Kersti Theander

Nurse-led multidisciplinary programme for patients with COPD in primary health care: a controlled trial.

AIM To investigate the effects of a nurse-led multidisciplinary programme (NMP) of pulmonary rehabilitation in primary health care with regard to functional capacity, quality of life (QoL), and exacerbations among patients with chronic obstructive pulmonary disease (COPD). METHOD A 1-year longitudinal study with a quasi-experimental design was undertaken in patients with COPD, 49 in the intervention group and 54 in the control group. Functional capacity was assessed using the 6-minute walking test, and quality of life (QoL) was assessed using the Clinical COPD Questionnaire. Exacerbations were calculated by examination of patient records. RESULTS No significant differences were found between the groups in functional capacity and QoL after 1 year. The exacerbations decreased in the intervention group (n = -0.2) and increased in the control group (n = 0.3) during the year after NMP. The mean difference of change in exacerbation frequency between the groups was statistically significant after one year (p=0.009). CONCLUSIONS The NMP in primary care produced a significant reduction in exacerbation frequency, but functional capacity and QoL were unchanged. More and larger studies are needed to evaluate potential benefits in functional capacity and QoL.

Symptoms and impact of symptoms on function and health in patients with chronic obstructive pulmonary disease and chronic heart failure in primary health care

Background Patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) seem to have several symptoms in common that impact health. However, methodological differences make this difficult to compare. Aim Comparisons of symptoms, impact of symptoms on function and health between patients with COPD and CHF in primary health care (PHC). Method The study is cross sectional, including patients with COPD (n=437) and CHF (n=388), registered in the patient administrative systems of PHC. The patients received specific questionnaires – the Memorial Symptom Assessment Scale, the Medical Research Council dyspnea scale, and the Fatigue Impact Scale – by mail and additional questions about psychological and physical health. Results The mean age was 70±10 years and 78±10 years for patients with COPD and CHF respectively (P=0.001). Patients with COPD (n=273) experienced more symptoms (11±7.5) than the CHF patients (n=211) (10±7.6). The most prevalent symptoms for patients with COPD were dyspnea, cough, and lack of energy. For patients with CHF, the most prevalent symptoms were dyspnea, lack of energy, and difficulty sleeping. Experience of dyspnea, cough, dry mouth, feeling irritable, worrying, and problems with sexual interest or activity were more common in patients with COPD while the experience of swelling of arms or legs was more common among patients with CHF. When controlling for background characteristics, there were no differences regarding feeling irritable, worrying, and sexual problems. There were no differences in impact of symptoms or health. Conclusion Patients with COPD and CHF seem to experience similar symptoms. There were no differences in how the patients perceived their functioning according to their cardinal symptoms; dyspnea and fatigue, and health. An intervention for both groups of patients to optimize the management of symptoms and improve function is probably more relevant in PHC than focusing on separate diagnosis groups.

Symptom burden in stable COPD patients with moderate or severe airflow limitation.

OBJECTIVES To describe a multidimensional symptom profile in patients with stable chronic obstructive pulmonary disease (COPD) and determine whether symptom experience differed between patients with moderate or severe airflow limitations. BACKGROUND Patients with severe airflow limitation experience numerous symptoms, but little is known regarding patients with moderate airflow limitation. METHODS A multidimensional symptom profile (Memorial Symptom Assessment Scale) was assessed in 42 outpatients with moderate and 49 with severe airflow limitations. RESULTS The mean number of symptoms in the total sample was 7.9 (±4.3) with no difference between patients with moderate and severe airflow limitations. The most prevalent symptoms with the highest MSAS symptom burden scores were shortness of breath, dry mouth, cough, sleep problems, and lack of energy in both groups. CONCLUSIONS Patients with moderate or severe airflow limitations experience multiple symptoms with high severity and distress. An assessment of their multidimensional symptom profile might contribute to better symptom management.

