Functional Performance in Patients with Chronic Obstructive Pulmonary Disease

Abstract

Objectives: Improvement of symptoms and activities is one of the major treatment goals for patients with Chronic Obstructive Pulmonary Disease (COPD). The COPD guidelines recognise the need to address the effect of the disease on the patient's daily life and reduce the risk of future exacerbations. This study aimed to explore the level of functional performance among patients with all stages of COPD. Methods :A cross-sectional survey design was conducted with a non-probability convenience sample of 214 patients with COPD. The sample was recruited from patients attending the respiratory outpatient clinic of one of the major teaching hospitals in Dublin, Ireland. Functional performance was measured using the Functional Performance Inventory-short form (FPI-SF). Results : The mean age was 68.1 years (SD=8.1), with the youngest participant aged 49 years and the oldest aged 90 years. Overall, over half of the participants were female (56%, n=120). Total functional performance scores ranged from 0.14 to 2.83, with a mean (SD) of 1.13(0.68), indicating that across all participant, functional performance was low. The mean subscale score was highest for the Body Care subscale, indicating that this was the domain that the participants had least difficulty with. In contrast, the mean subscale score was lowest for the Physical Exercise subscale, indicating that this was the domain that the participants didn't partake in or had the most difficulty with. For overall functional performance, participants with mild COPD had the highest median functional performance, followed by those with moderate COPD, very severe COPD, and severe COPD. Conclusion : Knowledge about the functional performance of each stage of COPD is lacking. To the best of the author's knowledge, this is the first study to explore the functional performance for each stage of COPD. The total functional performance score was low and suggests that management of functions in all patients with COPD such as regular visits and early assessment for those living in the community are essential. Early assessment helps to identify the candidate patients who require home or personal care support.

Full text

EAS Journal of Nursing and Midwifery
Abbreviated Key Title: EAS J Nurs Midwifery
ISSN: 2663-0966 (Print) & ISSN: 2663-6735 (Online)
Published By East African Scholars Publisher, Kenya
Volume-2 | Issue-4 |Jul-Aug -2020 | DOI: 10.36349/EASJNM.2020.v02i04.03
*Corresponding Author: Omar Melhem 16
Research Article
Functional Performance in Patients with Chronic Obstructive
Pulmonary Disease
Omar Melhem1, Nathira Al Hmaimat1, Moawia Khatatbeh3 and Saed Azizeh4
1Department of Nursing, Fatima College of Health Sciences, Abu Dhabi, United Arab Emirates
2Department of Medicine, Yarmouk University, Irbed, Jordan
3Department of Nursing, Higher College of Technology, Fujairah, United Arab Emirates
Article History
Received: 25.06.2020
Accepted: 05.07.2020
Published:08.07.2020
Journal homepage:
https://www.easpublisher.com/easjnm
Quick Response Code
Abstract: Objectives: Improvement of symptoms and activities is one of the major
treatment goals for patients with Chronic Obstructive Pulmonary Disease (COPD). The
COPD guidelines recognise the need to address the effect of the disease on the patient’s
daily life and reduce the risk of future exacerbations. This study aimed to explore the level
of functional performance among patients with all stages of COPD. Methods :A cross-
sectional survey design was conducted with a non-probability convenience sample of 214
patients with COPD. The sample was recruited from patients attending the respiratory
outpatient clinic of one of the major teaching hospitals in Dublin, Ireland. Functional
performance was measured using the Functional Performance Inventory- short form (FPI-
SF). Results : The mean age was 68.1 years (SD=8.1), with the youngest participant aged 49
years and the oldest aged 90 years. Overall, over half of the participants were female (56%,
n=120). Total functional performance scores ranged from 0.14 to 2.83, with a mean (SD) of
1.13(0.68), indicating that across all participant, functional performance was low. The mean
subscale score was highest for the Body Care subscale, indicating that this was the domain
that the participants had least difficulty with. In contrast, the mean subscale score was
lowest for the Physical Exercise subscale, indicating that this was the domain that the
participants didn’t partake in or had the most difficulty with. For overall functional
performance, participants with mild COPD had the highest median functional performance,
followed by those with moderate COPD, very severe COPD, and severe COPD.
