Chronic obstructive pulmonary disease and association with mild cognitive impairment: the Mayo Clinic Study of Aging

Increased exploration and hyperlocomotion in a cigarette smoke and LPS-induced murine model of COPD: linking pulmonary and systemic inflammation with the brain

Brain-related comorbidities are frequently observed in chronic obstructive pulmonary disease (COPD) and are related to increased disease progression and mortality. To date, it is unclear which mechanisms are involved in the development of brain-related problems in COPD. In this study, a cigarette smoke and lipopolysaccharide (LPS) exposure murine model was used to induce COPD-like features and assess the impact on brain and behavior. Mice were daily exposed to cigarette smoke for 72 days, except for days 42, 52, and 62, on which mice were intratracheally exposed to the bacterial trigger LPS. Emphysema and pulmonary inflammation as well as behavior and brain pathology were assessed. Cigarette smoke-exposed mice showed increased alveolar enlargement and numbers of macrophages and neutrophils in bronchoalveolar lavage. Cigarette smoke exposure resulted in lower body weight, which was accompanied by lower serum leptin levels, more time spent in the inner zone of the open field, and decreased claudin-5 and occludin protein expression levels in brain microvessels. Combined cigarette smoke and LPS exposure resulted in increased locomotion and elevated microglial activation in the hippocampus of the brain. These novel findings show that systemic inflammation observed after combined cigarette smoke and LPS exposure in this COPD model is associated with increased exploratory behavior. Findings suggest that neuroinflammation is present in the brain area involved in cognitive functioning and that blood-brain barrier integrity is compromised. These findings can contribute to our knowledge about possible processes involved in brain-related comorbidities in COPD, which is valuable for optimizing and developing therapy strategies.

Association of chronic obstructive pulmonary disease with mild cognitive impairment and dementia risk: A systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common public health issue that has been linked to cognitive dysfunction.

AIM

To investigate the relationship between COPD and a risk of mild cognitive impairment (MCI) and dementia.

METHODS

A comprehensive literature search of the PubMed, Embase, Google Scholar, and Cochrane Library electronic databases was conducted. Pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CIs) were calculated using a random or fixed effects model. Studies that met the inclusion criteria were assessed for quality using the Newcastle Ottawa Scale.

RESULTS

Twenty-seven studies met all the inclusion criteria. Meta-analysis yielded a strong association between COPD and increased risk of MCI incidence (OR = 2.11, 95%CI: 1.32-3.38). It also revealed a borderline trend for an increased dementia risk in COPD patients (OR = 1.16, 95%CI: 0.98-1.37). Pooled hazard ratios (HR) using adjusted confounders also showed a higher incidence of MCI (HR = 1.22, 95%CI: -1.18 to -1.27) and dementia (HR = 1.32, 95%CI: -1.22 to -1.43) in COPD patients. A significant lower mini-mental state examination score in COPD patients was noted (MD = -1.68, 95%CI: -2.66 to -0.71).

CONCLUSION

Our findings revealed an elevated risk for the occurrence of MCI and dementia in COPD patients. Proper clinical management and attention are required to prevent and control MCI and dementia incidence in COPD patients.

Respiratory Muscle Training Can Improve Cognition, Lung Function, and Diaphragmatic Thickness Fraction in Male and Non-Obese Patients with Chronic Obstructive Pulmonary Disease: A Prospective Study

Patients with chronic obstructive pulmonary disease (COPD) are frequently comorbid with mild cognitive impairment (MCI). Whether respiratory muscle training (RMT) is helpful for patients with COPD comorbid MCI remains unclear. Inspiratory muscle training (IMT) with or without expiratory muscle training (EMT) was performed. Patients were randomly assigned to the full training group (EMT + IMT) or the simple training group (IMT only). A total of 49 patients completed the eight-week course of RMT training. RMT significantly improved the maximal inspiratory pressure (MIP), the diaphragmatic thickness fraction and excursion, lung function, scores in the COPD assessment test (CAT), modified Medical Research Council (mMRC) scale scores, and MMSE. The between-group difference in the full training and single training group was not significant. Subgroup analysis classified by the forced expiratory volume in one second (FEV1) level of patients showed no significant differences in MIP, lung function, cognitive function, and walking distance. However, a significant increase in diaphragmatic thickness was found in patients with FEV1 ≥ 30%. We suggest that patients with COPD should start RMT earlier in their disease course to improve physical activity.

The relationship between cognitive function and competence in inhaler technique in older adults with airway disease

Cognitive impairment has high prevalence in older adults with airway diseases, and may influence their competence in inhaler use, thereby negatively affecting patient prognosis. We aimed to evaluate the relationship between cognitive function and competence in inhaler technique. We enrolled 108 inhaler naïve older adults (≥60 years) with airway disease in this prospective observational study and performed the Korean version of the Mini-Mental State Examination (K-MMSE). After explaining the inhaler technique, we scored its competence. While the total K-MMSE score was unrelated to the inhaler score, the orientation for place (estimates=0.62, p = 0.009), registration (estimates=0.988, p = 0.037), and recall (estimates=0.161, p = 0.048) were positively associated with the score. Low K-MMSE scores were associated with lower odds ratio for the competence of the "exhale" step (adjusted odds ratio= 0.23, p = 0.018). Thus, a K-MMSE-mediated evaluation of cognitive function in older adults with airway disease can be a useful tool to predict inhaler competence.

Severe obstructive sleep apnea in patients with chronic obstructive pulmonary disease is associated with an increased prevalence of mild cognitive impairment

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are associated with mild cognitive impairment (MCI). However, this association is unclear. This study aimed to assess the prevalence of MCI in patients with overlap syndrome, determine whether OSA increases the risk of MCI in patients with COPD, and investigate the potential mechanisms for this association.

METHODS

Participants with stable Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2-4 COPD and complaints of snoring in 2016-2018 were enrolled in this cross-sectional observational study. All were free of asthma, acute left-sided congestive heart failure, unstable coronary heart disease, uncontrolled hypertension, diabetes, encephalitis, and epilepsy. They underwent pulmonary function tests and overnight polysomnography and completed the Montreal Cognitive Assessment (MoCA). MCI was defined by an MoCA score of <23, while OSA was defined by an apnea-hypopnea index (AHI) of ≥15 per hour. The association between MCI, demographics, and comorbidities was tested by logistic regression analysis with adjustment for confounders. Sleep-disordered breathing measures were investigated as potential mechanisms underlying this relationship.

RESULTS

MCI was significantly more common in patients with overlap syndrome than in those with COPD (40.6% [43/106] vs 24.6% [42/171]). After adjustment, severe OSA was an independent contributor to MCI (odds ratio, OR 2.27; 95% confidence interval, CI 1.12-4.62). Increased percent of night-time spent with oxygen saturation <90% (TSat₉₀) was associated with increased odds of MCI (odds ratio 4.75, 95% CI 2.73-11.13).

CONCLUSIONS

MCI is more prevalent in overlap syndrome than in COPD. OSA may contribute to MCI in COPD. The mechanism may involve TSat₉₀.

