Post Hoc Analysis of Lung Function Improvement and Patient-Reported Outcomes With Revefenacin in Adults With Moderate-to-Very Severe COPD and Comorbid Anxiety or Depression.

Background: Revefenacin, a once-daily, nebulized, long-acting muscarinic antagonist approved in the United States for the maintenance of chronic obstructive pulmonary disease (COPD), significantly improves lung function and quality of life versus placebo in patients with moderate-to-very severe COPD. Comorbid anxiety and/or depression may alter patients' symptom perception and response to bronchodilators. The impact of revefenacin in patients with COPD with comorbid anxiety and/or depression has not been previously investigated. Methods: This post hoc subgroup analysis examined data from two 12-week, randomized, phase 3 trials in patients with moderate-to-very severe COPD with the following self-reported subgroups: anxiety only (A), depression only (D), anxiety and depression (+A/+D), and neither anxiety nor depression (-A/-D). We assessed change from baseline in trough forced expiratory volume in 1 second (FEV1) at Day 85 and health status by the St George's Respiratory Questionnaire (SGRQ) and COPD Assessment Test (CAT). Results: Of 812 patients, 90 (11%), 110 (14%), 141 (17%), and 471 (58%) had A, D, +A/+D, and -A/-D respectively. In revefenacin versus placebo, trough FEV1 significantly improved from baseline at Day 85 across all subgroups as well as the SGRQ and CAT scores in patients with A, +A/+D, and -A/-D. Revefenacin was well tolerated regardless of A/D status, with a minimal incidence of treatment-emergent antimuscarinic adverse events across subgroups. Conclusion: In this analysis, revefenacin versus placebo significantly improved health outcomes in patients with moderate-to-very severe COPD with A, +A/+D, and -A/-D, but not in patients with D. The safety profile of revefenacin was not affected by comorbid anxiety/depression status.

Association between self-reported falling risk and risk of hospitalization for patients with chronic obstructive pulmonary disease.

RATIONALE: The association between self-report falling risk in persons with COPD and hospitalization has not been previously explored. OBJECTIVE: To examine whether self-reported risk is associated with hospitalizations in patients with COPD. METHODS: A secondary analysis from a prospective observational cohort study of veterans with COPD. Participants completed questions from the Stopping Elderly Accidents, Deaths and Injuries (STEADI) tool kit at either baseline or at the end of the 12-month study. A prospective or cross-sectional analysis examined the association between responses to the STEADI questions and risk of all-cause or COPD hospitalizations. RESULTS: Participants (N = 388) had a mean age of 69.6 ± 7.5 years, predominately male (96 %), and 144 (37.1 %) reported having fallen in the last year. More than half reported feeling unsteady with walking (52.6 %) or needing to use their arms to stand up from a chair (61.1 %). A third were concerned about falling (33.3 %). Three questions were associated with all-cause (not COPD) hospitalization in both unadjusted and adjusted cross-sectional analysis (N = 213): "fallen in the past year" (IRR 1.77, 95 % CI 1.10 to 2.86); "unsteady when walking" (IRR 1.88, 95 % CI 1.14 to 3.10); "advised to use a cane or walker" (IRR 1.89, 95 % CI 1.16 to 3.08). CONCLUSIONS: The prevalence of self-reported falling risk was high in this sample of veterans with COPD. The association between falling risk and all-cause hospitalization suggests that non-COPD hospitalizations can negatively impact intrinsic risk factors for falling. Further research is needed to clarify the effects of all-cause hospitalization on falling risk in persons with COPD.

Anxiety and post-traumatic stress disorders in patients with chronic respiratory diseases.

