Mary C. Kapella

Subjective fatigue, influencing variables, and consequences in chronic obstructive pulmonary disease

Background: Fatigue is a common symptom of chronic obstructive pulmonary disease (COPD), but little is known about the specific nature of COPD-related fatigue and its impact on daily life. Objectives: To (a) describe characteristics of fatigue in people with COPD and (b) test a theoretically and empirically supported model of the relationships among subjective fatigue, dyspnea, functional performance, anxious and depressed moods, and sleep quality in people with COPD. Methods: A cross-sectional descriptive study was conducted with 130 people with moderate to severe COPD. Measures included the following: a Numerical Rating Scale (NRS) for frequency, intensity, and distress of fatigue and dyspnea; Fatigue Assessment Instrument (FAI); Chronic Respiratory Disease Questionnaire (CRQ); Profile of Mood States (POMS); Pittsburgh Sleep Quality Index (PSQI); Functional Performance Inventory (FPI); and spirometry. Path analysis was used to examine the relationships among variables. Results: Participants reported moderate amounts of fatigue, which was described as situation-specific, had considerable consequences, and was responsive to rest and sleep. Dyspnea was slightly greater than fatigue, as measured by the NRSs (p <.001), and there was a strong relationship between fatigue and dyspnea (r =.74, p < .001). Dyspnea, depressed mood, and sleep quality accounted for 42% of the variance in subjective fatigue. Fatigue, dyspnea, airflow obstruction, and anxious mood accounted for 36% of the variance in functional performance. Conclusions: Fatigue is an important problem that affects performance of daily activities in people with COPD. The relationships or interactions that exist among fatigue and other symptoms are complex.

Cognitive behavioral therapy for insomnia comorbid with COPD is feasible with preliminary evidence of positive sleep and fatigue effects.

Background Many people with COPD report difficulties falling asleep or staying asleep, insufficient sleep duration, or nonrestorative sleep. Cognitive behavioral therapy for insomnia (CBT-I) has proved effective not only in people with primary insomnia but also in people with insomnia comorbid with psychiatric and medical illness (eg, depression, cancer, and chronic pain). However, CBT-I has rarely been tested in those with COPD who have disease-related features that interfere with sleep and may lessen the effectiveness of such therapies. The purpose of this study was to determine the feasibility of applying a CBT-I intervention for people with COPD and to assess the impact of CBT-I on insomnia severity and sleep-related outcomes, fatigue, mood, and daytime functioning. Methods The study had two phases. In Phase 1, a 6-weekly session CBT-I intervention protocol in participants with COPD was assessed to examine feasibility and acceptability. Phase 2 was a small trial utilizing a prospective two-group pre- and post-test design with random assignment to the six-session CBT-I or a six-session wellness education (WE) program to determine the effects of each intervention, with both interventions being provided by a nurse behavioral sleep medicine specialist. Results Fourteen participants (five in Phase 1 and nine in Phase 2) completed six sessions of CBT-I and nine participants completed six sessions of WE. Participants indicated that both interventions were acceptable. Significant positive treatment-related effects of the CBT-I intervention were noted for insomnia severity (P = 0.000), global sleep quality (P = 0.002), wake after sleep onset (P = 0.03), sleep efficiency (P = 0.02), fatigue (P = 0.005), and beliefs and attitudes about sleep (P = 0.000). Significant positive effects were noted for depressed mood after WE (P = 0.005). Conclusion Results suggest that using CBT-I in COPD is feasible and the outcomes compare favorably with those obtained in older adults with insomnia in the context of other chronic illnesses.

The Experience of Stigma in Chronic Obstructive Pulmonary Disease

People with chronic obstructive pulmonary disease (COPD) can experience severe dyspnea, tenacious secretions, and a disruptive cough. They often struggle with daily activities and over time tend to decrease the amount of time they spend outside the home. The functional decline accompanying these changes is not adequately explained by physical changes alone. This descriptive, qualitative study describes social changes and experiences of stigma from the perspective of people with moderate to severe COPD. A total of 16 participants (11 men, 5 women) participated in individual interviews regarding effects of COPD on social relationships and experiences with COPD-related stigma. Participants were aware of the potential for stigma related to COPD. Emerging themes included the prevalence of blame related to smoking, both from others, including health care providers, and from themselves. Although many decreases in social activities appear to be pragmatic adaptations to functional limitations, these decisions may also be attempts to avoid potentially stigmatizing situations.

Reliability and validity of the functional performance inventory in patients with moderate to severe chronic obstructive pulmonary disease.