Conclusion : Knowledge about the functional performance of each stage of COPD is
lacking. To the best of the author’s knowledge, this is the first study to explore the
functional performance for each stage of COPD. The total functional performance score was
low and suggests that management of functions in all patients with COPD such as regular
visits and early assessment for those living in the community are essential. Early assessment
helps to identify the candidate patients who require home or personal care support.
Keywords: chronic obstructive pulmonary disease, COPD, function, activities of daily
livings, ADLs, functional performance
Copyright @ 2020: This is an open-access article distributed under the terms of the Creative Commons Attribution license which permits unrestricted
use, distribution, and reproduction in any medium for non commercial use (NonCommercial, or CC-BY-NC) provided the original author and source
are credited.
INTRODUCTION
Chronic obstructive pulmonary disease
(COPD) is a chronic, potentially fatal progressive
condition of the lungs. COPD defined as “a common
preventable and treatable disease characterized by
persistent airflow limitation that is usually progressive
and associated with an enhanced chronic inflammatory
response in the airways and the lungs to noxious
particles or gases. Exacerbations and comorbidities
contribute to the overall severity in individual patients
(Global Initiative for Chronic Obstructive Disease.
2011). COPD is a leading disease burden worldwide,
and by 2025, it is expected to become the leading cause
of death worldwide (World health organization. 2010)
Improvement of daily activities is one of the major
treatment goals for patients with COPD (Global
Initiative for Chronic Obstructive Disease. 2011).
However, the Global Initiative for Chronic Obstructive
Lung Disease (GOLD) guidelines and all other COPD
guidelines do not define or assess “functional
performance”. The GOLD (Global Initiative for Chronic
Obstructive Disease. 2011). guidelines recognise the
need to address the effect of the disease on the patient’s
daily life and reduce the risk of future exacerbations.
Researchers have used different terms to
describe individuals’ functional status, such as
functional performance, functional capacity, physical
functioning, activities of daily living, quality of life, and
health status. These terms are often used
interchangeably (Kocks, J. W. et al., 2011) as an

Omar Melhem et al.; EAS J Nurs Midwifery; Vol-2, Iss-4 (Jul-Aug-2020): 16-23
© East African Scholars Publisher, Kenya 17
outcome measure in COPD research. Furthermore,
functional status and quality of life are terms which are
often used interchangeably. The theoretical framework
of functional status proposed by Leidy (Leidy, N. K.
1994) provides clarity and gives a full description of
functional status. Leidy (Leidy, N. K. 1994) defined
functional status as a “multidimensional concept
characterising one’s ability to provide for the
necessities of life; that is, those activities people do in
the normal course of their lives to meet basic needs,
fulfil usual roles, and maintain their health and well-
being.” All dimensions of functional status must be
considered simultaneously in order that it be fully
analysed and understood. Individual elements of
functional status may be evaluated and studied
separately (Leidy, N. K. 1994).However, this should be
clarified through the appropriate use of terminology.
Functional performance is defined as the physical,
psychological, social, occupational or spiritual activities
that people actually do in the normal course of their
lives to meet basic needs, fulfil usual roles, and
maintain their health and well-being (Leidy, N. K.
1994).
Patients with COPD reported being chair
bound and dependent on others for their daily activities,
which makes them socially isolated and neglected by
family members (Avsar, G., & Kasikci, M. 201; Ek, K.,
& Ternestedt, B. M. 2008; Elofsson, L. C., & Öhlén, J.
