Added value of co-morbidity in predicting health-related quality of life in COPD patients

Differences in cardiovascular risk and health-related quality of life in COPD patients according to clinical phenotype

Chronic obstructive pulmonary disease (COPD) has a high prevalence and a major impact on health-related quality of life (HRQL). COPD exacerbations are an important cause of morbidity and mortality, affecting cardiovascular risk, and are associated with poorer health status. The aim of this study was to assess the association between cardiovascular risk (CVR) and HRQL, according to exacerbator or non-exacerbator phenotype. We undertook a cross-sectional, observational, descriptive study of 107 patients with COPD. Patients with two or more moderate exacerbations or one severe exacerbation in the previous year were considered as exacerbators. The CVR was calculated with the Framingham scale and SCORE (Systematic Coronary Risk Evaluation) and the HRQL was assessed with the generic questionnaire Short Form-36 Health Survey (SF-36), the St George Respiratory Questionnaire (SGRQ) and the COPD Assessment Test (CAT). Statistical analysis was done with SPSS version 26.0 for Windows. The SF-36 and the SGRQ showed lower values for the exacerbator phenotype, indicating a poorer quality of life. The CAT questionnaire showed values above 10 for the exacerbator phenotype, and lower values in the non-exacerbator group. After categorizing the sample according to their median age (65 years), we found a greater deterioration in HRQL in patients under 65 years of age according to the SF-36, the SGRQ and the CAT. We also detected differences in HRQL between non-exacerbator patients with a high CVR according to the Framingham (≥ 20%) and SCORE (≥ 5%) scales compared to those without this risk. A tendency towards worse HRQL was observed in non-exacerbator patients with a high CVR, which was statistically significant for the SGRQ impact domain on the SCORE scale. The CAT also showed a worse quality of life in non-exacerbator patients with a high CVR, which was significant in the Framingham model (Framingham high risk 8.41 vs non-high risk 6.05, p < 0.01). These differences were not observed in exacerbator patients. Our findings confirm that a high CVR influences HRQL in patients with COPD, especially in non-exacerbator patients with a high CVR, measured according to the SGRQ and the CAT.

The Clinical Profile of Patients with COPD Is Conditioned by Age

In recent years, many studies have analyzed the importance of integrating time, or aging, into the equation that relates genetics and the environment to the development and origin of COPD. Under conditions of daily clinical practice, our study attempts to identify the differences in the clinical profile of patients with COPD according to age and the impact on the global burden of the disease. This study is non-interventional and observational, using artificial intelligence and data captured from electronic medical records. The study population included patients who were diagnosed with COPD between 2011 and 2021. A total of 73,901 patients had a diagnosis of COPD. The mean age was 73 years (95% CI: 72.9-73.1), and 56,763 were men (76.8%). We observed a specific prevalence of obesity, heart failure, depression, and hiatal hernia in women (p < 0.001), and ischemic heart disease and obstructive sleep apnea (OSA) in men (p < 0.001). In the analysis by age ranges, a progressive increase in cardiovascular risk factors was observed with age. In conclusion, in a real-life setting, COPD is a disease that primarily affects older subjects and frequently presents with comorbidities that are decisive in the evolutionary course of the disease.

The Patient Acceptable Symptom State in Female Urinary Incontinence

OBJECTIVE

The objective of this study is to characterize an acceptable health state, using the patient acceptable symptom state (PASS) question, in adult women with urinary incontinence.

METHODS

This is a prospective multicenter cohort study determining PASS thresholds from condition-specific measures using an electronic research platform in English-speaking women seeking nonsurgical treatment of urinary incontinence between March 2019 and May 2020. Exclusions included pregnancy, isolated overactive bladder, and pelvic organ prolapse greater than stage II. The cohort was described and then grouped based on achievement of PASS. The PASS thresholds were determined using the 75th percentile and univariate regression methods. Multivariable regression modeling was used to understand the influence of covariates on PASS achievement.

RESULTS

The study was completed by 100 (80%) of the 125 enrolled subjects. Of these, 45% (n = 45) achieved PASS after a median of 7 weeks of treatment (range, 6-13 weeks). The corresponding questionnaire score for PASS was estimated to be 6 for the Incontinence Severity Index, 3 for the Patient Global Impression of Severity and Improvement, 37.5 using the Urinary Distress Inventory 6, and 33.3 using the Incontinence Impact Questionnaire 7. Increasing age was independently associated with achieving PASS after adjusting for treatment adherence and outcomes scores (adjusted odds ratio, 1.05 [95% confidence interval, 1.01-1.10]; P = 0.02).

CONCLUSIONS

PASS was achieved in 45% of women after conservative treatment of urinary incontinence. PASS offers a new perspective for analysis and interpretation of outcome measures used in pelvic floor disorders and can serve as a reference for future research and clinical care pathways.

Contributions of COPD, asthma, and ten comorbid conditions to health care utilization and patient-centered outcomes among US adults with obstructive airway disease

Background

Among persons with obstructive airway disease, the relative contributions of chronic obstructive pulmonary disease (COPD), asthma, and common comorbid conditions to health care utilization and patient-centered outcomes (PCOs) have not been previously reported.

Methods

We followed a total of 3,486 persons aged ≥40 years with COPD, asthma, or both at baseline, from the Medical Expenditure Panel Survey (MEPS) cohorts enrolled annually from 2008 through 2012 for 1 year. MEPS is a prospective observational study of US households recording self-reported COPD, asthma, and ten medical conditions: angina, arthritis, cancer, coronary heart disease, cognitive impairment, diabetes, hypertension, lung cancer, myocardial infarction, and stroke/transient ischemic attack. We studied the separate contributions of these conditions to health care utilization (all-cause and respiratory disease hospitalization, any emergency department [ED] visit, and six or more outpatient visits) and PCOs (seven or more days spent in bed due to illness, incident loss of mobility, and incident decline in self-perceived health).

