Recognition, diagnosis, and treatment of cognitive and psychiatric disorders in patients with COPD

Do Antidepressants Worsen COPD Outcomes in Depressed Patients with COPD?

The coexistence of depression with chronic obstructive pulmonary disease (COPD) has been associated with poorer outcomes. Studies have questioned the safety of antidepressants in patients with COPD. This review shows the potential relationships and the possible mechanisms and gives us good warnings on how to approach this problem. Treatment should be both non-pharmacological and pharmacological, but importantly tailored to the individual patient.

Psychiatric Disorders in Patients with Chronic Obstructive Pulmonary Disease: Clinical Significance and Treatment Strategies

Chronic obstructive pulmonary disease (COPD) is a debilitating lung disease characterized by chronic airflow limitation and persistent respiratory symptoms. It is a major cause of morbidity and mortality worldwide, significantly impacting healthcare systems with considerable socioeconomic consequences. The main risk factors include exposure to tobacco smoke, environmental pollutants, occupational dust, and genetic factors such as alpha-1 antitrypsin deficiency. COPD is often associated with extrapulmonary comorbidities, particularly psychiatric disorders like depression and anxiety, which worsen patients' quality of life and prognosis. The prevalence of these disorders in patients with COPD varies significantly but is always higher than in healthy controls. Psychiatric disorders can negatively influence COPD management and vice versa, creating a complex bidirectional interaction. Depression and anxiety are the most common psychiatric comorbidities in patients with COPD, influenced by factors such as social isolation, physical limitations, and fear of exacerbations. Diagnosis of these psychiatric disorders is complicated by the overlap of symptoms with those of COPD. However, some screening tools can facilitate early detection. The treatment of psychiatric disorders in patients with COPD in a rehabilitation setting requires a multidisciplinary approach involving pulmonologists, neurologists and psychologists. Pharmacological therapy with antidepressants shows mixed results in terms of efficacy and safety, with some studies reporting benefits on quality of life and others suggesting an increased risk of exacerbations and pneumonia. An integrated approach that includes the assessment and intervention of mental disorders is essential to improve the overall management of COPD and the quality of life of patients. This narrative review provides an overview of the main psychiatric comorbidities in COPD patients, aiming to fill gaps in the literature and suggest areas for future research.

Exploring the Relationship Between Education, Living Environment, and Anxiety/Depression Among Stable Patients: Insights from the COPD-AD China Registry Study

Background

Education and living environment are related to mental health. But the independent and combined effects of them on mental health among patients with chronic obstructive pulmonary disease (COPD) are uncertain.

Methods

The independent and combined effects of education and living environment on mental health were assessed by binary logistic regression in 1064 COPD patients. Additive interaction was assessed with the relative excess risk ratio (RERI), attribution percentage (AP), and synergy index (SI).

Results

Our results shown that low education level and urban living environment were independently associated with higher risks for anxiety (odds ratio [OR]: 1.56, 95% confidence interval [CI] 1.06-2.29 and OR:2.15, 95% CI 1.51-2.05) or depression (OR:1.62, 95% CI 1.17-2.27 and OR: 2.01, 95% CI 1.46-2.75) among COPD patients. The combination effect of them was also associated with higher risks for anxiety (OR: 7.90, 95% CI 3.83-16.29, P < 0.001) or depression (OR: 11.79, 95% CI 5.77-24.10, P < 0.001) among these patients. Furthermore, we observed strong synergistic additive interactions between them for anxiety (SI: 11.57, 95% CI 1.41-95.27; RERI: 6.31, 95% CI 1.60-11.01; AP: 0.8, 95% CI 0.66-0.94) and depression (SI: 31.31, 95% CI 1.59-617.04; RERI: 10.44, 95% CI 2.66-18.23; AP: 0.89, 95% CI 0.8-0.97).

Conclusion

Low education levels and living in urban areas had an independent and synergistic effects on mental health among COPD patients.

Evaluation of Event-Related Potentials in Somatic Diseases - Systematic Review

Many somatic illnesses (e.g. hypertension, diabetes, pulmonary and cardiac diseases, hepatitis C, kidney and heart failure, HIV infection, Sjogren's disease) may impact central nervous system functions resulting in emotional, sensory, cognitive or even personality impairments. Event-related potential (ERP) methodology allows for monitoring neurocognitive processes and thus can provide a valuable window into these cognitive processes that are influenced, or brought about, by somatic disorders. The current review aims to present published studies on the relationships between somatic illness and brain function as assessed with ERP methodology, with the goal to discuss where this field of study is right now and suggest future directions.

Apocynin Prevents Cigarette Smoke-Induced Anxiety-Like Behavior and Preserves Microglial Profiles in Male Mice

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally and is primarily caused by cigarette smoking (CS). Neurocognitive comorbidities such as anxiety and cognitive impairments are common among people with COPD. CS-induced lung inflammation and oxidative stress may "spill-over" into the systemic circulation, driving the onset of these comorbidities. We investigated whether a prophylactic treatment with the NADPH Oxidase 2 (NOX2) inhibitor, apocynin, could prevent CS-induced neurocognitive impairments. Adult male BALB/c mice were exposed to CS (9 cigarettes/day, 5 days/week) or room air (sham) for 8 weeks with co-administration of apocynin (5 mg/kg, intraperitoneal injection once daily) or vehicle (0.01% DMSO in saline). Following 7 weeks of CS exposure, mice underwent behavioral testing to assess recognition and spatial memory (novel object recognition and Y maze, respectively) and anxiety-like behaviors (open field and elevated plus maze). Mice were then euthanized, and blood, lungs, and brains were collected. Apocynin partially improved CS-induced lung neutrophilia and reversed systemic inflammation (C-reactive protein) and oxidative stress (malondialdehyde). Apocynin exerted an anxiolytic effect in CS-exposed mice, which was associated with restored microglial profiles within the amygdala and hippocampus. Thus, targeting oxidative stress using apocynin can alleviate anxiety-like behaviors and could represent a novel strategy for managing COPD-related anxiety disorders.

Clinical and economic burden of anxiety/depression among older adult COPD patients: evidence from the COPD-AD China Registry study

Background

Anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD), especially older adult patients. This can complicate the disease progression and lead to increased clinical and economic burden. We sought to investigate the clinical and economic burdens associated with the presence of anxious and/or depressive symptoms among older adult COPD patients.

Methods

We screened 579 patients aged over 60 years and diagnosed with COPD via a lung function test following the 2017 Global Initiative Chronic Obstructive Lung Disease (GOLD) guidelines. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS) through face-to-face interviews at admission. Follow-up was conducted by telephone calls at 6, 12, 18, 24, and 36 months after discharge to assess clinical and economic burden. COPD-anxiety and/or depression patients were matched to patients without anxiety and depression (COPD-only) using propensity scores. Multivariate regression models were used to compare clinical and economic burden between COPD-anxiety and/or depression and COPD-only groups.

Results

Compared with COPD-only patients, COPD patients complicated with anxiety and/or depression had increased clinical burden, including higher COPD-related outpatient visits, COPD-related hospitalizations, and length of COPD-related hospitalizations (p < 0.001). Moreover, they also had an increased economic burden, including higher annual total healthcare costs, medical costs, and pharmacy costs (p < 0.001).

Conclusion

Older adult COPD patients with anxiety or depression had significantly higher clinical and economic burdens than patients without these comorbidities. These findings deserve further exploration and may be useful for the formulation of relevant healthcare policies.

The impact on thirty day readmissions for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease admitted to an observation unit versus an inpatient medical unit: A retrospective observational study

OBJECTIVES

We aimed to evaluate the utility of an Observation Unit (OU) in management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and to identify the clinical characteristics of patients readmitted within 30-days for AECOPD following index admission to the OU or inpatient floor from the OU.

METHODS

This is a retrospective observational study of patients admitted from January to December 2017 for AECOPD to an OU in an urban-based tertiary care hospital. Primary outcome was rate of 30-day readmission after admission for AECOPD for patients discharged from the OU versus inpatient service after failing OU management. Regression analyses were used to define risk factors.