Experience of fatigue, and its relationship to physical capacity and disease severity in men and women with COPD

Introduction Several differences have been reported in the clinical characteristics of chronic obstructive pulmonary disease (COPD) between men and women. Differences have been found in the association between respiratory symptoms and lung function, and in the factors associated with dyspnea. This raises the question of whether there are differences between the sexes in the relationship between fatigue, the second most prevalent symptom, and the variables of physical capacity and disease severity. Objectives To examine the experience of fatigue and its relationship to physical capacity and disease severity in men and women with COPD. Methods In a cross-sectional study 121 patients with COPD (54 men and 67 women), the experience of fatigue (frequency, duration, and severity) and physical capacity (lung function, 6-minute walk distance [6MWD], grip strength, and timed-stand test) were assessed. Disease severity was graded according to the Body mass index, airway Obstruction, Dyspnoea and Exercise capacity (BODE) index. Two multiple logistic regression models were tested, both of which were performed separately in men and women, to examine the association between the experience of fatigue and variables of physical capacity and the BODE index. Results Eighty-nine (73.6%) patients experienced fatigue, with similar proportions in men and women. The men with fatigue had worse physical capacity and more severe disease than did the men without fatigue: for men with and without fatigue, respectively, the percent of predicted forced expiratory volume in 1 second (FEV1) (mean [standard deviation]) was 47 (14) vs 64 (17); the 6MWD (mean [standard deviation]) was 398 (138) vs 539 (105) m; and the BODE index (median [quartile 1–3]) was 3 (2–5) vs 1 (0–1) (P<0.01). In women, only higher leg fatigue post-6MWD was seen among those experiencing fatigue compared with women without fatigue: for women with and without fatigue, respectively, leg fatigue (median [quartile 1–3]) was 4 (3–5) vs 2 (0–3) (P<0.001). The regression models showed that the 6MWD and the BODE index were associated with fatigue in both men and women, but in women, leg fatigue remained an independent associate in both models. Conclusion Exercise capacity and disease severity were associated with fatigue in both men and women. In women, leg fatigue was strongly associated with fatigue, which warrants further investigation.

Factors associated with experience of fatigue, and functional limitations due to fatigue in patients with stable COPD.

Background: The aim of this study was to determine the influence of selected physiological, psychological and situational factors on experience of fatigue, and functional limitations due to fatigue in patients with stable chronic obstructive pulmonary disease (COPD). Methods: In total 101 patients with COPD and 34 control patients were assessed for experience of fatigue, functional limitation due to fatigue (Fatigue Impact Scale), physiological [lung function, 6-minute walk distance (6MWD), body mass index (BMI), dyspnoea, interleukin (IL)-6, IL-8, high sensitivity C-reactive protein (hs-CRP), surfactant protein D], psychological (anxiety, depression, insomnia), situational variables (age, sex, smoking, living alone, education), and quality of life. Results: Fatigue was more common in patients with COPD than in control patients (72% versus 56%, p < 0.001). Patients with COPD and fatigue had lower lung function, shorter 6MWD, more dyspnoea, anxiety and depressive symptoms, and worse health status compared with patients without fatigue (all p < 0.01). No differences were found for markers of systemic inflammation. In logistic regression, experience of fatigue was associated with depression [odds ratio (OR) 1.69, 95% confidence interval (CI) 1.28–2.25) and insomnia (OR 1.75, 95% CI 1.19–2.54). In linear regression models, depression, surfactant protein D and dyspnoea explained 35% (R2) of the variation in physical impact of fatigue. Current smoking and depression explained 33% (R2) of the cognitive impact of fatigue. Depression and surfactant protein D explained 48% (R2) of the psychosocial impact of fatigue. Conclusions: Experiences of fatigue and functional limitation due to fatigue seem to be related mainly to psychological but also to physiological influencing factors, with depressive symptoms, insomnia problems and dyspnoea as the most prominent factors. Systemic inflammation was not associated with perception of fatigue but surfactant protein D was connected to some dimensions of the impact of fatigue

The experience of a multidisciplinary programme of pulmonary rehabilitation in primary health care from the next of kin's perspective: a qualitative study.