PURPOSE OF REVIEW: This brief critical review evaluates recent research on the impact of anxiety disorders and post-traumatic stress disorders (PTSD) on patients with chronic obstructive pulmonary disease (COPD) and asthma. In these patients, untreated anxiety and PTSD exacerbate acute symptoms, increase disability and impair quality of life. Therefore, effective interventions are also reviewed. RECENT FINDINGS: Anxiety disorders and PTSD are prevalent in COPD and asthma, worsen symptoms in acute exacerbations, and increase morbidity and healthcare utilization. Pulmonary rehabilitation (PR), cognitive behavioural therapy and pharmacological therapy are each effective in COPD patients with anxiety or PTSD. However, very little work examined therapy for combined anxiety and PTSD in patients with either COPD or asthma. SUMMARY: Despite the high prevalence of anxiety disorder or PTSD in patients with chronic respiratory diseases, a paucity of literature remains demonstrating the efficacy of pharmacological therapies for these conditions. This review highlights the promising benefits of PR on anxiety, but prospective trials are needed to demonstrate the efficacy of interventions with PTSD alone, or with concomitant anxiety.

Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline.

Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.

Clinical Markers Associated With Risk of Suicide or Drug Overdose Among Individuals With Smoking Exposure: A Longitudinal Follow-up Study of the COPDGene Cohort.

BACKGROUND: Studies have shown that COPD and smoking are associated with increased suicide risk. To date, there are no prospective studies examining suicide risk among individuals with smoking exposure along a spectrum of pulmonary diseases ranging from normal spirometry to severe COPD. RESEARCH QUESTION: Which clinical variables predict death by suicide or overdose of indeterminate intent in a large cohort of individuals with smoking exposure within the Genetic Epidemiology of COPD (COPDGene) study? STUDY DESIGN AND METHODS: We studied data from 9,930 participants involved in COPDGene, a multisite, prospective cohort study of individuals with smoking exposure. Primary cause of adjudicated deaths was identified by using death certificates, family reports, and medical records. Time to death by suicide/overdose was examined as the primary outcome in Cox regression models including age, sex, race, BMI, pack-years, current smoking status, airflow limitation (FEV1 % predicted), dyspnea (modified Medical Research Council scale score ≥ 2), 6-min walk distance, supplemental oxygen use, and severe exacerbations in the prior year with time-varying covariates and other causes of death as a competing risk. RESULTS: The cohort was 47% female and 33% Black (67% White); they had a mean ± SD age of 59.6 ± 9.0 years and a mean FEV1 % predicted of 76.1 ± 25.5. Sixty-three individuals died by suicide/overdose. Factors associated with risk of suicide/overdose were current smoking (hazard ratio [HR], 6.44; 95% CI, 2.64-15.67), use of sedative/hypnotics (HR, 2.33; 95% CI, 1.24-4.38), and dyspnea (HR, 2.23; 95% CI, 1.34-3.70). Lower risk was associated with older age (per-decade HR, 0.45; 95% CI, 0.31-0.67), higher BMI (HR, 0.95; 95% CI, 0.91-0.99), and African-American race (HR, 0.41; 95% CI, 0.23-0.74). Severity of airflow limitation (FEV % predicted) was not associated with suicide risk. INTERPRETATION: In this well-characterized cohort of individuals with smoking exposure with and without COPD, risk factors for suicide/overdose were identified that emphasize the subjective experience of illness over objective assessments of lung function.

Technology-Dependent Rehabilitation Involving Action Observation and Movement Imagery for Adults with Stroke: Can It Work? Feasibility of Self-Led Therapy for Upper Limb Rehabilitation after Stroke.