RESULTS

163 OU encounters from 92 unique patients were included. There was a lower readmission rate (33%) for patients converted from OU to inpatient care versus patients readmitted after direct discharge from the OU (44%). Patients with 30-day readmissions were more likely to be undomiciled, with history of congestive heart failure (CHF), pulmonary embolism (PE), or had previous admissions for AECOPD. Patients with >6 annual OU visits for AECOPD had higher rates of substance abuse, psychiatric diagnosis, and prior PE; when these patients were excluded, the 30-day readmission rate decreased to 13.5%.

CONCLUSION

Patients admitted for AECOPD with a history of PE, CHF, prior AECOPD admissions, and socioeconomic deprivation are at higher risk of readmission and should be prioritized for direct inpatient admission. Further prospective studies should be conducted to determine the clinical impact of this approach on readmission rates.

The patient journey in Chronic Obstructive Pulmonary Disease (COPD): a human factors qualitative international study to understand the needs of people living with COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common condition that causes irreversible airway obstruction. Fatigue and exertional dyspnoea, for example, have a detrimental impact on the patient's daily life. Current research has revealed the need to empower the patient, which can result in not only educated and effective decision-making, but also a considerable improvement in patient satisfaction and treatment compliance. The current study aimed to investigate the perspectives and requirements of people living with COPD to possibly explore new ways to manage their disease.

METHODS

Adults with COPD from 8 European countries were interviewed by human factor experts to evaluate their disease journey through the gathering of information on the age, performance, length, and impact of diagnosis, symptoms progression, and family and friends' reactions. The assessment of present symptoms, services, and challenges was performed through a 90-min semi-structured interview. To identify possible unmet needs of participants, a generic thematic method was used to explore patterns, themes, linkages, and sequences within the data collected. Flow charts and diagrams were created to communicate the primary findings. Following analysis, the data was consolidated into cohesive insights and conversation themes relevant to determining the patient's unmet needs.

RESULTS

The 62, who voluntarily accepted to be interviewed, were patients (61% females, aged 32-70 years) with a COPD diagnosis for at least 6 months with stable symptoms of different severity. The main challenges expressed by the patients were the impact on their lifestyle, reduced physical activity, and issues with their mobility. About one-fourth had challenges with their symptoms or medication including difficulty in breathing. Beyond finding a cure for COPD was the primary goal for patients, their main needs were to receive adequate information on the disease and treatments, and to have adequate support to improve physical activity and mobility, helpful both for patients and their families.

CONCLUSIONS

These results could aid in the creation of new ideas and concepts to improve our patient's quality of life, encouraging a holistic approach to people living with COPD and reinforcing the commitment to understanding their needs.

Effect of individualized PEEP titration by ultrasonography on perioperative pulmonary protection and postoperative cognitive function in patients with chronic obstructive pulmonary disease

OBJECTIVE

To evaluate the effect of the individualized positive end-expiratory pressure (PEEP) lung protection ventilation strategy by combining driving pressure (ΔP) and pulmonary ultrasound (LUS)-based titration on lung function and postoperative cognitive function in patients with chronic obstructive pulmonary disease (COPD) during laparoscopic surgery.

METHODS

A total of 108 patients with COPD undergoing laparoscopic gastrointestinal surgery under general anesthesia were included in this study. They were randomly divided into three groups (n = 36): traditional volume ventilation group (Group C), fixed PEEP 5 cmH₂O group (Group P), and ΔP combined with LUS-based PEEP titration in the resuscitation room group (Group T). All three groups were given volume ventilation mode, I:E = 1:2; In group C, VT was 10 mL/kg and PEEP was 0 cmH₂O; In groups P and T, VT was 6 mL/kg and PEEP was 5 cmH₂O; After mechanical ventilation for 15 min in Group T, ΔP in combination with LUS was used to titrate PEEP. The oxygenation index (PaO2/FiO2), airway platform pressure (Pplat), dynamic lung compliance (Cdyn), Montreal Cognitive Assessment (MoCA), and venous interleukin-6(IL-6) were recorded at the corresponding time points, and the final PEEP value in Group T was recorded.

RESULTS

The final PEEP value of Group T was (6.4 ± 1.2) cmH₂O; Compared with groups C and P: PaO₂/FiO₂ and Cdyn in Group T were significantly increased (P < 0.05) and value of IL-6 was significantly decreased (P < 0.05) at the corresponding time points. Compared with group C, the MoCA score on day 7 after surgery in Group T was significantly higher (P < 0.05).

CONCLUSION

Compared with the traditional ventilation strategy, the individualized ΔP combined with LUS-based PEEP titration in patients with COPD during the perioperative period of laparoscopic surgery can play a better role in lung protection and can improve postoperative cognitive function.

COPD-Related Anxiety: A Systematic Review of Patient Perspectives

Background

Anxiety in patients with chronic obstructive pulmonary disease (COPD) is prevalent but often unidentified and therefore not adequately managed. Clinicians find it difficult to detect anxiety symptoms and to differentiate subclinical anxiety from anxiety disorders, because of the considerable overlap between symptoms of COPD and anxiety.

Purpose

We synthesized existing qualitative research on patients' experiences of COPD-related anxiety with the purpose of gaining a richer understanding and proposing a model of the construct.

Methods

Searches for qualitative studies of patients' experiences of COPD-related anxiety were conducted independently by two authors in the databases of PubMed (MEDLINE), CINAHL (EBSCO), and PsycInfo (APA). English-language studies including patients diagnosed with COPD were reviewed, and data were analyzed using thematic analysis.

Results

A total of 41 studies were included in the review. Four themes related to COPD-related anxiety were identified: initial events; internal maintaining factors; external maintaining factors; and behavioral maintaining factors. Based on the identified four themes, a conceptual model of COPD-related anxiety from the patient perspective was developed.

Conclusion

A conceptual model of COPD-related anxiety from the patient perspective is now available, with the potential to inform future attempts at improving identification and management of COPD-related anxiety. Future research should focus on the development of a COPD-specific anxiety questionnaire containing domains that are relevant from the patient perspective.

Cognitive decline and risk of dementia in older adults after diagnosis of chronic obstructive pulmonary disease

Cognitive screening has been proposed for older adults diagnosed with chronic obstructive pulmonary disease (COPD). Therefore, we examined the change over time in cognitive function and the risk of incident dementia in older adults after COPD diagnosis. A sample of 3,982 participants from the population-based cohort study Good Aging in Skåne was followed for 19 years, and 317 incident COPD cases were identified. The cognitive domains of episodic memory, executive function, and language were assessed using neuropsychological tests. Mixed models for repeated measures and a Cox model were implemented. Participants performed, on average, worse over time on all neuropsychological tests after COPD diagnosis in comparison to those without COPD, although statistical significance differences were only observed for episodic memory and language. The groups had a comparable risk of developing dementia. In conclusion, our results indicate that cognitive screening in the early stages of COPD may be of limited clinical relevance.

Nonpharmacological management of psychological distress in people with COPD

Psychological distress is prevalent in people with COPD and relates to a worse course of disease. It often remains unrecognised and untreated, intensifying the burden on patients, carers and healthcare systems. Nonpharmacological management strategies have been suggested as important elements to manage psychological distress in COPD. Therefore, this review presents instruments for detecting psychological distress in COPD and provides an overview of available nonpharmacological management strategies together with available scientific evidence for their presumed benefits in COPD. Several instruments are available for detecting psychological distress in COPD, including simple questions, questionnaires and clinical diagnostic interviews, but their implementation in clinical practice is limited and heterogeneous. Moreover, various nonpharmacological management options are available for COPD, ranging from specific cognitive behavioural therapy (CBT) to multi-component pulmonary rehabilitation (PR) programmes. These interventions vary substantially in their specific content, intensity and duration across studies. Similarly, available evidence regarding their efficacy varies significantly, with the strongest evidence currently for CBT or PR. Further randomised controlled trials are needed with larger, culturally diverse samples and long-term follow-ups. Moreover, effective nonpharmacological interventions should be implemented more in the clinical routine. Respective barriers for patients, caregivers, clinicians, healthcare systems and research need to be overcome.

Preliminary study of assessing cognitive impairment in older patients with chronic obstructive pulmonary disease by using a cognitive functional assessment tool via a touchscreen personal computer

Background

Unique cognitive impairments related to chronic obstructive pulmonary diseases (COPD) have been increasingly reported. Considering the dementia risk and medication management, older patients with COPD should be evaluated for cognitive impairment. This study aimed to examine whether specific cognitive impairments related to COPD could be detected by an assessment tool using a touchscreen personal computer (PC) in older patients with COPD.

