Health Literacy Among Patients With Chronic Lung Disease Entering Pulmonary Rehabilitation and Their Resident Loved Ones.

PURPOSE: The objective of this study was determine the prevalence of low health literacy (HL) and low reading ability among patients with chronic lung disease referred for pulmonary rehabilitation (PR) in the Netherlands and their loved ones; and to understand whether low HL or low reading ability influence PR outcomes. METHODS: Health literacy was measured using the Health Literacy Survey-Europe Q16 (HLS-EU-Q16). Reading ability and cognitive functioning were measured using the Rapid Estimate of Adult Literacy in Medicine-Dutch (REALM-D) and the Montreal Cognitive Assessment. Exercise capacity, health status, and symptoms of anxiety and depression were assessed. RESULTS: Patients (n = 120) entering PR and loved ones (n = 41) participated. Of all patients, 51% had low HL and 29% had low reading ability. Also, 39% of all loved ones had low HL. PR outcomes were comparable between patients with low or adequate HL. Patients with adequate reading ability showed greater improvement in symptoms of depression than patients with low reading ability (P = .047). CONCLUSION: Low HL and low reading ability are common among patients entering PR and their loved ones. For patients with low or adequate HL, PR is an effective treatment. Whether considering low HL and low reading ability by offering tailored education during treatment could augment the benefits of PR warrants further study.

Frailty in relation to psycho-social factors in elderly patients with rheumatoid arthritis: A cross-sectional mixed qualitative-quantitative study.

AIM: The aim of the study was to explore in patients with rheumatoid arthritis (RA) ≥55 years: (1) whether the occurrence of frailty as measured by the Groningen Frailty Indicator (GFI) increases with age (survey 1); and (2) to gain insight into which frailty characteristics (eg, loneliness) contribute to frailty (survey 2). METHODS: The GFI was assessed in 3 age groups (55-64/65-74/≥75-years), ensuring equal representation. GFI-subdomains that discriminated most between those classified as frail were further studied in a subset of patients using validated domain-specific questionnaires (eg Hospital Anxiety and Depression Scale [HADS]) and semi-structured interviews. Questionnaires were filled out twice: for current age and the recalled situation at age 40, to see whether psychiatric symptomatology might be misinterpreted for frailty. RESULTS: Of 90 patients included, frailty prevalence on the GFI across age groups was 43.3%-40.0%-43.4%, respectively. Frail patients often reported depressive (73.7% vs. 11.5%) and anxious (57.9% vs. 15.4%) feelings. There were 32/90 patients who filled out the psycho-social questionnaires twice. More frail patients had signs of an anxiety disorder on the HADS (missing data 4 patients), both at current age (5/11 frail patients vs. 0/17 non-frail patients, P = .01) and age 40 (7/11 frail patients vs. 0/0 non-frail patients, P < .01). During the interviews, especially frail patients reported gloomy feelings, although none confirmed depression or anxiety. CONCLUSIONS: Frailty is highly prevalent in RA patients ≥55 years. As frail patients were characterized by symptoms of anxiety both at current age but (recalled) also at age 40, this finding suggests that pre-existing psychiatric symptomatology may confound assessment of frailty.

Development and Evaluation of a Clinic for Elderly Patients with Rheumatoid Arthritis and Multimorbidity: A Pilot Study.

OBJECTIVE: Integrating patient's and physician's goals, especially in elderly patients with multimorbidity, might ultimately improve care. Efforts to develop such care innovations in patients with rheumatoid arthritis (RA) are lacking. The objective of our study was to develop and to pilot test a clinic for elderly patients with RA and multimorbidity. METHODS: First, a referral strategy for and the content of an Elderly Multimorbidity Clinic (EMC) was developed. Next, the EMC was implemented, and it primarily focused on the personal goals of patients and medication review. The EMC was evaluated in a quantitative-qualitative approach. RESULTS: Referral considered useful by the rheumatologist was chosen as the referral criterion. A rheumatologist and internist-geriatrician provided care to referred patients (≥ 55 years) at the EMC during three visits over 1 year. Twenty patients with RA participated in the pilot study (mean age 76.8±7.7 years; 30% male). Only 12 (60%) patients attended the first follow-up consultation, and three (15%) attended the second follow-up consultation. During any follow-up visit, 9/12 (75%) patients achieved one or more goals. Examples of accomplished goals were reduction of medication and improvement of mobility. In 19/20 (95%) patients, medication was remediated (stop medication for 13 patients; start medication for five patients) during the first visit. After 1 year, medication was changed back in 10 patients. Rheumatologists revealed uncertainty about meaningful referral, and patients and rheumatologists mentioned high (caregiver) burden because of extra visits as reasons for not attending follow-up. Patients were satisfied with the care provided. CONCLUSION: This goal-directed EMC led to the accomplishment of at least one goal in 75% of patients. Sustained benefits could not be demonstrated because of low follow-up.