From Mild Cognitive Impairment (MCI) to Dementia in Chronic Obstructive Pulmonary Disease. Implications for Clinical Practice and Disease Management: A Mini-Review

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease characterized by partially irreversible chronic airflow limitation. Current literature highlights that COPD patients also have an increased risk to develop Mild Cognitive Impairment (MCI) and dementia. Chronic patients with cognitive impairment experience a worsening of health-related quality of life, mainly because it could affect treatment self-management, medication adherence and personal independence. Moreover, they also report high levels of anxiety and depression, which are associated with disease severity, poor quality of life, poor adherence to rehabilitation programs and difficulties in self-management. In current literature, there is a lack of studies describing simultaneously the associations between cognitive impairment, dysfunctional psychosocial factors, self-management abilities and their impact on pharmacological/non-pharmacological adherence. Therefore, the aim of the present short review is to describe the implications of cognitive impairment and psychosocial factors for clinical practice and disease management in COPD patients. Due to the interaction of these factors on adherence to rehabilitation programs, self-management and rehabilitation completion, future research should investigate simultaneously the role of all these different aspects to individuate a specific clinical approach that might include specific screening tools to evaluate cognitive impairment and psychosocial difficulties. A timely specific evaluation, within an interdisciplinary approach, could help to implement a more individualized and personalized treatment.

Influenza vaccination reduces dementia in patients with chronic obstructive pulmonary disease: a nationwide cohort study

This study aimed to explore the protective potential of influenza vaccination against occurrence of dementia in patients with chronic obstructive pulmonary disease (COPD), who are expected to be more vulnerable to influenza infection. This nationwide retrospective cohort study enrolled patients with COPD (aged ≥60 years) from 1 January 2001 to 31 December 2012 by using the Taiwan National Health Insurance Research Database. By applying time-dependent Cox proportional hazard model, we used multivariate analysis to calculate the adjusted HR (aHR) with 95% CI of dementia in relation to influenza vaccination among patients with COPD. Besides, patients were partitioned into four groups according to the vaccination number (unvaccinated, 1, 2-3 and ≥4 total vaccinations) to investigate the dose-response effect of vaccinations on the dementia incidence. This cohort study included 19 848 patients with COPD, and 45% of them received influenza vaccination. The aHR of dementia was 0.68 (95% CI: 0.62 to 0.74, p<0.001) comparing vaccinated patients with unvaccinated ones. Furthermore, there was a trend of dementia risk reduction with the vaccination number. For patients who received 2-3 vaccinations, the aHR was 0.81 (95% CI: 0.73 to 0.90), and for those received 4 vaccinations, the aHR was 0.44 (95% CI: 0.40 to 0.50), with p for trend <0.001. In conclusion, annual influenza vaccination can reduce the risk of dementia in patient with COPD in a dose-dependent manner.

Adenosine A2A receptor deficiency prevents p38MAPK activation and apoptosis of mouse hippocampal cells in the chronic hypoxic-hypercapnia model

This study aims to study the effects of adenosine A2A receptor (A2AR) on hippocampal cell apoptosis and the putative mechanisms in a mouse model of chronic hypoxic-hypercapnia. Wild-type (WT) or A2AR knockout (A2AR KO) mice were randomly divided into normal control (NC) groups and chronic hypoxic-hypercapnia (4HH) groups. Compared with their corresponding NC groups (WT-NC and KO-NC), the apoptosis index (AI), caspase-3 activity, Bax mRNA and P-p38 protein expression in the hippocampus of 4HH groups (WT-4HH and KO-4HH) were significantly increased, while Bcl2 mRNA expression was significantly decreased (P &lt; 0.05). Moreover, A2AR deficiency significantly rescued the effect of chronic hypoxic-hypercapnia on apoptosis when compared with the WT-4HH group (P &lt; 0.05). A2AR deficiency inhibits hippocampal cell apoptosis in mice exposed to chronic hypoxic-hypercapnia, which might be associated with dampened p38 MAPK activation and Bax mRNA expression, and augmented Bcl-2 mRNA expression.

Utility of FEV1/FEV6 index in patients with multimorbidity hospitalized for decompensation of chronic diseases

Spirometry remains essential for the diagnosis of airway obstruction. Nevertheless, its performance in elderly hospitalized patients with multimorbidity can be difficult. The aim of this study is to assess the utility of the COPD-6 portable device in this population. We included all patients hospitalized for exacerbation of chronic diseases in a medical ward specialized in the care of multimorbidity patients, between September 2017 and May 2018. A questionnaire including sociodemographic, cognitive and functional impairment, among other variables, was completed the last day of admission. Subsequently, patients attempted to perform three valid respiratory manoeuvres with the COPD-6 device and then conventional spirometry. A total of 184 patients were included (mean age of 79.61 years, 55% men). Forty-seven (25.54%) patients were able to perform complete spirometric manoeuvres and 99 (53.8%) could perform a valid FEV1/FEV6 determination. The inability to perform a valid spirometry was related with the patient’s age, functional physical disability, cognitive impairment or the presence of delirium or dysphagia during admission. Only 9% of patients with a Mini Mental Cognitive Examination (MMEC) lower than 24 points could perform a valid spirometry. Of the patients with an MMEC < 24 points and unable to perform spirometry, 34% were able to complete the FEV1/FEV6 manoeuvres. No differences were found in the Charlson index, multimorbidity scale, number of domiciliary drugs, or length of stay between those patients able and those not able to perform respiratory manoeuvres. The agreement between the values for FEV1 measured with COPD-6 and those observed in the spirometry was good (r: 0.71; p<0.0001). Inability to perform a valid spirometry during hospitalization in elderly patients with multimorbidity is frequent and related with functional and cognitive impairment. FEV1/FEV6 determination using the COPD-6 portable device allows an important percentage of the patients with limitations to complete spirometric measurement.

Altered amplitude of low-frequency fluctuation in basal ganglia correlates to pulmonary ventilation function in COPD patients: A resting-state fMRI study

INTRODUCTION

Patients under chronic obstructive pulmonary disease (COPD) has been reported to be associated with a higher prevalence of cognitive impairment (CI). However, it is still largely unknown whether the aberrant resting-state spontaneous neuronal activity pattern reflected by the amplitude of low-frequency fluctuation (ALFF) analysis will be associated with the CI in COPD patients.

MATERIALS

A total of 28 COPD patients and 26 healthy controls were enrolled in this study. Of all the subjects, structural and functional MRI data, spirometry tests performance and neuropsychological assessments of different cognitive domains were collected. Voxel-based two-sample t tests were used to detect brain regions showing differences in the ALFF value between COPD patients and healthy controls. An additional fMRI runs with supplementary oxygen delivery were employed to explore the impact of elevated partial pressure of oxygen (PaO₂ ) or moderate hyperoxia on ALFF in COPD patients and healthy controls respectively.

RESULTS

More extensive white matter lesion was detected in COPD patients. COPD patients exhibit decreased ALFF value in bilateral basal ganglia areas and right thalamus, and aberrant ALFF value is correlated with PaO₂ and pulmonary ventilation function (FEV1%pred). COPD patients performed worse in the Digit Span Test (reverse), Digit Symbol Substitution Test, Trail-making test (A and B) than controls. After supplementary oxygen inhalation, the ALFF value of basal ganglia and right thalamus significantly increased in the controls, but not in the COPD patients.

CONCLUSIONS

COPD patients mainly exhibit impaired executive function but not long-term memory in cognitive function assessment. Aberrant ALFF alteration in the deep brain may be directly related to lower PaO₂ in COPD patients.

Evaluation and Interpretation of Transcriptome Data Underlying Heterogeneous Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease, featured by airflow obstruction. Recently, a comprehensive analysis of the transcriptome in lung tissue of COPD patients was performed, but the heterogeneity of the sample was not seriously considered in characterizing the mechanistic dysregulation of COPD. Here, we established a new transcriptome analysis pipeline using a deconvolution process to reduce the heterogeneity and clearly identified that these transcriptome data originated from the mild or moderate stage of COPD patients. Differentially expressed or co-expressed genes in the protein interaction subnetworks were linked with mitochondrial dysfunction and the immune response, as expected. Computational protein localization prediction revealed that 19 proteins showing changes in subcellular localization were mostly related to mitochondria, suggesting that mislocalization of mitochondria-targeting proteins plays an important role in COPD pathology. Our extensive evaluation of COPD transcriptome data could provide guidelines for analyzing heterogeneous gene expression profiles and classifying potential candidate genes that are responsible for the pathogenesis of COPD.