Results

COPD made the largest contributions to all-cause and respiratory disease hospitalization and ED visits, while arthritis made the largest contribution to outpatient health care. Arthritis and COPD, respectively, made the greatest contributions to the PCOs.

Conclusion

COPD made the largest and second largest contributions to health care utilization and PCOs among US adults with obstructive airway disease. The twelve medical conditions collectively accounted for between 52% and 61% of the health care utilization outcomes and between 53% and 68% of the PCOs. Cognitive impairment, diabetes, hypertension, and stroke also made significant contributions.

Comorbidity and coexisting symptoms and infections presented in general practice by COPD patients: Does livestock density in the residential environment play a role?

OBJECTIVES

Patients with chronic obstructive pulmonary disease (COPD) constitute a potentially susceptible group towards environmental exposures such as livestock farm emissions, given their compromised respiratory health status. The primary aim of this study was to examine the association between livestock exposure and comorbidities and coexisting symptoms and infections in COPD patients.

METHODS

Data were collected from 1828 COPD patients (without co-occurring asthma) registered in 23 general practices and living in a rural area with a high livestock density. Prevalence of comorbid diseases/disorders and coexisting symptoms/infections were based on electronic health records from the year 2012. Various indicators of individual exposure to livestock were estimated based on residential addresses, using a geographic information system.

RESULTS

At least one comorbid disorder was present in 69% of the COPD patients (especially cardiac disorders and depression, while 49% had at least one coexisting symptom and/or infection (especially upper respiratory tract infections, respiratory symptoms and pneumonia). Half of the COPD-patients resided less than 500m of the nearest farm. Some positive as well as inverse associations were found between the examined outcomes and exposure estimates, although not consistent.

CONCLUSIONS

Despite the high prevalence of coexisting chronic and acute conditions presented in primary care by in COPD patients, this investigation found no convincing evidence for an association with livestock exposure estimates. There is a need for a replication of the present findings in studies with a longitudinal design, on different groups of potentially susceptible patients. Future research should also elucidate the biological plausibility of possible protective effects of exposure.

Assessing health-related quality of life in COPD: comparing generic and disease-specific instruments with focus on comorbidities

Background

Chronic Obstructive Pulmonary Disease (COPD) influences different aspects of patient’s health-related quality of life (HRQL). While disease-specific HRQL instruments focus on symptoms and functional impairments, generic instruments cover a broader view on health. This study compares the generic EQ-5D-3 L and two disease-specific questionnaires (St.-George’s Respiratory Questionnaire (SGRQ-C), COPD Assessment Test (CAT)) in a comprehensive spectrum of COPD disease grades with particular attention on comorbidities and assesses the discriminative abilities of these instruments.

Methods

Using data from the baseline visit of the German COPD cohort COSYCONET, mean HRQL scores in different COPD grades were compared by linear regression models adjusting for age, sex, education, smoking status, BMI, and low vs. high number of comorbidities or a list of several self-reported comorbid conditions. Discriminative abilities of HRQL instruments to differentiate between COPD grades were assessed by standardized mean differences.

Results

In 2,291 subjects in COPD GOLD grades 1–4 EQ-5D-3 L utility, EQ-5D VAS, SGRQ, and CAT were found able to discriminate between COPD grades, with some limitations for the EQ-5D utility in mild disease. Both generic and disease-specific HRQL instruments reflected the burden of comorbid conditions. The SGRQ showed the best discrimination between COPD grades and was less influenced by comorbidities, while EQ-5D utility put a higher weight on comorbid conditions. For all instruments, psychiatric disorders and peripheral artery disease showed the strongest negative associations with HRQL.

Conclusion

All HRQL instruments considered reflect considerable impairment of HRQL in COPD patients, worsening with increasing COPD grade and number of comorbidities. Findings may support clinical assessment, choice of HRQL instrument in future studies, and parameterization of decision-analytic models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0238-9) contains supplementary material, which is available to authorized users.

Prevalence and Comorbidities of Chronic Obstructive Pulmonary Disease Among Adults in Kentucky Across Gender and Area Development Districts, 2011

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in Kentucky, and precise estimates of the prevalence of this disease and its comorbidities are needed. This study aimed to determine the prevalence of both COPD and its comorbidities and risk differences of COPD comorbidities across Area Development Districts (ADDs) and gender. Methods: The demographic characteristics, prevalence of self- reported COPD and its comorbidities were determined by using data from the 2011 Kentucky Behavioral Risk Factor Survey (KyBRFS). Logistic regression was used to estimate adjusted odds ratios (ORs) for COPD and comorbidities. Results: The overall prevalence of age adjusted COPD was 10.09% (95% confidence interval [CI] 9.99, 10.19), 8.85% for men (95% CI 8.76, 8.93), and 10.78% for women (95% CI 10.67, 10.88). Odds ratios for risk of angina or coronary heart disease (CHD), and arthritis among patients with COPD, by sex and ADDs varied significantly (pooled overall OR=3.43, 95% CI 2.70-4.34, heterogeneity p=0.0001) and (pooled overall OR=2.16, 95% CI 1.75-2.67, heterogeneity p=0.0001), respectively. ORs for risk of depression (pooled OR=2.61, 95% CI 1.78-3.70, heterogeneity p=0.028) and hypertension (pooled OR=1.67, 95% CI 1.16-2.42, heterogeneity p=0. 006) only varied significantly in men. Odds ratios for risk of diabetes was not significant across ADDs and gender (pooled overall OR=2.02, 95% CI 1.61-2.53, heterogeneity p=0.709). Conclusion: Gender differences account for the discrepancy in the risk of comorbidities in patients with COPD across Kentucky's Area Development Districts. This should guide public health officials and physicians to create gender-based prevention interventions.