The Functional Performance inventory (FPI) is a new instrument designed to measure functional status in terms of activities that people perform on a daily basis. Psychometric characteristics were examined by a survey of 45 men and 27 women with chronic obstructive pulmonary disease (COPD). Internal consistency reliability was high and no ceiling and floor effects were observed for the Total FPI. Concurrent validity was demonstrated by correlations with the Total Sickness Impact Profile (r = -.59). Construct validity was supported by correlations with the Medical Outcomes Study Short Form-36, Physical Functioning (r = .69), the Physical Activity Scale for the Elderly (r = .62) and American Thoracic Society-Division of Lung Disease Breathlessness scale (r = - .62). The Total FPI is a reliable and valid measure of functional performance in persons with COPD.

Functional Performance in Chronic Obstructive Pulmonary Disease Declines with Time

PURPOSE it is well known that people with chronic obstructive pulmonary disease experience declines in functional performance, but little is known about the rate of decline. The purposes of this research were to describe the rate of decline in functional performance and to examine the contribution of disease severity, body composition, symptoms, and functional capacity. Functional performance was defined as the activities that people choose to engage in on a day-to-day basis. METHODS people (n = 108) with chronic obstructive pulmonary disease were enrolled and followed yearly for 3 yr with self-reported functional performance (Functional Performance Inventory), spirometry, lung volumes, diffusion capacity, body composition (dual-energy x-ray absorptiometry), dyspnea and fatigue (Chronic Respiratory Disease Questionnaire), and functional capacity (6-min walk distance (6MWD), isokinetic strength of knee flexors and extensors, handgrip strength, and maximal inspiratory pressure). A total of 88 subjects completed a (mean ± SD) of 2.7 ± 0.9 yr of follow-up. RESULTS significant negative slopes were observed for functional performance (P = 0.001), spirometry (the ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC), P < 0.0001), diffusion capacity (P < 0.0001), and muscle strength (P < 0.0001)). The slopes for dyspnea, fatigue, and functional capacity were not significantly different from zero, but there was a wide individual variation. Hierarchical regression demonstrated that 31% of the variance in the slope of functional performance was accounted for by the hierarchical model, and the primary predictors were the slopes of the FEV1/FVC, 6MWD, and muscle strength (knee flexors/extensor and handgrip). CONCLUSIONS subjects experienced a slow decline in functional performance, associated with declines in functional capacity and increases in body fat. Symptoms were relatively stable and not associated with declines in functional performance.

Innovative treatments for adults with obstructive sleep apnea

Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and reduced quality of life. For over 25 years, the primary treatment has been continuous positive airway pressure, which introduces a column of air that serves as a pneumatic splint for the upper airway, preventing the airway collapse that is the physiologic definition of this syndrome. However, issues with patient tolerance and unacceptable levels of treatment adherence motivated the exploration of other potential treatments. With greater understanding of the physiologic mechanisms associated with OSA, novel interventions have emerged in the last 5 years. The purpose of this article is to describe new treatments for OSA and associated complex sleep apnea. New approaches to complex sleep apnea have included adaptive servoventilation. There is increased literature on the contribution of behavioral interventions to improve adherence with continuous positive airway pressure that have proven quite effective. New non-surgical treatments include oral pressure devices, improved mandibular advancement devices, nasal expiratory positive airway pressure, and newer approaches to positional therapy. Recent innovations in surgical interventions have included laser-assisted uvulopalatoplasty, radiofrequency ablation, palatal implants, and electrical stimulation of the upper airway muscles. No drugs have been approved to treat OSA, but potential drug therapies have centered on increasing ventilatory drive, altering the arousal threshold, modifying loop gain (a dimensionless value quantifying the stability of the ventilatory control system), or preventing airway collapse by affecting the surface tension. An emerging approach is the application of cannabinoids to increase upper airway tone.

Self-efficacy enhancing intervention increases light physical activity in people with chronic obstructive pulmonary disease

Background People with chronic obstructive pulmonary disease lead sedentary lives and could benefit from increasing their physical activity. The purpose of this study was to determine if an exercise-specific self-efficacy enhancing intervention could increase physical activity and functional performance when delivered in the context of 4 months of upper body resistance training with a 12-month follow-up. Methods In this randomized controlled trial, subjects were assigned to: exercise-specific self-efficacy enhancing intervention with upper body resistance training (SE-UBR), health education with upper body resistance training (ED-UBR), or health education with gentle chair exercises (ED-Chair). Physical activity was measured with an accelerometer and functional performance was measured with the Functional Performance Inventory. Forty-nine people with moderate to severe chronic obstructive pulmonary disease completed 4 months of training and provided valid accelerometry data, and 34 also provided accelerometry data at 12 months of follow-up. The self-efficacy enhancing intervention emphasized meeting physical activity guidelines and increasing moderate-to-vigorous physical activity. Results Differences were observed in light physical activity (LPA) after 4 months of training, time by group interaction effect (P=0.045). The SE-UBR group increased time spent in LPA by +20.68±29.30 minutes/day and the other groups decreased time spent in LPA by −22.43±47.88 minutes/day and -25.73±51.76 minutes/day. Changes in LPA were not sustained at 12-month follow-up. There were no significant changes in moderate-to-vigorous physical activity, sedentary time, or functional performance. Subjects spent most of their waking hours sedentary: 72%±9% for SE-UBR, 68%±10% for ED-UBR, and 74%±9% for ED-Chair. Conclusion The self-efficacy enhancing intervention produced a modest short-term increase in LPA. Further work is needed to increase the magnitude and duration of effect, possibly by targeting LPA.