Association of chronic obstructive pulmonary disease with mild cognitive impairment and dementia

PURPOSE OF REVIEW

As age expectancy increases, both dementia and chronic obstructive pulmonary disease (COPD) have become more prevalent. Dementia and COPD together, however, occur more commonly than would be predicted from the incidence of either alone, suggesting a link between these two common senescent diseases. The purpose of this article is to review the extant literature and report findings in a clinically meaningful manner. We will look at the level of evidence, the risk factors for co-occurrence of the two diseases and the differential effects upon cognitive domains in the population with dementia and COPD.

RECENT FINDINGS

Cognitive impairment in patients with COPD may be 'dose-dependent' with the duration of COPD. Patients with COPD appear to develop nonamnestic mild cognitive impairment (MCI) as opposed to amnestic MCI. Newer studies exploring the impact of oxygen therapy and pulmonary rehabilitation upon cognitive function have reported some positive findings.

SUMMARY

Higher prevalence of MCI/dementia is seen in patients with COPD compared with age-matched controls. Imaging findings and dementia/MCI biomarkers provide preliminary evidence for an indirect association of the two conditions. Although no causality can be drawn with the available data, there is some indication that the severity of hypoxemia correlates with the severity of cognitive dysfunction.

Assessment of Cognitive Impairment in Patients with Chronic Obstructive Pulmonary Disease Using the Rapid Cognitive Screen

OBJECTIVES

To determine the prevalence of cognitive impairment in chronic obstructive pulmonary disease (COPD) patients using the Rapid Cognitive Screen (RCS).

DESIGN

Cross sectional study.

PARTICIPANTS

A total of 106 men and women with COPD 50 years of age or older.

SETTING

Pulmonary ambulatory clinic in a tertiary academic center in St. Louis, Missouri, USA.

MEASUREMENTS

We enrolled patients with COPD who completed the RCS tool. Patients were classified as having normal cognition, mild cognitive impairment (MCI), or dementia if they scored ≥ 8, 6-7, or ≤ 5, respectively. The prevalence of each category was measured, and patients' baseline characteristics were compared.

RESULTS

One hundred and six patients completed the RCS. Of those, 36 (33.9%) patients scored ≤ 5 on the RCS, 33 (31.1%) scored 6 or 7, and 37 (34.9%) scored ≥ 8. The prevalence of dementia, MCI, and normal cognition were 33.9%, 31.1%, and 34.9%, respectively. Baseline lung function was not different between patients with normal cognition and those with abnormal cognition (FEV1 1.53 ± 0.39 vs 1.45 ± 0.32 L). In patients with abnormal cognition, there was no difference in patients' characteristics between patients with MCI or dementia.

CONCLUSION

Cognitive impairment is highly prevalent in patients with COPD. RCS successfully identified cognitive impairment in COPD. We recommend performing RCS in patients with COPD routinely.

Chronic Obstructive Pulmonary Disease and Risk of Dementia and Mortality in Lower to Middle Income Countries

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major disease burden which accounts for 5% of all deaths globally, with most of those (>90%) occurring in lower to middle income countries (LMIC). It is also emerging as an important modifiable dementia risk factor.

OBJECTIVE

To address the knowledge gap surrounding the nature of the associations between COPD, dementia, and mortality, and the geographical variation of those associations in LMIC.

METHODS

Data from the 10/66 study surveying 15,394 participants (mean age 74 years, 62% female) across 8 countries was used to estimate the prevalence of self-reported COPD and its association with incident dementia and premature death. Proportional sub-hazards models using a cumulative incidence function were applied to identify the probability of incident dementia onset given the risk of premature death, with estimates pooled across countries via random effect meta-analysis.

RESULTS

Over the 3-year follow-up, almost 10% of participants developed dementia and 14% were deceased. COPD was not significantly associated with dementia incidence except in Cuba. However, fully adjusted models indicated that individuals with COPD were at a 28% increased risk of premature death, a trend present across most countries when analyzed individually.

CONCLUSION

The link between COPD and dementia is currently somewhat different and weaker in LMIC than in developed countries. This may be because premature death in the populations studied mask the development of clinical dementia. Given the global trend toward increased life expectancy, it is critical that the disease burden associated with COPD be addressed without delay if a further rise in dementia prevalence associated with COPD is to be avoided in LMIC.

Cognitive Impairment in Chronic Obstructive Pulmonary Disease (COPD): Possible Utility of Marine Bioactive Compounds

Chronic obstructive pulmonary disease (COPD) is characterized by long-term airflow limitation. Early-onset COPD in non-smoker subjects is ≥60 years and in the elderly is often associated with different comorbidities. Cognitive impairment is one of the most common feature in patients with COPD, and is associated with COPD severity and comorbidities. Cognitive impairment in COPD enhances the assistance requirement in different aspects of daily living, treatment adherence, and effectual self-management.This review describes various bioactive compounds of natural marine sources that modulate different targets shared by both COPD and cognitive impairment and hypothesizes a possible link between these two syndromes.

Screening for neuropsychological impairment in COPD patients undergoing rehabilitation

Introduction

Chronic obstructive pulmonary disease (COPD) is a complex multi-component disorder characterized by progressive irreversible respiratory symptoms and extrapulmonary comorbidities, including anxiety-depression and mild cognitive impairment (MCI). However, the prevalence of these impairments is still uncertain, due to non-optimal screening methods. This observational cross-sectional multicentre study aimed to evaluate the prevalence of anxiety-depressive symptoms and MCI in COPD patients, identify the most appropriate cognitive tests to screen MCI, and investigate specific cognitive deficits in these patients and possible predictive factors.

Materials and methods

Sixty-five stable COPD inpatients (n = 65, aged 69.9±7.6 years, mainly stage III–IV GOLD) underwent the following assessments: Hospital Anxiety and Depression Scale (HADS), Geriatric Depression Scale (GDS) or Beck Depression Inventory-II (BDI-II), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and a complete neuropsychological battery (ENB-2) including different cognitive domains (attention, memory, executive functions, and perceptive and praxis abilities).

Results

Moderate-severe anxiety was present in 18.5% of patients and depressive symptoms in 30.7%. The prevalence of MCI varied according to the test: 6.2% (MMSE), 18.5% (MoCA) and 50.8% (ENB-2). In ENB-2, patients performed significantly worse compared to Italian normative data on digit span (5.11±0.9 vs. 5.52±1.0, p = 0.0004), trail making test-B (TMT-B) (176.31±99.5 vs. 135.93±58.0, p = 0.004), overlapping pictures (26.03±8.9 vs. 28.75±8.2, p = 0.018) and copy drawing (1.370.6 vs. 1.61±0.5, p = 0.002). At logistic regression analysis, only COPD severity (p = 0.012, odds ratio, OR, 4.4 [95% CI: 1.4–14.0]) and anxiety symptoms (p = 0.026, OR 4.6 [1.2–17.7]) were significant and independent predictors of the deficit in copy drawing, which assesses visuospatial and praxis skills.

Conclusion

Given the prevalence of neuropsychological impairments in COPD patients, the routine adoption in rehabilitation of screening tools for mood and cognitive function, including digit span, TMT-B and copy drawing, may be useful to detect psychosocial comorbidities and personalize the rehabilitative program.

