ABSTRACT:

Objective:

To analyze factors associated with functional disability in older adults with cancer treated at reference outpatient clinics in the state of Mato Grosso, Brazil.

Methods:

This is a cross-sectional study of 463 older adults aged 60 years or older. The outcome variable was functional disability, evaluated by Lawton and Brody's Instrumental Activities of Daily Living (IADL) scale. The independent variables were sociodemographic characteristics, lifestyle, social support, and health aspects. We performed bivariate and multivariate analyses and calculated prevalence ratios (PR) using Poisson regression with robust variance.

Results:

The prevalence of IADL functional disability was 55.3%. The variables associated with this disability in the multivariate analysis were: not working (PR=1.36; 95% confidence interval — 95%CI 1.03–1.78); low (PR=1.49; 95%CI 1.10–2.03) and moderate (PR=1.30; 95%CI 1.04–1.64) perceived affectionate support; depressive symptoms (PR=1.31; 95%CI 1.10–1.56); malnutrition (PR=1.28; 95%CI 1.03–1.59); having two or more comorbidities (PR=1.30; 95%CI 1.03–1.64), and having a companion to health services (PR=1.39; 95%CI 1.05–1.83).

Conclusion:

In addition to physical health aspects, comorbidities, and malnutrition, functional disability was associated with emotional, social support, and work issues, reinforcing the importance of comprehensive care and actions to maintain and recover functional capacity, promoting a better quality of life, the independence of older adults with cancer, and a reduced risk of adverse biopsychosocial outcomes.

Keywords:
Aged; Functional status; Neoplasms; Medical oncology; Ambulatory care facilities; Epidemiology

INTRODUCTION

Cancer is one of the main causes of death in the world and has contributed to changing the pattern of life expectancy increase in all countries. Cancer incidence and mortality have grown rapidly¹1 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68(6): 394-424. https://doi.org/10.3322/caac.21492
https://doi.org/10.3322/caac.21492... . In 2020, approximately 19.3 million people worldwide had cancer, and this number is expected to reach 28.4 million by 2040²2 Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021; 71(3): 209-49. https://doi.org/10.3322/caac.21660
https://doi.org/10.3322/caac.21660... .

Around 70.0% of cancer cases globally affect people after the age of 65¹1 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68(6): 394-424. https://doi.org/10.3322/caac.21492
https://doi.org/10.3322/caac.21492... . In 2020, 12.3 million new cancer cases were estimated in older adults aged 60 years or more³3 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global cancer observatory: cancer today. Lyon: International Agency for Research on Cancer [Internet]. 2020 [cited on Jul 15, 2021]. Available at: https://gco.iarc.fr/today
https://gco.iarc.fr/today... . In Brazil, cancer prevalence is up to four times higher in older adults than in adults⁴4 Oliveira MM, Malta DC, Guauche H, Moura L, Azevedo e Silva G. Estimativa de pessoas com diagnóstico de câncer no Brasil: dados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015;18(Suppl 2): 146-57. https://doi.org/10.1590/1980-5497201500060013
https://doi.org/10.1590/1980-54972015000... , and estimates indicated 592 thousand new cancer cases in 2020, of which more than 62.0% affected older adults³3 Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global cancer observatory: cancer today. Lyon: International Agency for Research on Cancer [Internet]. 2020 [cited on Jul 15, 2021]. Available at: https://gco.iarc.fr/today
https://gco.iarc.fr/today... .

The cancer scenario, which includes diagnosis, progression, recurrence, and treatment, is a determinant of functional decline⁵5 Nightingale G, Battisti NML, Loh KP, Puts M, Kenis C, Goldberg A, et al. Perspectives on functional status in older adults with cancer: an interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG. J Geriatr Oncol 2021; 12(4): 658-65. https://doi.org/10.1016/j.jgo.2020.10.018
https://doi.org/10.1016/j.jgo.2020.10.01... , which, in turn, is a predictor of lower survival. It can also contribute to some adverse results, such as morbidity, mortality, hospitalizations, and chemotoxicity⁵5 Nightingale G, Battisti NML, Loh KP, Puts M, Kenis C, Goldberg A, et al. Perspectives on functional status in older adults with cancer: an interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG. J Geriatr Oncol 2021; 12(4): 658-65. https://doi.org/10.1016/j.jgo.2020.10.018
https://doi.org/10.1016/j.jgo.2020.10.01... — in addition to the negative effects on physical health, older adults also face the psychosocial and financial costs of cancer ⁶6 Estapé T. Cancer in the elderly: challenges and barriers. Asia Pac J Oncol Nurs 2018; 5(1): 40-2. https://doi.org/10.4103/apjon.apjon_52_17
https://doi.org/10.4103/apjon.apjon_52_1... .