2004). With severe COPD individuals come to terms
with their diminishing ability to care for themselves,
and finding the basic tasks such as showering and
dressing difficult making them feel useless and
dependent on others (Avsar, G., & Kasikci, M. 2010; &
Barnett M. 2005). The present study examined the
functional performance among patients with all stages
of COPD using a descriptive cross sectional design.
METHODS
A convenience sample of patients with COPD
fulfilling the inclusion criteria were eligible to
participate. Patients with a diagnosis of COPD in any of
the following GOLD classifications (GOLD 2014):
mild COPD (Forced Expiratory Volume in the one
second (FEV1) >=80%), moderate COPD (FEV1 50-
80%), severe COPD (FEV1 30-50%), very severe
COPD (FEV1 <30%), patients living in the community
in their own home, patients able to speak and read
English to allow self-completion of the questionnaire
were included in the study. Hospitalized inpatients with
COPD or patients with COPD residing in long term
care facilities or respite care; patients with a history of
cognitive impairment which would prevent their ability
to give informed consent were excluded. The sample
was recruited from patients attending the respiratory
outpatient clinic, either at the clinic or at home.
Participants at home included in this study were those
under the care of the COPD outreach team. Study
approval was granted from the Clinical Research Ethics
Committee. The revised Declaration of Helsinki was
performed during all procedures of the study.
Informed consent was obtained from all participants
and informed about al details regarding the study and its
intended purpose.
Functional performance was measured using
the Functional Performance Inventory-Short Form (FPI-
SF). The FPI is a self-administered questionnaire
developed to capture patient self-report of functional
performance (Leidy, N. K. 1999). The FPI is based on
an analytical framework that defines functional status as
a multidimensional concept characterising the activities
people do to meet basic needs, fulfil usual roles, and
maintain their health and well-being (Leidy, N. 1994;
&Leidy, N. K. 1999). The original, long form of the
tool comprising 65 items, was developed based on in-
depth qualitative interviews with men and women with
COPD (Leidy, N. K., & Haase, J. E. 1996). The 32-item
short form was designed as a parsimonious version of
the 65-item long form, with representative content and
the same psychometric performance properties but
reduced burden on the patient. The FPI-SF is a patient-
reported outcome measure developed to quantify daily
activities for patients with COPD (Leidy, N. K., &
Knebel, A. 2010). The FPI-SF is a 32-item instrument
with 6 subscales: body care (5 items), household
maintenance (8 items), physical exercise (5 items),
recreation (5 items), spiritual activities (4 items) and
social activities (5 items).
Participants score 0 points for activities they
do not perform in the last week, whether for health or
other reasons. If the participants are able to do an
activity in the last week, they are asked to indicate how
difficult the activity is for them to perform on a scale of
3 “no difficulty”, 2 “some difficulty”, to 1 “much
difficulty”. If respondents do not perform an activity,
they are asked if this is an activity they don’t do
because of “health reasons” or “choose not to”. The
total score was computed by taking the mean across all
subscale scores. The total FPI is 0 to 3, with higher
scores reflecting higher levels of functional
performance (Leidy, N. K., & Knebel, A. 2010). Data
were collected daily (except weekends) at the
respiratory outpatients’ clinic or at patients’ homes over
a three month period from December 3rd, 2014 to March
10th, 2015. For the participants in the outpatient clinic,
prior to each clinic, the Respiratory Nurse Specialist
(RNS) reviewed the scheduled patient’s medical notes
to identify those who met the inclusion and exclusion
criteria. Potentially eligible participants were informed
by the RNS about the study and invited them to meet
the researcher to complete the questionnaire. A stamped
return envelope with the researcher’s address was
provided for participants who were not able to complete
the questionnaire at the clinic but willing to complete
the questionnaire at a different time in their homes. For
participants at home, prior to her visit, the COPD
outreach nurse reviewed the scheduled patients and

Omar Melhem et al.; EAS J Nurs Midwifery; Vol-2, Iss-4 (Jul-Aug-2020): 16-23
© East African Scholars Publisher, Kenya 18
identified those who met the inclusion and exclusion
criteria. Eligible participants were informed by the
COPD outreach nurse about the study and invited them
to participate. For patients who agreed to participate in
the study, the COPD outreach nurse gave them a
stamped addressed for return to the researcher contains
the information leaflet of the study, consent form and a
copy of the FPI-SF to complete and posted.