Cerebral oxygen availability during exercise in COPD patients with cognitive impairment

Insufficient cerebral blood flow regulation to meet increasing metabolic demand during physical exertion could be associated with cognitive impairment. We compared cerebral oxygen availability during exercise in cognitively impaired (CI) to cognitively normal (CN) COPD patients. Fifty-two patients (FEV₁: 51 ± 16%) were classified as CN or CI according to the Montreal Cognitive Assessment. Patients performed cycle-ergometry at 75% peak capacity with continuous measurement of Near-Infrared Spectroscopy frontal-cortex Tissue oxygen Saturation Index (TSI), cerebral haemoglobin indices (oxy/deoxy/total- Hb), transcutaneous carbon-dioxide partial pressure (TcPCO₂), and arterial oxygen saturation (SpO₂). Twenty-one patients (40%) presented evidences of CI. During exercise, CN and CI patients exhibited mild to moderate SpO₂decline (nadir[Δ]≥ -3 ± 2% and -5 ± 3%, respectively) but preserved baseline frontal-cortex TSI levels, whilst presenting small TcPCO₂ perturbations and increased cerebral total-Hb (post [Δ]≥ 2.0 ± 3 μM sec^-1). CI patients preserve the capacity to adequately maintain cerebral oxygen availability during submaximal exercise. Therefore, rehabilitative exercise training in CI patients with COPD exhibiting mild to moderate exercise-induced SpO₂ decline does not appear to lead to reduced cerebral oxygen availability.

Chronic Physical Conditions, Multimorbidity, and Mild Cognitive Impairment in Low- and Middle-Income Countries

OBJECTIVES

To assess the association between chronic physical conditions and multimorbidity and mild cognitive impairment (MCI) in low- and middle-income countries (LMICs).

DESIGN

Nationally representative, cross-sectional, community-based study.

SETTING

Six countries that participated in the World Health Organization Study on Global Ageing and Adult Health.

PARTICIPANTS

Individuals aged 50 and older (N=32,715; mean age 62.1 ± 15.6; 51.7% female).

MEASUREMENTS

The definition of MCI was based on the recommendations of the National Institute on Ageing and Alzheimer's Association. Ten chronic conditions were assessed (angina pectoris, arthritis, asthma, cataract, chronic lung disease, diabetes mellitus, edentulism, hearing problems, hypertension, stroke). Multivariable logistic regression analysis was conducted to assess the association between chronic physical conditions, multimorbidity (≥2 chronic conditions), and MCI.

RESULTS

The prevalence of multimorbidity was 49.8% (95% confidence interval (CI)=48.1-51.5%) and of MCI was 15.3% (95% CI=14.4-16.3%). After adjustment for potential confounders, edentulism (odds ratio (OR)=1.24), arthritis (OR=1.24), chronic lung disease (OR=1.29), cataract (OR=1.33), stroke (OR=1.94), hearing problems (OR=2.27), and multimorbidity (OR=1.40) were significantly associated with MCI. There was a gradual increase in the likelihood of MCI (1 condition: OR=1.21, 95% CI=1.03-1.42; ≥4 conditions: OR=2.07, 95% CI=1.70-2.52).

CONCLUSION

These results highlight the need to investigate the underlying mechanisms linking chronic conditions and MCI and whether prevention or treatment of chronic conditions or multimorbidity can reduce the onset of cognitive decline and subsequent dementia, especially in LMICs.

Airflow obstruction, cognitive function and mortality in a US national cohort: NHANES-III

OBJECTIVE

To test the hypothesis that cognitive impairment increases mortality independent of airflow obstruction.

MATERIALS AND METHODS

In 1988-1994 the Third National Health and Nutrition Examination Survey (NHANES III) measured forced expiratory volume in the first second (FEV1) and the forced vital capacity (FVC) and selected items on cognitive function with mortality follow-up. For this survival analysis 4365 persons aged 60 and over with complete data formed the analytic sample.

RESULTS

The FEV1/FVC less than the lower limit of predicted ratio (LLP) defined airflow obstruction and Composite Cognitive Function Score (CCF) ≤4, cognitive impairment. The percentage who died during follow up was 67% among those with neither FEV1/FVC < LLP nor CCF ≤4, 82% with FEV1/FVC < LLP only, 85% with CCF score ≤4 only and 93% with both FEV1/FVC LLP and CCF score ≤4 (P < .001). Weighted Cox proportional hazards regression revealed an increased hazard ratio (HR) in persons with FEV1/FVC <LLP only and in persons with CCF ≤4 only, respectively, compared with persons with neither. FEV1/FVC ratio < LLP remained a significant predictor of mortality with an interaction between FEV1/FVC ratio < LLP and CCF ≤4 (P = .051).

CONCLUSION

Elderly persons with either airflow obstruction or cognitive impairment or both had increased all-cause mortality when compared to those with neither after adjusting for confounders. However, cognitive impairment was not a predictor of increased mortality independent of airflow obstruction.

Abnormal intrinsic brain activities in stable patients with COPD: a resting-state functional MRI study

OBJECTIVE

The majority of previous neuroimaging studies have reported both structural and functional changes in COPD, whereas the intrinsic low-frequency oscillations changes and the relationship between the abnormal brain regions and the clinical performances remain unknown. The present study was conducted with the aim of evaluating the intrinsic brain activity in COPD patients using the amplitude of low-frequency fluctuation (ALFF) method.

METHODS

All participants, including 19 stable patients with COPD and 20 normal controls (NCs) matched in age, sex, and education, underwent resting-state functional MRI scans and performed cognitive function tests and respiratory functions tests. The local spontaneous brain activity was examined using the voxel-wise ALFF. Pearson's correlation analysis was used to investigate the relationships between the brain regions with altered ALFF signal values and the clinical features in COPD patients.

RESULTS

Compared with the NCs, COPD patients showed significantly lower cognitive function scores. Also, lower ALFF areas in the cluster of the posterior cingulate cortex (PCC) and precuneus, as well as a higher ALFF area in the brainstem were also found in COPD patients. The mean ALFF values in the PCC, precuneus, and brainstem showed high sensitivity and specificity in operating characteristic curves analysis, which might have the ability to distinguish COPD from NCs. Meanwhile, the mean signal values of the lower ALFF cluster displayed significant positive correlations with FEV₁/FVC proportion and significant negative correlation with PaCO₂; the higher ALFF cluster showed significant positive correlation with FEV₁ proportion in COPD.

CONCLUSION

According to the results of the present study, the COPD patients showed abnormal intrinsic brain activities in the precuneus, PCC, and brainstem, which might provide useful information to better understand the underlying pathophysiology of cognitive impairment.

Physical chronic conditions, multimorbidity and sedentary behavior amongst middle-aged and older adults in six low- and middle-income countries

Background

Sedentary behavior (SB) is, irrespective of a person’s physical activity levels, associated with a wide range of deleterious outcomes such as diabetes, stroke and associated premature mortality. There are no nationally representative, multi-national, population-based studies investigating the relationship between SB, chronic conditions, and physical multimorbidity (i.e., two or more chronic physical conditions). Thus, this cross-sectional study aimed to assess the association between chronic conditions, physical multimorbidity and SB among community-dwelling adults in six low- and middle-income countries (LMICs). We also explored the influential factors of these relationships.

Method

The Study on Global Ageing and Adult Health (SAGE) survey included 34,129 adults aged ≥50 years. SB was self-reported and expressed as a categorical variable [<8 or ≥8 h per day (high SB)]. Eleven chronic physical conditions (angina, arthritis, asthma, chronic back pain, chronic lung disease, diabetes, edentulism, hearing problems, hypertension, stroke, visual impairment) were assessed. Multivariable logistic regression and mediation analyses were conducted.