The disease causes physical and emotional stress, regardless of age; however, compared to young patients, older adults have more pre-existing chronic diseases, impaired physical and cognitive function, and decreased physiological reserve⁷7 Hewitt M, Rowland JH, Yancik R. Cancer survivors in the United States: age, health, and disability. J Gerontol A Biol Sci Med Sci 2003; 58(1): 82-91. https://doi.org/10.1093/gerona/58.1.m82
https://doi.org/10.1093/gerona/58.1.m82... ; additionally, individuals with cancer have a greater chance of presenting functional disability⁸8 van Abbema D, van Vuuren A, van den Berkmortel F, van den Akker M, Deckx L, Buntinx F, et al. Functional status decline in older patients with breast and colorectal cancer after cancer treatment: a prospective cohort study. J Geriatr Oncol 2017; 8(3): 176-84. https://doi.org/10.1016/j.jgo.2017.01.003
https://doi.org/10.1016/j.jgo.2017.01.00... . The concept of functional disability has a multidimensional nature, and based on this approach, the World Health Organization (WHO), in its International Classification of Functioning, Disability and Health (ICF), defined functioning and disability as outcomes of a complex and dynamic interaction between health conditions (diseases, disorders, injuries, among others) and contextual factors: environmental and personal⁹9 Organização Mundial da Saúde. CIF: Classificação Internacional de Funcionalidade, Incapacidade e Saúde [Centro Colaborador da Organização Mundial da Saúde para a Família de Classificações Internacionais, org.; coordenação da tradução Cassia Maria Buchalla]. São Paulo: Editora da Universidade de São Paulo; 2003. Available at: http://uniapae.apaebrasil.org.br/wp-content/uploads/2019/10/CLASSIFICA%C3%87%C3%83O-INTERNACIONAL-DE-FUNCIONALIDADE-INCAPACIDADE-E-SA%C3%9ADE.pdf
http://uniapae.apaebrasil.org.br/wp-cont... .

Functional disability in older adults usually corresponds to difficulty in basic self-care tasks, including instrumental activities of daily living (IADL), which leads to autonomy restrictions and dependence, reducing their quality of life and increasing the use of health services¹⁰10 Zanesco C, Bordin D, Santos CB, Fadel CB. Dificuldade funcional em idosos brasileiros: um estudo com base na Pesquisa Nacional de Saúde (PNS – 2013). Ciênc Saúde Coletiva 2020; 25(3): 1103-18. https://doi.org/10.1590/1413-81232020253.19702018
https://doi.org/10.1590/1413-81232020253... ,¹¹11 Cabral JF, Silva AMC, Andrade ACS, Lopes EG, Mattos IE. Vulnerabilidade e declínio funcional em pessoas idosas da Atenção Primária à Saúde: estudo longitudinal. Rev Bras Geriatr Gerontol 2021; 24(1): e200302. https://doi.org/10.1590/1981-22562021024.200302
https://doi.org/10.1590/1981-22562021024... . Epidemiological studies often use the Lawton and Brody scale for its measurement¹²12 Neo J, Fettes L, Gao W, Higginson IJ, Maddocks M. Disability in activities of daily living among adults with cancer: a systematic review and meta-analysis. Cancer Treat Rev 2017; 61: 94-106. https://doi.org/10.1016/j.ctrv.2017.10.006
https://doi.org/10.1016/j.ctrv.2017.10.0... .

A meta-analysis showed that the prevalence of IADL functional disability in older adults with cancer from the overall world population was 54.0%¹²12 Neo J, Fettes L, Gao W, Higginson IJ, Maddocks M. Disability in activities of daily living among adults with cancer: a systematic review and meta-analysis. Cancer Treat Rev 2017; 61: 94-106. https://doi.org/10.1016/j.ctrv.2017.10.006
https://doi.org/10.1016/j.ctrv.2017.10.0... . Among the 43 works selected for the study, only one was carried out in Brazil, demonstrating that research related to the subject is still scarce in the country. In a national population-based survey, 33.0% of older adults reported that cancer or some problem caused by it restricted their usual activities¹³13 Francisco PMSB, Friestino JKO, Ferraz RO, Bacurau AGM, Stopa SR, Moreira Filho DC. Prevalência de diagnóstico e tipos de câncer em idosos: dados da Pesquisa Nacional de Saúde 2013. Rev Bras Geriatr Gerontol 2020; 23(2): e200023. https://doi.org/10.1590/1981-22562020023.200023
https://doi.org/10.1590/1981-22562020023... .