Cognitive performance in relation to metabolic disturbances in patients with COPD.

BACKGROUND & AIMS: Cognitive impairment (CI) and metabolic abnormalities, including the metabolic syndrome (MetS) and sarcopenia, are more prevalent in COPD patients compared to controls without diagnosed lung disease. Because earlier studies have shown these metabolic abnormalities may affect cognitive performance, this study investigated whether cognitive performance is more impaired in subgroups of COPD patients with MetS or sarcopenia. METHODS: Cognitive performance patterns of 170 COPD patients referred for pulmonary rehabilitation (53.5% male, 63.4 ± 9.4 years, FEV1 54.5 ± 22.7% predicted) were compared between COPD subgroups stratified by presence of MetS and sarcopenia. Cognitive performance was assessed using a detailed neuropsychological test battery, which measured psychomotor speed (Stroop Color-Word Test, Concept Shifting Test, Letter-Digit Substitution Test), planning (Behavioral Assessment of the Dysexecutive Syndrome), working memory (Visual-Verbal Learning Test, Digit Span), verbal memory (Visual-Verbal Learning Test) and cognitive flexibility (Stroop Color-Word Test, Concept Shifting Test). MetS was determined according to the NCEP ATP-III criteria. Sarcopenia was determined based on decreased appendicular lean mass by dual-energy x-ray absorptiometry and impaired physical performance by 6-min walking distance. RESULTS: MetS was observed in 54.7% and sarcopenia in 30.0% of COPD patients. The prevalence of general CI was not different between patients with and without MetS (30.4% and 39.0%, respectively) or those with and without sarcopenia (34.0% and 34.5%, respectively, both p > 0.05). Domain-specific cognitive performance was not different between metabolic subgroups, but those with sarcopenia displayed a lower prevalence of CI on verbal memory than those without (21.7% and 29.7%, respectively, p = 0.011). Only the digit span (working memory) subtest was significantly different between metabolic subgroups, in favor of those without MetS (p = 0.017). CONCLUSION: Cognitive performance was not affected more in COPD patients with sarcopenia or MetS.

Geriatric syndromes in patients with rheumatoid arthritis: a literature overview.

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease of unknown aetiology which principally affects the small joints of the hands and feet. The incidence of RA increases with age and peaks within the age range of 70 to 79 years. In the ageing population, therefore, it is expected that the number of patients with RA will grow proportionally and more patients will have comorbidities but also so-called geriatric syndromes (GS). GS are clinical and multifactorial conditions in older persons that are associated with poor health outcomes, do not fit into disease categories (comorbidities) and require a multidimensional treatment approach. Patients suffering from RA may be at increased risk for GS. Therefore, it is important that rheumatologists are knowledgeable about the constructs represented by GS, understand the main risk factors, and gain insight in how to recognise these syndromes. Limited awareness of the (risk for) GS in patients with RA among rheumatologists may lead to ineffective management of RA. Our objective was to provide a comprehensive overview about the prevalence, aetiologic factors and health consequences of the most important GS in patients with RA.

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

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

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

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

The Impact of Cognitive Impairment on Efficacy of Pulmonary Rehabilitation in Patients With COPD.