Results

The prevalence of physical multimorbidity and high SB (≥8 h/day) were 45.5% (43.7%–47.4%) and 10.8% (9.7%–12.1%), respectively. The prevalence of high SB increased in a linear fashion from 7.1% in people with no chronic condition to 24.1% in those with ≥4 chronic conditions. In the multivariable analysis, visual impairment (OR = 2.62), stroke (OR = 2.02), chronic back pain (OR = 1.70) hearing problems (OR = 1.58), chronic lung disease (OR = 1.48), asthma (OR = 1.39), arthritis (OR = 1.22) and multimorbidity (OR = 1.41) were significantly associated with high SB. Disability explained more than 50% of the association for all chronic conditions with particularly high percentages (>80%) for arthritis, asthma, and multimorbdity. Mobility problems explained 88.1% and 85.1% of the association of SB with arthritis and physical multimorbidiy, respectively. Pain was highly influential in the SB-arthritis relationship (85.6%). Sleep/energy problems explained between 9.3% (stroke) to 49.1% (arthritis) of the association, and cognitive problems from 21.5% (stroke) to 33.4% (hearing problems). Findings for anxiety and depression were mixed.

Conclusion

In LMICs, those with chronic conditions and physical multimorbidity are significantly more sedentary. Targeted messages to reduce time spent sedentary among individuals with chronic conditions may ameliorate associated disability, mobility difficulties and pain that are themselves the most important risk factors for SB.

Electronic supplementary material

The online version of this article (10.1186/s12966-017-0602-z) contains supplementary material, which is available to authorized users.

Aging and extrapulmonary effects of chronic obstructive pulmonary disease

INTRODUCTION

People with COPD have a decline in functional status, but little is known about the rate of decline and factors that contribute. Of particular concern is the decline in cognitive and functional performance. Decrease in cognitive and functional performance will finally lead to decreased health status, sedentary life style and premature frailty.

AIM

The aim of this study is to compare functional performance and cognitive status in patients with COPD of different ages and to examine the changes in extrapulmonary effects.

PATIENTS AND METHODS

This study included 62 patients with COPD risk class D who were divided into two groups (<70 years, N=30 and >70 years, N=32). Patients first completed the Montreal Cognitive Assessment (MoCA), which is a 30-point test that assesses different cognitive domains, while isometric knee extension (IKE) was measured using a digital handheld dynamometer, and functional exercise level was assessed using the 6-minute walking distance (6MWD) test.

RESULTS

The patients' older age (age higher than 70 years) was associated with a significantly lower body mass index (BMI, 27.50 vs 24.24 kg/m²; P=0.020), higher vital capacity parameters, forced vital capacity (FVC, 2.74 vs 2.82 L; P=0.799), FVC (%) (73.00 vs 66.50, P=132), forced expiratory volume in the first second (FEV₁, 0.93 vs 1.13 L; P=0.001) and FEV₁ (%) (28.50 vs 30.50, P=0.605). In addition, patients at older age presented a significantly reduced physical activity capacity, 6MWD (385.93 vs 320.84 m, P<0.001) and IKE (24.75 vs 22.55 kgf, P=0.005), as well as higher values for inflammatory biomarkers, C-reactive protein (8.77 vs 3.34 mg/L, P=0.022). Moreover, patients at older age presented significantly lower score at the cognitive assessment, MoCA (23.50 vs 20.00, P<0.001).

CONCLUSION

Elderly COPD patients have reduced exercise capacity and muscle strength, deteriorated cognitive function and increased inflammatory markers. Furthermore, inflammation markers were significantly correlated with muscle strength, walking distance and cognitive impairment.

Cognitive impairment and clinical characteristics in patients with chronic obstructive pulmonary disease

We aimed to investigate (1) the relationship between cognitive impairment (CI) and disease severity and (2) the potential differences in exercise performance, daily activities, health status, and psychological well-being between patients with and without CI. Clinically stable chronic obstructive pulmonary disease (COPD) patients, referred for pulmonary rehabilitation, underwent a neuropsychological examination. Functional exercise capacity (6-minute walk test [6MWT]), daily activities (Canadian Occupational Performance Measure [COPM]), health status (COPD Assessment Test [CAT]) and St George’s Respiratory Questionnaire-COPD specific [SGRQ-C]), and psychological well-being (Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory [BDI], and Symptom Checklist 90 [SCL-90]) were compared between patients with and without CI. Of 183 COPD patients (mean age 63.6 (9.4) years, FEV₁ 54.8 (23.0%) predicted), 76 (41.5%) patients had CI. The prevalence was comparable across Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 1–4 (44.8%, 40.0%, 41.0%, 43.5%, respectively, p = 0.97) and GOLD groups A–D (50.0%, 44.7%, 33.3%, 40.2%, respectively, p = 0.91). Patients with and without CI were comparable for demographics, smoking status, FEV₁% predicted, mMRC, 6MWT, COPM, CAT, HADS, BDI, and SCL-90 scores. Clinical characteristics of COPD patients with and without CI are comparable. Assessment of CI in COPD, thus, requires an active case-finding approach.

The Relationship between Cerebral Small Vessel Disease, Hippocampal Volume and Cognitive Functioning in Patients with COPD: An MRI Study

The neural correlates of cognitive impairment in chronic obstructive pulmonary disease (COPD) are not yet understood. Structural brain abnormalities could possibly be associated with the presence of cognitive impairment through cigarette smoke, inflammation, vascular disease, or hypoxemia in these patients. This study aimed to investigate whether macrostructural brain magnetic resonance imaging (MRI) features of cerebral small vessel disease (SVD) and hippocampal volume (HCV) are related to cognitive performance in patients with COPD. A subgroup of cognitively high and low-performing COPD patients of the COgnitive-PD study, underwent a brain 3T MRI. SVD as a marker of vascular damage was assessed using qualitative visual rating scales. HCV as a marker of neurodegeneration was assessed using the learning embedding for atlas propagation (LEAP) method. Features of SVD and HCV were compared between cognitively high and low-performing individuals using Mann Whitney U tests and independent samples t-tests, respectively. No group differences were reported between 25 high-performing (mean age 60.3 (standard deviation [SD] 9.7) years; 40.0% men; forced expiratory volume in first second [FEV₁] 50.1% predicted) and 30 low-performing patients with COPD (mean age 60.6 (SD 6.8) years; 53.3% men; FEV₁ 55.6% predicted) regarding demographics, clinical characteristics, comorbidities and the presence of the SVD features and HCV. To conclude, the current study does not provide evidence for a relationship between cerebral SVD and HCV and cognitive functioning in patients with COPD. Additional studies will be needed to determine other possible mechanisms of cognitive impairment in patients with COPD, including microstructural brain changes and inflammatory-, hormonal-, metabolic- and (epi)genetic factors.

One-year and long-term mortality in patients hospitalized for chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Identifying potentially-modifiable predictors of mortality could help optimize COPD patient management. The aim of this study is to determine long-term mortality following hospitalization due to acute exacerbations of COPD (AECOPD), as well as AECOPD mortality predictors.

METHODS

We conducted a retrospective study by reviewing the medical records of all patients admitted with AECOPD in the University Hospital Complex of Santiago de Compostela in 2007 and 2008. In order to identify variables independently associated with mortality, we conducted a multivariate Cox proportional hazard regression analysis including those variables which proved to be significant in the univariate analysis.

RESULTS

Seven hundred and fifty seven patients were assessed. Patient mean age was 74.8 years and males accounted for 77% of all patients. Mean stay was 12.2 days. Three point six percent of all patients required intensive care. As for mortality rates, 1-year mortality was 26.2%, and 5-year mortality was 64.3%. In both scenarios, the most frequent causes of death were respiratory and cardiovascular disorders. Factors independently associated with mortality were older age, hospitalization by internal medicine (IMU), length of stay, the need for mechanical ventilation (MV) or noninvasive mechanical ventilation (NIV), early readmission, and history of atrial fibrillation (AF) and dementia.