A sample size of 200 was deemed sufficient to
detect a medium effect (f2=0.15) in a multiple linear
regression with up to 20 predictor variables, with a
power of 80% and a level of significance of 0.05 in a 2-
tailed test. Data collected were stored and analysed
using Predictive Analytics Software (PASW). A data –
coding framework was developed prior to data
collection. After screening and cleaning of the data file,
data were analysed using descriptive and inferential
statistics. Descriptive statistics were used to examine
the clinical and demographic characteristics of the
participants.
Descriptive statistics were used to describe the
demographic characteristics and functional
performance. Inferential statistics were conducted to
compare functional performance between COPD stages.
For comparisons between COPD stages, Fisher’s exact
test was used for categorical variables and if a
statistically significant difference was found, pairwise
comparisons were performed using Fisher’s exact test,
with Bonferroni correction for multiple testing. The
Kruskal-Wallis test was used for the comparison of
continuous variables between COPD stages.
RESULTS
A sample of 214 patients with COPD
participated in this study. The mean age was 68.1 years
(SD=8.1), with the youngest participant aged 49 years
and the oldest aged 90 years. Overall, over half of the
participants were female (56%, n=120). More than half
of the participants (56.1%, n=120) were unable to work.
A minority (5.1%, n=11) were employed with wages or
were self-employed (3.3%, n=7). With regard to living
arrangements, over half of the participants were living
with their family members (57.9%, n=124) (Table 1).
Of the 214 participants, 20.1% (n=43) had mild COPD,
26.2% (n=56) had moderate COPD, 33.2% (n=71) had
severe COPD, and 20.5% (n=44) had very severe
COPD. Participants experienced comorbid conditions.
The most frequent were hypertension, ischaemic heart
disease (IHD), atrial fibrillation (A.Fib), and chronic
cardiac failure (CCF). The socio-demographic and
clinical characteristics of the patients overall and by
COPD stage are presented in Table (1).
For each participant, subscale scores were
calculated by averaging the items within the subscale.
Subscale scores could range from 0 to 3 with higher
scores reflecting greater functional performance.
Missing values for items within the subscale were
replaced with the mean of the items within that subscale
to which the patients had responded if the patient had
answered at least 80% of the items within the subscale.
The total score was calculated by taking the average
across all subscale scores. Total scores could range
from 0 to 3 with higher scores reflecting greater
functional performance. For a participant, all subscale
scores had to be present in order to calculate.
Overall, total functional performance scores
ranged from 0.14 to 2.83, with a mean (SD) of
1.13(0.68), indicating that across all participant,
functional performance was low. The mean subscale
score was highest for the Body Care subscale (mean
(SD): 2.00(0.88)), indicating that this was the domain
that the participants had least difficulty with. In
contrast, the mean subscale score was lowest for the
Physical Exercise subscale (mean (SD): 0.75(0.89),
indicating that this was the domain that the participants
didn’t partake in or had the most difficulty with. The
distribution of scores for the overall scale and subscales
are presented graphically in Figure 1.

