Martin J. Connolly

Depression and anxiety in elderly outpatients with chronic obstructive pulmonary disease: prevalence, and validation of the BASDEC screening questionnaire

Objectives. Depressive and anxiety symptoms are common in elderly patients with chronic obstructive pulmonary disease (COPD). However, true prevalence of clinical depression and anxiety is uncertain. We thus aimed to assess prevalence of clinical depression and/or anxiety in elderly COPD patients using the Geriatric Mental State Schedule (GMS) and determine severity of clinical depression by the Montgomery Asberg Depression Rating Scale (MADRS). We also aimed to validate the Brief Assessment Schedule Depression Cards (BASDEC) screening test for depressive symptoms against GMS.

Pulmonary rehabilitation programmes in the UK: a national representative survey

Background: Respiratory disease is a common cause of disability in middle and late life. Pulmonary rehabilitation programmes improve exercise capacity and quality of life in patients with chronic lung diseases. However, currently, in the UK the availability of pulmonary rehabilitation programmes and their characteristics are unknown. Methods: We surveyed pulmonary rehabilitation programmes in terms of number, size, duration, content of educational and exercise programme, and staffing. We mailed a 17-item questionnaire previously used in Canadian study to 190 physiotherapy departments within acute hospitals in UK. Results: One hundred and seventy-one (90%) responses were received. Sixty-eight centres (40%) run a pulmonary rehabilitation programme (99% outpatient). Mean age of subjects was]=70 in only seven centres (10%), though most cited no upper age limit. Ninety-nine per cent of centres incorporated exercise training. Programmes recruited a median group size of 10 patients (range 4 - 17) at a given time with a median duration of eight weeks (range 5 - 24) weeks. Most (71%) run twice per week with a duration of 2 hours (63%). Only half offered smoking cessation support, and a minority gave advice on coping with disease, travel and sexual matters. Conclusion: Around 40% of surveyed hospitals run a pulmonary rehabilitation programme and most of the programmes are similar in their format, content and staffing. Despite the high prevalence of chronic obstructive pulmonary disease (COPD)-related disability in old age most programmes chiefly included younger subjects. This may reflect lack of referral. Greater awareness and expansion of availability of programmes is indicated.

Quality of life in elderly patients with COPD: measurement and predictive factors

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity in old age. It leads to reduced quality of life (QoL), but the factors that contribute to this are less understood. There is no consensus on measurement of QoL in elderly COPD patients. We assessed (a) factors predicting QoL in elderly COPD out-patients and (b) specificity (SP), sensitivity (SEN), positive and negative predictive values (PPV and NPV) and repeatability of two disease-specific QoL instruments, the Chronic Respiratory Disease Questionnaire (CRQ) and the Breathing Problems Questionnaire (BPQ) in elderly people. All subjects also completed an ADL measure [Nottingham Extended ADL (NEADL)] and a measure of psychological well-being [Brief Assessment of Depression Cards (BASDEC)] as well as a 6-min walk test. Subjects comprised 96 (56 men) elderly out-patients with irreversible COPD aged 70-93 years (mean 78) who were clinically stable for > or = 6 weeks. Controls were 55 (23 men) aged 71-90 years (mean 78) with normal lung function. All were cognitively intact. Mean FEV1/FVC in COPD subjects was 45.5 (SE = 1.4)% and for controls was 71.4 (SE = 1.3)%. Repeatability was good for both BPQ and CRQ with no significant difference. There were no significant differences in specificity and positive predictive values between the two questionnaires but BPQ performed better than CRQ with regard to sensitivity (P = 0.02) and NPV (P < 0.001). A multiple regression analysis was used to identify variables that best predicted BPQ and CRQ in COPD subjects. For BPQ predictive values were NEADL (P < 0.0001); BASDEC (P < 0.0001); age (P < 0.0001); 6-min walk distance (P = 0.001); body mass index (P < 0.05); resting oxygen saturation (P < 0.05); and household composition (living alone or with relatives, P = 0.05). In contrast only the following predicted CRQ: NEADL, BASDEC and resting oxygen saturation. Sixteen per cent of the variance in BPQ was accounted for by NEADL score, 9% by BASDEC, 4% by age and 3% by 6-min walk distance (total r2 = 0.70). It was concluded that: (1) BPQ provides more valid assessment than CRQ of QoL in elderly COPD subjects; (2) severity of disease in terms of its impact on QoL is not predicted by lung function tests; (3) the most important determinants of QoL are ADL score and emotional status.