Cross-sectional studies indicate a relationship between the variables: socioeconomic status¹⁴14 Jang BS, Chang JH. Socioeconomic status and survival outcomes in elderly cancer patients: a national health insurance service-elderly sample cohort study. Cancer Med 2019; 8(7): 3604-13. https://doi.org/10.1002/cam4.2231
https://doi.org/10.1002/cam4.2231... , sedentary lifestyle¹⁵15 Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behavior. Br J Sports Med 2020; 54(24): 1451-62. http://doi.org/10.1136/bjsports-2020-102955
http://doi.org/10.1136/bjsports-2020-102... , malnutrition¹⁶16 Van Den Broeke C, De Burghgraeve T, Ummels M, Gescher N, Deckx L, Tjan-Heijnen V, et al. Occurrence of malnutrition and associated factors in community-dwelling older adults: those with a recent diagnosis of cancer are at higher risk. J Nutr Health Aging 2018; 22(2): 191-8. https://doi.org/10.1007/s12603-017-0882-7
https://doi.org/10.1007/s12603-017-0882-... , comorbidities¹⁷17 Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer and its treatment. CA Cancer J Clin 2016; 66(4): 337-50. https://doi.org/10.3322/caac.21342
https://doi.org/10.3322/caac.21342... , depression¹⁸18 Presley CJ, Arrato NA, Janse S, Shields PG, Carbone DP, Wong ML, et al. Functional disability among older versus younger adults with advanced non-small-cell lung cancer. JCO Oncol Pract 2021; 17(6): e848-58. https://doi.org/10.1200/OP.20.01004
https://doi.org/10.1200/OP.20.01004... , social support¹⁹19 Guida JL, Holt CL, Dallal CM, He X, Gold R, Liu H. Social relationships and functional impairment in aging cancer survivors: a longitudinal social network study. Gerontologist 2020; 60(4): 607-16. https://doi.org/10.1093/geront/gnz051
https://doi.org/10.1093/geront/gnz051... , and functional disability in older adults with cancer. Longitudinal investigations show the importance of evaluating baseline functional impairment, polypharmacy, depression, abnormal nutritional status, cognitive impairment, comorbidities, and higher symptom burden, as they are predictors of functional decline in older adults with cancer⁵5 Nightingale G, Battisti NML, Loh KP, Puts M, Kenis C, Goldberg A, et al. Perspectives on functional status in older adults with cancer: an interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG. J Geriatr Oncol 2021; 12(4): 658-65. https://doi.org/10.1016/j.jgo.2020.10.018
https://doi.org/10.1016/j.jgo.2020.10.01... ,⁸8 van Abbema D, van Vuuren A, van den Berkmortel F, van den Akker M, Deckx L, Buntinx F, et al. Functional status decline in older patients with breast and colorectal cancer after cancer treatment: a prospective cohort study. J Geriatr Oncol 2017; 8(3): 176-84. https://doi.org/10.1016/j.jgo.2017.01.003
https://doi.org/10.1016/j.jgo.2017.01.00... ,²⁰20 Hoppe S, Rainfray M, Fonck M, Hoppenreys L, Blanc JF, Ceccaldi J, et al. Functional decline in older patients with cancer receiving first-line chemotherapy. J Clin Oncol 2013; 31(31): 3877-82. https://doi.org/10.1200/JCO.2012.47.7430
https://doi.org/10.1200/JCO.2012.47.7430... –²²22 Zhang X, Edwards BJ. Malnutrition in older adults with cancer. Curr Oncol Rep 2019; 21(9): 80. https://doi.org/10.1007/s11912-019-0829-8
https://doi.org/10.1007/s11912-019-0829-... .

Considering that disability is a multidimensional concept and the scarcity of regional research, the present study aimed to analyze sociodemographic, lifestyle, health, and social support factors associated with functional disability in older adults with cancer treated at reference outpatient clinics in the state of Mato Grosso.

METHODS

This cross-sectional study is part of the research "Cancer and its associated factors: analysis of the population- and hospital-based registry from Cuiabá-MT", developed by the Institute of Collective Health from Universidade Federal de Mato Grosso (UFMT) in partnership with the Ministry of Public Labor Prosecution and the State Health Department. Interviews were conducted from November 2019 to March 2020, and data were collected from medical records between December 2019 and June 2021, with suspension between March 2020 to April 2021 due to the COVID-19 pandemic. The hospitals selected for the study were: Hospital Universitário Júlio Muller (HUJM) — UFMT's teaching hospital — and Hospital de Câncer de Mato Grosso (HCan), as well as a Tertiary Care Cancer Center (Unidade de Assistência de Alta Complexidade em Oncologia — UNACON), responsible for about 70% of the total cancer care in the state²³23 Governo de Mato Grosso. Secretaria de Estado de Saúde. Resolução CIB/MT no 001 de 20 de fevereiro de 2017. Dispõe sobre a Aprovação do Plano de Ação da Atenção Oncológico no Estado de Mato Grosso de 2017 a 2019..

The estimated population of Mato Grosso in 2021 was 3,567,234 inhabitants, and according to the last census, almost 8% of the population corresponded to older adults. The state has 141 municipalities heterogeneously distributed — only five of them have a population greater than 100 thousand inhabitants —, and the largest population concentration is in the capital Cuiabá, with 623,614 inhabitants²⁴24 Brasil. Instituto Brasileiro de Geografia e Estatística. Cidades. Mato Grosso. População. [Internet]. [cited on Apr 27, 2021]. Available at: https://cidades.ibge.gov.br/brasil/mt/panorama
https://cidades.ibge.gov.br/brasil/mt/pa... ,²⁵25 Brasil. Instituto Brasileiro de Geografia e Estatística. Mato Grosso. População residente. Available at: https://cidades.ibge.gov.br/brasil/mt/pesquisa/23/25207?tipo=ranking&indicador=25186
https://cidades.ibge.gov.br/brasil/mt/pe... .

The sample of the original research was calculated considering the number of cancer-related hospitalizations — obtained from the Cancer Hospital Registry (2015) — of patients aged 20 years or older treated at two hospitals in Mato Grosso, with a maximum proportion of p=0.50, 2.5% error tolerance, and 95% confidence level. The estimated sample was 1,050 patients, considering a 10% loss. The inclusion criteria for participant selection were: individuals aged 18 years or older, receiving cancer treatment, treated at the HCan and HUJM outpatient clinics during data collection, who agreed to participate in the study and signed the Informed Consent Form. A total of 1,122 patients were invited to participate in the study, six of whom refused, totaling 1,116. During the collection of information from medical records, 21 interviewees did not have their medical records located, and 83 did not have a confirmed cancer diagnosis. Thus, the final sample comprised 1,012 patients.

The present study selected from the total sample older adults aged 60 years or older receiving outpatient care, with a cancer diagnosis confirmed by medical records, regardless of staging and type of treatment, totaling 463 participants. Since the sample of the original study was not restricted to older adults, the sample power to investigate factors associated with functional disability was calculated a posteriori. Thus, with the sample size defined as 463 older adults, a ratio between exposed and non-exposed of 1.4, prevalence of 0.65 and 0.48 for exposed and non-exposed, respectively, and alpha of 0.05, the power was 95.7%.