CONCLUSIONS

In patients with COPD, age, exacerbation severity and comorbidity have long-term prognostic significance.

Domain-specific cognitive impairment in patients with COPD and control subjects

Impaired cognitive function is increasingly recognized in COPD. Yet, the prevalence of cognitive impairment in specific cognitive domains in COPD has been poorly studied. The aim of this cross-sectional observational study was to compare the prevalence of domain-specific cognitive impairment between patients with COPD and non-COPD controls. A neuropsychological assessment was administered in 90 stable COPD patients and 90 non-COPD controls with comparable smoking status, age, and level of education. Six core tests from the Maastricht Aging Study were used to assess general cognitive impairment. By using Z-scores, compound scores were constructed for the following domains: psychomotor speed, planning, working memory, verbal memory, and cognitive flexibility. General cognitive impairment and domain-specific cognitive impairment were compared between COPD patients and controls after correction for comorbidities using multivariate linear and logistic regression models. General cognitive impairment was found in 56.7% of patients with COPD and in 13.3% of controls. Deficits in the following domains were more often present in patients with COPD after correction for comorbidities: psychomotor speed (17.8% vs 3.3%; P<0.001), planning (17.8% vs 1.1%; P<0.001), and cognitive flexibility (43.3% vs 12.2%; P<0.001). General cognitive impairment and impairments in the domains psychomotor speed, planning, and cognitive flexibility affect the COPD patients more than their matched controls.

Guiding Principles for the Use of Nebulized Long-Acting Beta2-Agonists in Patients with COPD: An Expert Panel Consensus

Determining which patients with COPD may benefit from a nebulized long-acting beta2-agonist (LABA) is a challenge in current practice. In the absence of strong clinical guidelines addressing this issue, an expert panel convened to develop guiding principles for the use of nebulized LABA therapy in patients with COPD. This article summarizes these guiding principles and other practical issues discussed during a roundtable meeting.

Desensitisation to cigarette package graphic health warnings: a cohort comparison between London and Singapore

OBJECTIVES

We compared 2 sociocultural cohorts with different duration of exposure to graphic health warning labels (GHWL), to investigate a possible desensitisation to their use. We further studied how a differing awareness and emotional impact of smoking-associated risks could be used to prevent this.

SETTING

Structured interviews of patients from the general respiratory department were undertaken between 2012 and 2013 in 2 tertiary hospitals in Singapore and London.

PARTICIPANTS

266 participants were studied, 163 Londoners (35% smokers, 54% male, age 52±18 years) and 103 Singaporeans (53% smokers, p=0.003; 78% male, p<0.001; age 58±15 years, p=0.012).

MAIN OUTCOMES AND MEASURES

50 items assessed demographics, smoking history, knowledge and the deterring impact of smoking-associated risks. After showing 10 GHWL, the impact on emotional response, cognitive processing and intended smoking behaviour was recorded.

RESULTS

Singaporeans scored lower than the Londoners across all label processing constructs, and this was consistent for the smoking and non-smoking groups. Londoners experienced more 'disgust' and felt GHWL were more effective at preventing initiation of, or quitting, smoking. Singaporeans had a lower awareness of lung cancer (82% vs 96%, p<0.001), despite ranking it as the most deterring consequence of smoking. Overall, 'blindness' was the least known potential risk (28%), despite being ranked as more deterring than 'stroke' and 'oral cancer' in all participants.

CONCLUSIONS

The length of exposure to GHWL impacts on the effectiveness. However, acknowledging the different levels of awareness and emotional impact of smoking-associated risks within different sociocultural cohorts could be used to maintain their impact.

Dementia and Traffic Accidents: A Danish Register-Based Cohort Study

Background

As a consequence of a rapid growth of an ageing population, more people with dementia are expected on the roads. Little is known about whether these people are at increased risk of road traffic-related accidents.

Objective

Our study aims to investigate the risk of road traffic-related accidents for people aged 65 years or older with a diagnosis of dementia in Denmark.

Methods

We will conduct a nationwide population-based cohort study consisting of Danish people aged 65 or older living in Denmark as of January 1, 2008. The cohort is followed for 7 years (2008-2014). Individual’s personal data are available in Danish registers and can be linked using a unique personal identification number. A person is identified with dementia if the person meets at least one of the following criteria: (1) a diagnosis of the disease in the Danish National Patient Register or in the Danish Psychiatric Central Research Register, and/or (2) at least one dementia diagnosis-related drug prescription registration in the Danish National Prescription Registry. Police-, hospital-, and emergency room-reported road traffic-related accidents occurred within the study follow-up are defined as the study outcome. Cox proportional hazard regression models are used for the main analysis.

Results

Our study protocol has 3 phases including data collection, data analysis, and reporting. The first phase of register-based data collection of 853,228 individual’s personal information was completed in August, 2016. The next phase is data analysis, which is expected to be finished before December 2016, and thereafter writing publications based on the findings. The study started in January 2016 and will end in December 2018.

Discussion

This study covers the entire elderly population of Denmark, and thereby will avoid selection bias due to nonparticipation and loss to follow-up. Furthermore, this ensures that the study results are reliable and generalizable. However, underreporting of traffic-related accidents may occur, which will limit estimation of absolute risks.

Executive Function, Survival, and Hospitalization in Chronic Obstructive Pulmonary Disease. A Longitudinal Analysis of the National Emphysema Treatment Trial (NETT)

RATIONALE

Cognitive dysfunction has been demonstrated in chronic obstructive pulmonary disease (COPD), but studies are limited to cross-sectional analyses or incompletely characterized populations.

OBJECTIVES

We examined longitudinal changes in sensitive measures of executive function in a well-characterized population of patients with severe COPD.

METHODS

This study was performed on patients enrolled in the National Emphysema Treatment Trial. To assess executive function, we analyzed trail making (TM) A and B times at enrollment in the trial (2,128 patients), and at 12 (731 patients) and 24 months (593 patients) after enrollment, adjusted for surgery, marriage status, age, education, income, depression, PaO2, PaCO2, and smoking. Associations with survival and hospitalizations were examined using Cox regression and linear regression models.

MEASUREMENTS AND MAIN RESULTS

The average age of the patients was 66.4 years, and the average FEV1 was 23.9% predicted. At the time of enrolment, 38% had executive dysfunction. Compared with those who did not, these patients were older, less educated, had higher oxygen use, higher PaCO2, worse quality of life as measured by the St. George's Respiratory Quotient, reduced well-being, and lower social function. There was no significant change over 2 years in TM A or B times after adjustment for covariables. Changes in TM B times were modestly associated with survival, but changes in TM B-A times were not. Changes in TM scores were not associated with frequency of hospitalization. Lung function, PaO2, smoking, survival, and hospitalizations were not significantly different in those with executive dysfunction.

CONCLUSIONS

In this large population of patients with severe emphysema and heavy cigarette smoking exposure, there was no significant decline over 2 years in cognitive executive function as measured by TM tests. There was no association between executive function impairment and frequency of hospitalization, and there was a possible modest association with survival. It is plausible that cerebrovascular comorbidities explain previously described cognitive pathology in COPD.

Influence of Allergy on Immunoglobulins and Amyloid-β in the Cerebrospinal Fluid of Patients with Alzheimer's Disease

BACKGROUND

Peripheral inflammation has been suggested to influence the development of Alzheimer's disease (AD). Elevated levels of pro-inflammatory markers in the plasma of patients with AD indicate that a systemic pro-inflammatory status occurs concomitantly with inflammatory changes in the brain.