Methods

This study included 28 older male patients with COPD and 30 healthy older male individuals. A touchscreen PC-based cognitive assessment application called CogEvo was used to assess and compare the cognitive function according to five domains: spatial cognition, orientation, working memory, executive function, and attention.

Results

Analysis of variance showed an interaction effect on the indices of cognitive function based on five domains between the two groups, indicating differences in the characteristics of cognitive function in such groups. Betweengroup comparisons as a subtest showed that attention, executive function, and working memory were significantly lower in the COPD group than in the healthy group.

Conclusions

CogEvo can detect specific cognitive impairments associated with COPD, suggesting that it can be potentially used as a screening tool for cognitive impairment in older patients with COPD.

Flourishing despite Chronic Obstructive Pulmonary Disease (COPD): Findings from a Nationally Representative Survey of Canadians Aged 50 and Older

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of mortality and is often associated with serious disability and depression. Little is known about the characteristics of those who are in complete mental health (CMH) despite having COPD. This study’s objectives are to: (1) estimate the prevalence and odds of absence of psychiatric disorders (APD) and CMH among older adults that reported having COPD, compared to their peers that did not; (2) identify factors associated with APD and with CMH. Bivariate and logistic regression analyses were conducted using the nationally representative Canadian Community Health Survey—Mental Health. The results indicate that there was a significantly (p < 0.001) lower prevalence of APD (86.7% vs. 95.0%) and CMH (66.7% vs. 77.0%) among older adults aged 50+ with COPD (n = 703) compared to those without COPD (n = 10,189). Half of the sample was female (50.5%) and the majority of whom were under age 70 (62.5%). Factors significantly (p < 0.05) associated with higher odds of APD and of CMH among older adults with COPD include being married, having a confidant, being physically active, and having no lifetime history of major depressive disorder or generalized anxiety disorder. For every additional adverse childhood experience, the odds of APD declined by 31%. The majority of those with COPD are mentally flourishing despite having this disabling and life-threatening disorder. These findings underline the importance of targeted interventions and outreach to those most vulnerable to poorer mental health outcomes including the socially isolated.

Effects of a nutritional intervention on impaired behavior and cognitive function in an emphysematous murine model of COPD with endotoxin-induced lung inflammation

One cluster of the extrapulmonary manifestations in chronic obstructive pulmonary disease (COPD) is related to the brain, which includes anxiety, depression and cognitive impairment. Brain-related comorbidities are related to worsening of symptoms and increased mortality in COPD patients. In this study, a murine model of COPD was used to examine the effects of emphysema and repetitive pulmonary inflammatory events on systemic inflammatory outcomes and brain function. In addition, the effect of a dietary intervention on brain-related parameters was assessed. Adult male C57Bl/6J mice were exposed to elastase or vehicle intratracheally (i.t.) once a week on three consecutive weeks. Two weeks after the final administration, mice were i.t. exposed to lipopolysaccharide (LPS) or vehicle for three times with a 10 day interval. A dietary intervention enriched with omega-3 PUFAs, prebiotic fibers, tryptophan and vitamin D was administered from the first LPS exposure onward. Behavior and cognitive function, the degree of emphysema and both pulmonary and systemic inflammation as well as blood-brain barrier (BBB) integrity and neuroinflammation in the brain were assessed. A lower score in the cognitive test was observed in elastase-exposed mice. Mice exposed to elastase plus LPS showed less locomotion in the behavior test. The enriched diet seemed to reduce anxiety-like behavior over time and cognitive impairments associated with the presented COPD model, without affecting locomotion. In addition, the enriched diet restored the disbalance in splenic T-helper 1 (Th1) and Th2 cells. There was a trend toward recovering elastase plus LPS-induced decreased expression of occludin in brain microvessels, a measure of BBB integrity, as well as improving expression levels of kynurenine pathway markers in the brain by the enriched diet. The findings of this study demonstrate brain-associated comorbidities - including cognitive and behavioral impairments - in this murine model for COPD. Although no changes in lung parameters were observed, exposure to the specific enriched diet in this model appeared to improve systemic immune disbalance, BBB integrity and derailed kynurenine pathway which may lead to reduction of anxiety-like behavior and improved cognition.

Relationship between chronic obstructive pulmonary disease and cognition in an aging population

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is a common and severe respiratory illness. Prior research suggests that COPD may be associated with depression as well as cognitive impairment and increased risk of dementia. Many studies to date have been relatively small, have largely relied on global screening measures to identify cognitive impairment, and have not examined the potential role of comorbid depression on cognition. This cross-sectional study examined the relationship between COPD and multiple cognitive domains at two time points using data from a large longitudinal population database.

METHODS

Linear multivariate analyses were conducted using secondary data from the Wisconsin Longitudinal Study to determine the effect of lifetime COPD and depressive symptom severity, assessed with the Center for Epidemiological Studies Depression Scale (CESD), on multiple cognitive outcomes.

RESULTS

In both 2004 (n = 1608) and 2011 (n = 1743), lifetime COPD was found to be a non-significant predictor of all cognitive outcomes, while depressive symptom severity predicted significantly lower scores on the immediate recall and digit ordering tasks in 2004 and on all outcomes in 2011. Exploratory analyses in only those with lifetime COPD revealed COPD severity to be a non-significant factor for all outcomes in 2004 and 2011.

CONCLUSION

COPD was not significantly associated with cognition. Conversely, higher depressive symptom severity was significantly associated with poorer performance on additional cognitive tasks in 2011 compared to 2004, suggesting that depression may contribute to cognitive decline, dependent upon the context of aging.

Efficacy and safety of vortioxetine in treatment of patients with major depressive disorder and common co-morbid physical illness

BACKGROUND

The multimodal antidepressant vortioxetine is effective in reducing somatic symptoms in patients with major depressive disorder (MDD), but little is known about its effects in reducing depressive symptoms in patients with common comorbid physical illnesses.

METHODS

This was a pooled analysis of 13 randomized, placebo-controlled trials which evaluated the efficacy (using the Montgomery-Åsberg Depression Rating Scale [MADRS]) and safety of vortioxetine (5-20 mg/day) in adult patients with MDD. We evaluated stable somatic comorbid conditions that were verified by a diagnosis and had sufficient database representation.

RESULTS

Of the 5982 patients included in the database, 963 (16.1%) patients had a diagnosis of cardiovascular disease, 152 (2.5%) had diabetes mellitus and 26 (0.4%) had chronic obstructive pulmonary disorder (COPD). At Week 8, adjusted mean[95%CI] treatment differences (vortioxetine vs. placebo) on MADRS total scores were -2.7[-4.2, -1.3] (p = 0.0002) points for the cardiovascular disease, -4.0[-7.7, -0.4] (p = 0.03) for the diabetes, and -6.2[-21.3, 8.9] (p = 0.36) for the COPD groups. The rate and pattern of adverse events were similar across the sub-groups with comorbidities and was consistent with that expected for vortioxetine treatment.

LIMITATIONS

The primary studies were not designed to investigate the relationship between vortioxetine and comorbidities, nor were the post hoc analyses powered to detect group differences.

CONCLUSIONS

Patients with MDD and comorbid cardiovascular disease or diabetes respond to vortioxetine in a similar way to the broader MDD population. Vortioxetine was generally safe and well tolerated and without unexpected adverse events in these subpopulations, most of whom are taking multiple concomitant medications.

Disease-Specific Anxiety in Chronic Obstructive Pulmonary Disease: Translation and Initial Validation of a Questionnaire

Background

Commonly applied measures of symptoms of anxiety are not sensitive to disease-specific anxiety in patients with chronic obstructive pulmonary disease (COPD). There is a need for validated instruments measuring COPD-specific anxiety. Therefore, we translated the COPD-Anxiety Questionnaire (CAF) into Danish (CAF-R-DK) and performed an initial validation of the psychometric properties in a sample of patients with COPD.

Materials and Methods

Translation procedures followed the World Health Organization guidelines. Participants with COPD completed questionnaires measuring COPD-specific anxiety (CAF-R-DK), general psychological distress (Hospital Anxiety and Depression Scale) as well as variables related to COPD (COPD Assessment Test; modified Medical Research Council dyspnea scale), quality of life (the 12-item Short Form survey, SF12), and socio-demography.

