Psychosocial Issues in Chronic Obstructive Pulmonary Disease

COPD and emotional distress: not always noticed and therefore untreated

There are more than three million people in the UK living with chronic obstructive pulmonary disease (COPD). Focus tends to be on the physical effects of the condition; however, many patients living with COPD develop mental health symptoms that could go unnoticed and therefore untreated. The community nurse's role includes the management of patients with complex long-term conditions, which may include mental health issues. However, training to support patients whose condition includes a mental health component has long been considered inadequate and may lead to under diagnosis. Compared with other patients with long-term conditions, patients with COPD recount worse psychological functioning and greater psychological distress. Health-care workers' lack of mental health knowledge may be a contributory factor to why only a small proportion of patients are diagnosed and receive effective treatment.

Relationship among differentiation of self, relationship satisfaction, partner support, and depression in patients with chronic lung disease and their partners

The purpose of the present study is to test the relationships among differentiation of self, relationship satisfaction, perceived partner support, and depression in a sample of patients with chronic lung disease (CLD) and their partners. The sample consisted of 52 patients with CLD and their partners. Hierarchical multiple regression was used for data analysis. The results indicate that (a) patients' differentiation of self is significantly lower than partners' differentiation of self, (b) patients' relationship satisfaction is positively correlated with partners' relationship satisfaction, (c) patients' relationship satisfaction predicts perceived partner supportive behavior, (d) perceived partner unsupportive behavior predicts patients' depression, (e) partners' differentiation of self predicts partners' relationship satisfaction, (f) partners' relationship satisfaction predicts partner supportive behavior, and (g) partners' differentiation of self and relationship satisfaction predicts partners' depression. The study serves to highlight the fact that the patient is part of a system, and that taking the system into account is relevant to the well-being of both the patient and the partner, in particular for patients with CLD, a heretofore unstudied population. The results of such studies have significant implications for couple and family therapists.

Exercise training raises daily activity stronger than predicted from exercise capacity in patients with COPD

The 6-min walking (6MWD) and 6-min treadmill distance (6MTD) are often used as measures of exercise performance in patients with COPD. The aim of our study was to assess their relationship to daily activity in the course of an exercise training program. Eighty-eight patients with stable COPD (71m/17f; mean +/- SD age, 60 +/-8 year; FEV1, 43+/-14% pred) were recruited, 66 of whom performed a hospital-based 10-day walking training, whereas 22 were treated as control. On day 16MTD, and on days 8 and 10, 6MTD and 6MWD were determined. In addition, patients used an accelerometer (TriTrac-R3D) to record 24 h-activity, whereby training sessions were excluded. In both groups there was a linear relationship (r > or = 0.84 and P < 0.0001) between 6MTD and 24 h-activity, the slope of which was 2.5-fold greater in the training group (P < 0.01). Similar relationships emerged for 6MWD. There was no association between baseline 6MTD, FEV1 or BMI and any of the other measures. These data suggest that daily activity did not markedly vary with exercise capacity under baseline conditions. Participation in a training program increased activity significantly stronger than predicted from the gain in exercise capacity. This underlines the importance of non-physiological, patient-centered factors associated with training in COPD.

Evaluation of patients with severe pulmonary disease before and after pulmonary rehabilitation

PURPOSE

The purpose was to evaluate the impact of inpatient pulmonary rehabilitation program upon changes in anxiety, depression, psychological outlook, and dyspnea. A secondary purpose was to predict changes in psychological outlook, depression, anxiety, and dyspnea by using three pulmonary function tests and age.

METHODS

The design consisted of an observational study with pre-post comparisons. Forty-five patients with severe pulmonary disease, mean age 67.4 years (SD 9.2), mean FEV(1)=31.44% predicted, 13 men, 32 women were compared on four measures before and after 3 weeks of rehabilitation. Measures were Beck Depression Inventory, Hamilton Anxiety Scale, Goldberg Scale, and Modified Borg Scale. In addition, a linear multiple regression model using age, gender, % predicted FEV(1), FEV(1)/FVC, % predicted DLCO as independent variables were used to predict changes.

RESULTS

Patients who completed the pulmonary program showed significant changes in favour of post scores on all four scales at p<0.001. The program significantly reduced anxiety and depression, and increased positive psychological outlook in severe pulmonary disease. Perceived breathlessness on the Borg Scale was significantly reduced (p<0.0001). The multiple regression model was not statistically significant for prediction of any of the changes.

