This document discusses COPD and its frequent comorbidity with mental health conditions like depression, anxiety, and cognitive impairment. Key points include: - Smoking is the leading cause of COPD. Mental illnesses like depression and anxiety often co-occur with COPD and can exacerbate its symptoms and progression. - COPD can cause cognitive impairment through hypoxia and other mechanisms. This impacts medication adherence and self-management. - Conditions like depression and anxiety increase COPD exacerbations and mortality. Their treatments must be carefully managed to avoid adverse effects. - Non-pharmacological therapies like pulmonary rehabilitation and CBT can effectively treat both COPD and comorbid mental illnesses. However, integrated care remains

1. COPD on the CL
GAZI RASHID
17 AUG 2017

2. What is COPD?
Causes:
◦ Smoking
◦ Smoking
◦ Smoking
◦ 2nd hand smoking, occupational
exposures, genetics
Debilitating and progressive inflammatory
Multi-systemic implications
In the US
◦ 24 million adults
◦ 3rd leading cause of death
Veterans
◦ 3x as likely to develop COPD
◦ 5th most prevalent disease

3. Emphysema
Chronic
Bronchitis
↓ ↓FEV1
↓ FVC
Ratio

4. ↑CO2
↓O2
↑CO2
↓O2

5. Progression
1) Chronic productive cough
2) Progressive dyspnea 
can’t exercise
can’t work
can’t socialize
can’t perform ADLs
3) Chronic hypoxia and hypercapnia

6. Treatment & Management

7. Exacerbations
How?
◦ Acute worsening SOB & productive cough
◦ Can precipitate to acute respiratory failure  often fatal
Why?
◦ Infections
◦ Non-compliance
Treatments
◦ IV and oral corticosteroids
◦ ABx
◦ Positive Pressure ventilation
◦ Intubation and mechanical ventilation

8. Mental Illness & COPD

9. 1: Mr. C
74 yo widower with FEV1/FEVC of 48%
Lives alone and wants to keep it that way
Daughter is concerned he’s becoming forgetful, worried about medications
Managed exacerbations at home, consults telemedicine

10. Cognitive Dysfunction & COPD
US longitudinal health survey: 9.5% of
17535 participants >53 had COPD
◦ 17.5% of those had MCI (13.1%)
◦ 1.3 million US adults
Another study found 36% of COPD pt.
(12%)
Generally, deficits seem to occur in verbal
skills, memory, fluency

11. Impact of COPD on Cognition
Longitudinal study found that at baseline, disability of COPD vs. Non-
◦ Baseline (12.8% vs. 5.2%)  Incidence at 2 yr follow-up (9.2% vs. 4.0 %)
Hospitalized Pt
◦ CV Health Study of 3093 pt >65: Comorbid pt. had highest all-cause
hospitalization rate and highest death rate compared with other patients
◦ Study of 63 pt. showed that after exacerbation or mechanical ventilation, pt.
had worse cognitive status from baseline
Treatment
◦ Various studies have shown pt. with impairment have difficulty using and
dosing MDIs correctly, synchronize inhalation with activation, etc

12. Managing Cognitive Dysfunction & COPD
Limited evidence for any one therapy to
improve cognitive outcomes
O2 therapy
◦ continuous O2 showed improvements
compared to use it at night or “PRN”
◦ Short-term use seems to be ineffective
Taking Rx
◦ Training on correctly taking Rx
◦ Nebulizers require less cognitive ability and
don’t require level of hand-breath
coordination

13. 2: Mr. D
45 yo male hospitalized for pneumonia-
associated COPD exacerbation
Started on ABx, albuterol, theophylline,
and IV methylprednisone
On day 2, speech becomes hard to
understand and incoherent
MOCA: 21; now disoriented and has poor
verbal memory
Admission note just says “AOx4”

14. COPD & Delirium
Pt. w/ COPD face various risk factors
Why?
◦ Metabolic disturbances
◦ Hypoxia
◦ Hypercapnia
◦ Various Rx
◦ Corticosteroids
◦ Anticholinergics
◦ Agitation Rx like BZD
Monitor for sudden change in cognition
or mental status
◦ Steroid-induced psychosis
◦ Delirium
Check SaO2 and ABG
Review Rx, including high-dose vs. low-
dose of steroids
Increased risk on NIPPV

15. 3: Mr. P
-60 yo with 10 yr hx of COPD and anxiety
treated with lorazepam and sertraline
-Went into respiratory failure
-Now on a ventilator
-Currently being treated with nebulized
albuterol, ipratropium; IV
methylprednisone, ABx, theophylline,
sertraline, clonazepam
-Doctors tried to wean him off, but pt.
experienced severe anxiety

16. “Is my next breath my last?”
Anxiety, fatigue, and irritability due
to SOB and air hunger
Often hard to distinguish symptoms
Comorbidity rates vary: GAD 3x
more likely than in US population
◦ Higher rates of mortality and
readmission after COPD
exacerbation
◦ Higher rates of 30-day mortality
with anxiety comorbidity