Results

A total of 260 patients with COPD (mean age: 65.0, 69% female) completed questionnaires. The Danish version of CAF-R-DK demonstrated acceptable Cronbach’s α values that were comparable with those of the original CAF. As expected, the CAF-R-DK showed positive correlations with convergent constructs (CAT; HADS) and negative correlations with discriminant constructs (SF-12). However, the results for specific subdomains of the CAF-R-DK indicated inconsistency in the underlying concept of disease-specific anxiety, which was also suggested based on the subsequent confirmatory and exploratory factor analyzes.

Conclusion

The CAF could serve as an important supplement to generic psychological distress screening of patients with COPD in somatic health care settings, and the questionnaire is now available in Danish. Translation into other languages is needed with the purpose of obtaining data for further testing the psychometric properties of the questionnaire.

Impact of anxiety and depression on the prognosis of copd exacerbations

Background

Frequent and highly prevalent as comorbidities in Chronic Obstructive Pulmonary Disease (COPD) patients, both depression and anxiety seem to have an impact on COPD prognosis. However, they are underdiagnosed and rarely treated properly.

Aim

To establish the prevalence of depression and anxiety in patients admitted for Acute Exacerbation of COPD (AECOPD) and determine their influence on COPD prognosis.

Methods

Prospective observational study conducted from October 1, 2016 to October 1, 2018 at the following centers in Galicia, Spain: Salnés County Hospital, Arquitecto Marcide, and Clinic Hospital Complex of Santiago de Compostela. Patients admitted for AECOPD who agreed to participate and completed the anxiety and depression scale (HADS) were included in the study.

Results

288 patients (46.8%) were included, mean age was 73.7 years (SD 10.9), 84.7% were male. 67.7% patients were diagnosed with probable depression, and depression was established in 41.7%; anxiety was probable in 68.2% and established in 35.4%. 60.4% of all patients showed symptoms of both anxiety and depression. Multivariate analysis relates established depression with a higher risk of late readmission (OR 2.06, 95% CI 1.28; 3.31) and a lower risk of mortality at 18 months (OR 0.57, 95% CI 0.37; 0.90).

Conclusion

The prevalence of anxiety and depression in COPD patients is high. Depression seems to be an independent factor for AECOPD, so early detection and a multidisciplinary approach could improve the prognosis of both entities. The study was approved by the Ethical Committee of Galicia (code 2016/460).

Association of using biomass fuel for cooking with depression and anxiety symptoms in older Chinese adults

BACKGROUNDS

Household air pollution exposure is a crucial public concern and have the potential to seriously affect human health. Using biomass fuels for cooking is the main contributor to household air pollution. However, current evidence linked between cooking with biomass fuels and mental health remains limited.

OBJECTIVES

To explore whether cooking with biomass fuels is associated with depression and anxiety symptoms among older adults in China.

METHODS

We obtained data from Chinese Longitudinal Healthy Longevity Survey (CLHLS). Depressive and anxiety symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) and the 7-item Generalized Anxiety Disorder Scale (GAD-7), respectively. Primary cooking fuel type was self-reported. We used logistic regression and linear regression to evaluate the effects of cooking with biomass fuels on depression and anxiety.

RESULTS

A total of 13,361 participants aged 65 years and older (mean age, 84.2 ± 11.5 years) were included in the presented study. A positive association was found between cooking with biomass fuels and both depression symptoms (adjusted odds ratio 1.23, 95% CI 1.03 to 1.47) and anxiety symptoms (adjusted odds ratio 1.31, 95% CI 1.02 to 1.68). Biomass fuel users had a higher depression scores (0.33, 95% CI 0.03 to 0.61) and a higher anxiety scores (0.20, 95% CI 0.02 to 0.38) compared to clean fuel users. We found no significant interactions between participant characteristics and biomass fuel use on either depression or anxiety symptoms.

CONCLUSIONS

Cooking with biomass fuels was associated with depression and anxiety symptoms in order adults. Further large prospective cohort studies are warranted to confirm this association.

A low postabsorptive whole body protein balance is associated with markers of poor daily physical functioning in Chronic Obstructive Pulmonary Disease

BACKGROUND & AIMS

Postabsorptive whole body protein kinetics are related to age, gender, body mass index (BMI), and habitual protein intake level. It is unclear how protein synthesis, breakdown, and postabsorptive protein balance rates are affected in Chronic Obstructive Pulmonary Disease (COPD)) and whether these relate to disease severity, lifestyle characteristics and poor daily functioning.

METHODS

We studied 91 COPD (GOLD 1-4) and 56 age matched control subjects without COPD or other chronic or acute health disease/condition in the postabsorptive state and measured body composition by Dual-energy X-ray Absorptiometry, and disease severity and comorbidities by medical screening, blood analysis and questionnaires. We assessed whole body production rates of phenylalanine and tyrosine by pulse stable isotope tracer infusion to calculate whole body protein breakdown (PB) and hydroxylation of phenylalanine to tyrosine, representative of postabsorptive protein balance. We measured muscle and cognitive function, and physical performance by isokinetic dynamometry, cognitive assessments, and 6-min walk test. We assessed physical activity level, mood and dietary protein intake by questionnaires. We measured plasma enrichments by LC-MS/MS and statistics by Fisher's exact test or analysis of covariance. Data are mean [95% CI].

RESULTS

The COPD patients had moderate to severe airflow obstruction, multiple comorbidities, and elevated values for plasma high sensitivity c-reactive protein (hs-CRP) and glucose. Although PB (3630 [3361, 3900] vs 3504 [3297, 3711] umol/h, p = 0.1649) was not different, postabsorptive protein balance was lower in COPD patients (274.2 [242.4, 306.1] vs 212.9 [194.7, 231.0] umol/h, p < 0.0001), both compared to control subjects. A lower postabsorptive protein balance was associated with age (p < 0.0001) and higher levels for systolic blood pressure (p = 0.0051) and hs-CRP (p = 0.0046) but not with lung function. Furthermore, a lower postabsorptive protein balance level was associated with a lower intake of total calories and protein (p < 0.0001) and lower muscle strength (p = 0.0248), while only in COPD with a lower physical performance (p = 0.0343). We found no association with cognitive function or mood. For all subjects, a cumulative model that included group, gender, age, BMI, systolic blood pressure, hs-CRP, caloric intake, protein intake, and leg strength was able to explain 55% of the variation in postabsorptive protein balance.

CONCLUSION

These data suggest that systemic inflammation, high blood pressure and low protein intake are risk factors of a lower postabsorptive protein balance in COPD patients. A lower postabsorptive protein balance is associated with markers of poor daily physical functioning.

Therapeutic Drug Monitoring of Antidepressants: An Underused but Potentially Valuable Tool in Primary Care

Depressive disorders are among the most burdensome diseases globally in terms of prevalence, as well as in terms of quality of life, morbidity, and mortality. Hence, it is becoming increasingly common for primary care physicians to administer and monitor the treatment of individuals affected by depressive disorders. In this framework, Therapeutic Drug Monitoring (TDM) comes to the forefront. TDM is the measurement of specific drugs in the blood or plasma/serum, and its usefulness lies in the fact that it allows physicians to assess drug levels to personalize and optimize treatments. TDM has been used for decades to measure several classes of psychotropic drugs, such as antiepileptics and antipsychotics, but the use of this tool is still in its infancy in regard to antidepressants. In the context of primary care, TDM of antidepressant drug treatment shows promise, as it can enable primary care physicians to monitor the safety and efficacy of the treatment, leaving to secondary care, i.e., psychiatrists, the management of the more complex clinical cases.

Working memory training efficacy in COPD: the randomised, double-blind, placebo-controlled Cogtrain trial

BACKGROUND

Cognitive impairment is highly prevalent in COPD and is associated with a sedentary lifestyle, unhealthy diet and increased cognitive stress susceptibility. Enhancement of cognitive performance by working memory training (WMT) may reverse these effects. Therefore, this study aimed to investigate the efficacy of WMT in COPD on cognitive performance, healthy lifestyle behaviours and cognitive stress susceptibility.

METHODS

The double-blind randomised, placebo-controlled Cogtrain trial consisted of a 12-week training phase comprising 30 active or sham WMT sessions, followed by a second 12-week maintenance phase with 12 sessions. Measurements took place at baseline and after the first and second phases. The primary outcome was cognitive performance. Secondary outcomes were the recall of prespecified healthy lifestyle goals, physical capacity and activity, dietary quality and cognitive stress susceptibility. Motivation towards exercising and healthy eating and psychological wellbeing were exploratory outcomes.

