Psychosocial Support in Pulmonary Rehabilitation.

Pulmonary rehabilitation (PR) improves exercise capacity and quality of life (QOL) while reducing dyspnea in patients with COPD. However, little is known about the efficacy of PR, cognitive behavioral therapy (CBT), or antidepressant drug therapy on psychosocial factors in patients with COPD. Knowledge gaps include which therapy is most efficacious, what barriers exist for each treatment, and the optimal duration of each intervention. Potential barriers to antidepressant therapy include patient fears of potential adverse effects, apprehension and misconception, and stigma related to depression. Both CBT and PR reduce anxiety and depressive symptoms in short-term studies. However, their potential benefits over medium-to-long-term follow-up and specifically on psychosocial factors warrant exploration. Furthermore, new emerging treatment strategies such as the collaborative care model and home-based telehealth coaching are promising interventions to promote patient-centered care treatment and reduce psychosocial factors adversely affecting patients with COPD. This update and critical synthesis reviews the effectiveness of both pharmacologic and non-pharmacologic interventions on psychosocial factors in patients with COPD. It also provides brief screening tools used in the assessment of anxiety and depression for patients with COPD.

Benefit-Risk Assessment of Psychotropic Drugs in Older Patients with Chronic Obstructive Pulmonary Disease.

Depression, anxiety, and other mental health disorders, including bipolar disorder and schizophrenia, occur commonly in older adults with chronic obstructive pulmonary disease (COPD), and they are often inadequately treated. We review the available evidence for benefits and risks of pharmacologic treatments (e.g. selective serotonin reuptake inhibitors [SSRIs], serotonin-noradrenaline reuptake inhibitors [SNRIs], tricyclic antidepressants [TCAs], antipsychotic drugs, and benzodiazepines) for common mental illnesses in older persons with COPD. Evidence to use both SSRIs/SNRIs and TCAs from randomized controlled trials is uncertain for treating major depression in patients with COPD. However, population-based findings indicate that they are widely used, and this valuable intervention (preferably SSRIs/SNRIs) should not be denied for selected patients after evaluating potential risks and benefits, especially patients presenting with major depression and suicidal ideation, when a collaborative-care approach is being used. Although there is some evidence for the short-term use of benzodiazepines for treating insomnia, breathlessness, and anxiety in patients with COPD, their long-term use should be closely monitored or avoided to reduce the increased rate of major adverse events. Currently, there are only limited data on the use of antipsychotic drugs for managing schizophrenia or bipolar disorder in older patients with COPD. Hence, clinicians should use extra caution when prescribing antipsychotic agents and be vigilant for symptoms of acute respiratory failure and other adverse effects. Psychotropic medications are clearly beneficial for younger, healthy persons with depression and anxiety; however, the risk-benefit calculation is not so clear for treating psychological problems, schizophrenia, and bipolar disorder in older adults with COPD, given older-adult sensitivity to medications and the mixed findings of relatively few controlled trials.

Predictors of premature discontinuation and prevalence of dropouts from a pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease.

INTRODUCTION: To date, very little is known about the risk factors that contribute to premature discontinuation (dropout) from pulmonary rehabilitation (PR) in patients with chronic obstructive pulmonary disease (COPD). We examined prevalence and predictors of premature discontinuation in patients who participated in an eight week PR program. METHODS: We analyzed a prospectively maintained data-base of patients with COPD who attended a PR program from 2013 to 2019. We included patients 40 years or older with forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio less than 0.7. Subjects were assigned completers or non-completers based on whether they completed the 8-week PR program. Quality of life was measured using the St-George's Respiratory Questionnaire (SGRQ), anxiety using the Anxiety Inventory for Respiratory disease (AIR), dyspnea using the modified Medical Research Council (mMRC) scale, and exercise capacity using the Incremental Shuttle Walk Test (ISWT). RESULTS: Nine hundred nighty three COPD patients (mean age = 70.82 years, FEV1 = 59.21% predicted, 51% male) entered the PR program. Of these, 259 (26%) discontinued PR prematurely and 139 (53%) were male. Compared with completers, non-completers had elevated symptoms of dyspnea and anxiety, had reduced exercise tolerance, were younger, and had poorer quality of life at entry (all p < 0.05). On multivariate analysis, the following variables were independently associated with discontinuation from PR: younger age (p < 0.001), elevated symptoms of anxiety (p < 0.001), elevated symptoms of dyspnea (p < 0.01) and reduced exercise tolerance (p < 0.002). CONCLUSION: Over a quarter of COPD patients discontinued the PR program prematurely. Discontinuation of PR was associated with younger age, elevated symptoms of dyspnea and anxiety, and reduced exercise capacity, but not with severity of airflow obstruction.

