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Kochovska S, Iyer R, Chang S, Ferreira D, Brunelli VN, Kinchin I, Eckert DJ, Clark J, Sandberg J, Ekström M, Currow D, Rajan S. Prevalence, severity and impacts of breathlessness in Indian adults: An exploratory, nationally representative, cross-sectional online survey. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002655. [PMID: 38696528 PMCID: PMC11065295 DOI: 10.1371/journal.pgph.0002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/26/2024] [Indexed: 05/04/2024]
Abstract
There are no known estimates of the prevalence, severity and impacts from breathlessness in low- and middle-income countries. This study aimed to explore the prevalence, severity, self-attributed underlying conditions and impacts of breathlessness limiting exertion in community-dwelling adults in India. This exploratory, population-based online survey recruited a pre-planned sample of 3,000 adult respondents stratified by age, sex and rurality (quotas as per the 2011 Indian National Census). Measures included: demographics; breathlessness limiting exertion (modified Medical Research [mMRC] scale); health-related quality of life (EQ-5D-5L); and disability (World Health Organisation's Disability Assessment Schedule 2.0 12-item questionnaire [WHODAS-12]). Respondents (n = 3,046) had a mean age of 38 years (SD 15); 57% were male, 59% lived in rural areas and 33% had completed 12th grade. Breathlessness limiting exertion (mMRC ≥1) was reported by 44%, mostly attributed to poor nutrition (28%), lung conditions excluding tuberculosis (17%) or anaemia (13%). Compared to those without breathlessness, a higher proportion of people with breathlessness (mMRC ≥1) reported problems across all EQ-5D-5L dimensions. Most people reporting breathlessness (81%) indicated the symptom had adversely affected their normal activities. Disability scores (WHODAS-12 total and individual domains) increased as breathlessness worsened. To conclude, in India, conservative estimates indicate 626 million people live with breathlessness of whom 52 million people live with severe breathlessness. The symptom is associated with poorer health-related quality of life and marked disability, including reduced ability to perform daily activities.
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Affiliation(s)
- Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Rajam Iyer
- P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Sungwon Chang
- IMPACCT, Faculty of Health, University of Technology Sydney, New South Wales, Australia
| | - Diana Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Vanessa N. Brunelli
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Irina Kinchin
- Centre for Health Policy and Management, Discipline of Public Health & Primary Care, School of Medicine, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Danny J. Eckert
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Joseph Clark
- Wolfson Palliative Care Research Centre, Hull University, Hull, United Kingdom
| | - Jacob Sandberg
- Department of Clinical Sciences Lund, Faculty of Medicine, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Magnus Ekström
- Department of Clinical Sciences Lund, Faculty of Medicine, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - David Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Sujeet Rajan
- Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Ekström M, Sundh J, Andersson A, Angerås O, Blomberg A, Börjesson M, Caidahl K, Emilsson ÖI, Engvall J, Frykholm E, Grote L, Hedman K, Jernberg T, Lindberg E, Malinovschi A, Nyberg A, Rullman E, Sandberg J, Sköld M, Stenfors N, Sundström J, Tanash H, Zaigham S, Carlhäll CJ. Exertional breathlessness related to medical conditions in middle-aged people: the population-based SCAPIS study of more than 25,000 men and women. Respir Res 2024; 25:127. [PMID: 38493081 PMCID: PMC10944596 DOI: 10.1186/s12931-024-02766-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Breathlessness is common in the population and can be related to a range of medical conditions. We aimed to evaluate the burden of breathlessness related to different medical conditions in a middle-aged population. METHODS Cross-sectional analysis of the population-based Swedish CArdioPulmonary bioImage Study of adults aged 50-64 years. Breathlessness (modified Medical Research Council [mMRC] ≥ 2) was evaluated in relation to self-reported symptoms, stress, depression; physician-diagnosed conditions; measured body mass index (BMI), spirometry, venous haemoglobin concentration, coronary artery calcification and stenosis [computer tomography (CT) angiography], and pulmonary emphysema (high-resolution CT). For each condition, the prevalence and breathlessness population attributable fraction (PAF) were calculated, overall and by sex, smoking history, and presence/absence of self-reported cardiorespiratory disease. RESULTS We included 25,948 people aged 57.5 ± [SD] 4.4; 51% women; 37% former and 12% current smokers; 43% overweight (BMI 25.0-29.9), 21% obese (BMI ≥ 30); 25% with respiratory disease, 14% depression, 9% cardiac disease, and 3% anemia. Breathlessness was present in 3.7%. Medical conditions most strongly related to the breathlessness prevalence were (PAF 95%CI): overweight and obesity (59.6-66.0%), stress (31.6-76.8%), respiratory disease (20.1-37.1%), depression (17.1-26.6%), cardiac disease (6.3-12.7%), anemia (0.8-3.3%), and peripheral arterial disease (0.3-0.8%). Stress was the main factor in women and current smokers. CONCLUSION Breathlessness mainly relates to overweight/obesity and stress and to a lesser extent to comorbidities like respiratory, depressive, and cardiac disorders among middle-aged people in a high-income setting-supporting the importance of lifestyle interventions to reduce the burden of breathlessness in the population.