RESULTS

Sixty-four patients with moderate COPD (45% male, aged 66.2±7.2 years, median forced expiratory volume in 1 s 60.6% predicted) were randomised. WMT significantly increased patients' performance on the trained tasks in the first phase, which remained stable in the second phase. Of the 17 cognitive outcome measures, only one measure of memory improved after the first phase and one measure of reaction time after the second phase. This intervention did not influence physical capacity and activity, recall of prespecified healthy lifestyle goals, psychological wellbeing or cognitive stress susceptibility.

CONCLUSION

WMT improved performance on the trained tasks but not overall cognitive performance, healthy lifestyle behaviours or cognitive stress susceptibility in patients with COPD.

Role of new digital technologies and telemedicine in pulmonary rehabilitation : Smart devices in the treatment of chronic respiratory diseases

BACKGROUND

Asthma and chronic obstructive pulmonary diseases are conditions characterized by a variable progression. Some individuals experience longer asymptomatic periods while others acute worsening periods and/or exacerbations triggered by symptom multiplication factors. Medications are adjusted to the patients' respiratory function, self-assessment of health and emerging certain physical changes. A more effective treatment may be applied by real-time data registered during the patient's everyday life.

AIM AND METHODS

Introducing new modern digital technology in pulmonary rehabilitation (PR) to help tracking the patients' medication, thus we systematically reviewed the latest publications on telemedicine and pulmonary telerehabilitation.

CONCLUSION

The use of the latest digital technologies in PR is very exciting and offers great opportunities while treating patients affected by specific conditions. On the one hand, adherence to medication can be improved in patients with chronic respiratory diseases by using these new state of the art devices; on the other hand, digital devices will also be able to monitor various physiological parameters of patients during their usual everyday activities. Data can be stored on a smartphone and shared with the provider. Relying on this information, physicians will be able to tailor medications and dosage to the specific needs of individual patients. Telerehabilitation may be a sustainable solution to the growing burden of chronic respiratory disease worldwide. However, PR must keep its cornerstones, such as education and motivations, which are most successful when conducted in person. Many issues remain to be resolved in the future, e.g. cybersecurity while using smart devices since they offer unique opportunities for PR.

The complexity of mental health care for people with COPD: a qualitative study of clinicians' perspectives

Anxiety and depression are common mental health illnesses in people with chronic obstructive pulmonary disease (COPD). However, patients often decline formal mental health care with barriers identified at the patient, health provider and health system levels. Currently clinicians’ perspectives on this issue are not well understood. A qualitative study using semi-structured interviews was undertaken to explore clinician perceived barriers and facilitators to acceptance of psychological care amongst people with COPD. Twenty-four Australian respiratory health professionals participated. Interview transcripts were analysed thematically. An overarching theme of ‘complexity’ was identified, which was evident across five domains: (1) physical and mental health illnesses; (2) psychosocial circumstances; (3) community views and stigma; (4) educational needs and knowledge gaps; (5) navigating the health system. Targeted patient education around psychological interventions and integration of mental health clinicians within multidisciplinary outpatient respiratory services are needed to address the current challenges.

Prevalence and Determinants of Mental Health among COPD Patients in a Population-Based Sample in Spain

(1) Background: To assess the prevalence of mental disorders (depression and anxiety), psychological distress, and psychiatric medications consumption among persons suffering from COPD; to compare this prevalence with non-COPD controls and to identify which variables are associated with worse mental health. (2) Methods: This is an epidemiological case-control study. The data were obtained from the Spanish National Health Survey 2017. Subjects were classified as COPD if they reported suffering from COPD and the diagnosis of this condition had been confirmed by a physician. For each case, we selected a non-COPD control matched by sex, age, and province of residence. Conditional logistic regression was used for multivariable analysis. (3) Results: The prevalence of mental disorders (33.9% vs. 17.1%; p < 0.001), psychological distress (35.4% vs. 18.2%; p < 0.001), and psychiatric medications consumption (34.1% vs. 21.9%; p < 0.001) was higher among COPD cases compared with non-COPD controls. After controlling for possible confounding variables, such as comorbid conditions and lifestyles, using multivariable regression, the probability of reporting mental disorders (OR 1.41; 95% CI 1.10–1.82).), psychological distress (OR 1.48; 95% CI 1.12–1.91), and psychiatric medications consumption (OR 1.38 95% CI 1.11–1.71) remained associated with COPD. Among COPD cases, being a woman, poor self-perceived health, more use of health services, and active smoking increased the probability of suffering from mental disorders, psychological distress, and psychiatric medication use. Stroke and chronic pain were the comorbidities more strongly associated with these mental health variables. (4) Conclusions: COPD patients have worse mental health and higher psychological distress and consume more psychiatric medications than non-COPD matched controls. Variables associated with poorer mental health included being a woman, poor self-perceived health, use of health services, and active smoking.

Effect of internet-based self-management on pulmonary function rehabilitation and living quality in patients with chronic obstructive pulmonary disease

OBJECTIVE

This study explored and analyzed the effect of Internet-based self-management on pulmonary function rehabilitation and living quality in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Altogether, 106 stable-staged COPD patients admitted to our hospital from June 2018 to September 2019 were enrolled as the research subjects, and divided into the control group (n=51) and the observation group (n=55) according to the order of visit. The control group received conventional health education, and the observation group was treated with an educational model by Internet-based self-management. Afterwards, the changes of self-management ability, pulmonary function and living quality before and after intervention were compared between the two groups.

RESULTS

The scores of each dimension of self-management behavior in both groups of patients after intervention were critically higher than those prior to intervention (P<0.05), and the scores in observation-group patients were remarkably higher than thoes in control-group patients (P<0.05). Besides, the two groups of subjects were observed with elevated pulmonary function indexes FVC, FEV1 and 6MWD after intervention compared with that in prior-intervention (P<0.05), and the indexes in the observation-group after intervention were obviously higher than those in the control-group (P<0.05). In addition, the scores of each dimension of living quality in both groups after the intervention had a conspicuously rise compared with the prior-intervention period (P<0.05), and the scores in the observation group were remarkably lower than those in the control group (P<0.05). The satisfaction in observation group was obviously higher than that in control group (P<0.05).

CONCLUSION

Internet-based self-management can effectually improve the self-management ability of COPD patients. It is conducive to improve the patients' pulmonary function, and their living quality, thus it is worthy of clinical popularization and application.

Asthma and Chronic Obstructive Pulmonary Disease as a Comorbidity and Association with the Choice of Antidementia Medication Among Persons with Alzheimer's Disease

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are common comorbidities in persons with Alzheimer's disease (AD). However, pharmacotherapy of these diseases may have opposite mechanisms of action; anticholinergics in asthma/COPD and acetylcholinesterase inhibitors (AChEI) in AD.

OBJECTIVE

To investigate whether existing asthma/COPD affects the choice of AD medication, and the survival of the patients with AD.

METHODS

In this retrospective cohort study, data from the MEDALZ-study, which includes all community-dwelling persons with AD during 2005-2011 in Finland (n = 70718) was utilized. Persons with asthma/COPD (N = 7211) were defined as having a special reimbursement for asthma/COPD, or long-term use (≥250 days) of inhaled anticholinergics, inhaled corticosteroids, or leukotriene antagonists during the year before AD diagnosis. We compared persons with and without asthma/COPD regarding the choice of the initial antidementia medication (AChEI versus memantine) with logistic regression and mortality with Cox regression model during the follow-up (up to end of 2015).

RESULTS

Memantine was favored over AChEIs as first-line treatment to AD in persons with asthma/COPD compared to those without asthma/COPD (odds ratio 1.23, 95% confidence interval (CI) 1.15-1.31). Memantine was also more commonly used among those who used multiple asthma/COPD medications (7.9% of memantine initiators used ≥3 asthma/COPD medications compared with 5.5% of those who initiated with AChEI). Mortality was higher in persons with asthma/COPD compared to those without asthma/COPD (adjusted hazard ratio 1.10, 95% CI 1.07-1.13).