The Effectiveness of Cardiopulmonary Rehabilitation Programs on Psychosocial Factors in Patients With Pulmonary and Cardiac Disease.

PURPOSE: Those with chronic cardiac and pulmonary diseases are predisposed to several psychosocial disorders. Tailored rehabilitation programs have been shown to improve physiological and psychosocial well-being. The purpose of this study was, first, to assess the psychosocial improvements among patients with cardiac and pulmonary diseases who have finished cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs; second, to assess the differences in psychosocial factors among those patients based on smoking status at the beginning and end of these programs. METHODS: The CR and PR programs in hospital settings were retrospectively analyzed from 2013-2018. Before and after, all patients completed the sociodemographic characteristics along with the Psychosocial Risk Factor Survey that measures total distress, depression, anxiety, hostility, and social isolation. RESULTS: There were 355 patients with cardiac and 244 patients with pulmonary disease who completed 6- to 12-wk CR or PR programs. There were significant improvements in all psychosocial symptoms among cardiac patients. Patients with pulmonary disease exhibited significant improvements in all psychosocial factors except for social isolation. Moreover, current smokers in the CR group reported elevated symptoms of several psychosocial scores. CONCLUSION: These findings provide critical information about the effects of tailored rehabilitation programs among patients with chronic cardiac and pulmonary diseases on psychosocial levels. By using the Psychosocial Risk Factor Survey, we have found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR or PR programs. Current smokers exhibited the elevated mean scores on psychosocial symptoms in the cardiac group that may be a target for smoking cessation program. The advantages of tailored rehabilitation programs are significant, which may be of benefit for physical, social, behavioral, and psychological well-being.

Serotonin transporter gene polymorphisms and depressive symptoms in patients with chronic obstructive pulmonary disease.

Background: We examined the relationship between polymorphisms in the promoter region of the serotonin transport (SERT) gene (5-HTTLPR, short 'S' and long 'L' alleles) and in intron 2 variable number tandem repeat (STin2VNTR, 9, 10, or 12-repeat alleles) with depression or anxiety in patients with COPD.Methods: 302 patients with moderate to severe COPD participated in SERT study. History and number of prior depressive episodes were measured using the Structured Clinical Interview for Depression; Hospital Anxiety Depression Scale (HAD) depression ≥8 or a Patient Health Questionnaire-9 (PHQ-9) >,10.Results: 240 (80%) male sample had a mean age of 68.0 years. Current depression was 22% (HAD) or 21% (PHQ-9), anxiety was 25% (HAD), and suicidal ideation (6%). 5-HTTLPR or STin2 VNTR genotypes were not associated with current depressive or anxiety symptoms. The mean number of prior depressive episodes was higher for patients with the 5-HTTLPR genotype S/S or S/L compared with L/L (4.4 ± 6.1; 5.3 ± 6.8; 4.0 ± 6.1, p < 0.001) and with STin2VNTR high-risk genotype (9/12 or 12/12), medium risk (9/10 or 10/12) compared to low risk (10/10) genotypes (5.1 ± 6.8; 4.9 ± 6.7; 2.7 ± 4.5, p < 0.001).Conclusions: SERT 5-HTTLPR and STin2-VNTR polymorphisms were not associated with current depressive and anxiety symptoms, but the high-risk STin2-VNTR genotypes and S/L were associated with the number of prior depressive episodes.

The Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living questionnaire: construct validity, reliability, and measurement error.

OBJECTIVE: To test the construct validity, reliability, and measurement error of the Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living (MRADL) questionnaire in patients with COPD. METHODS: We evaluated 50 patients with COPD, among whom 30 were men, the mean age was 64 ± 8 years, and the median FEV1 as a percentage of the predicted value (FEV1%predicted) was 38.4% (interquartile range, 29.1-57.4%). Pulmonary function and limitations in activities of daily living (ADLs) were assessed by spirometry and by face-to-face application of the MRADL, respectively. For the construct validity analysis, we tested the hypothesis that the total MRADL score would show moderate correlations with spirometric parameters. We analyzed inter-rater reliability, test-retest reliability, inter-rater measurement error, and test-retest measurement error. RESULTS: The total MRADL score showed moderate correlations with the FEV1/FVC ratio, FEV1 in liters, FEV1%predicted, and FVC%predicted, all of the correlations being statistically significant (r = 0.34, r = 0.31, r = 0.42, and r = 0.38, respectively; p < 0.05 for all). For the reliability and measurement error of the total MRADL score, we obtained the following inter-rater and test-retest values, respectively: two-way mixed-effects model intraclass correlation coefficient for single measures, 0.92 (95% CI: 0.87-0.96) and 0.89 (95% CI: 0.81-0.93); agreement standard error of measurement, 1.03 and 0.97; smallest detectable change at the individual level, 2.86 and 2.69; smallest detectable change at the group level, 0.40 and 0.38; and limits of agreement, -2.24 to 1.96 and -2.65 to 2.69. CONCLUSIONS: In patients with COPD in Brazil, this version of the MRADL shows satisfactory construct validity, satisfactory inter-rater/test-retest reliability, and indeterminate inter-rater/test-retest measurement error.

The Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living questionnaire: construct validity, reliability, and measurement error / Versão em português do Brasil do questionário Manchester Respiratory Activities of Daily Living: validade de construto, confiabilidade e erro de medida

ABSTRACT Objective: To test the construct validity, reliability, and measurement error of the Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living (MRADL) questionnaire in patients with COPD. Methods: We evaluated 50 patients with COPD, among whom 30 were men, the mean age was 64 ± 8 years, and the median FEV1 as a percentage of the predicted value (FEV1%predicted) was 38.4% (interquartile range, 29.1-57.4%). Pulmonary function and limitations in activities of daily living (ADLs) were assessed by spirometry and by face-to-face application of the MRADL, respectively. For the construct validity analysis, we tested the hypothesis that the total MRADL score would show moderate correlations with spirometric parameters. We analyzed inter-rater reliability, test-retest reliability, inter-rater measurement error, and test-retest measurement error. Results: The total MRADL score showed moderate correlations with the FEV1/FVC ratio, FEV1 in liters, FEV1%predicted, and FVC%predicted, all of the correlations being statistically significant (r = 0.34, r = 0.31, r = 0.42, and r = 0.38, respectively; p < 0.05 for all). For the reliability and measurement error of the total MRADL score, we obtained the following inter-rater and test-retest values, respectively: two-way mixed-effects model intraclass correlation coefficient for single measures, 0.92 (95% CI: 0.87-0.96) and 0.89 (95% CI: 0.81-0.93); agreement standard error of measurement, 1.03 and 0.97; smallest detectable change at the individual level, 2.86 and 2.69; smallest detectable change at the group level, 0.40 and 0.38; and limits of agreement, −2.24 to 1.96 and −2.65 to 2.69. Conclusions: In patients with COPD in Brazil, this version of the MRADL shows satisfactory construct validity, satisfactory inter-rater/test-retest reliability, and indeterminate inter-rater/test-retest measurement error.