Data were collected through face-to-face interviews conducted at the outpatient clinics by trained interviewers who used an electronic data collection device (Open Data Kit — ODK)²⁶26 Detoni MB, Lima DM, Silva TP, Machado LF, Tomiotto-Pellissier F, Costa IN, et al. Temporal and spatial distribution of American tegumentary leishmaniasis in north Paraná: 2010-2015. Rev Soc Bras Med Trop 2019; 52: e20180119. https://doi.org/10.1590/0037-8682-0119-2018
https://doi.org/10.1590/0037-8682-0119-2... . Older adults who had visits scheduled were invited to participate in the study, and only the patients could answer the questions. The data collection questionnaire had questions about the main risk factors for cancer, chronic diseases, and disability, as well as validated questions used in population-based surveys²⁷27 Brasil. Instituto Brasileiro de Geografia e Estatística. Manual básico da entrevista. Pesquisa Nacional de Saúde. Coordenação de Trabalho e Rendimento. Rio de Janeiro: IBGE; 2019. Available at: https://biblioteca.ibge.gov.br/visualizacao/instrumentos_de_coleta/doc5591.pdf
https://biblioteca.ibge.gov.br/visualiza... ,²⁸28 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise em Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2018: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2018. Brasília: Ministério da Saúde, 2019. Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/vigitel/vigitel-brasil-2018.pdf/view
https://www.gov.br/saude/pt-br/centrais-... .

The outcome variable was functional disability, assessed by the Lawton and Brody²⁹29 Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969; 9(3): 179-86. PMID: 5349366 scale and validated for use in Brazil³⁰30 Santos RL, Virtuoso Júnior JS. Confiabilidade da versão brasileira da escala de atividades instrumentais de vida diária. Rev Bras Promoc Saúde 2008; 21(4): 290-6. https://doi.org/10.5020/18061230.2008.p290
https://doi.org/10.5020/18061230.2008.p2... ; this scale evaluates the individual's performance in eight activities that are more elaborated and involve cognitive functions: ability to use telephone, shopping, housekeeping, food preparation, doing manual household chores, using a mode of transportation, responsibility for own medications, and ability to handle finances. Each question has three possible answers, producing the following score: 1 point (dependent), 2 points (partly dependent), and 3 points (independent). The final score corresponds to the sum of the points of each domain, ranging from 8 to 24 points. Disability was defined as the need for partial or total aid in at least one activity (score≤23 points)²⁹29 Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969; 9(3): 179-86. PMID: 5349366.

The independent variables were sociodemographic characteristics, lifestyle, social support, religiosity, and health aspects. Sociodemographic variables were gender, age group, marital status, ethnicity/skin color, schooling, economic status according to the Brazilian Economic Classification Criteria³¹31 Associação Brasileira de Empresas de Pesquisa. Critério de Classificação Econômica Brasil. Alterações na aplicação do critério Brasil, válidas a partir de 01/09/2020. [Internet] 2019. Available at: https://www.abep.org/criterioBr/01_cceb_2020.pdf
https://www.abep.org/criterioBr/01_cceb_... , current working situation, and municipality of residence.

The lifestyle, religiosity, and social support variables included alcohol consumption, smoker and/or former smoker, passive smoker at home, leisure-time physical activity, excessive screen time, and using the mobile phone for more than 3 h/day. Organizational and non-organizational religiosity. Social support: tangible support, informational/emotional support, affectionate support, and positive social interaction. Each dimension was categorized according to low, moderate, and high scores.

We included the following variables related to health aspects: family history of cancer, staging, self-rated health, having health insurance, depressive symptoms, having a companion to health services, and body mass index (BMI) obtained from self-reported weight and height during the interview and classified according to the Ministry of Health's recommendation for older adults³²32 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Manual para utilização da caderneta de saúde da pessoa idosa. Brasília: Ministério da Saúde; 2018. Available at: http://bvsms.saude.gov.br/bvs/publicacoes/manual_utilizacao_caderneta_pessoa_idosa.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... (self-reported weight and height measurements can be used as valid alternatives to estimate the weight status in the Brazilian older population)²⁸28 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise em Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2018: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2018. Brasília: Ministério da Saúde, 2019. Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/vigitel/vigitel-brasil-2018.pdf/view
https://www.gov.br/saude/pt-br/centrais-... ,³³33 Moreira NF, Luz VG, Moreira CC, Pereira RA, Sichieri R, Ferreira MG, et al. Peso e altura autorreferidos são medidas válidas para determinar o estado nutricional: resultados da Pesquisa Nacional de Saúde (PNS 2013). Cad Saúde Pública 2018; 34(5): e00063917. https://doi.org/10.1590/0102-311X00063917
https://doi.org/10.1590/0102-311X0006391... . Comorbidities were assessed by the question "Has any physician ever diagnosed you with: hypertension, diabetes, kidney disease, endocrine disease, respiratory disease, or another disease (if yes, which one or ones)?" and classified as: two or more, one, or no comorbidities. The following clinical variables were also included: cancer type, according to the International Classification of Diseases — ICD-10 (C00-C97; D46), staging, metastasis, and type of treatment, obtained from medical records.