CONCLUSION

More frequent use of memantine instead of AChEI may result from an attempt to prevent possible worsening of asthma/COPD by AChEIs. Vulnerable persons with both AD and asthma/COPD need individually assessed pharmacotherapy for their medical conditions.

[COPD, anxiety-depression and cognitive disorders: Does inflammation play a major role?]

COPD is a chronic respiratory disease, often associated with extrapulmonary manifestations. Co-morbidities, including anxiety, depression and cognitive impairment, worsen its progression and quality of life. The prevalence of these disorders is high, yet they are often poorly understood and inadequately managed. In the development of psychological disorders, there is accumulated evidence highlighting the major role of systemic inflammation, as well as chronic disease, genetics, the consequences of smoking, hypoxaemia, oxidative stress, and the gut microbiome In addition to traditional treatments such as bronchodilatator medications, respiratory rehabilitation and smoking cessation, systemic inflammation is an interesting therapeutic target, with the use of anti-inflammatory drugs, anti-cytokines, and nutritional interventions.

Neurological and Psychiatric Comorbidities in Chronic Obstructive Pulmonary Disease

Background and Purpose

Chronic obstructive pulmonary disease (COPD) is often accompanied by different neurological and psychiatric comorbidities. The purpose of this study was to examine which of them are the most frequent and to explore whether their manifestation can be explained by underlying latent variables.

Methods

Data about patients with COPD and their neurological and psychiatric comorbidities were extracted from an electronic database of the National Health Insurance Fund of Lithuania for the period between January 1, 2012, and June 30, 2014. Exploratory factor analysis (EFA) was used to investigate comorbidity patterns.

Results

A study sample of 4834 patients with COPD was obtained from the database, 3338 (69.1%) of who were male. The most frequent neurological and psychiatric comorbidities were nerve, nerve root and plexus disorders (n=1439, 29.8%), sleep disorders (n=666, 13.8%), transient ischemic attack (n=545, 11.3%), depression (n=364, 7.5%) and ischemic stroke (n=349, 7.2%). The prevalence of ischemic stroke, transient ischemic attack, Parkinson’s disease, dementia and sleep disorders increased with age. One latent variable outlined during EFA grouped neurological disorders, namely ischemic stroke, transient ischemic attack, epilepsy, dementia and Parkinson’s disease. The second encompassed depression, anxiety, somatoform and sleep disorders. While similar patterns emerged in data from male patients, no clear comorbidity profiles among women with COPD were obtained.

Conclusion

Our study provides novel insights into the neurological and psychiatric comorbidities in COPD by outlining an association among cerebrovascular, neurodegenerative disorders and epilepsy, and psychiatric and sleep disorders. Future studies could substantiate the discrete pathological mechanism that underlie these comorbidity groups.

Extra-pulmonary manifestations of COPD and the role of pulmonary rehabilitation: a symptom-centered approach

Introduction: Chronic obstructive pulmonary disease (COPD) is a complex and heterogenous disease that is associated with a range of respiratory and non-respiratory symptoms, which highly contribute to the daily burden of the disease. Symptoms burden remains high despite optimal bronchodilator therapy, but pulmonary rehabilitation (PR) is an effective intervention to improve patients' symptoms. A comprehensive interdisciplinary approach within the framework of a PR program is warranted to tackle these complex symptoms and their consequences. Areas covered: This narrative review describes how symptoms of dyspnea, fatigue, cough, sputum, anxiety, depression, pain, sleep disturbances, and cognitive decline arise in COPD and can contribute to several non-pulmonary manifestations of the disease. It also describes evidence of the effectiveness of interdisciplinary PR programs to counteract these symptoms. A literature search was performed on PubMed and Scopus between June and July 2020. Expert opinion: Respiratory and non-respiratory symptoms are highly prevalent, often not comprehensively assessed, and result in several extra-pulmonary manifestations of the disease (physical, emotional and social). Interdisciplinary PR programs can improve these negative manifestations through different pathways, contributing for an effective symptoms' management. A thorough assessment of symptoms (beyond dyspnea) should be routinely performed and may support the identification of treatable traits, allowing the tailoring of PR interventions and assessment of their real-life impact.

Cognitive function following pulmonary rehabilitation and post-discharge recovery from exacerbation in people with COPD

BACKGROUND

Cognitive impairment (CI) is prevalent in COPD and is associated with poor health-related quality of life. Recovery of cognition following an acute exacerbation of COPD (AECOPD), the impact of CI on pulmonary rehabilitation (PR) uptake and the effect of PR on CI are not fully understood.

METHODS

This 6-week prospective study analysed 67 people with stable COPD symptoms who completed PR (PR group) and the recovery of 45 people admitted for AECOPD (AECOPD group). All participants were assessed for cognitive function (Montreal Cognitive Assessment [MoCA]), health status (COPD Assessment Test, Chronic Respiratory Questionnaire), lower extremity function (Short Physical Performance Battery), and psychological well-being (Hospital Anxiety and Depression Score). Follow up assessments were carried out after a 6-week recovery post-discharge in AECOPD group and after PR in the PR group.

RESULTS

AECOPD group showed no improvement in MoCA following a 6-week recovery post-discharge (Δ-0.8 ± 3.2, p = 0.205), despite improvements in all other clinical outcomes. PR uptake among the AECOPD group was not associated with the presence of CI (p = 0.325). Participants in the PR group with CI at baseline showed a significant improvement in MoCA score following PR (Δ1.6 ± 2.4, p = 0.004).

CONCLUSIONS

Cognition does not improve following 6-week recovery post-AECOPD, and CI may influence patients' response to PR referral as an inpatient. PR improves cognition in people with stable COPD symptoms and CI. People with AECOPD should be actively encouraged to attend PR irrespective of mild-moderate cognition but may require additional support or opportunities to take part.

Intrinsic low-frequency oscillation changes in multiple-frequency bands in stable patients with chronic obstructive pulmonary disease

Abnormal local spontaneous brain activity during the resting state has been observed in chronic obstructive pulmonary disease (COPD). However, it is still largely unclear whether the abnormalities are related to specific frequency bands. Our purpose was to explore intrinsic neural activity changes in different frequency bands by using the amplitude of low-frequency fluctuation (ALFF) method in stable COPD patients. Nineteen stable COPD patients and twenty gender-, age- and education-matched normal controls (NCs) underwent functional magnetic resonance imaging scans, cognitive function tests and lung function tests. Two different frequency bands (slow-4: 0.027-0.073 Hz; slow-5: 0.01-0.027 Hz) were calculated and analyzed for frequency-dependent intrinsic neural activity by using the ALFF method. A two-way analysis of variance test was used to compare the main effects of the groups and the frequency bands in the ALFF method. Further post-hoc t-tests were used to compare the differences between COPD patients and NCs in terms of the different frequency bands. A Pearson's correlation analysis was performed to explore the relationship between the altered ALFF brain areas in the different frequency bands and the clinical evaluations in the COPD patients. There were main effects of the groups including significantly higher ALFF values in the right superior temporal gyrus (STG), the bilateral cerebellum posterior lobe (CPL), the right lingual gyrus (LG) and the right brainstem, and as well as significantly decreased ALFF values in the right inferior parietal lobule (IPL) and the angular. The main effect of frequency was demonstrated in the CPL, the STG, the prefrontal cortex and the middle cingulate gyrus. Furthermore, COPD patients exhibited more widespread alterations in intrinsic brain activity in the slow-5 band than in the slow-4 band. Moreover, the abnormal intrinsic brain activity in the slow-4 and slow-5 bands were associated with PaCO₂ in COPD patients. These current results indicated that COPD patients showed abnormal intrinsic brain activity in two different frequency bands, and abnormal intrinsic neuronal activity in different brain regions could be better detected by slow-5 band. These observations may provide a neoteric view into understanding the local neural psychopathology in stable COPD patients.

COVID-19 and clinical neuropsychology: A review of neuropsychological literature on acute and chronic pulmonary disease

Objective: The illness resulting from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), better known as COVID-19, has quickly escalated to a worldwide pandemic. Although understanding of the short and long-term manifestations of COVID-19 remains incomplete, there is a preponderance of respiratory pathology in COVID-19 and potential for chronic loss of pulmonary function in recovered patients, raising concerns for associated cognitive impacts.Method: We conducted a narrative review of the existing literature on neuropsychological variables in acute/severe respiratory disease and various forms of chronic pulmonary disease to inform expectations about potential cognitive manifestations of COVID-19.Results: Cognitive dysfunction is common but not inevitable in acute and chronic pulmonary disease, although unique predictors and symptom trajectories appear to be associated with each.Conclusions: Although the full scope of neuropathophysiology associated with COVID-19 remains to be established, pulmonary insults associated with the disease are likely to produce cognitive dysfunction in a substantial percentage of patients.