Mood disorders in elderly patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is a major cause of morbidity, disability and mortality in old age. The disease is characterized by shortness of breath, impaired ventilatory function and easy fatiguability. These are the most distressing and disabling symptoms of COPD, limiting exercise tolerance, interfering with basic activities of daily living and often, in turn, impairing quality of life.

Early mobilization with walking aids following hospital admission with acute exacerbation of chronic obstructive pulmonary disease

Objective: We hypothesized that early ambulation with a gutter frame (GF) in elderly patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may reduce physical disability and allow earlier discharge. Design: Blinded, randomized parallel groups trial. Subjects: One hundred and ten consecutive AECOPD inpatients. Interventions: Participants were recruited two days post admission and randomly allocated to four groups: GF with supplemental oxygen (GFSO), GF with supplemental air (GFSA), rollator with supplemental air (RSA) and rollator with supplemental oxygen (RSO) (air/oxygen was double-blinded to patients and investigators). Patients exercised three times daily (maximum of 15 minutes per session) with a physiotherapist or nurse. Outcome measures: Physical disability measured by Barthel Index and perceived respiratory effort by Borg Scale. Results: After intervention no significant difference was observed between the four groups in length of hospital stay (F = 0.78; p = 0.50), changes in mean Barthel score (F = 2.08; p = 0.11) and Borg score (F = 0.35; p = 0.79). However, improvement in Barthel score (mean 1.22 combined gutter frame group air/oxygen) was greater than the combined rollator group (mean 0.55; p = 0.003). Baseline Barthel score and nurses’ assessment of compliance were associated with improvement in Barthel score (p < 0.0001 and p < 0.002). Barthel score was predicted by use of gutter frame (F = 6.17; p = 0.01), not by use of rollator. Use of air/oxygen group was not related to improvement in Barthel score. Conclusion: Short-term exercise therapy with gutter frame after AECOPD admission reduces physical disability in older patients but does not affect length of hospital stay. Use of supplemental oxygen during exercise has no additional benefits.

Ageing, late-onset asthma and the beta-adrenoceptor

Late-onset asthma in old age is a common clinical problem. There are similarities between receptor and post-receptor beta 2-adrenoceptor abnormalities reported in young asthmatics and in elderly normal subjects. Recent evidence lends some support to the idea of the aging beta 2-adrenoceptor as a contributory factor in the development of late-onset asthma, although questions of the validity of the peripheral mononuclear cell model and of receptor tachyphylaxis to intrinsic and extrinsic beta-adrenoceptor agonists remain unresolved. Further work should focus on in vivo studies of airway receptor function and on beta 2-adrenoceptor-mediated pathways other than smooth muscle-related bronchoconstriction.

Improving Outcomes in Elderly Patients with Asthma

Although often regarded as a disease of childhood, asthma is common in elderly people. Although recent figures show a decline over the past few years in the number of asthma deaths in children and younger adults, the same is not true of older adults, in whom most asthma deaths occur.Differences between asthma in young and old patients are seen not only in response to treatment. The nonspecific presentation of asthma in elderly adults means that the diagnosis of asthma is difficult to make. In addition, research suggests that physicians are reluctant to use spirometry and measurement of reversibility when investigating respiratory symptoms in old people. This leads to a tendency to label breathless or wheezy elderly patients as having chronic obstructive pulmonary disease (COPD) rather than asthma. In turn, patients with a diagnosis of COPD are less likely to be treated with bronchodilators and corticosteroids.Treatment guidelines for the management of asthma in children and younger adults may need to be adapted when applied to older patients. Reduced perception of bronchoconstriction may lead to underuse of bronchodilators prescribed ‘as required’. The bronchodilator response to β2-agonists is attenuated as part of the normal aging process, and other groups of bronchodilator medications should be considered. Inhaler technique can be a particular problem in elderly patients with asthma, requiring careful choice of inhaler device. However, the frequent presence of multiple pathology and multiple medication in this age group enhances the risk of adverse effects from oral preparations, and so the inhaled route should be preferred wherever possible.Underestimation of the severity of an acute exacerbation of asthma by both patient and doctor has been suggested as a contributory factor to poor outcome in older people. Since the cardiovascular responses to hypoxia and bronchoconstriction tend to diminish with increasing age, objective measures of asthma severity (peak flow monitoring and blood gas estimation) are essential in this age group.