OBJECTIVE

To investigate whether allergy influences the levels of immunoglobulins (Ig) and of pro- and anti-inflammatory cytokines in the serum and cerebrospinal fluid (CSF) from patients with AD, mild cognitive impairment (MCI), and subjective cognitive impairment (SCI).

METHODS

IgA, IgG, and its subclasses, IgM, and cytokines were analyzed in CSF and serum from patients with SCI, MCI, and AD, with or without allergy. The relation between allergy and Mini-Mental State Examination (MMSE) scores, and between allergy and CSF biomarkers for AD (phosphorylated (p)-tau, total (t)-tau, amyloid-β 42 (Aβ₄₂), were analyzed.

RESULTS

In MCI, the CSF levels of IgG2 were lower in allergic patients, and in AD, the levels of IgA and the IgG1/total IgG ratio were lower in allergic patients, compared to patients without allergy. MCI subjects with allergy had higher serum IgM levels compared to those without allergy. CSF levels of Aβ₄₂ were lower and MMSE scores were higher in AD patients with allergy than in those without allergy.

CONCLUSIONS

The presence of allergy was associated with seemingly beneficial effects on AD as suggested by higher Aβ₄₂ levels in CSF, and higher MMSE scores. Higher IgM levels and lower other Ig classes suggest that allergy may influence senescence of the immune response.

Chronic Obstructive Pulmonary Disease is associated with risk of Chronic Kidney Disease: A Nationwide Case-Cohort Study

Patients with chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) share common risk factors. However, there is limited information about COPD and CKD. This is case-cohort study was carried out using the Taiwanese National Health Insurance Research Database to evaluate the correlation between COPD and CKD. We identified cases aged older than 40 years who had an inpatient hospitalization with a first-time COPD diagnosis between 1998 and 2008. Control were selected from hospitalized patients without COPD or CKD and were matched according to age, gender, and year of admission at a 2:1 ratio. Cox proportional hazards model was used to assess the association of CKD and COPD. The overall incidence of CKD was higher in the COPD group (470.9 per 10⁴ person-years) than in the non-COPD group (287.52 per 10⁴ person-years). The adjusted hazard ratio of case was 1.61 (P < 0.0001) times that of control. COPD was found to be associated with kidney disease from our follow-up. To detect CKD early, early diagnosis of CKD in patients with COPD and prompt initiation of monitoring and treatment are imperative.

Cognitive function and living situation in COPD: is there a relationship with self-management and quality of life?

BACKGROUND

Cognitive impairment is increasingly being found to be a common comorbidity in chronic obstructive pulmonary disease (COPD). This study sought to understand the relationship of comprehensively measured cognitive function with COPD severity, quality of life, living situation, health care utilization, and self-management abilities.

METHODS

Subjects with COPD were recruited from the outpatient pulmonary clinic. Cognitive function was assessed using the Montreal Cognitive Assessment (MOCA). Self-management abilities were measured using the Self Management Ability Score 30. Quality of life was measured using the Chronic Respiratory Disease Questionnaire. Pearson correlation was used to assess the bivariate association of the MOCA with other study measures. Multivariate analysis was completed to understand the interaction of the MOCA and living situation on COPD outcomes of hospitalization, quality of life, and self-management ability.

RESULTS

This study included 100 participants of mean age 70±9.4 years (63% male, 37% female) with COPD (mean FEV1 [forced expiratory volume in 1 second] percentage predicted 40.4±16.7). Mean MOCA score was 23.8±3.9 with 63% of patients having mild cognitive impairment. The MOCA was negatively correlated with age (r=-0.28, P=0.005) and positively correlated with education (r=+0.24, P=0.012). There was no significant correlation between cognitive function and exacerbations, emergency room (ER) visits, or hospitalizations. There was no association between the MOCA score and self-management abilities or quality of life. We tested the interaction of living situation and the MOCA with self-management abilities and found statistical significance (P=0.017), indicating that individuals living alone with higher cognitive function report lower self-management abilities.

CONCLUSION

Cognitive impairment in COPD does not appear to be meaningfully associated with COPD severity, health outcomes, or self-management abilities. The routine screening for cognitive impairment due to a diagnosis of COPD may not be indicated. Living alone significantly affects the interaction between self-management abilities and cognitive function.

Serum Amyloid-Beta Levels are Increased in Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is associated with cognitive decline, but the molecular link between COPD and dementia or Alzheimer's disease (AD) remains unclear. This study was aimed to investigate whether serum Aβ levels are correlated with COPD. 77 cognitively normal COPD patients and 45 age- and gender-matched normal controls were admitted to the study. Serum Aβ40 and Aβ42 levels were measured using ELISA kits. Serum C-reactive protein (CRP), interleukin 6 (IL-6), and procalcitonin (PCT) measurements were done using standard laboratory methods. Pulmonary function tests were performed to assess the pulmonary function and determine the degree of lung damage. Significantly increased levels of serum Aβ40, Aβ42, and total Aβ levels were found in patients with COPD in comparison with normal controls. In COPD patients, serum Aβ levels were higher in subjects with serum CRP, IL-6, and PCT upper the limit of normal. Moreover, serum Aβ levels were dramatically higher in COPD patients with worse pulmonary function. Our study suggests that cognitively normal COPD patients may undergo AD-related pathological changes, and COPD might facilitate AD-type pathogenesis.

Increased Risk of Dementia in Patients With Acute Organophosphate and Carbamate Poisoning: A Nationwide Population-Based Cohort Study

Organophosphate (OP) and carbamate (CM) are the most commonly used pesticides against insects. Little is known regarding the relationship between dementia and acute OP and CM poisoning. A nationwide population-based cohort study was conducted from the National Health Insurance Research Database in Taiwan. The incidence and relative risk of dementia were assessed in patients hospitalized for acute OP and CM poisoning from 2000 to 2011. The comparison cohort was matched with the poisoned cohort at a 4:1 ratio based on age, sex, and the year of hospitalization. During the follow-up period, the incidence of dementia was 29.4 per 10,000 person-years in the poisoned group, and represented a 1.98-fold increased risk of dementia compared with the control cohort (95% confidence interval, 1.59-2.47). This study provides evidence on the association between dementia and acute OP and CM poisoning. Regular follow-up of poisoned patients for dementia is suggested.

Dementia Increases Severe Sepsis and Mortality in Hospitalized Patients With Chronic Obstructive Pulmonary Disease

Dementia increases the risk of morbidity and mortality in hospitalized patients. However, information on the potential effects of dementia on the risks of acute organ dysfunction, severe sepsis and in-hospital mortality, specifically among inpatients with chronic obstructive pulmonary disease (COPD), is limited. The observational analytic study was inpatient claims during the period from 2000 to 2010 for 1 million people who were randomly selected from all of the beneficiaries of the Taiwan National Health Insurance in 2000. In total, 1406 patients with COPD and dementia were admitted during the study period. Hospitalized patients with COPD and free from a history of dementia were randomly selected and served as control subjects (n = 5334). The patient groups were matched according to age (±3 years), gender, and the year of admission, with a control/dementia ratio of 4. Only the first-time hospitalization data for each subject was analyzed. Logistic regression models were used to calculate the odds ratio (OR) of outcome measures (acute organ dysfunction, severe sepsis, and mortality), controlling for confounding factors (age, sex, comorbidity, infection site, hospital level, and length of stay). In COPD patients with dementia, the incidence rate of severe sepsis and hospital mortality was 17.1% and 4.8%, respectively, which were higher than the controls (10.6% and 2.3%). After controlling for potential confounding factors, dementia was found to significantly increase the odds of severe sepsis and hospital mortality with an adjusted OR (OR) of 1.38 (95% confidence interval [CI] 1.10-1.72) and 1.69 (95% CI 1.18-2.43), respectively. Dementia was also significantly associated with an increased OR of acute respiratory dysfunction (adjusted OR 1.39, 95% CI 1.09-1.77). In hospitalized COPD patients, the presence of dementia may increase the risks of acute respiratory dysfunction, severe sepsis, and hospital mortality, which warrants the attention of health care professionals.