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Affiliation(s)
- Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Faculty of Medicine, Lund University, 221 84, Lund, Sweden.
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Andersson
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
- COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Blomberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mats Börjesson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg, Sweden
- Center for Lifestyle Intervention, Department MGAÖ, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kenneth Caidahl
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Sahlgrenska University Hospital, and Sahlgrenska Academy, Gothenburg, Sweden
| | - Össur Ingi Emilsson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Jan Engvall
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Erik Frykholm
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Ludger Grote
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Sleep Disorders Centre, Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - André Nyberg
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Eric Rullman
- Department of Laboratory Medicine, Section of Clinical Physiology, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jacob Sandberg
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Faculty of Medicine, Lund University, 221 84, Lund, Sweden
| | - Magnus Sköld
- Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Nikolai Stenfors
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hanan Tanash
- Department of Respiratory Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Suneela Zaigham
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Carl-Johan Carlhäll
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
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Olsson M, Björkelund AJ, Sandberg J, Blomberg A, Börjesson M, Currow D, Malinovschi A, Sköld M, Wollmer P, Torén K, Östgren CJ, Engström G, Ekström M. Factors most strongly associated with breathlessness in a population aged 50-64 years. ERJ Open Res 2024; 10:00582-2023. [PMID: 38529345 PMCID: PMC10962452 DOI: 10.1183/23120541.00582-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/31/2023] [Indexed: 03/27/2024] Open
Abstract
Background Breathlessness is a troublesome and prevalent symptom in the population, but knowledge of related factors is scarce. The aim of this study was to identify the factors most strongly associated with breathlessness in the general population and to describe the shapes of the associations between the main factors and breathlessness. Methods A cross-sectional analysis was carried out of the multicentre population-based Swedish CArdioPulmonary bioImage Study (SCAPIS) of adults aged 50 to 64 years. Breathlessness was defined as a modified Medical Research Council breathlessness rating ≥2. The machine learning algorithm extreme gradient boosting (XGBoost) was used to classify participants as either breathless or nonbreathless using 449 factors, including physiological measurements, blood samples, computed tomography cardiac and lung measurements, lifestyle, health conditions and socioeconomics. The strength of the associations between the factors and breathlessness were measured by SHapley Additive exPlanations (SHAP), with higher scores reflecting stronger associations. Results A total of 28 730 participants (52% women) were included in the study. The strongest associated factors for breathlessness were (in order of magnitude): body mass index ( SHAP score 0.39), forced expiratory volume in 1 s (0.32), physical activity measured by accelerometery (0.27), sleep apnoea (0.22), diffusing lung capacity for carbon monoxide (0.21), self-reported physical activity (0.17), chest pain when hurrying (0.17), high-sensitivity C-reactive protein (0.17), recent weight change (0.14) and cough (0.13). Conclusion This large population-based study of men and women aged 50-64 years identified the main factors related to breathlessness that may be prevented or amenable to public health interventions.