Omar Melhem et al.; EAS J Nurs Midwifery; Vol-2, Iss-4 (Jul-Aug-2020): 16-23
© East African Scholars Publisher, Kenya 19
Table 1: Socio-demographic and clinical characteristics of patients, overall and by COPD stage
Characteristic
Age (years): Mean(SD) 68.1 (8.1) 61.5 (8.1) 69.2 (8.4) 70.7 (6.4) 68.9 (6.7)
Range
% (n) % (n) % (n) % (n) % (n)
Gender
Male 43.9 (94) 34.9 (15) 32.1 (18) 64.8 (46) 34.1 (15)
Female 56.1 (120) 65.1 (28) 67.9 (38) 35.2 (25) 65.9 (29)
Marital status
Single 4.2 (9) 0.0 (0) 3.6 (2) 9.9 (7) 0.0 (0)
Married 37.4 (80) 41.9 (18) 28.6 (16) 38.0 (27) 43.2 (19)
Separated 23.8 (51) 34.9 (15) 46.4 (26) 11.3 (8) 4.5 (2)
Divorced 11.7 (25) 2.3 (1) 8.9 (5) 2.8 (2) 38.6 (17)
Widowed 22.9 (49) 20.9 (9) 12.5 (7) 38.0 (27) 13.6 (6)
Employment status
Employed with wages 5.1 (11) 23.3 (10) 1.8 (1) 0.0 (0) 0.0 (0)
Self employed 3.3 (7) 2.3 (1) 1.8 (1) 7.0 (5) 0.0 (0)
Unemployed 6.1 (13) 20.9 (9) 5.4 (3) 1.4 (1) 0.0 (0)
Retired 29.4 (63) 11.6 (5) 32.1 (18) 25.4 (18) 50.0 (22)
Unable to work 56.1 (120) 41.9 (18) 58.9 (33) 66.2 (47) 50.0 (22)
Living arrangements
Alone 22.9 (49) 14.0 (6) 3.6 (2) 42.3 (30) 25.0 (11)
With family member 57.9 (124) 79.1 (34) 66.1 (37) 38.0 (27) 59.1 (26)
Shared accommodation 19.2 (41) 7.0 (3) 30.4 (17) 19.7 (14) 15.9 (7)
Currently using oxygen therapy
No 52.8 (113) 79.1 (34) 62.5 (35) 26.8 (19) 56.8 (25)
Intermittent oxygen 31.3 (67) 20.9 (9) 19.6 (11) 40.8 (29) 40.9 (18)
Permanent oxygen 15.9 (34) 0.0 (0) 17.9 (10) 32.4 (23) 2.3 (1)
Current medication use
Inhalers 39.7 (85) 53.5 (23) 42.9 (24) 35.2 (25) 29.5 (13)
Nebulizers 16.4 (35) 23.3 (10) 21.4 (12) 16.9 (12) 2.3 (1)
Both inhalers and nebulizers 43.9 (94) 23.3 (10) 35.7 (20) 47.9 (34) 68.2 (30)
Smoking status
Currently not smoking 84.1 -180 76.7 -33 80.4 -45 88.7 -63 88.6 -39
Currently smoking 15.9 (34) 23.3 (10) 19.6 (11) 11.3 (8) 11.4 (5)
Smoked in the past 68.7 (147) 69.8 (30) 62.5 (35) 78.9 (56) 59.1 (26)
Never smoked 3.3 (7) 0.0 (0) 3.6 (2) 7.0 (5) 0.0 (0)
Hospital admission in the last 6 months
None 21.0 (45) 51.2 (22) 28.6 (16) 9.9 (7) 0.0 (0)
Once 39.3 (84) 48.8 (21) 50.0 (28) 29.6 (21) 31.8 (14)
Two times 23.8 (51) 0.0 (0) 12.5 (7) 31.0 (22) 50.0 (22)
Three times or more 15.9 (34) 0.0 (0) 8.9 (5) 29.6 (21) 18.2 (8)
56 to 81
60 to 87
Overall (n=214)
COPD Stages
Mild (n=43)
Moderate (n=56)
Severe (n=71)
Very severe(n=44)
49 to 90
49 to 85
49 to 90

Omar Melhem et al.; EAS J Nurs Midwifery; Vol-2, Iss-4 (Jul-Aug-2020): 16-23
© East African Scholars Publisher, Kenya 20
Figure (1) Scores on the FPI-SF scale and subscales
For overall functional performance,
participants with mild COPD had the highest median
functional performance (median (IQR): 2.02 (0.98 to
2.45)), followed by those with moderate COPD (median
(IQR): 1.16 (0.86 to 1.84)), very severe COPD (median
(IQR): 0.85(0.56 to 0.87)), and severe COPD (median
(IQR): 0.74 (0.45 to 1.14)). Based on the average ranks,
the highest ranking was for the mild group, followed by
the moderate group, severe group and very severe
group. The difference between groups was statistically
significant (p<0.001). Post-hoc pairwise comparisons
using Bonferroni correction indicated significant
differences in overall functional performance between
participants with very severe COPD and those with
moderate or mild COPD and between participants with
severe COPD and those with moderate or mild COPD
(Figure 2).