Background: Pulmonary rehabilitation increases functional capacity and quality of life and decrease exacerbations in patients with chronic obstructive pulmonary disease (COPD), but there is little knowledge of how it influences their next of kin. Aims: To describe the experience of a multidisciplinary programme of pulmonary rehabilitation in primary health care from the perspective of the next of kin. Methods: A descriptive qualitative study was undertaken as part of a longitudinal study comprising a multidisciplinary programme for patients with COPD where the next of kin were invited to one session. Semi-structured interviews were conducted with 20 next of kin and analysed by qualitative content analysis. Results: One main theme emerged — Life still remains overshadowed by illness. There were three sub-themes: a sense of deepened understanding; a sense of personal vulerability; and a sense of relief of burden. Conclusions: The next of kins life was still overshadowed by illness, despite the multidisciplinary programme. Although experiencing positive outcomes two years after the programme, the next of kin expressed a need for more support. This study has shown that next of kin could benefit from their own participation and/or that of the patient in a multidisciplinary programme of pulmonary rehabilitation. We believe that next of kin should be offered primary health care support for the sake of their own health, but also in order to manage their informal caregiver role. The experiences described here could form a basis for further development of interventions for next of kin of patients with COPD.

No gender differences in fatigue and functional limitations due to fatigue among patients with COPD

AIMS AND OBJECTIVES To examine gender differences in experiences of fatigue and functional limitations due to fatigue in patients with chronic obstructive pulmonary disease and a comparison group. BACKGROUND Fatigue is a major problem for patients with chronic obstructive pulmonary disease. The prevalence rate of chronic obstructive pulmonary disease in females is increasing and to our knowledge there are few studies reporting gender differences in one of their worst symptoms, fatigue and functional limitations due to fatigue. DESIGN This study has a descriptive cross-sectional design. METHODS Patients with chronic obstructive pulmonary disease (n = 345) and a comparison group of the same gender and age from the same region as the patients (n = 245) answered mailed questions about the frequency, duration and severity of fatigue and the fatigue impact scale. RESULTS High frequency (≥ 20 days/month), long duration (≥ 6 hours/day) and great severity (one of my worst symptoms) of fatigue were experienced by 51%, 54% and 44% of the male patients with chronic obstructive pulmonary disease, respectively and 60%, 55% and 51% of the female patients with chronic obstructive pulmonary disease, respectively. The figures for the males from the comparison group were 14%, 24% and 17% and for the females 30%, 42% and 32%, respectively. There were no gender differences regarding fatigue (frequency, duration and severity) or functional limitations due to fatigue in the chronic obstructive pulmonary disease patients, while the differences between males and females from the comparison group were statistically significant for frequency and severity of fatigue as well as functional limitation due to fatigue. CONCLUSION In the comparison group, there were gender differences regarding fatigue, as well as functional limitations due to fatigue. This was not observed in the chronic obstructive pulmonary disease group. RELEVANCE TO CLINICAL PRACTICE The results of this study suggest that nurses should not take for granted that female patients with chronic obstructive pulmonary disease experience more fatigue than men.

Factors associated with low physical activity in patients with Chronic Obstructive Pulmonary Disease : A cross-sectional study

OBJECTIVES Low physical activity (PA) in chronic obstructive pulmonary disease (COPD) is associated with poor prognosis. In addition, physical activity seems to be low early in the disease. The aim of this study was to describe the level of PA in patients with stable COPD and to explore factors associated with low PA, with a focus on fatigue, symptom burden and body composition METHODS In a cross-sectional study, 101 patients (52 women) with COPD were classified having low, moderate or high PA according to the International Physical Activity Questionnaire-Short. Fatigue, dyspnoea, depression and anxiety, symptom burden, body composition, physical capacity (lung function, exercise capacity, muscle strength), exacerbation rate and systemic inflammation were assessed. A multiple logistic regression was used to identify independent associations with low PA. RESULTS Mean age was 68 (±7) years, and mean percentage of predicted forced expiratory volume in 1 second was 50 (±16.5). Forty-two patients reported a low PA level, while 34 moderate and 25 reported high levels. Factors independently associated with low PA, presented as odds ratio (95% confidence interval), were severe fatigue 5.87 (1.23-28.12), exercise capacity 0.99 (0.99-1.0) and the number of pack-years 1.04 (1.01-1.07). No relationship was found between depression, anxiety, body composition, exacerbation rate or systemic inflammation and PA. CONCLUSIONS Severe fatigue, worse exercise capacity and a higher amount of smoking were independently associated with low PA. Promoting physical activity is important in all patients with COPD. Our result suggests that patients with severe fatigue might need specific strategies to prevent physical inactivity.