Health-Related Stigma as a Determinant of Functioning in Young Adults with Narcolepsy

Symptoms of narcolepsy tend to arise during adolescence or young adulthood, a formative time in human development during which people are usually completing their education and launching a career. Little is known about the impact of narcolepsy on the social aspects of health-related quality of life in young adults. The purpose of this study was to examine relationships between health-related stigma, mood (anxiety and depression) and daytime functioning in young adults with narcolepsy compared to those without narcolepsy. Young adults (age 18–35) with narcolepsy (N = 122) and without narcolepsy (N = 93) were mailed a packet that included questionnaires and a self-addressed postage paid envelope. The questionnaire included demographic information and a composite of instruments including the SF 36, Functional Outcomes of Sleep Questionnaire (FOSQ), Fife Stigma Scale (FSS), Epworth Sleepiness Scale (ESS) and Hospital Anxiety and Depression Scale (HADS). Variable associations were assessed using descriptive statistics, ANOVA, Mann-Whitney U Test, correlations, stepwise multiple regression and path analysis. Young adults with narcolepsy perceived significantly more stigma and lower mood and health-related quality of life than young adults without narcolepsy (p<0.01). Health-related stigma was directly and indirectly associated with lower functioning through depressed mood. Fifty-two percent of the variance in functioning was explained by the final model in the young adults with narcolepsy. Health-related stigma in young adults with narcolepsy is at a level consistent with other chronic medical illnesses. Health-related stigma may be an important determinant of functioning in young adults with narcolepsy. Future work is indicated toward further characterizing stigma and developing interventions that address various domains of stigma in people with narcolepsy.

An evidence-based approach to COPD: part 1.

OVERVIEWChronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States, affecting as many as 24 million Americans and resulting in 1.5 million ED visits, 700,000 hospital admissions, and 124,000 deaths annually. This article, the first in a two-part series on COPD, outlines current guidelines and other evidence-based recommendations on diagnosing and managing stable COPD in the outpatient setting. Part 2 will appear in a future issue of AJN and will focus on managing acute exacerbations of COPD.

Upper-Body Resistance Training and Self-Efficacy Enhancement in COPD

Purpose Loss of skeletal muscle strength is commonly seen with chronic obstructive pulmonary disease (COPD). The study aim was to determine the effects of comprehensive upper-body resistance training (8 different lifts) and a self-efficacy enhancing intervention in COPD with respect to muscle strength, symptoms, functional status and exercise adherence. Methods This randomized trial had 3 groups: upper-body resistance training with an intervention to enhance self-efficacy (UBR + SE), upper-body resistance training and health education (UBR + HE), gentle chair exercises and health education (CE + HE). Subjects performed 16 weeks of supervised training, then 12 months of long-term maintenance at home. Outcomes were: muscle strength, dyspnea, functional status, self-efficacy, and adherence. Results Sixty-four subjects completed 16 wks of training: age 71 ± 8 yr, fat-free mass index 19 ± 3 kg/m2, forced expiratory volume in one second 58 ± 18 percent predicted. The UBR + SE intervention produced a 46% increase in strength compared to a 36% increase in the UBR + HE group (P = 0.054). The combined UBR + SE and UBR + HE groups produced a 41% increase in strength compared to an 11% increase in the CE+HE (P < 0.001). The combined UBR groups also demonstrated increases in lean arm mass (P = 0.003) and a trend toward decreased dyspnea (P = 0.053). There were no group differences in attrition, attendance and training progression. Fifty subjects completed long-term maintenance and the UBR + SE and UBR + HE groups retained some gains in muscle strength, 24% and 21% respectively, and the CE + HE group lost 3% of muscle strength from baseline. Conclusion The study provides strong evidence that comprehensive resistance training increased strength and lean arm mass and that strength can be partially maintained through a simple home program using hand weights. It provides limited evidence that upper-body resistance training improved dyspnea and that the exercise-specific self-efficacy enhancing intervention was beneficial.