The characteristics of the hemodialysis population has changed with respect to two decades ago. With the aging of the population and the technical aspects of renal replacement therapy, dialysis facilities face, the challenge of caring for patients with a progressive increase in the degree of functional dependence.1

This has implications for the structure, organization and operation of the dialysis units.2,3 Also there is an impact on patients, being a risk factor for mortality4–6 and influence decisively on issues such as interaction with the environment and the health-related quality of life (HRQL).7

Most of the studies that analyze the level of dependence of dialysis patients have focused on the basic activities of daily living (BADL),2,8–10 and only analyze the functional deficit in instrumental activities of daily life (IADL). The latter are more complex activities, with a greater requirement of personal autonomy and interaction with the environment. Deficits in IADL are observed earlier than the deficits in the BADL.4,5,9,11 The IADL include activities such as: the use the telephone, preparation of food, basic household chores (washing dishes, beds …), shopping, laundry, use of medication, use of transport and use of money.

The disability in the IADL could precede the appearance of a more important functional deficit affecting the BADL. It has been proposed that an early action aimed at helping the patient to improve their autonomy may delay the progression of the dependency.12

The objective of this study has been to determine in hemodialysis patients the prevalence of functional deficit in IADL, its relationship with functional deficit in BADL and the influence on health-related quality of life (HRQL).

The demographics of the patient population are shown in Table 1.

Eighty point three percent of the patients studied had some degree of dependence for IADL (57.5% in moderate/severe degree) (Fig. 1) and 40.8% had dependence for BADL (9% in grade moderate/severe). The IADL in which the patients showed more dependence were activities related to the house (shopping, taking care of the house, cooking, washing clothes) (Fig. 2). There was a correlation between the dependence on the BADL (the higher score the greater the dependence) at the global level (R: –0.583; p = 0.000); physical (R: –0.389; p = 0.001) and psychological (R: –0.271; p = 0.028) and the AIVD (lower score the means greater dependence) (Table 2).

Fig. 1.

Percent of patients according to the scores obtained on the Lawton and Brody scale in relation to the instrumental activities of daily life (the higher the score the more independence — maximum dependence: 0 points; total independence: 8 points —).

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Fig. 2.

Percentage of dependent patients in relation to the instrumental activities of daily life (Lawton and Brody scale).

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The time on HD, gender, the etiology of CKD and marital status do not influence the performance of the IADL or the dependence on the BADL, however age and employment status had an effect on IADL and BADL (Table 3). There were no gender differences in the dependence of the different activities except laundry (X2 : 9.4; p = 0.003) where men were more dependent.

Patients with greater dependence on IADL showed worse perception of health status HRQoL (moderate-severe dependent: 23.8 [6.5], independent or mildly dependent: 19.2 [5.4]; p = 0.004) (Fig. 3 and Table 4). The areas "daily activities" and "social activities" were the ones that showed worse scores in moderate-severe dependent patients compared to the rest.

Fig. 3.

Health-related quality of life scores in the COOP-WONCA (CW) charts according to the degree of dependence on the instrumental activities of daily life (Lawton and Brody scale).

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The patients with a greater degree of dependence on the BADL (Fig. 4 and Table 4) had significantly higher scores on the COOP-WONCA sheets than the valid patients, equivalent to a worse perception of their HRQL. The areas in which they showed the greatest differences were "daily activities", " social activities" and "social support".

Fig. 4.

Scores in health-related quality of life in COOP-WONCA charts (CW) according to the degree of dependence on basic activities of daily living (Delta test).

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The results of the present study indicate that disability in the activities required for independent living (BADL and IADL) is a highly prevalent condition in patients on hemodialysis and is associated with a reduced HRQL.

In the present study 40.8% of patients had some degree of dependence for the BADL (9% in a severe degree), a similar result to that obtained in a multicenter study conducted in our community in a larger group of patients.2 The dependence on IADL showed a higher prevalence (80%), and more than half were moderate-severe. Functional dependence for IADL has not been sufficiently evaluated in hemodialysis patients, and the few publication that have included this parameter estimate global prevalence between 19% and 59%,4,6,9,11 which is lower than reported by this study. This prevalence vary depending on the parameter analyzed and the countries, as demonstrated in the DOPPS6 study, in which the prevalence of dependent patients for some IADL in the United Kingdom was 81% and in Spain it was 62%. In our study the prevalence is higher than other studies, which may be due to several factors: 1) the specific characteristics of the population in our unit as it is a single center of a specific geographical area; 2) the collection of information was not obtained by the unit staff (nurses, nephrologists …), but by experienced personnel (occupational therapists), with greater knowledge in the area and with the ability to identify this type of deficiencies; or 3) high number, about a third, of patients were excluded, because the high complexity and time invested in completing the questionnaires, which also implies a limitation of this study when determining prevalence, since a high number of patients could not be studied.