Clinical InvestigationsAsthmaThe Relationship Between Age and Bronchial Responsiveness: Evidence From a Population Survey

OBJECTIVESnIncreased bronchial responsiveness is a feature of symptomatic asthma, and it predicts the onset of wheezing. We have investigated the relationship between bronchial responsiveness and age in a population sample with an age range of 45 to 86 years.nnnDESIGNnCross-sectional population survey.nnnSETTINGnPopulation of Central Manchester, UK.nnnPARTICIPANTSnAn age-stratified random sample of white adults aged > or = 45 years old and living in Central Manchester. They were recruited from their primary care physician (general practitioner) lists. Patients with confusion and patients who were housebound were excluded.nnnMEASUREMENTSnRespondents to a mail questionnaire were invited to attend a methacholine bronchial challenge performed using the Newcastle dosimeter method. Respondents with ischemic heart disease or respondents taking oral steroids, beta-blockers, or anticholinergic medication were excluded.nnnRESULTSnOf the 783 subjects contacted, 92.3% of the subjects responded, and 508 subjects returned enough information for us to deduce their suitability for the bronchial challenge. Of the 395 suitable subjects, 247 subjects participated (62.5% of those invited; 31.5% of the study population), and 208 participants completed the bronchial challenge. Participants were slightly younger than nonparticipants, but they were otherwise representative of the population. Increased bronchial responsiveness (provocative dose of methacholine causing a 20% fall in FEV1 < or = 200 microg) was present in 71 (34.1%) participants. Stepwise multiple regression analysis showed weak, independent, positive associations between bronchial responsiveness and age, and between bronchial responsiveness and the total immunoglobulin E level. There was an independent negative relationship between bronchial responsiveness and the airways caliber (expressed as standardized residuals; R2 = 0.29).nnnCONCLUSIONSnWe have found a high prevalence of increased bronchial responsiveness in this inner-city population of older adults. Bronchial responsiveness showed a weak independent positive association with age.

Factors affecting oxygen saturation during methacholine challenge in a mixed population

Bronchial challenge with methacholine or histamine is associated with a reduction in arterial oxygen tension, which can be appreciable. In this study, oxygen saturation was monitored during methacholine challenge in subjects with and without respiratory disease, over a wide age range, in order to identify factors predicting a large fall in saturation during the challenge. Two hundred and twenty subjects aged 24-86 years were included, comprising 15 healthy adult volunteers, and 205 adults from a random sample of the local adult population taking part in a survey of bronchial responsiveness. Subjects with ischaemic heart disease or baseline FEV1 < 60% predicted were excluded. Methacholine challenge was performed by the Newcastle Dosimeter technique; oxygen saturation (SaO2) was monitored using a pulse oximeter and finger probe. Of the 220 subjects, 27% were current smokers and 39.5% were ex-smokers; 26% reported asthma or bronchitis. Mean baseline FEV1 was 100% predicted; mean baseline saturation was 97%. Mean fall in saturation was 3.2% (range 0-17.5%). Multiple regression analysis revealed that fall in saturation during methacholine challenge is related to baseline FEV1, baseline SaO2, log of total methacholine dose inhaled, and fall in FEV1 during challenge. Change in saturation was not related to subject age, smoking history, reported asthma or bronchitis, or the presence of respiratory symptoms. Methacholine challenge produces a significant fall in oxygen saturation, but this is not greater in subjects who are old or have low baseline saturation.

Predictors of hospital admission and mortality in patients with chronic obstructive pulmonary disease

Hospital readmission rates for COPD patients are high, with two-week readmission rates of 22% being recorded in one study of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In a separate study, patients admitted with PaCO2> 50 mm Hg had a readmission rate of 40% at six months. There are no agreed clinical evidence factors that determine readmission. A few studies have reported that readmission is associated with an individuals inability to cope with the disease, and that anxiety and socioeconomic status are important variables. Others argue that readmission relates to severity of lung function abnormality, changes in atmospheric pollution, and impaired quality of life (QoL).