17. Complications of Treatment
Bronchodilators (beta-agonists) can
increase heart rate
Theophylline (toxicity at > 20
mg/ml) acts as cardiac, CNS
stimulant
ABx like erythromycin, ciprofloxacin
can increase levels of theophylline
by inhibiting CYP enzymes
Steroid-induced psychosis
Challenge to wean pt. off ventilator

18. Managing Anxiety & COPD
SSRIs are first line
Buspirone, Gabapentin, Valproic acid adjunctive
DON’T give benzodiazapenes or anticholinergics
◦ can lower respiratory drive and worsen the situation
◦ Withdrawal can lead to worse anxiety
Ventilator Weaning with relaxation techniques, music therapy, etc

19. 4: Mrs. H
59 yo diagnosed with COPD 3 years
ago after 40 pack-years
Despite counseling, she’s still
smoking 1 ppd
Progressive SOB has left her unable
to garden and play with grandkids
Has become increasingly apathetic
and poor COPD Rx compliance
Also reports poor sleep, poor
appetite, decreased energy

20. Depression & COPD
Often hard to distinguish symptoms
Prevalence of MDD among COPD pt.
can range from 40-50%
2/3 of pt. with both don’t get
antidepressant treatment
Depression worsens COPD by:
◦ Reduces physical activity
◦ Increased tobacco consumption
◦ Cessation is harder
◦ Decreased Rx compliance
NETT – 610 COPD pt
◦ 41% had depression
◦ Pt. w/ moderate depressive symptom
(BDI) had higher risk of COPD
hospitalizations, ED visits, and inc risk
of 3 yr mortality
Another study found that comorbidity
with MDD or GAD increases risk of
exacerbation rises by 31%
◦ In those pt, MDD inc risk of death by
83%

21. Managing Depression & COPD
SSRIs are first line compared to TCAs
Mirtazapine – stimulates appetite
Steroid-induced psychosis: most commonly presents as depression

22. Pulmonary Rehabilitation
Now an essential component of care in COPD alone
Weekly program with a team
Goal: improve functional status and quality of life
Education + exercise + therapy + relaxation
Shown to be effective in decreasing depression and
anxiety following completion

23. Psychological Interventions
Relaxation Therapy – like breathing, meditation, visualization, sequential muscle
relaxation
Singing classes – for quality of life, functional status, and mood
CBT – face-face, internet, and telemedicine shown to be equally effective
Self-management interventions: empowering individual with resources and
behavioral changes
◦ Improved quality of life
◦ Reduced exacerbations and hospital admissions
◦ More effective than just COPD education alone

24. Barriers
<1/3 with comorbid anxiety or depression get appropriate treatments

25. Physician
Patient
- No standardized test
- Poor confidence
- Time limited to COPD
- Masking
- Lack of knowledge
- Stigma
- Reluctance
- Masking

26. What’s Next?
How to catch these comorbidities earlier so they don’t exacerbate each other
Validate tools and questionnaires for COPD population
Not enough definitive research for any specific Rx or non-Rx therapies
Need to study and approach problems in an integrated manner

27. Five For the Road
1. Mental illness are COMMONLY comorbid with
COPD
2. Negative effects go BOTH ways
3. Routinely check and track cognition
4. Look at the Rx for culprits and solutions
5. Several non-Rx options available

28. Resources
http://www.mdedge.com/currentpsychiatry/article/108303/somatic-disorders/copd-comorbid-mental-illness-what-psychiatrists
http://www.atsjournals.org/doi/full/10.1164/rccm.201105-0939PP
◦ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255157/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293292/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974694/
https://link.springer.com/article/10.1007/s12529-017-9663-2
http://www.sciencedirect.com/science/article/pii/S0163834316304339
http://www.mdedge.com/jfponline/article/107643/cardiology/anxiety-and-depression-easing-burden-copd-patients
http://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201602-136OC
https://www.copdfoundation.org/Praxis/Community/Blog/Article/598/Dr-Robert-Benzo-Changing-Outcomes-in-COPD-through-
Motivational-Interviewing.aspx
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2849676/pdf/nihms101564.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2706604/

29. Smoking Cessation
Motivational interviewing: activate their own autonomy and motivations
Doesn’t REVERSE, but SLOWS DOWN progression
Prolongs survival rate
Respiratory symptoms can start to increase within 1 year
Some efficacy in decreasing readmission and improved quality of life

30. Mechanisms
Biological Theory
◦ Depression and anxiety Inc HPA activation and systemic inflammation
◦ This chronic psychological stress state can weaken immune function  vulnerability to infections and EC
◦ Not enough research done
Cognitive and Behavioral
◦ Comorbid anx and dep  poor self-confidence and efficacy  poor self-coping and self-care
◦ Can lead to unwillingness to engage in PR, dec physical activity, poor eating habis, poor medical
adherence
◦ Depression - hopelessness, helplessness, isolation  reduce motivation to seek help
◦ Fear and anxiety  amplifies awareness of symptoms  higher rates of outpt Rx
◦ All of which  inc vulnerability and speeds up progression