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Affiliation(s)
- Max Olsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
| | - Anders J. Björkelund
- Lund University, Faculty of Science, Centre for Environmental and Climate Science, Lund, Sweden
| | - Jacob Sandberg
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
| | - Anders Blomberg
- Umeå University, Department of Public Health and Clinical Medicine, Umeå, Sweden
| | - Mats Börjesson
- Dept of Molecular and Cardiovascular Medicine, Center for Health and Performance, Sahlgrenska Academy, Gothenburg, Sweden
- Dept MGAÖ, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Andrei Malinovschi
- Dept of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Magnus Sköld
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Per Wollmer
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Kjell Torén
- Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carl Johan Östgren
- Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Gunnar Engström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Malmö, Cardiovascular Epidemiology, Malmö, Sweden
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
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Gustafsson D, Elmberg V, Schiöler L, Jensen D, Ekström M. The modified Medical Research Council scale misclassifies exertional breathlessness among people referred for exercise testing. ERJ Open Res 2023; 9:00592-2023. [PMID: 38152083 PMCID: PMC10752288 DOI: 10.1183/23120541.00592-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/01/2023] [Indexed: 12/29/2023] Open
Abstract
Background Exertional breathlessness is a major symptom in cardiorespiratory disease and is often assessed using the modified Medical Research Council (mMRC) questionnaire. The mMRC might underestimate exertional breathlessness in people with impaired exercise capacity who have reduced their physical activity to avoid the symptom. We aimed to evaluate the ability of mMRC to detect abnormally high exertional breathlessness or abnormally low exercise capacity during incremental cycle exercise testing (IET). Methods A secondary analysis of data from a randomised controlled trial of outpatients aged 18 years or older referred for IET was carried out. Participants completed the mMRC before IET. Abnormally high exertional breathlessness was defined as a breathlessness (Borg 0-10) intensity response more than the upper limit of normal. Abnormally low exercise capacity was defined using published reference equations. The sensitivity, specificity, accuracy and discriminative ability of each mMRC rating to detect each outcomewas calculated. Results 92 participants were included; the mean age was 59 years, 61% were male, and 64% and 15% had mMRC 1 and ≥2, respectively. An mMRC ≥2 had the highest accuracy (71%) to detect abnormally high exertional breathlessness, with a specificity of 93% but a sensitivity of only 28%, failing to identify 72% of people with abnormally high exertional breathlessness. The accuracy, specificity and sensitivity for abnormally low exercise capacity was 64%, 88% and 19%, respectively. Conclusion Among people referred for clinical exercise testing, the mMRC dyspnoea scale misclassified exertional breathlessness and exercise capacity assessed using cycle IET, with substantial underdetection. A mMRC dyspnoea rating of 0-1 does not preclude the presence of abnormally high exertional breathlessness or abnormally low exercise capacity.
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Affiliation(s)
- David Gustafsson
- Department of Respiratory Medicine, Allergology and Palliative Medicine, Institution for Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Blekinge Hospital, Karlskrona, Sweden
| | - Viktor Elmberg
- Department of Respiratory Medicine, Allergology and Palliative Medicine, Institution for Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Blekinge Hospital, Karlskrona, Sweden
| | - Linus Schiöler
- Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Dennis Jensen
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montréal, QC, Canada
- Research Institute of the McGill University Health Centre, Translational Research in Respiratory Diseases Program and Respiratory Epidemiology and Clinical Research Unit, Montréal, QC, Canada
| | - Magnus Ekström
- Department of Respiratory Medicine, Allergology and Palliative Medicine, Institution for Clinical Sciences in Lund, Lund University, Lund, Sweden
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Yun JY, Yun YH. Health-promoting behavior to enhance perceived meaning and control of life in chronic disease patients with role limitations and depressive symptoms: a network approach. Sci Rep 2023; 13:4848. [PMID: 36964273 PMCID: PMC10039031 DOI: 10.1038/s41598-023-31867-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 03/20/2023] [Indexed: 03/26/2023] Open
Abstract