Moderate-to-Severe Obstructive Sleep Apnea and Cognitive Function Impairment in Patients with COPD

Purpose

Prior studies have indicated that patients with chronic obstructive pulmonary disease (COPD) exhibit significant cognitive defects on neuropsychological testing. Obstructive sleep apnea (OSA) is common in patients with COPD and is associated with reduced cognitive function; however, the combined impact of these two conditions on cognitive function is unknown. The aim of the study was to investigate the impact of OSA on cognitive impairment in patients with COPD.

Methods

Sixty-five stable COPD patients aged over 60 years underwent overnight polysomnography (PSG). Global cognitive functions were evaluated using the Mini-Mental State Examination (MMSE).

Results

Compared to patients with COPD alone, patients with both COPD and OSA performed worse on the MMSE (25.5±2.9 vs 23.5±3.2; p=0.01) and were more likely to be at risk for developing dementia based on the MMSE score (MMSE≤24) (31% vs 66%; p<0.01), independent of key demographic, educational and medical variables known to affect cognitive function in COPD. COPD patients with an apnea hypopnea index (AHI) of ≥30 events/h had lower MMSE scores than those with an AHI of <15 events/h. In addition to age and education level, the severity of nocturnal intermittent hypoxia is an independent predictor of the risk of dementia in patients with COPD (OR=1.24, 95% CI 1.04-1.48, p = 0.02).

Conclusion

The current findings indicate that patients with COPD with comorbid OSA may be at greater risk for global cognitive impairment relative to patients with COPD alone. The mechanisms underlying the exaggerated cognitive dysfunction seem to be related to intermittent hypoxia. Further work is needed to understand the impact of OSA on the specific domains of cognitive impairment and the therapeutic implications of OSA in COPD.

Multimorbidity in COPD, does sleep matter?

A good night's sleep is a prerequisite for sustainable mental and physical health. Sleep disorders, including sleep disordered breathing, insomnia and sleep related motor dysfunction (e.g., restless legs syndrome), are common in patients with chronic obstructive pulmonary disease (COPD), especially in more severe disease. COPD is commonly associated with multimorbidity, and sleep disorders as a component of this multimorbidity spectrum have a further negative impact on COPD-related comorbidities. Indeed, concomitant diseases in COPD and in obstructive sleep apnea (OSA) are similar, suggesting that the combination of COPD and OSA, the so called OSA-COPD overlap syndrome (OVS), affects patient outcomes. Potential clinically important interactions of OVS exist in cardiovascular and metabolic disease, arthritis, anxiety, depression, neurocognitive disorder and the fatigue syndrome. Correct diagnosis for recognition and treatment of sleep-related disorders in COPD is recommended. However, surprisingly limited information is available and further research and improved diagnostic tools are needed. In the absence of clear evidence, we agree with the recommendation of the Global Initiative on Chronic Obstructive Lung Disease that sleep disorders should be actively searched for and treated in patients with COPD. We believe that both aspects are important components of the holistic approach required in patients with chronic multimorbid conditions.

Presence or Absence of Skeletal Muscle Dysfunction in Chronic Obstructive Pulmonary Disease is Associated With Distinct Phenotypes

INTRODUCTION

Reduced skeletal muscle function and cognitive performance are common extrapulmonary features in Chronic Obstructive Pulmonary Disease (COPD) but their connection remains unclear. Whether presence or absence of skeletal muscle dysfunction in COPD patients is linked to a specific phenotype consisting of reduced cognitive performance, comorbidities and nutritional and metabolic disturbances needs further investigation.

METHODS

Thirty-seven patients with COPD (grade II-IV) were divided into two phenotypic cohorts based on the presence (COPD dysfunctional, n=25) or absence (COPD functional, n=12) of muscle dysfunction. These cohorts were compared to 28 healthy, age matched controls. Muscle strength (dynamometry), cognitive performance (Trail Making Test and STROOP Test), body composition (Dual-energy X-Ray Absorptiometry), habitual physical activity, comorbidities and mood status (questionnaires) were measured. Pulse administration of stable amino acid tracers was performed to measure whole body production rates.

RESULTS

Presence of muscle dysfunction in COPD was independent of muscle mass or severity of airflow obstruction but associated with impaired STROOP Test performance (p=0.04), reduced resting O₂ saturation (p=0.003) and physical inactivity (p=0.01), and specific amino acid metabolic disturbances (enhanced leucine (p=0.02) and arginine (p=0.06) production). In contrast, COPD patients with normal muscle function presented with anxiety, increased fat mass, plasma glucose concentration, and metabolic syndrome related comorbidities (hypertension and dyslipidemia).

CONCLUSION

COPD patients with muscle dysfunction show characteristics of a cognitive - metabolic impairment phenotype, influenced by the presence of hypoxia, whereas those with normal muscle function present a phenotype of metabolic syndrome and mood disturbances.

Association between medicated obstructive pulmonary disease, depression and subjective health: results from the population-based Gutenberg Health Study

Medicated obstructive pulmonary disease (asthma or COPD) has been associated with depression. Yet, there is little knowledge of the interplay of contributing social, biological, behavioral and psychological factors in the community. The study was conducted: (1) To determine the prevalence of depression in participants with medicated COPD or asthma from the general population, (2) to identify underlying social, biological, behavioral and psychological factors and (3) to determine the contribution of obstructive pulmonary disease and depression to subjective health. The population-based sample of 15.010 study participants (35–74 years) from the Gutenberg Health Study (GHS) was queried according to a medical diagnosis of obstructive pulmonary disease, defined as medicated COPD or asthma, and comorbid disorders. Demographic, behavioral and psychological factors were assessed by self-report; lung function (FEV1; FCV) was measured by spirometry. 307 men (4.3%) and 396 women (5.6%) reported a medical diagnosis of COPD or asthma. The prevalence of depression (PHQ-9 > = 10) was twice as high (16.2% vs. 7.5%) compared to participants without obstructive pulmonary disease. Participants with obstructive pulmonary disease were older, had a lower SES, more comorbid diseases and cardiovascular risk factors, higher distress and took more psychotropic medication. In multivariable logistic regression analyses, obstructive pulmonary disease was associated with a 71% increase of depression (OR = 1.71; 95% CI = 1.30 to 2.24). Additional contributors were FEV1 (1.18; 95% CI = 1.05 to 1.32) and dyspnea (NYHA > = 1) (2.19; 1.82 to 2.64), sex (women) (OR = 1.73; 95% CI 1.41 to 2.12), lower SES (OR = 0.98; 95%CI = 0.96 to 0.99). Lack of active sports OR = 0.79; 95% CI 0.68 to 0.92), obesity (OR 1.27; 95% CI 1.07 to 1.50), smoking (OR = 1.26; 95% CI 1.06 to 1.49) and dyslipidemia (OR = 1.35; 95% CI 1.15 to 1.57) also increased the risk of depression. Additional psychological risks were social phobia, type D, low social support, loneliness and life events in the past 12 months. In multivariable linear regression analyses, obstructive pulmonary disease and depression independently contributed to reduced subjective health in addition to sedentary behavior, smoking and comorbid somatic and mental disorders. These findings provide evidence that COPD and asthma are associated with depression in the community. Complex underlying demographic, medical and psychosocial variables have been identified which may justify an integrative treatment approach. Promoting health behavior (smoking cessation, exercising, weight reduction) and social integration may not only improve the somatic course of the disease, but also mental health. Mental health treatment may also improve health behavior and subjective health.