To analyze the practice of leisure-time physical activity, we considered some answers regarding the type of activity performed by the older adult, as well as the frequency and duration of the practice: individuals were considered active during leisure time when they practiced more than 150 minutes of moderate physical activity or 75 minutes of vigorous activities weekly or a combination of the two, totaling 150 minutes, following WHO recommendations¹⁵15 Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behavior. Br J Sports Med 2020; 54(24): 1451-62. http://doi.org/10.1136/bjsports-2020-102955
http://doi.org/10.1136/bjsports-2020-102... . We multiplied the duration by the weekly frequency of activities considered moderate and vigorous¹⁵15 Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behavior. Br J Sports Med 2020; 54(24): 1451-62. http://doi.org/10.1136/bjsports-2020-102955
http://doi.org/10.1136/bjsports-2020-102... ,²⁷27 Brasil. Instituto Brasileiro de Geografia e Estatística. Manual básico da entrevista. Pesquisa Nacional de Saúde. Coordenação de Trabalho e Rendimento. Rio de Janeiro: IBGE; 2019. Available at: https://biblioteca.ibge.gov.br/visualizacao/instrumentos_de_coleta/doc5591.pdf
https://biblioteca.ibge.gov.br/visualiza... ,²⁸28 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise em Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2018: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2018. Brasília: Ministério da Saúde, 2019. Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/vigitel/vigitel-brasil-2018.pdf/view
https://www.gov.br/saude/pt-br/centrais-... .

The following questions were used to evaluate current and past smoking: "Do you currently smoke any tobacco product?" And "In the past, have you smoked any tobacco product on a daily basis?". To investigate passive smoking: "Does anyone who lives with you smoke inside the house?". Regular alcohol consumption was defined as drinking alcoholic beverages in the previous 30 days, regardless of the amount consumed²⁷27 Brasil. Instituto Brasileiro de Geografia e Estatística. Manual básico da entrevista. Pesquisa Nacional de Saúde. Coordenação de Trabalho e Rendimento. Rio de Janeiro: IBGE; 2019. Available at: https://biblioteca.ibge.gov.br/visualizacao/instrumentos_de_coleta/doc5591.pdf
https://biblioteca.ibge.gov.br/visualiza... .

Sedentary behavior was evaluated by the questions: "On average, how many hours of your free time do you spend watching TV or using the computer, tablet, or mobile phone per day?"²⁸28 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise em Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2018: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2018. Brasília: Ministério da Saúde, 2019. Available at: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/publicacoes-svs/vigitel/vigitel-brasil-2018.pdf/view
https://www.gov.br/saude/pt-br/centrais-... . Excessive screen time was defined as three or more hours of free time spent on these activities per day.

Questions about religiosity are part of the Portuguese version of the Duke University Religion Index (P-DUREL), from which we used the first two items³⁴34 Moreira-Almeida A, Peres MF, Aloe F, Lotufo Neto F, Koenig HG. Versão em português da escala de religiosidade da Duke: DUREL. Rev Psiq Clín. 2008; 35(1): 31-2. https://doi.org/10.1590/S0101-60832008000100006
https://doi.org/10.1590/S0101-6083200800... . Questions related to depressive symptoms are part of the Patient Health Questionnaire-9 (PHQ-9), which proved to be appropriate for the screening of major depressive episodes in the Brazilian population. We adopted a cut-off point ≥9, as recommended³⁵35 Santos IS, Tavares BF, Munhoz TN, Almeida LSP, Silva NTB, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saude Publica 2013; 29(8): 1533-43. http://doi.org/10.1590/0102-311X00144612
http://doi.org/10.1590/0102-311X00144612... .

Social support questions are part of the Social Support Survey (MOS-SSS) validated for Portuguese³⁶36 Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study adaptada para o português do Estudo Pró-Saúde. Cad Saúde Pública 2005; 21(3): 703-14. https://doi.org/10.1590/S0102-311X2005000300004
https://doi.org/10.1590/S0102-311X200500... , which uses a Likert scale: 0 (none of the time); 1 (a little of the time); 2 (some of the time); 3 (most of the time), and 4 (all of the time). The classification used the cut-off points proposed by Zanini et al.³⁷37 Zanini DS, Peixoto EM, Nakano TC. Escala de Apoio Social (MOS-SSS): proposta de normatização com referência nos itens. Trends Psychol 2018; 26(1): 387-99. https://doi.org/10.9788/tp2018.1-15pt
https://doi.org/10.9788/tp2018.1-15pt... to evaluate the dimensions: tangible support, emotional/informational support, affectionate support, and positive social interaction. The higher the score, the greater the perceived support received in each dimension³⁷37 Zanini DS, Peixoto EM, Nakano TC. Escala de Apoio Social (MOS-SSS): proposta de normatização com referência nos itens. Trends Psychol 2018; 26(1): 387-99. https://doi.org/10.9788/tp2018.1-15pt
https://doi.org/10.9788/tp2018.1-15pt... .

The descriptive data analysis used absolute and relative frequencies for categorical variables and mean and standard deviations (SD) for numerical variables. In the bivariate and multivariate analysis, we calculated prevalence ratios (PR) and their respective 95% confidence intervals (95%CI) to measure the association between the dependent — IADL functional disability — and independent variables, using Poisson regression with robust variance. The multivariate analysis included all variables with p<0.20 in the bivariate analysis. We adopted the backward method, that is, we progressively removed from the model the variables that did not present p<0.05, except for gender and age group, which were retained in the model as adjustments. The adequacy of the model was verified by the goodness of fit test. All analyses were performed in the Stata^® software, version 16.1.