CONCLUSIONS

Patients with severe pulmonary disease can significantly improve their psychological outlook and decrease anxiety and depression when they complete an inpatient pulmonary rehabilitation program. Psychological gains and perception of breathlessness improve with rehabilitation, even though FEV(1) and other pulmonary function tests may not predict these changes. A second implication is that rehabilitation improves psychological outlook with both severely ill patients and a group with mixed pulmonary and cardiac disease.

The influence of rehabilitation on behaviour modification in COPD

Psychological and social factors are important in functioning and well-being of patients with chronic lung disease. While a rehabilitation programme of 4-10 weeks may optimise physical function, maintenance of results of rehabilitation depends for a substantial part on psychological factors such as mood, coping and lifestyle. Behavioural research suggests that modifying behavioural patterns and coping styles takes time and improvement of depressive state or symptoms may also take months. While no clear recommendations can be abstracted from the present literature concerning composition and duration of psychosocial programmes, we would suggest a duration of the programme of at least 3 months with inclusion of structured psychosocial elements aiming at behaviour modification. Regular physical and social activities in the post-rehabilitation period are necessary for relapse prevention. Evidence for this approach, however, is up to now only circumstantial. Further research should focus on maintaining results of rehabilitation and in particular on the role of psychological factors.

Quality of life and coping strategies of clients with COPD

A descriptive correlational design was used to study quality of life and coping in 39 clients with severe chronic obstructive pulmonary disease (COPD). Quality of life was measured by using the Sickness Impact Profile (SIP) and Cantril's Ladder; coping strategies were measured with Jalowiec's Coping Scale Revised (JCS). SIP and Cantril's Ladder scores revealed that the subjects experienced a high quality of life. Total coping scores were low, however, implying that patients used the JCS coping strategies only minimally and did not find them particularly helpful. A moderately strong relationship was found between the objective and subjective measures of quality of life. Coping strategies and quality of life were found not to be significantly related. Findings suggest that the caregivers of those with severe COPD should consider the client's perception of quality of life and use of coping strategies. Further research is needed to determine the factors that affect quality of life for these persons.

Adjustment and social behaviour in older adults with chronic obstructive pulmonary disease: the family's perspective

This study employed secondary data analysis to explore family perceptions of adjustment and social behaviour in older adults (n = 51) with chronic obstructive pulmonary disease (COPD) and their relationship to published norms and patient self-report. According to the Katz Adjustment Scale for Relatives, these COPD patients had significantly higher levels of belligerence, negativism, helplessness, withdrawal, psychopathology, nervousness and confusion than reports from relatives of older adults from the general population. No differences were found in performance, expectation or dissatisfaction with socially expected activities, or performance of free-time activities. However, family members of COPD patients were significantly more dissatisfied with their relative's free-time activities. Although family perceptions of socially expected activities corresponded to patient descriptions of general and physical functioning (Sickness Impact Profile), patient perceptions of psychosocial functioning were independent of the family's. The results supported the tenet that older adults with COPD have difficulties with adjustment that may adversely affect social relationships, but were not consistent with the belief that the performance of socially expected or free-time activities is more impaired than in others of this age group. The data also suggested there may be some perceptual discrepancy between family and patient views of social behaviour.

Advance directive education during pulmonary rehabilitation

We conducted a questionnaire survey of 346 pulmonary rehabilitation programs to determine the present utilization and potential value of these sites for promoting advance directive education for patients with chronic lung diseases. Responses were analyzed for all responding programs and for programs categorized by size. Eighty-two percent of the 218 responding programs discussed with patients prognostic information. Only 33% of programs asked patients if they had advance directives and 17% kept these documents on file. Thirty-three percent of programs provided some form of advance directive education, and 42% distributed directive educational material, usually through informal and unstructured methods. Seventy-seven percent of responders considered pulmonary rehabilitation an appropriate site for directive education, and 86% indicated willingness to incorporate directive education into their programs. Larger programs were more likely to present information about patient prognosis (p = 0.0003) and advance directives (p = 0.021). We conclude that most of the responding pulmonary rehabilitation programs do not educate patients about advance directives but are willing to do so if supplied with appropriate teaching materials. Rehabilitation programs may be valuable sites for educating patients with chronic disorders about advance directives and promoting an improved patient-physician dialogue about these issues.

Psychophysiologic factors contributing to functional performance in people with COPD: are there gender differences?

The purpose of this study was to compare the functional performance profiles of men and women with chronic obstructive pulmonary disease, describe the extent to which physiologic impairment, physical symptoms, and psychosocial resources contribute in a cumulative manner to performance, and outline the extent to which these contributions differ across gender. Secondary data analyses were employed. Although women (n = 45) reported more functional difficulty than men (n = 44) in 9 of 12 Sickness Impact Profile categories, the differences were not significant. Using hierarchical regression procedures, physiologic, symptomatic, and interactive variables predicted total (R2 = .64) and physical performance (R2 = .52), while symptomatic and psychosocial variables predicted psychosocial performance (R2 = .53). Results indicate that models of functional performance may be different for men and women.