Figure (2) Scores on the FPI-SF scale by COPD stage
Similarly, significant differences were found
between the COPD stages for the Body Care subscale
(p<0.001), and the Household Maintenance subscale
(p<0.001) with the mild and moderate groups having
significantly higher functioning compared to the severe
and very severe groups. The mild group were also
found to have significantly higher functioning on the
Household Maintenance subscale compared to the
moderate group. For the Physical Exercise subscale,
the mild group had significantly higher functioning than
the very severe group. The severe group had the lowest
functioning on the Recreation subscale and had
significantly lower functioning than the mild or very
severe groups.
Based on the average ranks, the mild group
had the highest functioning on the Spiritual Activities
subscale, followed by the moderate group, severe group
and very severe group. The difference between groups
was statistically significant (p<0.001). Post-hoc
pairwise comparisons using Bonferroni correction
indicated significant difference between all groups
except the moderate and severe groups. However, no
differences in the distribution of scores for the Social
Activities subscale were found between the stages of
COPD (p=0.375). The summary statistics for the scale
and subscales split by COPD stage are presented in
Table 2.
0 1 2 3
Score
Social Activities
Spiritual Activities
Recreation
Physical Exercise
Household maintenance
Body Care
Total
(possible range: 0 to 3)
Distribution of scores on the FPI-SF scale and subscales
0 1 2 3
Score
Very severe
Severe
Moderate
Mild
(possible range: 0 to 3)
Distribution of scores on the FPI-SF scale by COPD stage

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© East African Scholars Publisher, Kenya 21
Table 2: Comparison of total functional performance and subscales by COPD stage
nmean (SD) median (IQR) p-value1
Total functional performance (FPI-SF) <0.001
Mild COPD 36 1.75 (0.75) 2.02 (0.98 to 2.45)
Moderate COPD 56 1.33 (0.61) 1.16 (0.86 to 1.84)
Severe COPD 62 0.85 (0.53) 0.74 (0.45 to 1.14)
Very severe COPD 36 0.71 (0.28) 0.85 (0.56 to 0.87)
Subscales
Body Care <0.001
Mild COPD 43 2.41 (0.47) 2.40 (2.20 to 2.60)
Moderate COPD 56 2.42 (0.88) 3.00 (2.00 to 3.00)
Severe COPD 71 1.52 (0.78) 1.20 (1.00 to 2.00)
Very severe COPD 44 1.83 (0.93) 1.80 (1.60 to 2.60)
Household maintenance <0.001
Mild COPD 43 1.99 (0.81) 2.00 (1.25 to 2.50)
Moderate COPD 56 1.49 (1.00) 1.54 (0.81 to 2.22)
Severe COPD 71 0.56 (0.53) 0.50 (0.00 to 1.00)
Very severe COPD 44 0.57 (0.35) 0.40 (0.38 to 1.00)
Physical Exercise 0.006
Mild COPD 40 1.26 (1.17) 1.60 (0.00 to 2.20)
Moderate COPD 56 0.86 (0.94) 0.40 (0.00 to 1.80)
Severe COPD 67 0.64 (0.73) 0.40 (0.00 to 1.20)
Very severe COPD 41 0.27 (0.29) 0.20 (0.00 to 0.50)
Recreation 0.001