Background: Motor (re)learning via technology-dependent therapy has the potential to complement traditional therapies available to older adults living with stroke after hospital discharge and increase therapy dose. To date, little is known about the feasibility of technology-dependent therapy in a home setting for this population. Objective: To develop a technology-dependent therapy that provides mental and physical training for older adults with stroke and assess feasibility. Specifically we ask, "Can it work"? Design: Single group repeated measures. Methods: 13 participants, aged 18 years and over, were recruited over a six-month period. All participants had mild upper limb impairment following a stoke and were no longer receiving intensive rehabilitation. All participants received 18 days of technology-dependent therapy in their own home. Information was gathered on recruitment and retention, usability, and suitability of outcome measures. Results: 11 participants completed the study. The recruitment rate (number recruited/number canvassed; 10.7%) suggests 1907 participants would need to be canvassed to recruit the necessary sample size (n = 204) for a definitive trial designed to provide 90% power at 5% level of significance to detect a clinically meaningful difference of 5.7 points on the Action Research Arm Test. The usability of the application was rated as exceptional on the System Usability Scale. Effectiveness cannot be determined from this study; however, there was a trend for improvement in measures of upper limb function and emotional well-being. Limitations. The study was limited by a relatively small sample size and lack of control group. Conclusions: This study demonstrated proof of concept of a technology-dependent therapy for upper limb rehabilitation following stroke. The data suggest a definitive trial is feasible, additional strategies to improve recruitment should be considered. Outcome measures aligned with the residual motor function of participants are required.

Depressive and anxiety symptoms in patients with COPD: A network analysis.

BACKGROUND: Individuals with Chronic Obstructive Pulmonary Disease (COPD) often develop anxiety and depression, which worsen illness management and prognosis. Physical and psychological symptoms, contextual and illness-related factors display complex reciprocal interactions, which give rise to heterogeneous presentations. Examining the patterns of association between specific physical and psychological symptoms in patients with COPD may help to focus on the precision of the patient-centred care. RESEARCH QUESTION: We used network analyses to examine the links between symptoms of COPD, depression and anxiety. METHODS: Data from 1587 individuals with COPD from the COPDGene study were included. We estimated a Bayesian Gaussian Graphical Model to highlight the unique associations between symptoms of COPD (assessed with the COPD Assessment Test), depression and anxiety (assessed with the Hospital Anxiety and Depression Scale (HADS), while examining the role of sociodemographic characteristics, lung function tests, and health status. RESULTS: Unique Variable Analysis reduced 14 HADS items to Tension/worry (chronic anxiety), Fear/panic (acute anxiety), Restlessness, Anhedonia, Sadness and Slowing. In network analyses, chest-tightness was related to acute anxiety, while cough and weakness were connected with core depressive symptoms (sadness and lack of pleasure). Chronic anxiety was linked with acute anxiety and depressive symptoms. Findings were confirmed accounting for the role of confounders, including lung function, sex, ethnicity and lifestyle factors. A simulation based on our model yielded distinct predictions about anxiety and depression in two participants with similar COPD severity, but different symptom profiles. CONCLUSION: Network analyses highlighted specific associations between symptoms of COPD, depression and anxiety. Accounting for symptom-level interactions may help to promote personalized treatment approaches.

The effectiveness of pulmonary rehabilitation on chronic obstructive pulmonary disease patients with concurrent presence of comorbid depression and anxiety.

BACKGROUND: We examined the prevalence of comorbid depression and anxiety in patients with chronic obstructive pulmonary disease (COPD) and their response to eight-weeks of pulmonary rehabilitation (PR). METHODS: Seven hundred thirty four patients with clinically stable COPD completed an eight-week outpatient multidisciplinary PR, comprising 2-h (1-h exercise and 1-h education) per/week. Depression and anxiety, exercise capacity, quality of life (QOL), and dyspnea were measured pre- and post-PR by the incremental shuttle walk test (ISWT), St. George's Respiratory Questionnaire (SGRQ), and modified Medical Research Council (mMRC) scale, respectively. The Depression Anxiety Stress Scale (DASS-21) was completed and patients classified as having clinically significant comorbid anxiety and depression, anxiety alone, depression alone, or with neither. RESULTS: The mean (SD) age of patients was 71 (8.8) years, and 51% were men. Prevalence of pre-PR comorbid depression and anxiety was 34%, anxiety alone 20%, depression alone 5% and neither 41%. The prevalence of stress was 59%. In patients with anxiety and depressive symptoms, total SGRQ score improved from 64.9 (13.8) pre-PR to 50.1 (17.2) post PR (p < 0.001), mMRC score improved from 3.4(1.0) pre-PR to 2.8 (1.1) post PR (p < 0.001), and ISWT distance walked increased from 188.6 (117.6) pre-PR to 248.6 (149.1) post PR, p < 0.001. CONCLUSION: One in three patients with COPD suffer from comorbid depression and anxiety with a high level of disease burden, reflected by symptoms of elevated dyspnea and impaired QOL. PR improves QOL and exercise capacity, and reduces dyspnea in patients with COPD and comorbid depression and anxiety.