OBJECTIVES: To compare changes in pulmonary rehabilitation (PR) dropout and outcomes between chronic obstructive pulmonary disease (COPD) patients with and without cognitive impairment. DESIGN: A cross-sectional observational study. SETTING: Patients with COPD were recruited from a PR centre in the Netherlands. PARTICIPANTS: The study population consisted of 157 patients with clinically stable COPD who were referred for and completed PR. MEASUREMENTS: A comprehensive neuropsychological examination before start of PR was administered. Changes from baseline to PR completion in functional exercise capacity [6-minute walk test (6MWT)], disease-specific health status [COPD Assessment Test (CAT) and St George's Respiratory Questionnaire-COPD specific (SGRQ-C)], psychological well-being [Hospital Anxiety and Depression Scale (HADS)], COPD-related knowledge, and their need for information [Lung Information Needs Questionnaire (LINQ)] were compared between patients with and without cognitive impairment using independent samples t tests or Mann-Whitney U tests. RESULTS: Out of 157 patients with COPD [mean age 62.9 (9.4) years, forced expiratory volume in the first second 54.6% (22.9%) predicted], 24 patients (15.3%) did not complete PR. The dropout rate was worse in patients with cognitive impairment compared to those without cognitive impairment (23.3% and 10.3%, P = .03). Mean changes in PR outcomes after PR did not differ between completers with and without cognitive impairment. The proportion of patients with a clinically relevant improvement in 6MWT, CAT, SGRQ-C, HADS, and LINQ scores was comparable for patients with and without cognitive impairment. CONCLUSION: PR is an effective treatment for patients with COPD and cognitive impairment. Yet patients with cognitive impairment are at increased risk for not completing the PR program.

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

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

Sleep quality disturbances and cognitive functioning in elderly patients with COPD.

Information about the association between cognitive functions, such as copying function, and sleep disturbances in patients with chronic obstructive pulmonary disease (COPD) is lacking. This cross-sectional observational study aimed to investigate the association between copying function and self-reported sleep quality disturbances and disease severity in an elderly COPD population. Cognitive function performances, assessed using the Mini-Mental State Examination, were compared in 562 ambulatory COPD patients with and without sleep disturbances; assessed using the Established Populations for Epidemiologic Studies of the Elderly questionnaire; and stratified by Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades. Sleep disturbances overall were not correlated with cognitive functioning. A trend was revealed towards worse design copying in patients with sleep disturbances overall. GOLD I patients with difficulties falling asleep and nocturnal awakenings had worse copying ability compared to GOLD I patients without these sleep disturbances. Copying ability was worse for GOLD III than GOLD I, orientation was worse for GOLD II than GOLD I and language was worse for GOLD II and III than GOLD I. To conclude, sleep disturbances seem to be a weak correlate of cognitive functioning, and are not a marker of disease severity.

Presence of brain pathology in deceased subjects with and without chronic obstructive pulmonary disease.

Patients with chronic obstructive pulmonary disease (COPD) have extrapulmonary co-morbidities, such as cardiovascular disease, musculoskeletal wasting and neuropsychological conditions. To date, it remains unknown whether and to what extent COPD is associated with a higher prevalence of brain pathology. Therefore, the aim of this retrospective study was to compare the prevalence of neuropathological brain changes between deceased donors with and without COPD. Brain autopsy reports of age-matched donors with (n = 89) and without COPD (n = 89) from the Netherlands Brain Bank were assessed for demographics, cause of death, co-morbidities and brain pathology. The prevalence of degenerative brain changes was comparable for donors with and without COPD (50.6% vs. 61.8%, p > 0.05). Neoplastic brain changes were reported in a minority of the donors (5.6% vs. 10.1%, p > 0.05). After correction for cerebrovascular accident or cardiac cause of death and Charlson co-morbidity index score, the prevalence of vascular brain changes was higher among control versus COPD donors (27.0% vs. 11.2%, adjusted p = 0.013, odds ratio = 2.98). Brain autopsy reports of donors with and without COPD did not reveal differences in the presence of degenerative or neoplastic brain changes. Vascular brain changes were described more often in controls. Prospective studies including spirometry and structural and functional brain imaging should corroborate our findings.

COgnitive-pulmonary disease.