Comorbid Influences on Generic Health-Related Quality of Life in COPD: A Systematic Review

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and of loss of disability-adjusted life years worldwide. It often is accompanied by the presence of comorbidity.

Objectives

To systematically review the influence of COPD comorbidity on generic health-related quality of life (HRQoL).

Methods

A systematic review approach was used to search the databases Pubmed, Embase and Cochrane Library for studies evaluating the influence of comorbidity on HRQoL in COPD. Identified studies were analyzed according to study characteristics, generic HRQoL measurement instrument, COPD severity and comorbid HRQoL impact. Studies using only non-generic instruments were excluded.

Results

25 studies met the selection criteria. Seven studies utilized the EQ-5D, six studies each used the SF-36 or SF-12. The remaining studies used one of six other instruments each. Utilities were calculated by four EQ-5D studies and one 15D study. Patient populations covered both early and advanced stages of COPD and ranged from populations with mostly stage 1 and 2 to studies with patients classified mainly stage 3 and 4. Evidence was mainly created for cardiovascular disease, depression and anxiety as well as diabetes but also for quantitative comorbid associations. Strong evidence is pointing towards the significant negative association of depression and anxiety on reduced HRQoL in COPD patients. While all studies found the occurrence of specific comorbidities to decrease HRQoL in COPD patients, the orders of magnitude diverged. Due to different patient populations, different measurement tools and different concomitant diseases the study heterogeneity was high.

Conclusions

Facilitating multimorbid intervention guidance, instead of applying a parsimony based single disease paradigm, should constitute an important goal for improving HRQoL of COPD patients in research and in clinical practice.

Quality of life in older patients with chronic obstructive pulmonary disease (COPD) in Hong Kong: a case-control study

PURPOSE

To date, there have been few studies examining quality of life (QOL) in older patients with chronic obstructive pulmonary disease (COPD) in China. The aim of the study was to assess QOL in Chinese older patients with COPD and explore its demographic and clinical correlates.

DESIGN AND METHODS

Case-control study of 142 outpatients with COPD and 218 matched control subjects without COPD. COPD patients were recruited from a prospective study sample hospitalized in Hong Kong for acute COPD exacerbation (≥ 2 major COPD symptoms or > 1 major + minor COPD symptoms for ≥ 2 consecutive days). Controls were recruited from social centers in Hong Kong. Activity of daily living was assessed with the Instrumental Activities of Daily Living Scale (IADL), life events were evaluated with the Life Event Scale, depressive disorders were diagnosed using the Geriatric Depression Scale (GDS), and QOL was measured using the Medical Outcomes Study Short Form-12 (SF-12) and St. George's Respiratory Questionnaire (SGRQ).

FINDINGS

Compared to controls, patients had significantly lower scores in the physical (PCS score), but not in the mental (MCS score) QOL domain. Multivariate analyses showed that more hospitalizations in the past year significantly contributed to higher PCS score (p = .03), while higher GDS total score contributed to lower MCS score (p = .003). Severe and very severe COPD, more physical illnesses, and higher IADL total score each independently contributed to higher SGRQ total score, explaining 40.0% of the variance (p < .001).

PRACTICE IMPLICATIONS

Our results suggest that therapeutic and psychosocial interventions alleviating depressive symptoms, severe COPD, comorbidities, and improving IADL in Chinese patients with COPD are likely of considerable benefit for improving QOL in patients with COPD.

Managing comorbidities in COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Age and smoking are common risk factors for COPD and other illnesses, often leading COPD patients to demonstrate multiple coexisting comorbidities. COPD exacerbations and comorbidities contribute to the overall severity in individual patients. Clinical trials investigating the treatment of COPD routinely exclude patients with multiple comorbidities or advanced age. Clinical practice guidelines for a specific disease do not usually address comorbidities in their recommendations. However, the management and the medical intervention in COPD patients with comorbidities need a holistic approach that is not clearly established worldwide. This holistic approach should include the specific burden of each comorbidity in the COPD severity classification scale. Further, the pharmacological and nonpharmacological management should also include optimal interventions and risk factor modifications simultaneously for all diseases. All health care specialists in COPD management need to work together with professionals specialized in the management of the other major chronic diseases in order to provide a multidisciplinary approach to COPD patients with multiple diseases. In this review, we focus on the major comorbidities that affect COPD patients. We present an overview of the problems faced, the reasons and risk factors for the most commonly encountered comorbidities, and the burden on health care costs. We also provide a rationale for approaching the therapeutic options of the COPD patient afflicted by comorbidity.

A simplified score to quantify comorbidity in COPD

Importance

Comorbidities are common in COPD, but quantifying their burden is difficult. Currently there is a COPD-specific comorbidity index to predict mortality and another to predict general quality of life. We sought to develop and validate a COPD-specific comorbidity score that reflects comorbidity burden on patient-centered outcomes.

Materials and Methods

Using the COPDGene study (GOLD II-IV COPD), we developed comorbidity scores to describe patient-centered outcomes employing three techniques: 1) simple count, 2) weighted score, and 3) weighted score based upon statistical selection procedure. We tested associations, area under the Curve (AUC) and calibration statistics to validate scores internally with outcomes of respiratory disease-specific quality of life (St. George's Respiratory Questionnaire, SGRQ), six minute walk distance (6MWD), modified Medical Research Council (mMRC) dyspnea score and exacerbation risk, ultimately choosing one score for external validation in SPIROMICS.

Results

Associations between comorbidities and all outcomes were comparable across the three scores. All scores added predictive ability to models including age, gender, race, current smoking status, pack-years smoked and FEV₁ (p<0.001 for all comparisons). Area under the curve (AUC) was similar between all three scores across outcomes: SGRQ (range 0·7624–0·7676), MMRC (0·7590–0·7644), 6MWD (0·7531–0·7560) and exacerbation risk (0·6831–0·6919). Because of similar performance, the comorbidity count was used for external validation. In the SPIROMICS cohort, the comorbidity count performed well to predict SGRQ (AUC 0·7891), MMRC (AUC 0·7611), 6MWD (AUC 0·7086), and exacerbation risk (AUC 0·7341).