RESUMO Objetivo: Testar a validade de construto, a confiabilidade e o erro de medida da versão em português do Brasil do questionário Manchester Respiratory Activities of Daily Living (MRADL) em pacientes com DPOC. Métodos: Avaliamos 50 pacientes com DPOC, 30 dos quais eram homens. A média de idade foi de 64 ± 8 anos, e a mediana do VEF1 em porcentagem do previsto (VEF1%previsto) foi de 38,4% (intervalo interquartil: 29,1-57,4%). A função pulmonar e limitações experimentadas durante a realização de atividades cotidianas foram avaliadas por meio de espirometria e da aplicação presencial do MRADL, respectivamente. Para a análise de validade de construto, testamos a hipótese de que haveria correlações moderadas entre a pontuação total no MRADL e parâmetros espirométricos. Analisamos a confiabilidade e o erro de medida entre avaliadores e entre teste e reteste. Resultados: Houve correlações moderadas e estatisticamente significativas entre a pontuação total no MRADL e VEF1/CVF, VEF1 em litros, VEF1%previsto e CVF%previsto (r = 0,34, r = 0,31, r = 0,42 e r = 0,38, respectivamente; p < 0,05 para todas). No tocante à confiabilidade e ao erro de medida para a pontuação total no MRADL entre avaliadores e entre teste e reteste, respectivamente, foram obtidos os seguintes valores: coeficiente de correlação intraclasse de duas vias e efeitos mistos para medidas únicas = 0,92 (IC95%: 0,87-0,96) e 0,89 (IC95%: 0,81-0,93); erro-padrão de medida do tipo concordância = 1,03 e 0,97; mínima mudança detectável no indivíduo = 2,86 e 2,69; mínima mudança detectável no grupo = 0,40 e 0,38; limites de concordância = −2,24 a 1,96 e −2,65 a 2,69. Conclusões: Em pacientes com DPOC, a versão brasileira do MRADL apresenta validade de construto satisfatória, confiabilidade interavaliadores/teste-reteste satisfatória e erro de medida interavaliadores/teste-reteste indeterminado.

The need for improved cognitive, hearing and vision assessments for older people with cognitive impairment: a qualitative study.

BACKGROUND: Hearing and vision (sensory) impairments are highly prevalent in people with dementia (PwD) and exacerbate the impact of living with dementia. Assessment of sensory or cognitive function may be difficult if people have concurrent dual or triple impairments. Most standard cognitive assessment tests are heavily dependent on having intact hearing and vision, and impairments in these domains may render the assessments unreliable or even invalid. Likewise, dementia may impede on the accurate reporting of symptoms that is required for most hearing and vision assessments. Thus, there is an urgent need for hearing, vision and cognitive assessment strategies to be adapted to ensure that appropriate management and support can be provided. OBJECTIVE: To explore the perspectives of PwD and the care partners regarding the need for accurate hearing, vision and cognitive assessments. METHODS: We conducted focus groups and semi-structured interviews regarding the clinical assessment for cognitive, hearing and visual impairment. Participants (n = 18) were older adults with mild to moderate dementia and a sensory impairment as well as their care partners (e.g. a family member) (n = 15) at three European sites. The qualitative material was analysed according to Mayring's summative content analysis approach. RESULTS: Participants reported that hearing, vision and cognitive assessments were not appropriate to the complex needs of PwD and sensory comorbidity and that challenges in communication with professionals and conveying unmet needs and concerns by PwD were common in all three types of clinical assessments. They felt that information about and guidance regarding support for the condition was not adequate in the assessments and that information sharing among the professionals regarding the concurrent problems was limited. Professionals were reported as being concerned only with problems related to their own discipline and had limited regard for problems in other domains which might impact on their own assessments. CONCLUSIONS: The optimal assessment and support for PwD with multiple impairments, more comprehensive, yet easy to understand, information regarding these linked to conditions and corrective device use is needed. Communication among health care professionals relevant to hearing, vision and cognition needs to be improved.

The responsiveness of the Manchester Chronic Obstructive Pulmonary Disease Fatigue Scale to pulmonary rehabilitation.