Reliability and validity of the Modified Erikson Psychosocial Stage Inventory in diverse samples

The Modified Erikson Psychosocial Stage Inventory (MEPSI) is a relatively simple survey measure designed to assess the strength of psychosocial attributes that arise from progression through Erikson's eight stages of development. The purpose of this study was to employ secondary analysis to evaluate the internal-consistency reliability and construct validity of the MEPSI across four diverse samples: healthy young adults, hemophilic men, healthy older adults, and older adults with chronic obstructive pulmonary disease. Special attention was given to the performance of the measure across gender, with exploratory analyses examining possible age cohort and health status effects. Internal-consistency estimates for the aggregate measure were high, whereas subscale reliability levels varied across age groups. Construct validity was supported across samples. Gender, cohort, and health effects offered interesting psychometric and theoretical insights and direction for further research. Findings indicated that the MEPSI might be a useful instrument for operationalizing and testing Eriksonian developmental theory in adults.

Functional performance in people with chronic obstructive pulmonary disease

The extent to which individuals with a chronic physical illness perform their day-to-day activities and maintain the independence and autonomy they desire is both an indicator of adaptation and an important clinical outcome criterion. Yet the concept of functional performance is not well understood. Studies of people with chronic obstructive pulmonary disease (COPD) have attempted to identify physiologic and psychosocial factors that contribute to functioning in this population. These studies have used a melange of terms, including functional status, functional ability, quality of life, and health status interchangeably. They have also employed a variety of instruments to operationalize functional performance and an assortment of predictors to understand the phenomena. Perhaps as a result of this disarray, no attempt has been made to synthesize the literature for nursing research and practice. The purpose of this paper is to summarize the research on functional performance in people with COPD, indicate areas of understanding and quandary, suggest possible flaws, and propose several new directions for practice and research.

Psychiatric disorders complicating treatment of patients with pulmonary disease

Treatment of pulmonary disease can be significantly complicated by the presence of psychiatric disorders. It is therefore essential to evaluate and understand the interaction of the pulmonary and psychiatric disorders in order to optimize patient care and management.

Psychological factors affecting pulmonary and rheumatologic diseases. A review

This review examines some of the questions and current literature regarding psychological factors as they affect pulmonary and rheumatologic diseases. Recommendations are made concerning directions for future research in these areas.

Disease and symptom severity, functional status, and quality of life in chronic bronchitis and emphysema (CBE)

A path analysis model examined interrelationships among variables significantly associated with chronic dyspnea in chronic bronchitis and emphysema (CBE) and the relative influence of these variables on each other and on functional status and quality of life. Results from the 45 adults (mean age, 61) with moderate CBE disease severity showed that dyspnea severity has a sizable effect on functional status and quality of life. Disease severity was more strongly related to functional status than to quality of life. Depression and mastery had the strongest total effects on quality of life. Dyspnea severity had strong but separate effects on functional status and quality of life. From these preliminary results, it is suggested that a direct focus on psychologic interventions to ameliorate depression and improve mastery is likely to improve quality of life with some resultant positive effect on functional status.

Effects of alprazolam on respiratory drive, anxiety, and dyspnea in chronic airflow obstruction: a case study

Alprazolam, an anxiolytic benzodiazepine, has a pharmacologic profile similar to that of diazepam. An intermediate half-life of 10-12 hours and a comparatively brief duration of activity relative to other anxiolytic benzodiazepines justified evaluation of a 0.5-mg test dose in an anxious patient with chronic obstructive lung disease. Subjective indexes, breath-by-breath respiratory drive response to hypercapnia, and blood alprazolam concentrations were determined before and after dosing. Subjective testing included a visual analog dyspnea scale, the state anxiety inventory, and subjective feelings visual analog scales (represented by alertness, calmness, and level of contentment). After dosing, the patient was better able to tolerate the rebreathing study technique. Statistically significant improvements in dyspnea (t - 10.20; p 0.0005), anxiety (t - 45.85; p less than 0.0001), alertness (t - 13.04; p less than 0.0001), cententedness (t - 12.27; p less than 0.0001), and calmness (t - 8.05; p less than 0.0001) occurred after alprazolam administration. Drive to breathe, as determined by mouth occlusion pressure and minute ventilation, was not statistically different before and after dosing. No adverse effects were reported or observed. Further study is warranted.