Conclusions

Quantifying comorbidity provides a more thorough understanding of the risk for patient-centered outcomes in COPD. A comorbidity count performs well to quantify comorbidity in a diverse population with COPD.

Epidemiology and clinical impact of major comorbidities in patients with COPD

Comorbidities are frequent in chronic obstructive pulmonary disease (COPD) and significantly impact on patients’ quality of life, exacerbation frequency, and survival. There is increasing evidence that certain diseases occur in greater frequency amongst patients with COPD than in the general population, and that these comorbidities significantly impact on patient outcomes. Although the mechanisms are yet to be defined, many comorbidities likely result from the chronic inflammatory state that is present in COPD. Common problems in the clinical management of COPD include recognizing new comorbidities, determining the impact of comorbidities on patient symptoms, the concurrent treatment of COPD and comorbidities, and accurate prognostication. The majority of comorbidities in COPD should be treated according to usual practice, and specific COPD management is infrequently altered by the presence of comorbidities. Unfortunately, comorbidities are often under-recognized and under-treated. This review focuses on the epidemiology of ten major comorbidities in patients with COPD. Further, we emphasize the clinical impact upon prognosis and management considerations. This review will highlight the importance of comorbidity identification and management in the practice of caring for patients with COPD.

[Impact of COPD on quality of life and mental health among one hundred Tunisian patients]

Chronic obstructive pulmonary disease (COPD) constitutes a penalty in physical activities of patients. Its mental repercussions are important and expressed in a significant impairment of quality of life.

OBJECTIVES

To evaluate the quality of life and its determinants in Tunisian patients with COPD.

METHODS

We conducted a cross-sectional study over a period of 6 months from January 2008 to June 2008 and focused on patients with COPD hospitalized and monitored in the department of respiratory diseases in Farhat Hached Teaching hospital of Sousse in Tunisia. We used the French version of Saint George's respiratory questionnaire (SGRQ) to study the quality of life and the Hospital Anxiety Depression (HAD) for the exploration of anxiety and depression.

RESULTS

Among 100 patients included in the study, the SGRQ overall score average was 44.31 ± 13.85%. Ten patients had depression and 9 patients had an anxiety state. The results of the multiple linear regression analysis showed that four factors were associated significantly with impaired quality of life: dyspnea, the number of exacerbations, comorbidity and depression.

CONCLUSION

The psychological impact and effect on quality of life of COPD are additional tools combined with physical and spirometric data during the follow-up of treatment of patients and should be systematically sought by practitioners, which is still rare in Tunisia.

Co-morbidities are the key nominators of the health related quality of life in mild and moderate COPD

Background

Co-morbidities are common in chronic obstructive pulmonary disease (COPD). We assessed the contribution of common co-morbidities on health related quality of life (HRQoL) among COPD patients.

Methods

Using both generic (15D) and respiratory-specific (AQ20) instruments, HRQoL was assessed in a hospital based COPD population (N = 739, 64% males, mean age 64 years, SD 7 years) in this observational study with inferential analysis. The prevalence of their co-morbidities was compared with those of 5000 population controls. The patients represented all severity stages of COPD and the patterns of common concomitant disorders differed between patients.

Results

Co-morbidities such as psychiatric conditions, alcohol abuse, cardiovascular diseases, and diabetes were more common among COPD patients than in age and gender matched controls. Psychiatric conditions and alcohol abuse were the strongest determinants of HRQoL in COPD and could be detected by both 15D (Odds Ratio 4.7 and 2.3 respectively) and AQ20 (OR 2.0 and 3.0) instruments. Compared to respiratory specific AQ20, generic 15D was more sensitive to the effects of comorbidities while AQ20 was slightly more sensitive for the low FEV₁. FEV₁ was a strong determinant of HRQoL only at more severe stages of disease (FEV₁ < 40% of predicted). Poor HRQoL also predicted death during the next five years.

Conclusions

The results suggest that co-morbidities may impair HRQoL at an early stage of the disease, while bronchial obstruction becomes a significant determinant of HRQoL only in severe COPD.

Five comorbidities reflected the health status in patients with chronic obstructive pulmonary disease: the newly developed COMCOLD index

OBJECTIVE

This study aimed to identify those comorbidities with greatest impact on patient-reported health status in patients with chronic obstructive pulmonary disease (COPD) and to develop a comorbidity index that reflects their combined impact.

STUDY DESIGN AND SETTING

We included 408 Swiss and Dutch primary care patients with COPD from the International Collaborative Effort on Chronic Obstructive Lung Disease: Exacerbation Risk Index Cohorts (ICE COLD ERIC) in this cross-sectional analysis. Primary outcome was the Feeling Thermometer, a patient-reported health status instrument. We assessed the impact of comorbidities at five cohort assessment times using multiple linear regression adjusted for FEV1, retaining comorbidities with associations P ≤ 0.1. We developed an index that reflects strength of association of comorbidities with health status.

RESULTS

Depression (prevalence: 13.0%; regression coefficient: -9.00; 95% CI: -13.52, -4.48), anxiety (prevalence: 11.8%; regression coefficient: -5.53; 95% CI -10.25, -0.81), peripheral artery disease (prevalence: 6.4%; regression coefficient: -5.02; 95% CI-10.64, 0.60), cerebrovascular disease (prevalence: 8.8%; regression coefficient: -4.57; 95% CI -9.43, 0.29), and symptomatic heart disease (prevalence: 20.3%; regression coefficient: -3.81; 95% CI -7.23, -0.39) were most strongly associated with the Feeling Thermometer. These five comorbidities, weighted, compose the COMorbidities in Chronic Obstructive Lung Disease (COMCOLD) index.