Behavioural interventions targeting physical activity improve psychocognitive outcomes in COPD

This study explored the impact of a self-management behaviour modification (SMBM) programme with/without bronchodilators and with/without exercise training (ExT) to improve daily physical activity on psychological and cognitive outcomes in COPD patients as a secondary analysis of the PHYSACTO trial. A 12-week, four-group, randomised, partially double-blind, placebo-controlled, parallel-group trial of SMBM in addition to tiotropium 5 µg, tiotropium/olodaterol 5/5 µg, tiotropium/olodaterol 5/5 µg plus ExT, or placebo was conducted in 304 patients. Outcomes included anxiety (Hospital Anxiety and Depression Scale (HADS)-A), depression (HADS-D and Patient-Health Questionnaire (PHQ)-9) and cognitive function (Montreal Cognitive Assessment (MoCA)). All outcomes showed statistically and clinically significant improvements after 12 weeks independent of treatment group. However, greater improvements in HADS-A and MoCA were seen in patients who exhibited greater increases in physical activity and exercise capacity, respectively, whereas greater improvements in HADS-D and PHQ-9 were seen in patients who exhibited increases in either physical activity or exercise capacity. The results indicate that SMBM with/without bronchodilators or ExT was associated with improved psychological and cognitive functioning. Anxiety reduced with increased physical activity, cognitive function improved with increased exercise capacity, and depression reduced with increases in either physical activity or exercise capacity. Interventions that increase daily physical activity or exercise capacity may improve psychological and cognitive outcomes in COPD.

Effects of hospital–community integrated transitional care on quality of life in patients with chronic obstructive pulmonary disease†

Objective

To explore the effects of “hospital–community integrated transitional care” model on quality of life in patients with chronic obstructive pulmonary disease (COPD).

Methods

A total of 117 inpatients with COPD from the Department of Respiratory Medicine in a tertiary general hospital in Nanjing were enrolled by convenience sampling from January to December in 2016 and then were divided into intervention group (n = 60) and control group (n = 57) by random number table. Patients in the intervention group accepted both routine care and hospital–community integrated transitional care for 3 months after discharge. Assessment of quality of life by telephone follow-up or interview within a week before discharge and 1, 3, and 6 months after discharge was evaluated using the Short Form-36 (SF-36) health survey questionnaire.

Results

For a total score of quality of life, there was a significant difference between the two groups (P < 0.05): 1, 3, and 6 months after discharge. In addition, for each dimension score of quality of life, there were no significant differences (P > 0.05) except vitality dimension, 1 month after discharge, and there were significant differences in all dimensions, 3 and 6 months after discharge (P < 0.05)

Conclusions

Hospital–community integrated transitional care model can improve the quality of life of patients with COPD.

Enabling patients with advanced chronic obstructive pulmonary disease to identify and express their support needs to health care professionals: A qualitative study to develop a tool

BACKGROUND

Patients with advanced chronic obstructive pulmonary disease have difficulty reporting their holistic support needs to health care professionals, undermining delivery of person-centred care. We lack tools that directly support patients with this.

AIM

To develop an evidence-based, designed-for-purpose, tool to enable patients to directly identify and express support needs to health care professionals.

DESIGN

Two-stage qualitative study. Stage 1: domains of support need were identified through a systematic review, analysis of an established qualitative dataset and patient/carer focus groups. Stage 2: draft tool developed using the identified domains of need and then refined through feedback from patients, carers and health care professionals, ensuring acceptability and suitability.

SETTING/PARTICIPANTS

Stage 1 patients/carers recruited via four primary care practices and two patient support groups (East of England). Stage 2 health care professionals recruited via the Clinical Research Network and local community trust and patients/carers through two further practices and two additional support groups (East of England). In total, 57 patients, carers and health care professionals participated.

RESULTS

A comprehensive set of evidence-based support domains (for example: overcoming boredom or loneliness, knowing what to expect in the future) was identified and formulated into questions. The resulting tool asks patients to consider whether they need more support in 15 broad areas. Patients, carers and clinical stakeholders broadly endorsed the tool's content and wording.

CONCLUSION

The Support Needs Approach for Patients (SNAP) tool is a concise evidence-based tool designed to help patients with advanced chronic obstructive pulmonary disease identify and express their support needs to enable delivery of person-centred care.

Association Between Relevant Co-Morbidities and Dementia With Atrial Fibrillation-A National Study

BACKGROUND

The risk of dementia is increased in patients with atrial fibrillation (AF).

OBJECTIVE

To study relevant co-morbidities and incident dementia (vascular dementia, Alzheimers disease, other dementia and all dementia) in AF patients.

METHODS

All adults (n = 537,513) ≥45 years diagnosed with AF in hospitals in Sweden 1998-2012 were included. Cox regression was used to estimate hazard ratios (HR) with 95% CIs for association between co-morbidities, and incident dementia, after adjustment for age, residence place in Sweden, and socio-economic factors.

RESULTS

Totally 30,332 patients (5.6%) were diagnosed with dementia during the follow-up, with 14,097 men (4.9%) and 16,235 women (6.5%). After adjustments (HRs; 95% CI), hypertension was associated with lower risk of incident dementia (all types) in men (0.79; 0.76-0.82) and women (0.77; 0.74-0.79). Higher risk of dementia was seen in patients with stroke, diabetes, depression and anxiety. Lower risks of dementia were also seen in AF patients with concomitant coronary heart disease and congestive heart failure.

CONCLUSIONS

The findings regarding incident dementia need to be interpreted with great caution, owing to possible "survival bias" or reversed causation. However, the lower associated risks of dementia associated with hypertension could possibly be explained by protective effects of certain antihypertensive drugs.

Implementation of a depression screening protocol among respiratory insufficiency patients

INTRODUCTION

Unnoticed and untreated depression is prevalent among patients with chronic respiratory insufficiency. Comorbid depression causes suffering and worsens patients' outcomes.

OBJECTIVES

The objective of this evaluation was to assess preliminary outcomes of a depression screening protocol among chronic respiratory insufficiency patients at a tertiary care pulmonary outpatient clinic.

METHODS

In the depression screening protocol, the patients filled the Depression Scale (DEPS) questionnaire. Patients whose scores suggested depression were offered the opportunity of a further evaluation of mood at a psychiatric outpatient clinic. The outcomes of the protocol were evaluated retrospectively from the patient records.

RESULTS

During the period of evaluation, 238 patients visited the outpatient clinic. DEPS was administered to 176 patients (74%), of whom 60 (34%) scored ≥9 (out of 30), thus exceeding the cut-off for referral. However, only 13 patients were referred, as the remainder declined the referral. Finally, seven patients were evaluated at the psychiatric clinic, and they all were deemed depressive. Symptoms of depression were most prevalent among patients with a long smoking history, refractory dyspnoea and a history of depression.

CONCLUSION

Depression screening was positive in a third of the patients. The depression screening protocol improved the detection of depression symptoms, but the effects on the patients' treatment and clinical course were small. Rather than referring patients to a psychiatric unit, the evaluation and management of depression should be undertaken at the pulmonary unit.

Psychoeducation for chronic cognitive impairment and reduced early readmissions amongst pulmonary inpatients

Patients with chronic pulmonary disease have been found to have among the highest rates of early (30 days) readmissions by the Center for Medicare and Medicaid Services. Proactive identification and psychoeducational intervention for the effect of chronic cognitive impairment on readmission have not been tested in this population. This is a pre-post quality improvement study for service-wide inpatient pulmonary readmission rates in chronic pulmonary disease. We examined the impact of screening patients for likely cognitive impairment and providing patients/families with psychoeducation regarding 'forgetfulness' on 30-day readmission rates on an inpatient pulmonary service. We observed a 50% decline in early readmissions (25.7% > 12.3%) for the inpatient pulmonary service after initiation of screening and psychoeducation of patients/families for improved adherence despite cognitive impairment (t = -2.53, df= 17, p = 0.011). A randomly assigned, controlled clinical trial is warranted.

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.

Psychological co-morbidities in COPD: Targeting systemic inflammation, a benefit for both?

COPD is a chronic lung disease characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities. Furthermore, COPD is often characterized by extrapulmonary manifestations and comorbidities worsening COPD progression and quality of life. A neglected comorbidity in COPD management is mental health impairment defined by anxiety, depression and cognitive problems. This paper summarizes the evidence for impaired mental health in COPD and focuses on current pharmacological intervention strategies. In addition, possible mechanisms in impaired mental health in COPD are discussed with a central role for inflammation. Many comorbidities are associated with multi-organ-associated systemic inflammation in COPD. Considering the accumulative evidence for a major role of systemic inflammation in the development of neurological disorders, it can be hypothesized that COPD-associated systemic inflammation also affects the function of the brain and is an interesting therapeutic target for nutra- and pharmaceuticals.

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.