The study was approved by the Research Ethics Committee (REC) of HUJM, under opinion No. 3,048,183, and the REC of SES/MT, under opinion No. 3,263,744.

RESULTS

In the present study, most older adults with cancer were aged 60 to 69 years (56.4%), the mean age was 69.4 years (SD=7), 61.8% were male, 54.2% lived with a partner, 72.1% had up to eight years of schooling, and 80.8% earned from one to less than three times the minimum wage. The most frequent types of cancer were: prostate (36.7%), breast (17.7%), colorectal (7.1%), lung (3.9%), and skin (2.6%) cancer. Among the participants, 31.6% self-reported two or more comorbidities, of which the most common were hypertension (60.0%), diabetes (17.3%), chronic kidney disease (10.6%), and chronic lung disease (7.6%).

Regarding cancer staging, 29.8% were classified as 0, I, and II; 46.2% as III and IV; and 24.0% did not have this information. Those receiving curative cancer treatment totaled 79.3%, while 20.7% received palliative treatment. As for distant metastasis, 49.5% did not present metastasis (M0), 19.2% presented metastasis (M1), 4.3% were cases in which assessing distant metastasis was impossible (MX), and 27.0% of the medical records did not have such information.

The prevalence of IADL disability was 55.3% (95%CI 50.7–59.9), and older adults showed greater disability in the following activities: housekeeping (41.3%), shopping (25.9%), and using a mode of transportation (22.9%).

In the bivariate analysis, the sociodemographic variables associated with IADL disability were the age group 70 years and older, up to eight years of schooling, and not working currently (Table 1). No lifestyle variable was associated with IADL disability in the bivariate analysis (Table 2).

The social support variables associated with IADL disability were: moderate perceived informational and emotional support and moderate perceived positive social interaction (Table 3).

The variables related to health aspects associated with IADL disability were: not having health insurance, having two or more chronic comorbidities, depressive symptoms, malnutrition, and having a companion to health services. Staging showed no significant association with functional disability (III, IV: p=0.841; no information: p=0.422) (Table 4).

The variables that remained associated with IADL functional disability in the multivariate analysis were: not working currently (PR=1.36; 95%CI 1.03–1.78); low (PR=1.49; 95%CI 1.10–2.03) and moderate (PR=1.30; 95%CI 1.04–1.64) perceived affectionate support; depressive symptoms (PR=1.31; 95%CI 1.10–1.56); malnutrition (PR=1.28; 95%CI 1.03–1.59); having two or more comorbidities (PR=1.30; 95%CI 1.03–1.64), and having a companion to health services (PR=1.39; 95%CI 1.05–1.83) (Table 5).

DISCUSSION

This study showed a high prevalence of IADL functional disability in older adults with cancer treated at outpatient clinics; functional disability was associated with depressive symptoms, affectionate support, work, comorbidities, malnutrition, and having a companion to health services.

In a meta-analysis, the mean disability prevalence in Brazilian older adults was 42.8% among women and 39.6% among men. Prevalence rates ranged from 12.3 to 94.1% in men and 14.9 to 84.6% in women³⁸38 Campos ACV, Almeida MHM, Campos GV, Bogutchi TF. Prevalence of functional incapacity by gender in elderly people in Brazil: a systematic review with meta-analysis. Rev Bras Geriatr Gerontol 2016; 19(3): 545-59. https://doi.org/10.1590/1809-98232016019.150086
https://doi.org/10.1590/1809-98232016019... , which may be explained by the different types of study and data collection contexts. Another meta-analysis of worldwide studies identified a prevalence of IADL disability in older adults with cancer between 13.0 and 75.0% in outpatient settings¹²12 Neo J, Fettes L, Gao W, Higginson IJ, Maddocks M. Disability in activities of daily living among adults with cancer: a systematic review and meta-analysis. Cancer Treat Rev 2017; 61: 94-106. https://doi.org/10.1016/j.ctrv.2017.10.006
https://doi.org/10.1016/j.ctrv.2017.10.0... .

In a study of Brazilian older adults with multimorbidities, the prevalence of IADL disability was much lower (29.1%)³⁹39 Schmidt TP, Wagner KJP, Schneider IJC, Danielewicz AL. Padrões de multimorbidade e incapacidade funcional em idosos brasileiros: estudo transversal com dados da Pesquisa Nacional de Saúde. Cad Saúde Pública 2020; 36(11): e00241619. https://doi.org/10.1590/0102-311X00241619
https://doi.org/10.1590/0102-311X0024161... . A population-based study of older adults from a community identified a prevalence of 34.0%, even with 89.3% of them presenting some type of comorbidity⁴⁰40 Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/S1679-49742018000200005
https://doi.org/10.5123/S1679-4974201800... .

The activities that older adults reported having a greater disability were: housekeeping, shopping, and using a mode of transportation. These findings corroborate studies with similar results¹²12 Neo J, Fettes L, Gao W, Higginson IJ, Maddocks M. Disability in activities of daily living among adults with cancer: a systematic review and meta-analysis. Cancer Treat Rev 2017; 61: 94-106. https://doi.org/10.1016/j.ctrv.2017.10.006
https://doi.org/10.1016/j.ctrv.2017.10.0... ,⁴⁰40 Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/S1679-49742018000200005
https://doi.org/10.5123/S1679-4974201800... , which demonstrated that older adults presented IADL disability in essential activities to their well-being, autonomy, and even freedom of movement.