CONCLUSION

The COMCOLD index reflects the combined impact of five important comorbidities from patients' perspective and complements existing comorbidity indices that predict death. It may help clinicians focus on comorbidities affecting patients' health status the most.

Internet access and use by COPD patients in the National Emphysema/COPD Association Survey

Background

Technology offers opportunities to improve healthcare, but little is known about Internet use by COPD patients. We tested two hypotheses: Internet access is associated with socio-demographic disparities and frequency of use is related to perceived needs.

Methods

We analyzed data from a 2007–2008 national convenience sample survey of COPD patients to determine the relationship between Internet access and frequency of use with demographics, socio-economic status, COPD severity, and satisfaction with healthcare.

Results

Among survey respondents (response rate 7.2%; n = 914, 59.1% women, mean age 71.2 years), 34.2% reported lack of Internet access, and an additional 49% had access but used the Internet less than weekly. Multivariate models showed association between lack of access and older age (OR 1.10, 95% CI 1.07, 1.13), lower income (income below $30,000 OR 2.47, 95% CI 1.63, 3.73), less education (high school highest attainment OR 2.30, 95% CI 1.54, 3.45), comorbid arthritis or mobility-related disease (OR 1.56, 95% CI 1.05, 2.34). More frequent use (at least weekly) was associated with younger age (OR 0.95, 95% CI 0.93, 0.98), absence of cardiovascular disease (OR 0.48, 95% CI 0.29, 0.78), but with perception of needs insufficiently met by the healthcare system, including diagnostic delay (OR 1.72, 95% CI 1.06, 2.78), feeling treated poorly (OR 2.46, 95% CI 1.15, 5.24), insufficient physician time (OR 2.29, 95% CI 1.02, 5.13), and feeling their physician did not listen (OR 3.14, 95% CI 1.42, 6.95).

Conclusions

An analysis of the characteristics associated with Internet access and use among COPD patients identified two different patient populations. Lack of Internet access was a marker of socioeconomic disparity and mobility-associated diseases, while frequent Internet use was associated with less somatic disease but dissatisfaction with care.

Impact of co-morbidities on self-rated health in self-reported COPD: an analysis of NHANES 2001-2008

Chronic Obstructive Pulmonary Disease (COPD) coexists with co-morbidities. While co-morbidity has been associated with poorer health status, it is unclear which conditions have the greatest impact on self-rated health. We sought to determine which, and how much, specific co-morbid conditions impact on self-rated health in current and former smokers with self-reported COPD. Using the 2001-2008 National Health and Nutrition Examination Survey we characterized the association between thirteen co-morbidities and health status among individuals self-reporting COPD. Adjusted odds ratios (ORs) were generated using ordinal logistic regression. Additionally we evaluated the impact of increasing number of co-morbidities with self-rated health. Eight illnesses had significant associations with worse self-rated health, however after mutually adjusting for these conditions, congestive heart failure (OR 3.07, 95% CI 1.69-5.58), arthritis (OR 1.69, 95% CI 1.13-2.52), diabetes (OR 1.63, 95% CI 1.01-2.64), and incontinence/prostate disease (OR 1.63, 95% CI 1.01-2.62) remained independent predictors of self-rated health. Each increase in co-morbidities was associated with a 43% higher chance of worse self-rated health (95% CI 1.27-1.62). Individuals with COPD have a substantial burden of co-morbidity, which is associated with worse self-rated health. CHF, arthritis, diabetes and incontinence/prostate disease have the most impact on self-rated health. Targeting these co-morbidities in COPD may result in improved self-rated health.

The prevalence of clinically-relevant comorbid conditions in patients with physician-diagnosed COPD: a cross-sectional study using data from NHANES 1999-2008

Background

Treatment of chronic diseases such as chronic obstructive pulmonary disease (COPD) is complicated by the presence of comorbidities. The objective of this analysis was to estimate the prevalence of comorbidity in COPD using nationally-representative data.

Methods

This study draws from a multi-year analytic sample of 14,828 subjects aged 45+, including 995 with COPD, from the National Health and Nutrition Examination Survey (NHANES), 1999–2008. COPD was defined by self-reported physician diagnosis of chronic bronchitis or emphysema; patients who reported a diagnosis of asthma were excluded. Using population weights, we estimated the age-and-gender-stratified prevalence of 22 comorbid conditions that may influence COPD and its treatment.

Results

Subjects 45+ with physician-diagnosed COPD were more likely than subjects without physician-diagnosed COPD to have coexisting arthritis (54.6% vs. 36.9%), depression (20.6% vs. 12.5%), osteoporosis (16.9% vs. 8.5%), cancer (16.5% vs. 9.9%), coronary heart disease (12.7% vs. 6.1%), congestive heart failure (12.1% vs. 3.9%), and stroke (8.9% vs. 4.6%). Subjects with COPD were also more likely to report mobility difficulty (55.6% vs. 32.5%), use of >4 prescription medications (51.8% vs. 32.1), dizziness/balance problems (41.1% vs. 23.8%), urinary incontinence (34.9% vs. 27.3%), memory problems (18.5% vs. 8.8%), low glomerular filtration rate (16.2% vs. 10.5%), and visual impairment (14.0% vs. 9.6%). All reported comparisons have p < 0.05.

Conclusions

Our study indicates that COPD management may need to take into account a complex spectrum of comorbidities. This work identifies which conditions are most common in a nationally-representative set of COPD patients (physician-diagnosed), a necessary step for setting research priorities and developing clinical practice guidelines that address COPD within the context of comorbidity.