Improvement in Lung Function and Patient-Reported Outcomes in Patients with COPD with Comorbid Anxiety and Depression Receiving Nebulized Glycopyrrolate in the GOLDEN 3 and 4 Studies.

BACKGROUND: Anxiety and depression (A/D) are common in patients with chronic obstructive pulmonary disease (COPD) and are often associated with lower adherence to treatment and worse patient-related outcomes. However, studies on the impact of comorbid A/D on responses to bronchodilators are limited. METHODS: This post hoc analysis of pooled data (N=861) from the GOLDEN 3 and 4 studies compared the efficacy and safety of nebulized glycopyrrolate (GLY) 25 µg in patients with moderate-to-very-severe COPD, grouped by self-reported A/D. Changes in forced expiratory volume in 1 second (FEV1) and health-related quality of life determined by St George's Respiratory Questionnaire (SGRQ) scores in patients with or without comorbid A/D (A/D [+] or A/D [-]) were examined following 12 weeks of GLY 25 µg twice-daily (BID) or placebo treatment. RESULTS: A/D (+) patients were predominantly female, younger, included a higher proportion of current smokers, and had higher baseline SGRQ scores compared with the A/D (-) group. At 12 weeks, GLY resulted in placebo-adjusted improvements from baseline in FEV1 of 46.9 mL (p=0.19; not significant) and 106.7 mL (p<0.0001), in the A/D (+) and A/D (-) groups, respectively. Improvements were observed with GLY compared to placebo in SGRQ scores, regardless of baseline A/D status; the placebo-adjusted least squares mean change from baseline in SGRQ total scores was -3.16 (p>0.05) and -3.34 (p<0.001), for the A/D (+) and A/D (-) groups, respectively. Despite numerical improvements in SGRQ scores with GLY in the A/D (+) group, a higher response to placebo was observed. GLY was generally well tolerated throughout 12 weeks of treatment; incidence of adverse events was higher in the A/D (+) group compared with the A/D (-) group in both treatment arms. CONCLUSION: GLY 25 µg BID resulted in numerical improvements in FEV1, SGRQ total scores and SGRQ responder rates in patients with moderate-to-very-severe COPD, regardless of A/D status at baseline; significant improvements were noted only in the A/D (+) group. The results emphasize the importance of considering underlying comorbidities including A/D when evaluating the efficacy of COPD treatments.

Association of mild cognitive impairment and characteristic of COPD and overall health status in a cohort study.

Introduction: We evaluated risk factors and demographic characteristics of associated with mild cognitive impairment (MCI) in patients with COPD. Methods: 220 individuals with COPD enrolled in a cohort study designed to evaluate anxiety conducted at 16 clinical centers. Cognitive impairment was assessed with the Montreal Cognitive Assessment (MoCA), a cutoff score of <26 defined as MCI. Data were collected including spirometry, 6-minute walk test, symptom burden by COPD Assessment Test and dyspnea by Modified Medical Research Council, anxiety measured by Anxiety Inventory of Respiratory Disease, Generalized Anxiety Disorder-7 and Hospital Anxiety Depression Scale, depression by Patient Health Questionnaire-9 and health status by Patient Reported Outcomes Measurement Information System and sleep quality by the Pittsburg Sleep Quality Index. Results: The median age was 65 years and 54% of participants were male. 119(54%) of participants had MCI as classified by MoCA. In multivariable logistic regression, higher odds ratios (OR) (95% confidence interval) for MCI (MoCA) <26 were associated with increased years of age, 1.06 (1.02 -1-09, p<0.003); African-American race, 3.68(1.67-8.11, p<0.001); persistent phlegm, 2 (1.12-3.57, p<0.01) and sleep disturbance, 1.04(1.01-1.08, p<0.01). Conclusions: COPD patients commonly screen positive for MCI. Characteristics associated with MCI included age, African-American race, sleep disturbance and persistent phlegm.