We found an association between depressive symptoms and greater functional disability in older adults with cancer. Other works highlight this association, which may have negative and even irreversible consequences¹¹11 Cabral JF, Silva AMC, Andrade ACS, Lopes EG, Mattos IE. Vulnerabilidade e declínio funcional em pessoas idosas da Atenção Primária à Saúde: estudo longitudinal. Rev Bras Geriatr Gerontol 2021; 24(1): e200302. https://doi.org/10.1590/1981-22562021024.200302
https://doi.org/10.1590/1981-22562021024... ,⁴¹41 Hajek A, König HH. Longitudinal predictors of functional impairment in older adults in Europe––evidence from the survey of health, ageing and retirement in Europe. PLoS One 2016; 11(1): e0146967. https://doi.org/10.1371/journal.pone.0146967
https://doi.org/10.1371/journal.pone.014... . A comparative study of older adults with and without cancer that also used PHQ-9 found a higher prevalence of depression in those with cancer⁴²42 Hammermüller C, Hinz A, Dietz A, Wichmann G, Pirlich M, Berger T, et al. Depression, anxiety, fatigue, and quality of life in a large sample of patients suffering from head and neck cancer in comparison with the general population. BMC Cancer 2021; 21(1): 94. https://doi.org/10.1186/s12885-020-07773-6
https://doi.org/10.1186/s12885-020-07773... . The literature reports a group of associated factors, including depression and isolation, that indicate a higher risk of suicide in older adults with cancer⁴³43 Santos MA. Câncer e suicídio em idosos: determinantes psicossociais do risco, psicopatologia e oportunidades para prevenção. Ciênc Saúde Coletiva 2017; 22(9): 3061-75. https://doi.org/10.1590/1413-81232017229.05882016
https://doi.org/10.1590/1413-81232017229... .

Low and moderate perceived affectionate support was associated with IADL functional disability. Similar to our finding, a Mexican study assessing older adults from a community revealed that those dissatisfied with the social support received were more likely to have IADL limitations⁴⁴44 Mendoza-Núñez VM, González-Mantilla F, Correa-Muñoz E, Retana-Ugalde R. Relationship between social support networks and physical functioning in older community-dwelling mexicans. Int J Environ Res Public Health 2017; 14(9): 993. https://doi.org/10.3390/ijerph14090993
https://doi.org/10.3390/ijerph14090993... . Population-based research in Brazil revealed that older adults who do not live with a partner, do not participate in social activities, and do not have voluntary/paid work are more likely to have IADL disability⁴⁵45 Oliveira-Figueiredo DST, Felisbino-Mendes MS, Velasquez-Melendez G. Associação entre rede social e incapacidade funcional em idosos brasileiros. Rev Bras Enferm 2021; 74(3): e20200770. https://doi.org/10.1590/0034-7167-2020-0770
https://doi.org/10.1590/0034-7167-2020-0... . For older adult cancer survivors in the United States, adding new relationships to their social network had a protective effect against functional impairment; in turn, the reduced frequency of contact with people from the social network was associated with functional deficit¹⁹19 Guida JL, Holt CL, Dallal CM, He X, Gold R, Liu H. Social relationships and functional impairment in aging cancer survivors: a longitudinal social network study. Gerontologist 2020; 60(4): 607-16. https://doi.org/10.1093/geront/gnz051
https://doi.org/10.1093/geront/gnz051... .

Malnutrition was also associated with IADL functional disability in the present study. This health condition may worsen the prognosis and lead not only to functional decline but also to other complications in older patients with cancer, such as low overall survival, worse quality of life, longer length of stay, and hospital readmission, among others¹⁶16 Van Den Broeke C, De Burghgraeve T, Ummels M, Gescher N, Deckx L, Tjan-Heijnen V, et al. Occurrence of malnutrition and associated factors in community-dwelling older adults: those with a recent diagnosis of cancer are at higher risk. J Nutr Health Aging 2018; 22(2): 191-8. https://doi.org/10.1007/s12603-017-0882-7
https://doi.org/10.1007/s12603-017-0882-... ,²²22 Zhang X, Edwards BJ. Malnutrition in older adults with cancer. Curr Oncol Rep 2019; 21(9): 80. https://doi.org/10.1007/s11912-019-0829-8
https://doi.org/10.1007/s11912-019-0829-... .

Comorbidity was also associated with functional decline (comorbidity is the coexistence of disorders in addition to a primary disease of interest)¹⁷17 Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer and its treatment. CA Cancer J Clin 2016; 66(4): 337-50. https://doi.org/10.3322/caac.21342
https://doi.org/10.3322/caac.21342... ; the most frequent ones in the present investigation were hypertension and diabetes. These diseases were also more common in a population-based study of Brazilian older adults, followed by arthritis, heart disease, depression, stroke, and lung disease. The study also emphasized that the diseases that contributed the most to IADL dependence were arthritis and stroke⁴⁶46 Costa Filho AM, Mambrini JVM, Malta DC, Lima-Costa MF, Peixoto SV. Contribution of chronic diseases to the prevalence of disability in basic and instrumental activities of daily living in elderly Brazilians: the National Health Survey (2013). Cad Saude Publica 2018; 34(1): e00204016. https://doi.org/10.1590/0102-311X00204016
https://doi.org/10.1590/0102-311X0020401... . However, in the present study, the prevalence of musculoskeletal diseases, such as arthritis (1.5%, data not shown), and stroke (0.4%, data not shown) was low; yet, this result may be related to the measurement method since these morbidities were evaluated in the "other diseases" option and not as separate questions.

