay for assistance. The APN can serve as
a link to providers Of home care services, insurance carriers, and planners for
government legislation to ensure that services become available for those
needing the assistance.

Forty-six percent of the patients reported scores indicative of clinical
depression. This high percentage leads this writer to suggest that screening for
depression and suicidal risk should be on-going when working lung cancer
patients. An untreated depression could lead to increased distress, decreased
physical and social functioning, and decreased adherence to medical
recommendations. The APN should screen all lung cancer patients for factors
which increase their risk Of depressive disorders. An easy question for screening
is “Have you ever had depression”? Some of the risk factors for depression can
be decreased or eliminated. For example, poorly controlled pain is a risk factor
predisposing the cancer patient to develop depression (Miaskowski, 1997). The
APN should ensure that all patients have effective pain management or refer the
patients to resources who can assist with pain management.

The APN may need to consult with a mental health specialist or provide a
referral if the patient is actively suicidal, suffering very severe depression, fails to
respond to medication trials, severe psychotic features indicate that

hospitalization should be considered, psychosocial problems persist, or

54

specialized treatments are needed (Depression Guideline Panel, 1993b). The
value of cognitive strategies should not be underestimated. Valente, Saunders,
and Cohen (1994) report that cognitive strategies can significantly alleviate
depression within brief periods Of time.

The Given and Given (1996) model suggests that higher levels Of
symptoms and physical function will increase the levels Of depression. This
study supported only the positive relationship between the level of symptoms
and the level Of physical function. The APN should be aware that the level Of
symptoms and functional impairment will not necessarily predict which lung
cancer patients will be depressed. The APN should expect and be prepared to
deal with significant levels of depression in newly diagnosed lung cancer
patients. The patients can also be expected to experience fatigue, poor appetite,
and other symptoms along with significant levels Of functional impairment. The
APN is in the unique role tO have influence on many of these factors. With

skillful intervention, the quality of life of the patient may be maximized.

APPENDICES

APPENDIX A

55

CES-D Items Divided Into the Four Factors

Depressive Affect:

I felt that I could not shake off the blues even with the help of my family
and friends.

I felt depressed.

I thought my life had been a failure.

I felt fearful.

I felt lonely.

I had crying spells.

I felt sad.

Somatic Symptoms:

l was bothered by things that usually don’t bother me.
I did not feel like eating; my appetite was poor.

I had trouble keeping my mind on what I was doing.

I felt that everything I did was an effort.

My sleep was restless.

I talked less than usual.

I could not get “going.”

Well-being or Positive:
I felt that l was just as good as other people.
I felt hopeful about the future.
I was happy.
I enjoyed life.
Interpersonal distress:

People were unfriendly.
I felt that people disliked me.

APPENDIX B

 
   
   
   
    
 
   

Slim-21m
FAX 517/432-1171

.-lhum8n0nnw
”BMW.
(mu-abet

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56

MICHIGAN STATE

 

UNIV

ERSITY

Jun. 60 1995

To: Barbara A. Given
h230 Life Sciences

RE: IRBI: 92-280
TITLE: :SSéEY HOME CARE FOR CANCER--A COMMUNITY-BASED
REVISION REQUESTED: 05 25 9S
CATEGORY: PU L VIE“
APPROVAL DATE: 06/05/95

The University Committee on Research Involving Human Subjects'(UCRIHS)

review of this project is complete. I am pleased to advise that the

rights and welfare of the human aubjects appear to be adequately
rotected and methods to obtain informed consent are appropriate.

heretore.
above.

RINEHAL:

REVISIONS:

priestess]
camera 3

If we can be c
at (517)355-2180 or tax (517)4

Sincerel

vid 2
UCRIHS Ch

  

the UCRIHS approved this project and any revisions listed

UCRIHS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project be end one year must use the green renewal
form (enclosed with t e original approval letter or when a
project is renewed) to seek u ated certification. There is a
maximum of tour such expedite renewals ssible. Investigators
wishing to continue a project beyond the time need to submit it
again or complete review.

UCRIHS must review any changes in rocedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal. please use the green renewal form. To
revise an approved protocol at an 0 her time during the year,
send your written request to the_ CRIHS Chair, requesting revised
approval and referencing the preject's 133 I and title. Include
in or request a description of the change and any revised

ins ruments, consent forms or advertisements that are applicable.

Should either of the followin arise during the course of the
work. investigators must noti UCRIHS romptly: {1) problems
(unexpected side effects. comp aints. e c.) involv ng uman
subjects or 12) changes in the research environment or new
information ndicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

t any future helpé piggee do not hesitate to contact us

. Wright, Ph.D.
air

DEWIKaa/lcp

APPENDIX C

 

GRADUATE

   
 
  

517355.21”
FAX.517I‘32-1171

lhuunmSIunnmw
Woman/Dunn.
Manama.

talcum
"WM

57

MICHIGANSTATE
UNIVERSITY

June 17, 1996

 

To: Jan Cooper
1444 N. Robinhood Dr.
Huskegon. HI 49445

RE: IRBA: 90-336
TITLE: THE RELATIONSHIP BETWEEN THE LEVELS OF
DEPRESSION SYMPTOMS. AND PHYSICAL FUNCTION AMONG
A GROUP OF ELDERLY PATIENTS NEWLY DIAGNOSED WITH

LUNG CANCER
REVISION REQUESTED: N/A
CATEGORY: :4!
APPROVAL pars: 05/23/96

The university Committee on Research Involving Human Subjects'lUCRIHSl
review of this project is complete.. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately

rotected and methods to obtain informed consent are appropriate.
Therefore, the UCRIHS approved this preject and any reVisions listed
above.

RIIIIAL: UCRIRS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a prOject be and one year must use the green renewal
form (enclosed with t e original asproval letter or when a
project is renewed) to seek update certification. There_is a
maXimum of four such expedite renewals ssible. Investigators
wishing to continue a preject beyond tha time need to submit it
again or complete review.

IIVIBIOIII UCRIHS must review an changes in rocedures involving human
subjects, rior to in tiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any other time during the year,
send your written request to the. CRIHS Chair, requesting revised
epproval and referencing the preject's IRB fl and title.. Include
in or request a description of the change and any reVised
ins ruments. consent forms or advertisements that are applicable.

PROBLIIB/ ,

ClAlGlS: Should.either of the followi' arise during the course of the

work. investigators must noti y UCRIRS romptly: (1) roblems

(unexpected side effects, comp aints. e c.) involving uman

subjects or (2) changes in the research enVironment or new

informatipn indicating greater risk to_the human subjects than
existed when the precocol was previously reviewed and approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2160 or FAX lSl7l4 2- 171.

Sincerel

id E. wright, Ph.
UCRIHS Chair

DEVI:bed

cc: Sharon King

LIST OF REFERENCES

58

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