Long-Term Benefits of Pulmonary Rehabilitation in Patients With COPD: A 2-Year Follow-Up Study.

BACKGROUND: Pulmonary rehabilitation (PR) improves exercise capacity in patients with COPD in the short term. RESEARCH QUESTION: In patients with COPD, does 8 weeks of PR confer long-term benefits on symptoms of dyspnea, anxiety, and depression, and on quality of life, 2 years after completion? STUDY DESIGN AND METHODS: One hundred and sixty-five patients with COPD completed an 8-week, community-based, comprehensive PR program, comprising 2-h sessions twice weekly. Sessions included aerobic exercise and an educational program. Patients were encouraged to perform daily walking exercise up to 30 min at home. We evaluated a number of outcome measures at baseline, 8 weeks, and 2 years, including the following: dyspnea measured with the modified Medical Research Council (mMRC) questionnaire, quality of life assessed with the St. George's Respiratory Questionnaire (SGRQ), and anxiety measured with the Anxiety Inventory for Respiratory Disease (AIR) and the Depression Anxiety Stress Scale (DASS). In addition, we measured exercise capacity, using the Incremental Shuttle Walk Test (ISWT), at baseline and 8 weeks. RESULTS: Mean age (SD) was 72 (8.6) years; 55% were men. At 8 weeks, improvements in mMRC, SGRQ, ISWT, DASS, and AIR were all statistically significant (P < .001). During the 2-year follow-up, changes observed at 8 weeks were maintained for anxiety symptoms, and for symptoms, impact, and total SGRQ scores. In multivariate analysis, initial elevated levels of dyspnea, depression, anxiety, and decreased exercise capacity predicted greater quality of life improvement at 2 years (all P < .001). INTERPRETATION: Over a 2-year period, an effective 8-week PR program provides sustained improvement in anxiety and quality of life. Short-term improvements in dyspnea, depression, and stress symptoms at 8 weeks were not maintained at 2 years.

Psychiatric Collaborative Care for Patients With Respiratory Disease.

Psychiatric disorders are common in patients with advanced respiratory diseases, including COPD and asthma. These comorbid illnesses are often associated with poor compliance with medical treatment, increased disability, heightened health-care utilization, and premature mortality. Seeking to improve patient outcomes, improve patient satisfaction, and decrease the cost of care has led to the creation of alternative care and reimbursement models. One of the most mature of these models is the collaborative care model (CoCM). This model is team-based care; team members being the primary care provider, a care manager, and a psychiatric care provider. Studies have shown improved outcomes, improved patient satisfaction, and decreased cost when this model has been used to care for patients with general medical illness and psychiatric comorbidities. The primary care provider really drives the care, identifying the comorbidities and enlisting the patient's participation with care. Care managers could include nurses, social workers, or psychologists. Their responsibilities include monitoring symptoms, brief behavioral interventions, and other activities including case review with the psychiatric care provider. The psychiatric care provider is not expected to be on-site but will review cases with the care manager, who will communicate recommendations back to the primary care provider. Those services could be billed for under other Current Procedural Terminology (CPT) codes. As of January 1, 2018, report CoCM services using CPT codes 99492, 99493, and 99494 have been utilized for psychiatric collaborative care, in this new model to provide mental health services to patients with chronic medical conditions such as advanced respiratory diseases. They are endorsed by the Centers for Medicare and Medicaid Services, these new CPT codes support CoCM services and replace the 2017 codes G0502, G0503, and G0504 for Behavioral Health Integration. This article provides guidance on CoCM for patients with advanced respiratory disease and the new CPT codes for reimbursement of these services.