Adherence to guidelines in patients with chronic heart failure in primary health care

Abstract Objective: To describe adherence to international guidelines for chronic heart failure (CHF) management concerning diagnostics, pharmacological treatment and self-care behaviour in primary health care. Design: A cross-sectional descriptive study of patients with CHF, using data obtained from medical records and a postal questionnaire. Setting: Three primary health care centres in Sweden. Subjects: Patients with a CHF diagnosis registered in their medical record. Main outcome measures: Adherence to recommended diagnostic tests and pharmacological treatment by the European Society of Cardiology guidelines and self-care behaviour, using the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Results. The 155 participating patients had a mean age of 79 (SD9) years and 89 (57%) were male. An ECG was performed in all participants, 135 (87%) had their NT-proBNP measured, and 127 (82%) had transthoracic echocardiography performed. An inhibitor of the renin angiotensin system (RAS) was prescribed in 120 (78%) patients, however only 45 (29%) in target dose. More men than women were prescribed RAS-inhibition. Beta blockers (BBs) were prescribed in 117 (76%) patients, with 28 (18%) at target dose. Mineralocorticoidreceptor antagonists were prescribed in 54 (35%) patients and daily diuretics in 96 (62%). The recommended combination of RAS-inhibitors and BBs was prescribed to 92 (59%), but only 14 (9%) at target dose. The mean score on the EHFScBS-9 was 29 (SD 6) with the lowest adherence to daily weighing and consulting behaviour. Conclusion: Adherence to guidelines has improved since prior studies but is still suboptimal particularly with regards to medication dosage. There is also room for improvement in patient education and self-care behaviour.

Assessment of nutritional status and meal-related situations among patients with chronic obstructive pulmonary disease in Primary health care - obese patients; a challenge for the future.

AIMS AND OBJECTIVES To describe nutritional status, meal related situations, food habits and food preferences of patients with chronic obstructive pulmonary disease (COPD) in a Primary health care (PHC) setting. BACKGROUND To date, guidelines have mainly focused on underweight patients with COPD, as a low body mass index (BMI) is a risk factor for mortality. However, in recent years there has been an increase in the number of overweight patients with COPD, and therefore nutritional management must be developed to cover problems related to both under and overweight. DESIGN Descriptive. METHODS One hundred and three patients from PHC centres representing COPD stages 2 and 3 were included. The Mini Nutritional Assessment (MNA) was used to collect nutritional status data while semi-structured interviews provided information on food and meal related situations. RESULTS Mean age was 69 (± 5)years and 45% were women. Among all patients mean BMI was 27 and 14% had a BMI ≤ 21 kg/m(2) . More women (31%) than men (26%) had a BMI ≥ 30 kg/m(2) . According to the MNA screening score, 86% of the patients were assessed as normal or not at risk of malnutrition. The total MNA assessment score revealed that 10 patients were at risk of malnutrition or malnourishment. Problems with meal related situations were mostly associated with eating, and only a small number reported difficulties with shopping or preparing food. CONCLUSIONS In PHC, more patients with COPD were obese than malnourished and their self-reported nutritional status was not always accurate. RELEVANCE TO CLINICAL PRACTICE It is challenging to identify the patients nutritional status, individualize nutritional care and educate obese patients with COPD at PHC centres. It is necessary to develop screening instruments to assess the risk of both obesity and malnutrition.