Defining patient-reported outcomes in chronic obstructive pulmonary disease: the patient-centered experience

Patients with COPD have reduced HRQOL, and HRQOL worsens as COPD progresses.Although long-term interventions such as smoking cessation, supplemental oxygen therapy for hypoxemia, LVRS, and lung transplantation may save lives, these and other therapies have variable but important effects on PROs. Measures of HRQOL can serve as measures of disease severity and predict outcome. Moreover, these measures are sensitive to change following interventions, and can thus be used as measures of intervention effect. Future research will provide a better understanding of the effects of COPD on HRQOL and the impact of various interventions.

Factors that influence disease-specific quality of life or health status in patients with COPD: a review and meta-analysis of Pearson correlations

BACKGROUND

A major goal in the management of chronic obstructive pulmonary disease (COPD) is to ensure that the burden of the disease for patients with COPD is limited and that patients will have the best possible quality of life.

AIMS

To explore all the possible factors that could influence disease-specific quality of life and health status in patients with COPD.

METHODS

A systematic review of the literature and a meta-analysis were performed to explore the factors that could have a positive or negative effect on quality of life and/or health status in patients with COPD.

RESULTS

Quality of life and health status are determined by certain factors included gender, disease severity indices, lung function parameters, body mass index, smoking, symptoms, co-morbidity, depression, anxiety, and exacerbations. Factors such as dyspnoea, depression, anxiety and exercise tolerance were found to be more correlated with health status than the widely used spirometric values. Forced expiratory volume in one second had a weak to modest Pearson weighted correlation coefficient which ranged from -0.110 to -0.510 depending on the questionnaire used.

CONCLUSIONS

The broad range of determining factors suggests that, in order to reach the management goals, health status should be measured in addition to lung function in patients with COPD.

Co-morbidity, body mass index and quality of life in COPD using the Clinical COPD Questionnaire

INTRODUCTION

Quality of life is an important patient-oriented measure in COPD. The Clinical COPD Questionnaire (CCQ) is a validated instrument for estimating quality of life. The impact of different factors on the CCQ-score remains an understudied area. The aim of this study was to investigate the association of co-morbidity and body mass index with quality of life measured by CCQ.

METHODS

A patient questionnaire including the CCQ and a review of records were used. A total of 1548 COPD patients in central Sweden were randomly selected. Complete data were collected for 919 patients, 639 from primary health care and 280 from hospital clinics. Multiple linear regression with adjustment for sex, age, level of education, smoking habits and level of care was performed. Subanalyses included additional adjustment for lung function in the subgroup (n = 475) where spirometry data were available.

RESULTS

Higher mean CCQ score indicating lower quality of life was statistically significant and independently associated with heart disease (adjusted regression coefficient (95%CI) 0.26; 0.06 to 0.47), depression (0.50; 0.23 to 0.76) and underweight (0.58; 0.29 to 0.87). Depression and underweight were associated with higher scores in all CCQ subdomains. Further adjustment for lung function in the subgroup with this measure resulted in statistically significant and independent associations with CCQ for heart disease, depression, obesity and underweight.

CONCLUSION

The CCQ identified that heart disease, depression and underweight are independently associated with lower health-related quality of life in COPD.

The impact of age on prevalence of positive skin prick tests and specific IgE tests

Aging is associated with modifications of the immune system, defined as immunosenescence. This could contribute to a reduced prevalence of allergic disease in the elderly population. In this regard, atopy has rarely been considered in the clinical assessment of the geriatric respiratory patient. This article is a review of the available literature assessing the impact of age on atopy. In the majority of papers, we found a lower prevalence of atopy in the most advanced ages, both in healthy subjects and in individuals affected by allergic respiratory diseases. Unfortunately, no large, longitudinal studies performed in the general population have been conducted to further explore this observation. Although available data seem to favor the decline of allergen sensitization with age, the prevalence of allergic sensitizations in the elderly population with respiratory symptoms is substantial enough to warrant evaluation of the atopic condition. From a clinical perspective, allergic reactions in older adults can have the same or even worse manifestations compared to young people. For this reasons, the evaluation of the atopic condition also in the geriatric patient is recommended. Thus, the role of atopy as it pertains to the diagnosis, therapy (adoption of preventive measure such as removal of environmental allergen or immunotherapy), and prognosis (influence on morbidity and mortality) of chronic respiratory illnesses in the elderly is addressed.

The influence of heart disease on characteristics, quality of life, use of health resources, and costs of COPD in primary care settings

Background

To evaluate the influence of heart disease on clinical characteristics, quality of life, use of health resources, and costs of patients with COPD followed at primary care settings under common clinical practice conditions.

Methods

Epidemiologic, observational, and descriptive study (EPIDEPOC study). Patients ≥ 40 years of age with stable COPD attending primary care settings were included. Demographic, clinical characteristics, quality of life (SF-12), seriousness of the disease, and treatment data were collected. Results were compared between patients with or without associated heart disease.

Results

A total of 9,390 patients with COPD were examined of whom 1,770 (18.8%) had heart disease and 78% were males. When comparing both patient groups, significant differences were found in the socio-demographic characteristics, health profile, comorbidities, and severity of the airway obstruction, which was greater in patients with heart disease. Differences were also found in both components of quality of life, physical and mental, with lower scores among those patients with heart disease. Higher frequency of primary care and pneumologist visits, emergency-room visits and number of hospital admissions were observed among patients with heart diseases. The annual total cost per patient was significantly higher in patients with heart disease; 2,937 ± 2,957 vs. 1,749 ± 2,120, p < 0.05. Variables that were showed to be independently associated to COPD in subjects with hearth conditions were age, being inactive, ex-smokers, moderate physical exercise, body mass index, concomitant blood hypertension, diabetes, anxiety, the SF-12 physical and mental components and per patient per year total cost.

Conclusion

Patients with COPD plus heart disease had greater disease severity and worse quality of life, used more healthcare resources and were associated with greater costs compared to COPD patients without known hearth disease.