Validity and Responsiveness of the Depression Anxiety Stress Scales-21 (DASS-21) in COPD.

BACKGROUND: We examined the validity and responsiveness of the Depression Anxiety and Stress Scales-21 (DASS-21) in patients with COPD following an 8-week pulmonary rehabilitation program (PRP). METHODS: Five hundred and fifty-seven patients with clinically stable COPD completed an 8-week outpatient multidisciplinary PRP, comprising 2 h (1 h of exercise and 1 h of education) per week. Anxiety, exercise capacity, quality of life, and dyspnea were measured pre- and post-PRP, utilizing the Anxiety Inventory for Respiratory Disease, Incremental Shuttle Walk Test, St. George's Respiratory Questionnaire, and modified Medical Research Council dyspnea scale, respectively. In addition, we administered the DASS-21 to assess both the validity and responsiveness of this tool compared with other, well-established metrics. RESULTS: The mean (SD) age of participants was 71.6 (9.4) years, and 49% were women. The DASS-21 reflected responsiveness to pulmonary rehabilitation. Among participants with a high depression score (> 9), the depression subscale score fell from 18.62 pre-PRP to 13.12 post-PRP (P < .001). Similarly, among participants with a high anxiety score (> 7), the anxiety subscale fell from 14.60 pre-PRP to 10.99 post-PRP (P < .001). Likewise, among participants with a high stress score (> 14), the stress subscale score fell from 23.51 pre-PRP to 16.34 post-PRP (P < .001). Among these subsamples, the effect size was medium at 0.49 for depression and 0.54 for anxiety, and large at 0.81 for stress. The change in DASS-21 subset (depression, anxiety, and stress) correlated with the change in total SGRQ score, at P < .001. CONCLUSIONS: The DASS-21 has acceptable validity and is a responsive scale for use in PRP in patients with COPD.

Test Performance Characteristics of the AIR, GAD-7, and HADS-Anxiety Screening Questionnaires for Anxiety in Chronic Obstructive Pulmonary Disease.

Rationale: Anxiety is a common comorbidity of chronic obstructive pulmonary disease (COPD) that is associated with higher morbidity and mortality. We evaluated three anxiety screening questionnaires: the Generalized Anxiety Disorder 7-Item Scale (GAD-7), the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), and the Anxiety Inventory for Respiratory Disease (AIR).Objectives: To evaluate and compare the test performance characteristics of three anxiety screening questionnaires, using the Mini-International Neuropsychiatric Interview (MINI), version 7.0, as the "gold standard."Methods: Individuals with COPD were recruited at 16 centers. The MINI and questionnaires were administered by trained research coordinators at an in-person visit and readministered by telephone 2-4 weeks later. A composite score for the presence of any Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) anxiety disorder was computed, based on the MINI as the gold standard, compared with a participant screening positive on self-report measures for these analyses.Results: Two hundred and twenty eligible individuals with COPD were enrolled; 219 completed the study. Eleven percent were identified as having a DSM-V anxiety disorder, based on the MINI. Elevated anxiety symptoms based on questionnaires were 38% for the AIR, 30% for the GAD-7, and 20% for the HADS-A. Area under the receiver operating characteristic curve (AUC) was highest for the GAD-7 (0.78; 95% confidence interval [CI], 0.69-0.87), followed by the HADS-A (0.74; 95% CI, 0.64-0.84) and the AIR (0.66; 95% CI, 0.56-0.76). The AUC for the GAD-7 was significantly greater than for the AIR (P = 0.014). Sensitivity was not statistically different among the questionnaires: 77% for the GAD-7, 63% for the HADS-A, and 66% for the AIR. The HADS-A had the highest specificity, 85%, which was significantly higher than that of the GAD-7 (77%; P < 0.001) and the AIR (65%; P < 0.001); GAD-7 specificity was higher than AIR specificity (P < 0.001).Conclusions: Symptoms of anxiety among patients with COPD as identified by screening questionnaires were common and significantly higher than the prevalence of anxiety disorder meeting DSM-V criteria. The GAD-7, the HADS-A and the AIR questionnaires had fair to moderate psychometric properties as screening tools for anxiety in individuals with COPD, indicating the need for improved measures for this patient population.