BACKGROUND: We examined the responsiveness of the Manchester Chronic Obstructive Pulmonary Disease (COPD) Fatigue Scale (MCFS) in patients with COPD following 8 weeks of pulmonary rehabilitation (PR). METHODS: Patients (n = 273) with clinically stable COPD completed 8 weeks of outpatient multidisciplinary PR, comprising 2 h (1 h exercise and 1 h education) weekly. Anxiety, exercise capacity, quality of life, dyspnea, fatigue were measured pre- and post-PR, utilizing the Anxiety Inventory for Respiratory Disease (AIR), Incremental Shuttle Walk Test (ISWT), St. George's Respiratory Questionnaire (SGRQ), and modified Medical Research Council (mMRC) scale and MCFS, respectively. RESULTS: The mean (SD) age of participants was 72 (8) years, and 50% were women. Total MCFS score fell after PR mean (95% confidence interval) -4.89 (-7.90 to -3.79) as did domain scores: physical -1.89 (-2.33 to -1.46), cognition -1.37 (-1.65 to -1.09), and psychosocial -1.62 (-2.00 to -1.62). Total MCFS effect size (ES) was 0.55; and for domains, physical was 0.52, cognition was 0.59, and psychosocial was 0.51. The ES for AIR was 0.30, mMRC was 0.38, SGRQ was 0.66, and ISWT was 1.19. MCFS changes correlated with changes in both SGRQ (p < 0.002) and AIR (p < 0.004), but not ISWT (p = 0.30) or mMRC (p = 0.18). The AIR, SGRQ, mMRC, and ISWT all improved after PR (all, p < 0.001). CONCLUSION: The MCFS scale is a valid and responsive scale to measure fatigue in patients with COPD after pulmonary rehabilitation.

Nurse-led cognitive behavioural therapy for treatment of anxiety in COPD.

Nurse-led cognitive behavioural therapy is feasible and cost-effective for the treatment of anxiety in patients with chronic obstructive pulmonary disease. http://ow.ly/QZJT30mJdXU.

COPD in Primary Care: Key Considerations for Optimized Management: Anxiety and Depression in Chronic Obstructive Pulmonary Disease: Recognition and Management.

Ensuring that anxiety and depression are recognized and treated effectively in patients with chronic obstructive pulmonary disease (COPD) is essential for optimizing outcomes. Primary care practitioners are well placed to diagnose anxiety and depression, and to ensure these conditions are suitably managed alongside treatments of COPD.

Management of Dyspnea and Anxiety in Chronic Obstructive Pulmonary Disease: A Critical Review.

BACKGROUND: Anxiety and dyspnea, 2 major symptoms in patients with chronic obstructive pulmonary disease (COPD), are associated with high morbidity and mortality. Thus, critically evaluating and synthesizing the existing literature employing pulmonary rehabilitation (PR) and other behavioral therapies in the treatment of anxiety and dyspnea in patients with COPD may help clinicians determine the most efficacious potential treatments. We aim to examine the efficacy of PR and behavioral therapy [eg, cognitive behavioral therapy (CBT) and counseling] and other adjunct modalities used in patients with COPD. METHODS: We extracted relevant studies searching the published literature using an electronic database CINAHL, Medline, PubMed, Science Direct, and the Web of Science was conducted (spanning January 1, 2006 to November 15, 2016). Studies were included if they conducted PR and behavioral therapy (CBT, self-management, yoga) to treat anxiety and/or dyspnea in patients with COPD with or without randomized controlled trial. RESULTS: The 47 studies selected included 4595 participants (PR = 3756 and behavioral therapy = 839), ranging in age from 58 to 75 years. The total number of participants receiving a treatment was 3928, and 667 participants served in control groups. In the majority of studies, PR and CBT are effective in the treatment of anxiety and dyspnea in the short term, but the long-term benefit is limited. In addition, self-management, yoga therapy, and CBT plus PR were beneficial. CONCLUSIONS: PR and CBT reduced both anxiety and dyspnea symptoms in patients with COPD in the short term. However, maintenance programs and the long-term benefits of PR and CBT remain inconclusive. Generally, the studies were relatively small and uncontrolled. Thus, prospective and randomized controlled trials with larger sample sizes are needed.