In the cancer scenario, comorbidity is associated with the presence, nature, and severity of health conditions that coexist with the disease, and its impact should be assessed at both treatment and survival levels¹⁷17 Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer and its treatment. CA Cancer J Clin 2016; 66(4): 337-50. https://doi.org/10.3322/caac.21342
https://doi.org/10.3322/caac.21342... . Studies confirm the relation of the presence and burden of comorbidities with increased functional deficits, as well as worse survival in older adults with cancer⁷7 Hewitt M, Rowland JH, Yancik R. Cancer survivors in the United States: age, health, and disability. J Gerontol A Biol Sci Med Sci 2003; 58(1): 82-91. https://doi.org/10.1093/gerona/58.1.m82
https://doi.org/10.1093/gerona/58.1.m82... ,⁴⁷47 Pergolotti M, Deal AM, Lavery J, Reeve BB, Muss HB. The prevalence of potentially modifiable functional deficits and the subsequent use of occupational and physical therapy by older adults with cancer. J Geriatr Oncol 2015; 6(3): 194-201. https://doi.org/10.1016/j.jgo.2015.01.004
https://doi.org/10.1016/j.jgo.2015.01.00... ,⁴⁸48 Williams GR, Mackenzie A, Magnuson A, Olin R, Chapman A, Mohile S, et al. Comorbidity in older adults with cancer. J Geriatr Oncol 2016; 7(4): 249-57. https://doi.org/10.1016/j.jgo.2015.12.002
https://doi.org/10.1016/j.jgo.2015.12.00... .

The lack of work at the time of data collection was associated with disability, a result that corroborates other studies in which older adults without a professional activity presented a decrease in IADL functional capacity⁴⁰40 Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/S1679-49742018000200005
https://doi.org/10.5123/S1679-4974201800... ,⁴⁵45 Oliveira-Figueiredo DST, Felisbino-Mendes MS, Velasquez-Melendez G. Associação entre rede social e incapacidade funcional em idosos brasileiros. Rev Bras Enferm 2021; 74(3): e20200770. https://doi.org/10.1590/0034-7167-2020-0770
https://doi.org/10.1590/0034-7167-2020-0... and even a worsening in physical performance⁴⁹49 Ikegami EM, Souza LA, Tavares DMS, Rodrigues LR. Capacidade funcional e desempenho físico de idosos comunitários: um estudo longitudinal. Ciênc Saúde Coletiva 2020; 25(3): 1083-90. https://doi.org/10.1590/1413-81232020253.18512018
https://doi.org/10.1590/1413-81232020253... . Another possible explanation is reverse causality, that is, the fact that the older adult has cancer can lead to functional disability and the consequent loss or suspension of work activities.

Having a companion to health services was associated with disability, an expected result since dependent patients often have reduced mobility and difficulty using modes of transportation alone, relying on the assistance of their companion to travel⁴⁰40 Farías-Antúnez S, Lima NP, Bierhals IO, Gomes AP, Vieira LS, Tomasi E. Incapacidade funcional para atividades básicas e instrumentais da vida diária: um estudo de base populacional com idosos de Pelotas, Rio Grande do Sul, 2014. Epidemiol Serv Saúde 2018; 27(2): e2017290. https://doi.org/10.5123/S1679-49742018000200005
https://doi.org/10.5123/S1679-4974201800... ,⁵⁰50 Schenker M, Costa DH. Avanços e desafios da atenção à saúde da população idosa com doenças crônicas na Atenção Primária à Saúde. Ciên Saúde Coletiva 2019; 24(4): 1369-80. https://doi.org/10.1590/1413-81232018244.01222019
https://doi.org/10.1590/1413-81232018244... .

Some study limitations should be mentioned, such as the impossibility of using clinical cancer information in the association analysis due to the high frequency of missing data and the lack of evaluation of the cognitive status, which may be associated with depression and disability⁴¹41 Hajek A, König HH. Longitudinal predictors of functional impairment in older adults in Europe––evidence from the survey of health, ageing and retirement in Europe. PLoS One 2016; 11(1): e0146967. https://doi.org/10.1371/journal.pone.0146967
https://doi.org/10.1371/journal.pone.014... . In addition, the study was not designed to specifically assess the older population, so we used a subsample of the original study. Also, the cross-sectional design does not allow us to establish temporality between exposure and outcome. Lastly, survival bias should be taken into account, as older adults who are more dependent, have more severe types of cancer, and even those with more advanced age could have died or been hospitalized, thus underestimating the prevalence investigated. Among our strengths, we can mention that this study analyzed original primary data from Mato Grosso, using instruments validated for the Brazilian population, in addition to being carried out in reference outpatient clinics for cancer treatment.

The results reinforce the importance of comprehensive health care for older adults. In addition to physical health aspects, psychosocial factors are also important and should be considered in such a complex condition as cancer. Functional capacity should be evaluated before, during, and after treatment, providing means to maintain and recover the functional capacity of older adults, and thus reducing adverse biopsychosocial outcomes.

ACKNOWLEDGMENTS

We thank SES-MT for the partnership in the elaboration of instruments and the contact with cancer services; the 23^rd Region Ministry of Public Labor Prosecution for funding the research; and HUJM and HCan for providing an appropriate space for patients during data collection.

REFERENCES

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