Mild COPD 43 1.52 (1.31) 1.80 (0.00 to 3.00)
Moderate COPD 56 1.02 (0.94) 0.78 (0.20 to 1.80)
Severe COPD 71 0.63 (0.80) 0.40 (0.00 to 0.80)
Very severe COPD 43 0.90 (0.45) 0.80 (0.75 to 1.40)
Spiritual Activities <0.001
Mild COPD 39 1.91 (1.16) 2.00 (1.00 to 3.00)
Moderate COPD 56 1.23 (1.18) 0.75 (0.00 to 2.81)
Severe COPD 66 0.97 (0.92) 1.00 (0.00 to 1.50)
Very severe COPD 41 0.35 (0.38) 0.25 (0.00 to 0.75)
Social Activities 0.375
Mild COPD 43 1.15 (1.41) 0.00 (0.00 to 3.00)
Moderate COPD 56 0.94 (1.11) 0.40 (0.00 to 1.95)
Severe COPD 71 0.69 (0.93) 0.00 (0.00 to 1.60)
Very severe COPD 43 0.38 (0.23) 0.40 (0.20 to 0.60)
0 to 3
0 to 3
0 to 2.6
0 to 0.6
0 to 1.40
0 to 3
0 to 3
0 to 3
0 to 1
0 to 3
0 to 2.4
0 to 0.8
0 to 3
0 to 3
0 to 3
0 to 3
0 to 3
0 to 2
0 to 1.14
0 to 3
0.75 to 3
0 to 3
0 to 3
0 to 3
observed range
0.79 to 2.83
0.37 to 2.54
0.15 to 1.99
0.14 to 1.06
DISCUSSION
Functional performance in COPD was
measured in this study. Among the six subscales,
participants had the lowest mean functional
performance score for the physical exercise scale,
indicating that patients with COPD had the most
difficulty with this domain. Unsurprisingly, physical
exercises such as regular stretching, moving or lifting,
walking for short distances or exercising a long walk,
and engaging in activities such as swimming or
bicycling were reported as the most difficult activities.
Participants with mild and moderate COPD had similar
physical activity levels, whereas participants with
severe and very severe COPD differed markedly from
those with mild or moderate COPD.
The second lowest functional performance
domain found was recreation such as taking vacations
and engaging in activities. This was followed by social
activities, household maintenance, and spiritual
activities such as attending religious services and going
to religious ceremonies. Participants in this study had
least difficulty with the body care domain. Body care
includes dressing, showering, and washing hair. The
total functional performance score was 1.13, indicating
that functional performance was low for overall
participants. Participants experienced lower levels of
functional performance compared to previous research
(Park, S. K. et al., 2012; Kapella, M. C. et al., 2006;
Reishtein, J. L. 2005; & Yeh, M. L. et al., 2004). The
low level of functional performance is due to the high
symptom burden experienced and the severity of
COPD; this will be discussed in detail later in this
section.
The experience of functional impairment and
disability has been described in previous qualitative
literature. Patients with COPD described themselves as
being physically and functionally disabled, and
dependent on others. For example, social isolation and
loss of employment was attributed to being restricted at
home due to the disease (Avsar, G., & Kasilkci, M.