The association between health-related role limitations in the mental and physical subdomains and clinical status (i.e., chronic disease and comorbid depressive symptoms) is mediated by health-promoting behaviors. To enhance health-promoting behaviors in adults with chronic disease, it is necessary to identify item-level associations among targets of health-related monitoring and management. Therefore, the current study used a network approach to examine associations among health-related role limitations, depressive symptoms, existential well-being, socioeconomic position, and health-promoting behavior in adults with chronic disease. A total of 535 adults (mean ± SD age = 62.9 ± 11.9 years; males, n = 231, females, n = 304) who were regularly visiting an outpatient clinic for chronic disease treatment participated in this cross-sectional study. Data on participant demographics, chronic disease diagnoses, socioeconomic status, health-related role limitations (12-item short form survey scores), depressive symptoms (patient health questionnaire-9 scores), existential well-being (scores for four items of the McGill quality of life questionnaire-Revised), and health-promoting behavior (Healthy Habits Questionnaire scores) were acquired. "Undirected regularized partial correlations" and "directional joint probability distributions" among these variables were calculated using a mixed graphical model (MGM) and directed acyclic graph (DAG). In the MGM, the most influential nodes were emotional well-being, feelings of failure, and health-related limitations affecting usual role and physical activities. According to both the MGM and DAG, the relationship between emotional well-being and feelings of failure mediated the relationships of health-related role limitations with concentration difficulty and suicidal ideation. A positive mindset was dependent on the probability distributions of suicidal ideation, controllability of life, and positive self-image. Both the meaning of life and a positive mindset had direct associations with proactive living. Specifically, proactive living was associated with a balanced diet, regular exercise, volunteering in the community, and nurturing intimacy in social interactions. The meaning and controllability of life in individuals with chronic diseases could mediate the relationships of health-promoting behavior with health-related limitations related to usual role activities, physical activities, and depressive symptoms. Thus, interventions targeting health-promoting behaviors should aim to enhance the meaning and controllability of life (as it pertains to limitations in usual role and physical activities), as well as promote proactive screening and timely psychiatric treatment of depressive symptoms including feelings of failure, concentration difficulties, and suicidal ideation.
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Affiliation(s)
- Je-Yeon Yun
- Seoul National University Hospital, Seoul, Republic of Korea
- Yeongeon Student Support Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Ho Yun
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Family Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
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Kochovska S, Ekström M, Hansen-Flaschen J, Ferreira D, Similowski T, Johnson MJ, Currow DC. Hiding in plain sight: the evolving definition of chronic breathlessness and new ICD-11 wording. Eur Respir J 2023; 61:61/3/2300252. [PMID: 36997231 DOI: 10.1183/13993003.00252-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
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Kochovska S, Chang S, Olsson M, Ekström M, Currow DC. Associations in Perceived Health and Persistent Breathlessness: A Cross-Sectional Study. Palliat Med Rep 2023; 4:120-126. [PMID: 37095863 PMCID: PMC10122221 DOI: 10.1089/pmr.2022.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/26/2023] Open
Abstract
Background Persistent breathlessness is debilitating and increases in prevalence with advanced age and at end of life. This study aimed to evaluate any relationship between self-reported global impressions of change (GIC) in perceived health and breathlessness in older men. Design Cross-sectional study of 73-year-old Swedish men in the VAScular and Chronic Obstructive Lung disease study. A postal survey included items on perceived changes in health and breathlessness (GIC scales) and breathlessness (assessed using the modified Medical Research Council [mMRC] breathlessness scale, Dyspnea-12 and Multidimensional Dyspnea Scale) since age 65. Results Of 801 respondents, breathlessness (mMRC ≥2) was reported by 17.9%, worsening breathlessness by 29.1%, and worsening perceived health by 51.3%. Worsening breathlessness was strongly correlated with worsening perceived health (Pearson's correlation coefficient of 0.68 [p < 0.001] and Kendall's τ of 0.56 [p < 0.001]) and associated with more limited function (47.2% vs. 29.7%; p < 0.0001) and increased rates of anxiety/depression. Conclusion The strong correlation between perceived changes in health and persistent breathlessness helps delineate a more comprehensive picture of the challenges faced by older adults living with this disabling symptom.
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Affiliation(s)
- Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Sungwon Chang
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Max Olsson
- Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden
| | - Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, Lund, Sweden
| | - David C. Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Address correspondence to: David C. Currow, MPH, PhD, FAHMS, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales 2522, Australia.
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