Dependency is part of a process that begins with the initiation of a deficit in body function that, if not corrected adequately and on time, ends up in a limitation for the individual who needs the help of other people to carry out the everyday life activities. The IADL present greater complexity than BADL and require more personal autonomy and interaction with the environment, which justify its earlier appearance and the higher prevalence and severity found in our study. The detection of functional deficits in IADL with an impact on medical hygiene, nutrition, economic activity or taking medication may be important in the overall assessment for inclusion in the waiting list for renal transplantation, especially in those patients who do not have family support, and the lack of personal autonomy in these areas could even affect the viability of the graft if preventive measures are not taken.

Both types of functional dependence, IADL and BADL, showed a statistically significant association. It is possible that we are facing different gradations of the same problem. Some studies12 show that rehabilitation through education, cognitive, physical and psychosocial may prevent, reverse or delay the progression of functional impairment of IADL to BADL, so early detection of the deficit is important and its evaluation should be incorporated into the routine of standard dialysis care.

The IADL in which the patients showed more dependence were those related to home care (shopping, food preparation, household chores and laundry). This affected more than 50% of the patients (Fig. 2).

In our study, only age and labor status showed significant association with functional disability for IADL (patients with a moderate / severe degree of dependence on IADL were older and a high proportion were retired). The time in HD, gender and the etiology of CKD was not significantly associated with dependence on IADL (Table 2). It was know the association between age and disability as observed in other studies that have analyzed the problem.4,6,9,11

One could speculate that the high prevalence of disability in IADL in our population could be due to the high prevalence of men (71%), however we did not observed an association between males and functional disability. In the general population, a higher incidence of disability in IADL has been described in women with chronic diseases and greater social vulnerability, which is maintained even after controlling adverse social and clinical conditions.19 In our study the only differences in dependence between males and females was in the activity of washing clothes in which men were more dependent, and this may be related to sociocultural factors.

Although dialysis has immediate benefits, it also add stress to the patient. The onset of dialysis has been associated with a significant and sustained decrease in the functional status of patients 1 and has a strong impact on HRQL.20 In hemodialysis patient over 75 of age the HRQL has been linked to factors such as gender (worse HRQL in women), depression, cognitive impairment and the level of self — sufficiency measured by the Karnofsky scale.18,21 In the present study, HRQL is also influenced by the degree of dependence, both for BADL and for IADL, so that greater dependence is associated with worse HRQoL (Figs. 3 and 4 and Table 3).

HRQL has been defined as the subjective perception, influenced by the current state of health, of the ability to perform activities important to the individual.22 It measures how the value assigned to the duration of life is modified based on the perception of limited physical, psychological, social activities and the reduction of opportunities due to the disease, its sequelae, treatment and / or health policies.23 Therefore it is not strange to observe the great impact that functional disability has on HRQL. In this study, the areas that showed the greatest differences between dependent and non-dependent patients were "daily activities","social activities" and "social support."

The strategies to cope with the various situations and social support are aspects of maximum importance and with significant influence in the evaluation of HRQL. There is numerous evidence showing that, as the disease progresses, internal adjustments occur that preserve the person's satisfaction with life, so there are people with significant degrees of physical limitation who consider that their quality of life to be good.24

From the clinical point of view it is then possible to improve the process of adaptation to the disease, teaching strategies to handle the disease. Occupational therapists may help to plan and reinvent structures for life that were lost due to illness, disability or pain. It is important to provide the patient with the necessary tools so that with a new behavior and attitude they can restructure and regain control over their life and restore hope, competence, confidence and success as part of daily activities.25 Occupational therapy has been widely applied as a complementary intervention in different areas of medicine, especially in chronic diseases such as mental illnesses and neurological disorders. However, there is very little research aimed at assessing its effectiveness in dialysis patients. Some studies show a positive impact of occupational therapy programs on HRQL in dialysis patients, especially in the control of pain.26 The longer term benefits should be investigated in large number of patients.

The limitations of the study include the small number of patients evaluated. The study did not include all patients of our dialysis unit. It was a cross-sectional design and in a single center. But, we consider that these limitation are somewhat compensated by the strength of being the first study in our country studying the dependence on IADL in hemodialysis patients and the fact that the tests have been performed by occupational therapists skilled in the field. Also, our study was performed using the Lawton and Brody scale, which is widely used and it had to be validated for this purpose; though this scale is based on patient responses and not on objective tests and, the items measured may have cultural, environmental or gender influences that may affect the result.

In conclusion, hemodialysis patients have more dependence and with a greater degree of severity to the IADL than to BADL. The level of dependence in both types of activities has an important influence on HRQOL. Early detection of disability to perform IADL should be followed by implementation of programs that help to prevent, reverse or delay the progression of such functional impairment. This strategy may avoid that other spheres of the individual's life became affected.

The authors declare that they have no conflicts of interest for this article.

Our thanks to all the patients who have collaborated in the study.