Impaired sleep reduces quality of life in chronic obstructive pulmonary disease

Disturbed sleep is reportedly common in chronic obstructive pulmonary disease (COPD), but the impact of quality of sleep on health-related quality of life (HRQL) has not been previously investigated in these individuals. The purpose of this study was to assess the impact of quality of sleep on HRQL in patients with COPD. In 30 clinically stable patients with moderate to very severe COPD, we evaluated subjective sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and HRQL using the Saint George's Respiratory Questionnaire. Additionally, lung function was assessed by spirometry, severity of dyspnea by the Modified Medical Research Council scale, and functional exercise capacity by the Six-Minute Walk Test. Twenty-one (70%) patients showed poor quality of sleep (PSQI > 5). HRQL was significantly correlated with quality of sleep (P = 0.02), post-bronchodilator FEV1 (P = 0.04), and severity of dyspnea (P < 0.01). Multiple regression analysis showed that quality of sleep was the best predictor of quality of life in our subjects. Our data suggest that quality of sleep is major determinant of HRQL in COPD. Increased efforts to diagnose and treat sleep problems, including measures to improve factors that adversely affect sleep should receive great attention in the daily management of these patients.

Correlation between cognitive impairment and dependence in hypoxemic COPD

We studied 149 patients with stable chronic obstructive pulmonary disease (COPD). Three clusters were generated (high, mid, and low level of cognitive function) based on 11 neuropsychologic scores; personal independence in basic/instrumental activities of daily living (BADL/IADL) of clusters was compared by discriminant analysis. Pattern of BADL/IADL was cluster-specific in 79.2% of high and 54.9% of low clusters, but only 20.8% of mid cluster. Self-administering drugs, continence, managing money, and dressing items had the greatest discriminatory capacity. Clusters had comparable respiratory function. In older COPD patients, dependence parallels cognitive impairment only to some extent. Indices of COPD severity are poor correlates of dependence.

A 2-night, 3-period, crossover study of ramelteon's efficacy and safety in older adults with chronic insomnia

OBJECTIVE

To assess the efficacy and safety of ramelteon, a selective melatonin MT1/MT2-receptor agonist, for insomnia treatment in older adults.

METHODS

In a randomized, 9-week, 3-period crossover trial conducted at 17 sleep centers, older adults (N = 100) with chronic primary insomnia (37 men, 63 women; mean age [range], 70.7 [65-83] years) were administered placebo, ramelteon 4 mg, and ramelteon 8 mg in three treatment phases for two consecutive nights. Each phase was separated by 5- to 12-day washout periods. Sleep was monitored via polysomnography. Subjective sleep parameters, using a Postsleep Questionnaire, were recorded, and residual pharmacologic effects were assessed.

RESULTS

Statistically significant reductions in latency to persistent sleep were observed with both ramelteon 4 mg and 8 mg compared to placebo (28.7 min vs. 38.4 min, p < 0.001; 30.8 min vs. 38.4 min, p = 0.005, respectively). Total sleep time (p = 0.036 and p = 0.007, respectively) and sleep efficiency (p = 0.037 and p = 0.007, respectively) were also significantly improved with ramelteon 4 mg and 8 mg compared to placebo. Statistically significant reductions in subjective sleep latency on a Postsleep Questionnaire were reported with ramelteon 4 mg versus placebo (p = 0.037), but not ramelteon 8 mg (p = 0.120); no significant differences on other subjective sleep assessments were reported. A lack of power limits interpretation of self-reported sleep parameters. Incidences of adverse events considered treatment related were placebo (7%), ramelteon 4 mg (11%), and ramelteon 8 mg (5%). No residual pharmacologic effects were observed via Digit Symbol Substitution Test, memory recall tests (immediate and delayed), visual analog scales (feelings and mood), and Postsleep Questionnaire (level of alertness and ability to concentrate).

CONCLUSIONS

In older adults with chronic primary insomnia, ramelteon produced significant reductions in latency to persistent sleep and increases in total sleep time and sleep efficacy, and showed no evidence of adverse next-day psychomotor or cognitive effects.

One hundred years of chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, but knowledge about its pathogenesis has increased substantially in recent years. The disease results from interaction between individual risk factors (like enzymatic deficiencies) and environmental exposures to noxious agents, like cigarette smoking, occupational dusts, air pollution and infections in childhood. The main mechanisms that may contribute to airflow limitation in COPD are fixed narrowing of small airways, emphysema and luminal obstruction with mucus secretions. COPD is characterised by a chronic inflammatory process in the pulmonary tissue, with a pattern different from bronchial asthma, associated with extrapulmonary effects and is considered now a complex, systemic disease. Optimal therapeutic targeting of COPD depends on a clear understanding of the precise mechanisms of these complex processes and on early and correct evaluation of disease severity. A combination of pharmacological and non-pharmacological approaches is used to treat COPD. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. The use of LTOT for hypoxemic patients has resulted in increased survival, and expanded drug therapy options have effectively improved dyspnoea and quality of life. Recent studies have documented the benefits of pulmonary rehabilitation. In addition, non-invasive mechanical ventilation offers new alternatives for patients with acute or chronic failure.

Evaluation and validation of the patient acceptable symptom state (PASS) in patients with ankylosing spondylitis

OBJECTIVE

The Patient Acceptable Symptom State (PASS) constitutes an absolute level of patient well-being and represents an ambitious target for disease management. We explored contributors to PASS, validated the PASS concept, and assessed thresholds of self-reported outcomes below which patients considered themselves in PASS.

METHODS

Patients with ankylosing spondylitis completed a questionnaire that included self-reported assessments of pain, fatigue, disease activity, function, patient global, quality of life (QOL), and whether they considered their current disease state satisfactory or not. Stepwise logistic regression was used to assess contributors to PASS. PASS was validated by analyzing proportions of patients reporting need for a rheumatologist and who were in current flare. PASS thresholds for self-reported outcomes were estimated using an anchoring method based on the patient's opinion and targeting the 75th percentile of the cumulative distribution.