2011; Gysels, M., & Higginson, I. J. 2010; & Booth, S.
et al., 2003). Furthermore, the impairment of functional
performance was found to be a strong predictor of
survival in patients with COPD (Bowen, J. B. et al.,
2000) and difficulties in performing daily activities
have been associated with low physical and mental
scores that lead to low quality of life (Garcia-Aymerich,
J. et al., 2003). However, daily activities were
compared between patients with COPD and lung cancer
(Gore, J. M. et al., 2000), and found that patients with
COPD had significantly worse activities of daily living

Omar Melhem et al.; EAS J Nurs Midwifery; Vol-2, Iss-4 (Jul-Aug-2020): 16-23
© East African Scholars Publisher, Kenya 22
scores compared with those with lung cancer. Although
both groups of patients had similar palliative care
needs, patients with COPD had a significantly lower
quality of life scoring than those with cancer. Previous
research noted the unmet needs and lack of service,
particularly in the late stages of COPD (Gysels, M. H.,
& Higginson, I. J. 2009). The internationally recognised
COPD guidelines such as GOLD, recommend
rehabilitation and exercise training for patients with
COPD. The literature shows good evidence of the
effectiveness of pulmonary rehabilitation in improving
physical activity, dyspnoea, fatigue, and overall quality
of life for patients with COPD (Gysels, M. H., &
Higginson, I. J. 2009; & Williams, V. et al., 2010). The
present study, supported by previous research suggests
that the low functional performance in patients with
COPD needs to be addressed and managed. Low
functional performance could be eased, alongside
pharmacological and oxygen therapy, through
interventions such as rehabilitation, behavioural and
exercise programmes which will increase the level of
physical activity and reduce the difficulties with daily
activities. Furthermore, regular visits and assessment
for patients with COPD living in the community are
essential to identify the candidate patients for home or
personal care support.
An important finding of this study is that most
participants with COPD experienced a low functional
performance. Although assessing health-related quality
of life (HRQOL) was not the focus of this study,
functional performance is an important components of
HRQOL in patients with COPD (Reardon, J. Z. et al.,
2006). Current guidelines of management of COPD
such as GOLD have focused only on improving
pathological and pathophysiological parameters such as
inflammation and narrowing airways (Global Initiative
for Chronic Obstructive Disease. 2014). The present
study suggests that assessment of functional
performance among patients with COPD is necessary.
Evidence from literature on cancer indicated that a
palliative care approach to cancer patients increases the
quality of life. For patients with advanced COPD with
low functional performance, a palliative care approach
should be used as there is no cure for COPD. Patients
with COPD were reported to be the least likely to use
palliative care resources provided in the hospital or
home care setting (Goodridge, D. et al., 2008), and the
majority of patients with advanced COPD do not offer
palliative care to manage their illness (Elkington, H. et
al., 2005). Health care professionals have a duty also to
have open communication with patients, especially with
those with severe and very severe COPD, and discuss
the palliative care approach.
CONCLUSION
This study demonstrated that the total
functional performance score was low. The mean
subscale score was highest for the Body Care subscale,
suggesting that this was the subscale that the
participants had least difficulty with. Participants with
mild COPD had the highest median overall functional
performance, followed by those with moderate, very
severe, and severe COPD. Because of the low
functional performance found in the present study,
regular visits and assessment for patients with COPD
living in the community by their own general
practitioner, public health nurse, and COPD outreach
nurse, if available, are essential to identify the candidate
patients for home or personal care support.
Furthermore, it is important to educate patients on how
to adapt their daily activities in accordance with their
conditions. Findings from this study and previous
research revealed that poor functional performance and
palliative care needs in patients with severe and very
severe COPD seem to be very similar to patients with
cancer. Therefore, there is a need for palliative care
model for patients with advanced COPD. To the best of
the researchers’ knowledge, this is the first study
exploring functional performance in all stages of
COPD. Participants with mild, moderate, severe, and
very severe COPD have been represented in the study.
However, some limitations were recognised. The study
design was descriptive, cross-sectional and
correlational, based on a nonprobability convenience
sample consisting of patients with COPD. The cross-
sectional design used in this study did not allow the
researcher to determine whether functional performance
change over time, particularly as a disease progresses.
Therefore, future longitudinal study would be beneficial
to understand the pattern of functional performance
changes over time.
Funding
The authors did not receive any external
funding for this study.
Declaration of Interest
No potential conflict of interest was reported
by the authors.
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