Examining the Effects of Age on Health Outcomes of Chronic Obstructive Pulmonary Disease: Results From the Genetic Epidemiology of Chronic Obstructive Pulmonary Disease Study and Evaluation of Chronic Obstructive Pulmonary Disease Longitudinally to Identify Predictive Surrogate Endpoints Cohorts.

RATIONALE: The prevalence of chronic obstructive pulmonary disease (COPD) and its associated comorbidities increase with age. However, little is understood about differences in the disease in patients over 65 years of age compared with younger patients. OBJECTIVES: To determine disease characteristics of COPD and its impact in older patients compared with younger patients. METHODS: We examined baseline characteristics of patients with COPD (global obstructive lung disease stage II-IV) in 2 large cohorts: Genetic Epidemiology of COPD Study (COPDGene) and Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE). We compared demographics, indices of disease severity, prevalence of comorbidities, exacerbation frequency, and quality of life scores in patients ≥65 years of age vs patients <65 years of age. We also tested for associations of age with disease characteristics and health outcomes. RESULTS: In the COPDGene cohort, older patients (n = 1663) had more severe disease as measured by forced expiratory volume in 1 second (1.22 vs 1.52 L, P < .001), use of long-term oxygen therapy (35% vs 22%, P < .001), 6-minute walk distance (355 vs 375 m, P < .001), and radiographic evidence of emphysema (14% vs 8%, P < .001) and air trapping (47% vs 36%, P < .001) and were more likely to have comorbidities compared with younger patients (n = 2027). Similarly, in the ECLIPSE cohort, older patients (n = 1030) had lower forced expiratory volume in 1 second (1.22 vs 1.34 L, P < .001), greater use of long-term oxygen therapy (7% vs 5%, P = .02), shorter 6- minute walk distance (360 vs 389 m, P < .001), and more radiographic evidence of emphysema (17% vs 14%, P = .009) than younger patients (n = 1131). In adjusted analyses of both cohorts, older age was associated with decreased frequency of exacerbations [odds ratio = 0.52, 95% confidence interval (CI) = 0.43-0.64 in COPDGene, odds ratio = 0.79, 95% CI = 0.64-0.99 in ECLIPSE] and a better quality of life (lower St. Georges respiratory questionnaire score) (ß = -8.7, 95% CI = -10.0 to -7.4 in COPDGene, ß = -4.4, 95% CI = -6.1 to -3.2 in ECLIPSE). CONCLUSIONS: Despite greater severity of illness, older patients with COPD had better quality of life and reported fewer exacerbations than younger patients. Although this observation needs to be explored further, it may be related to the fact that older patients change their expectations and learn to adapt to their disease.

Cognitive Impairment in Chronic Obstructive Pulmonary Disease and Chronic Heart Failure: A Systematic Review and Meta-analysis of Observational Studies.

BACKGROUND: Cognitive impairment is common in people living with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF); however, accurate estimates of prevalence are lacking. To date, there are no meta-analyses that have specifically investigated prevalence of mild cognitive impairment (MCI) in this particular population. Our aim was to undertake a systematic review and apply meta-analytic methods to estimate the prevalence of MCI and any cognitive impairment (ACI) in people with COPD and CHF. METHODS: We identified relevant studies for COPD and CHF by searching the published literature from inception to February 2016 using the MEDLINE and Web of Science databases. Studies were included if they documented the prevalence of MCI and/or cognitive impairment for COPD and CHF patients without dementia. RESULTS: Seventeen studies including people with CHF (n = 29,456) and 14 studies including people with COPD (n = 23,116) were included. The pooled mean age for COPD was 66.3 years and for CHF, 75.6 years. The pooled prevalence of MCI in the COPD was 25% (95% CI: 23%, 42%) and ACI, 32% (95% CI: 18%, 38%). Correspondingly, the pooled prevalence of MCI in those with CHF was 32% (95% CI: 22%, 43%) and ACI, 31% (95% CI: 23%, 40%). CONCLUSIONS: One in 4 people with COPD and 1 in 3 people with CHF had MCI, respectively. The overall prevalence of ACI for COPD was 32% and for CHF, 31%. Future work should consider ways of detecting, managing, or improving cognitive function and other cognition-related outcomes in this group of people.