Over the past few decades, chronic obstructive lung disease (COPD) has been considered a disease of the lungs, often caused by smoking. Nowadays, COPD is regarded as a systemic disease. Both physical effects and effects on brains, including impaired psychological and cognitive functioning, have been demonstrated. Patients with COPD may have cognitive impairment, either globally or in single cognitive domains, such as information processing, attention and concentration, memory, executive functioning, and self-control. Possible causes are hypoxemia, hypercapnia, exacerbations, and decreased physical activity. Cognitive impairment in these patients may be related to structural brain abnormalities, such as gray-matter pathologic changes and the loss of white matter integrity which can be induced by smoking. Cognitive impairment can have a negative impact on health and daily life and may be associated with widespread consequences for disease management programs. It is important to assess cognitive functioning in patients with COPD in order to optimize patient-oriented treatment and to reduce personal discomfort, hospital admissions, and mortality. This paper will summarize the current knowledge about cognitive impairment as extrapulmonary feature of COPD. Hereby, the impact of smoking on cognitive functioning and the impact of cognitive impairment on smoking behaviour will be examined.

The COgnitive-Pulmonary Disease (COgnitive-PD) study: protocol of a longitudinal observational comparative study on neuropsychological functioning of patients with COPD.

INTRODUCTION: Intact cognitive functioning is necessary for patients with chronic obstructive pulmonary disease (COPD) to understand the value of healthy lifestyle guidelines, to make informed decisions and subsequently act on it. Nevertheless, brain abnormalities and cognitive impairment have been found in patients with COPD. To date, it remains unknown which cognitive domains are affected and what the possible consequences are of cognitive impairment. Therefore, objectives of the study described are to determine neuropsychological functioning in patients with COPD, and its influence on health status, daily functioning and pulmonary rehabilitation outcome. Furthermore, structural and functional brain abnormalities and the relationship with cognitive and daily functioning will be explored. METHODS AND ANALYSIS: A longitudinal observational comparative study will be performed in 183 patients with COPD referred for pulmonary rehabilitation and in 90 healthy control participants. Demographic and clinical characteristics, activities of daily living and knowledge about COPD will be assessed. Baseline cognitive functioning will be compared between patients and controls using a detailed neuropsychological testing battery. An MRI substudy will be performed to compare brain abnormalities between 35 patients with COPD with cognitive impairment and 35 patients with COPD without cognitive impairment. Patients will be recruited between November 2013 and November 2015. ETHICS AND DISSEMINATION: The study has been approved by the Medical Ethics Committee of the University Hospital Maastricht and Maastricht University (NL45127.068.13/METC 13-3-035) and is registered in the Dutch trial register. All participants will provide written informed consent and can withdraw from the study at any point in time. Assessment and home visit data material will be managed anonymously. The results obtained can be used to optimise patient-oriented treatment for cognitively impaired patients with COPD. The findings will be disseminated in international peer-reviewed journals and through research conferences.

Cognitive functioning in obstructive lung disease: results from the United Kingdom biobank.

OBJECTIVES: To compare domains of cognitive functioning between persons with and without obstructive lung disease (OLD) and to analyze the relationship between cognitive functioning and the degree of airflow limitation. DESIGN: An observational population-based study. SETTING: This research was conducted using the United Kingdom Biobank Resource. PARTICIPANTS: The study population consisted of 43,039 persons with complete data on cognitive functioning and spirometry. MEASUREMENTS: Cognitive functioning was compared between persons with and without OLD using linear regression analysis. The relationship between impairment in lung function and cognitive impairment was assessed among persons with OLD. RESULTS: Persons with OLD had significantly worse scores than persons without OLD on prospective memory [ß = -0.15 (-0.22 to -0.09)], visuospatial memory [ß round 1 = 0.06 (0.03‒0.10)]; ß round 2 = 0.09 (<0.001‒0.18)), numeric short-term memory [ß = ‒0.05 (‒0.10 to <0.001)] and cognitive processing speed [ß = 4.62 (1.25‒8.01)] after correction for possible confounders. Impairment in prospective memory [ß = 0.004 (<0.001‒0.01)] and numeric short-term memory [ß = 0.01 (0.003‒0.01)] were weakly related to FEV1 (adjusted P < .05). CONCLUSIONS: Persons with OLD experience cognitive impairment in different domains, which is partially related to airway obstruction. In particular, memory and information processing are affected. Further assessment of the relationship with patient-related outcomes is needed to optimize patient-oriented treatment.