Self-management following an acute exacerbation of COPD: a systematic review

BACKGROUND

Self-management (SM) reduces hospital admissions in patients with stable COPD. However, its role immediately post-acute exacerbation (AE) is unclear. The objectives of this review were to describe SM interventions delivered immediately following an AE of COPD (AECOPD) and to conduct a systematic review with meta-analysis of its impact on health-care utilization and health outcomes.

METHODS

Randomized controlled trials reporting on SM interventions delivered during hospitalization for an AECOPD or within 1 month of hospital discharge were included. Seven articles were identified. Data were extracted and assessed for quality by two researchers.

RESULTS

By definition, all interventions included action plans, education, and at least two SM skills. Nurses were responsible for providing all SM interventions. The delivery and follow-up periods varied widely. At 12 months, there were no significant differences between those who completed the SM intervention and control subjects in the number of patients readmitted to hospital (P = .38), or in health-related quality of life (P = .27). No effects were found on rate of mortality, depressive symptoms, primary care usage, or exercise capacity. Minimal effects were found on self-efficacy, anxiety symptoms, and health promoting behavior. SM was associated with positive effects on knowledge and management of an AECOPD.

CONCLUSIONS

SM interventions delivered immediately post-AE vary widely and outcome measures are inconsistent, making it difficult to draw strong recommendations regarding its effectiveness. The evaluation of SM interventions, delivered by trained health-care professionals to selected patients and which offer structured follow-up, appears necessary.

The association between chronic obstructive pulmonary disease and dementia: a population-based retrospective cohort study

BACKGROUND AND PURPOSE

Chronic obstructive pulmonary disease (COPD) is frequently associated with various comorbidities. However, the proportion of COPD patients with dementia has not been adequately examined. This retrospective cohort study investigated the association between COPD and dementia by using a nationwide population-based database in Taiwan.

METHODS

Data were retrieved from the Taiwanese National Health Insurance Research Database and analyzed using multivariate Cox proportional hazards regression models to assess the effects of COPD on the risk of dementia after adjusting for demographic characteristics and comorbidities.

RESULTS

The COPD cohort exhibited a higher prevalence of diabetes, hypertension, coronary artery disease, head injury and depression at baseline than did the non-COPD cohort (P < 0.0001). After adjusting for covariates, the COPD patients exhibited a 1.27-fold higher risk of developing dementia (hazard ratio 1.27, 95% confidence interval 1.20-1.36). The incidence rate was higher in patients with frequent acute exacerbations than in the non-COPD patients regardless of whether a hospital admission or emergency room visit was required (hazard ratio 196.8 vs. 41.7, 95% confidence intervals 145.9-265.5 and 22.3-78.0).

CONCLUSION

This study shows that COPD is associated with a subsequent higher risk of dementia after adjusting for comorbidities. Specifically, the association between COPD and dementia is greater in patients with more frequent acute exacerbation events of COPD.

A prospective study of chronic obstructive pulmonary disease and the risk for mild cognitive impairment

IMPORTANCE

Previous studies suggest cross-sectional associations between a diagnosis of chronic obstructive pulmonary disease (COPD) and mild cognitive impairment (MCI). However, few studies have assessed whether COPD, a potentially modifiable factor, is associated with an increased risk for MCI and whether the relation is specific to the type of MCI.

OBJECTIVE

To investigate whether a diagnosis of COPD and duration of COPD are associated with an increased risk for incident MCI and MCI subtypes (amnestic MCI [A-MCI] and nonamnestic MCI [NA-MCI]).

DESIGN, SETTING, AND PARTICIPANTS

A prospective population-based cohort from the Mayo Clinic Study on Aging. We included 1425 cognitively normal individuals aged 70 to 89 years who were randomly selected from Olmsted County, Minnesota, on October 1, 2004, using the medical records linkage system. At baseline and every 15 months thereafter, participants underwent assessment with a nurse interview, neurologic examination, and neuropsychological testing. A diagnosis of COPD was confirmed via medical record review. A baseline diagnosis of COPD and duration of COPD were examined as risk factors for MCI and MCI subtypes using Cox proportional hazards models and adjusting for demographic variables and medical comorbidities, with age as the time scale.

EXPOSURE

A baseline diagnosis of COPD and duration of COPD.

MAIN OUTCOMES AND MEASURES

Incident MCI, A-MCI, and NA-MCI.

RESULTS

Of the 1425 participants with normal cognition at baseline, 370 developed incident MCI. The median duration of follow-up was 5.1 years (interquartile range, 3.8-5.4 years). A diagnosis of COPD significantly increased the risk for NA-MCI by 83% (hazard ratio, 1.83 [95% CI, 1.04-3.23]), but not of any MCI or A-MCI in multivariate analyses. We found a dose-response relationship such that individuals with COPD duration of longer than 5 years at baseline had the greatest risk for any MCI (hazard ratio, 1.58 [95% CI, 1.04-2.40]) and NA-MCI (2.58 [1.32-5.06]).

CONCLUSIONS AND RELEVANCE

A diagnosis of COPD is associated with an increased risk for MCI, particularly NA-MCI. We have found a dose-response relationship between COPD duration and risk for MCI. These findings highlight the importance of COPD as a risk factor for MCI and may provide a substrate for early intervention to prevent or delay the onset and progression of MCI, particularly NA-MCI.

A cross-sectional survey investigating the desensitisation of graphic health warning labels and their impact on smokers, non-smokers and patients with COPD in a London cohort

OBJECTIVES

There is a lack of evidence regarding the effectiveness of graphic health warning labels (GHWL) in different individuals, including patients with chronic obstructive pulmonary disease (COPD). Investigating knowledge and attitudes may allow better implementation of future public health policies. We hypothesised that differences in the impact of GHWL exist between non-smokers, smokers and patients with COPD, with decreased efficacy in those groups who are longer and more frequently exposed to them.

PARTICIPANTS AND SETTING

163 participants (54% male, aged 21-80) including 60 non-smokers, 53 smokers and 50 patients with COPD (Gold stage II-IV), attending London respiratory outpatient clinics, participated in case-controlled surveys (50 items).

OUTCOME MEASURES

Ten different GHWL were shown and demographics, smoking history, plans to quit, smoking-risk awareness, emotional response, processing and impact of GHWL on behaviour were recorded. Patients were further asked to prioritise the hypothetical treatment or prevention of five specific smoking-related diseases.

RESULTS

Smokers, in particular those with COPD, were less susceptible to GHWL than non-smokers; 53.4% of all participants expressed fear when looking at GHWL, non-smokers (71.9%) more so than smokers (39.8%, p<0.001). COPD participants were less aware of the consequences than non-COPD participants (p<0.001), including an awareness of lung cancer (p=0.001). Lung cancer (95%), oral cancer (90.2%), heart disease (84.7%) and stroke (71.2%) were correctly associated with smoking, whereas blindness was least associated (23.9%). However, blindness was prioritised over oral cancer, stroke and in patients with COPD also over heart disease when participants were asked about hypothetical treatment or prevention.

CONCLUSIONS

GHWL are most effective in non-smokers and a desensitisation effect was observed in smokers and patients with COPD. As a consequence, a tailored and concerted public health approach to use such messages is required and 'blindness' deserves to be mentioned in this context because of an unexpectedly high-deterring impact.