The Responsiveness of the Anxiety Inventory for Respiratory Disease Scale Following Pulmonary Rehabilitation.

BACKGROUND: To date, there are no studies that have examined the responsiveness of the Anxiety Inventory for Respiratory disease (AIR) scale to any intervention in patients with COPD. We examined the responsiveness of the AIR scale in an 8-week pulmonary rehabilitation (PR) program. METHODS: A total of 192 patients with COPD who were clinically stable and had a percent predicted FEV1 < 70% completed 8-week outpatient multidisciplinary PR. The duration of the program was 2 h per/week (1 h exercise and 1 h education). Pre- and postrehabilitation outcome measures were evaluated: exercise capacity by the incremental shuttle walk test, quality of life by the St Georges Respiratory Questionnaire (SGRQ), and severity of dyspnea by the Medical Research Council (nMRC) scale. Anxiety was measured using the self-administered AIR scale. RESULTS: The mean (SD) age was 71 (8.4) years and 51% were women. The AIR scale was responsive to PR with (AIR ≥ 8, high anxiety load) a mean change pre- vs post scores (12.25 vs 6.70, t = 7.56, P < .001), in incremental shuttle walk test (183 vs 258, t = 9.49, P < .001), in total SGRQ score (62.54 vs 55.70, t = 4.77, P < .001) and in nMRC score (3.32 vs 3.04, t = 2.57, P = .03) following PR. Change in AIR was significantly correlated with change in total SGRQ (r = 0.16, P = .02) and in nMRC (r = 0.15, P = .03). The effect size for the AIR was 1.01 and minimal clinical important difference was 5.55. Anxiety is a predictor of noncompletion of PR. CONCLUSIONS: The AIR scale is sensitive to change following PR in patients with COPD and can be used in future studies evaluating interventions that reduce anxiety in this disease.

The Manchester Respiratory Activities of Daily Living questionnaire for use in COPD patients: translation into Portuguese and cross-cultural adaptation for use in Brazil.

OBJECTIVE: To translate The Manchester Respiratory Activities of Daily Living (MRADL) questionnaire into Portuguese and to create a version of the MRADL that is cross-culturally adapted for use in Brazil. METHODS: The English-language version of the MRADL was translated into Portuguese by two health care researchers who were fluent in English. A consensus version was obtained by other two researchers and a pulmonologist. That version was back-translated into English by another translator who was a native speaker of English and fluent in Portuguese. The cognitive debriefing process consisted in having 10 COPD patients complete the translated questionnaire in order to test its understandability, clarity, and acceptability in the target population. On the basis of the results, the final Portuguese-language version of the MRADL was produced and approved by the committee and one of the authors of the original questionnaire. RESULTS: The author of the MRADL questioned only a few items in the translated version, and some changes were made to the mobility and personal hygiene domains. Cultural differences regarding the domestic activities domain were found, in particular regarding the item "Do you have the ability to do a full clothes wash and hang them out to dry?", due to socioeconomic and climatic issues. The item "Do you take care of your garden?" was questioned by the participants who lived in apartments, being modified to "Do you take care of your garden or plants in your apartment?" CONCLUSIONS: The final Portuguese-language version of the MRADL adapted for use in Brazil was found to be easy to understand and easily applied.