RESULTS

PASS data were available for 291 patients, of whom 169 (58%) were in PASS. Significant contributors were age (Exp[B] 1.05; P = 0.003), patient global disease activity (Exp[B] 0.79; P = 0.008), and function (Bath Ankylosing Spondylitis Functional Index [BASFI]; Exp[B] 0.72; P < 0.001). PASS reflected need to consult the rheumatologist and current flare (71% and 73% correctly classified, respectively) and significantly contributed to QOL (B = -5.99; 95% confidence interval -7.16, -4.08). PASS thresholds were 5.0 for patient global disease activity, 5.0 for total back pain, 22.8 for fatigue, 4.8 for disease activity (Bath Ankylosing Spondylitis Disease Activity Index), and 4.0 for function (BASFI).

CONCLUSION

A majority of patients (58%) reported being in PASS. PASS thresholds for pain and function were unexpectedly high, possibly suggesting adaptation to the consequences of the disease.

Examining the Role of Gender in Health-Related Quality of Life: Perceptions of Older Adults With Chronic Obstructive Pulmonary Disease

The purpose of this cross-sectional study was to explore the impact of gender on health-related quality of life perceptions among 67 older adults with chronic obstructive pulmonary disease who were living with a spouse. Physical and psychosocial health-related quality of life perceptions as well as demographic and illness-related variables were compared by gender. A correlation and regression analysis revealed women experienced significantly greater psychosocial impairment, while preliminary support was found for symptom-related impairment among men. Initial recommendations for nursing interventions include incorporating anticipatory guidance from older adults with late stages of chronic obstructive pulmonary disease as well as exploring the impact of symptoms.

Co-morbidity in older patients with COPD--its impact on health service utilisation and quality of life, a community study

BACKGROUND

co-morbidity has been shown to be an important consideration in COPD with an estimated prevalence of 84%. In the Netherlands, a weak association between health-related quality of life and lung function has been found, with a closer link to co-morbidity.

OBJECTIVE

to determine the influence of co-morbidity on quality of life and health service utilisation in older patients with COPD in the community.

DESIGN

observational cohort study.

SETTING

general practice in the North East of England that has a list size of 8300.

PARTICIPANTS

27 patients aged 70 years or above on the practice COPD register.

MEASUREMENTS

data on age and sex, spirometry to confirm the diagnosis of COPD, questionnaires to assess quality of life, activities of daily living (ADLs) and co-morbidity. Health service utilisation was recorded by the number of primary and secondary care attendances in the previous year.

RESULTS

10 had mild, 12 had moderate, and 5 had severe disease. Mean age was 76 years. Quality of life (QOL), co-morbidity and health service utilisation measurements were not significantly different between COPD severity groups. There was a significant positive correlation between increasing co-morbidity and poor QOL (r = 0.45, P < 0.05), and significant negative correlation between co-morbidity and ADL scores (scored inversely), r = -0.54, P < 0.05. Significant negative correlation was found between co-morbidity and primary care attendances (r = -0.41, P < 0.05) and significant positive correlation between worsening QOL and secondary care attendances (r = 0.46, P < 0.05).

CONCLUSIONS

co-morbidity has an important part to play in COPD assessment, more accurately reflecting QOL in our population. Health service utilisation did not correlate to forced expiratory volume (FEV1)-defined COPD severity.

Psychiatric and somatic comorbidities are negatively associated with quality of life in physically ill patients

BACKGROUND AND OBJECTIVES

The relationship between somatic and psychiatric comorbidity in patients with somatic diseases and diverse outcome variables like mortality, costs, and duration of treatment is often examined and confirmed. In the last years, quality of life (QoL) as another important outcome variable received more attention.

METHODS

The present review comprises a summary of associations between comorbidity and QoL in patients with somatic diseases. For this reason a search for somatic diseases was performed, including metabolic, respiratory tract, musculoskeletal, cardiovascular, cancer, digestive system, and general somatic diseases. Four hundred eighty-one studies were found, of which 45 fulfilled the inclusion criteria.

RESULTS

Overall, there are mostly significant negative correlations between comorbidity and QoL. Predominantly, this applies to somatic-psychiatric comorbidity, which accounts for 70.3% (psychosocial aspects of QoL) to 100% (QoL in general) significantly lowered QoL results. Somatic-somatic comorbidities are primarily associated with somatic aspects of QoL (56.5-80.7% significant results), while psychosocial aspects as well as QoL in general are significantly associated in 8.3% to 71.7% of all calculations.

CONCLUSION

It is of high relevance for life quality research and clinical practice to pay attention to comorbidity. Methodological shortcomings should be taken into account in future research.

Impacto de los motivos comunes de consulta en el sentimiento de vitalidad y en el rendimiento físico de personas mayores de 65 años

OBJECTIVES

To measure two functional dimensions (vitality and physical function) involved in the quality of life of the over-65s and to find what relationship they maintain with the commonest reasons for consultation.

DESIGN

Cross-sectional, descriptive study.

SETTING

Primary care.

PARTICIPANTS

Randomised sample of 179 patients over 65 from 14 primary care clinics in Navarra.

METHODS

SF-36 quality-of-life questionnaire and most common reasons for consultation. Personal and family details and ongoing drug prescription were also recorded.

RESULTS

The most common reasons for consultation were insomnia (31.8%), arthrosis (48%), and urinary symptoms (16.2%). The greatest differences in the SF-36 scales occurred in patients with insomnia. In the multiple regression models, inverse associations were found for each of the reasons for consultation with the vitality and physical function dimensions. Vitality was associated with urinary symptoms, with an adjusted beta coefficient of -11.2 points (95% CI, -18.6 to -3.7). Insomnia was associated with significant decline in vitality and physical function, with beta of -7.7 points (95% CI, -13.9 to -1.5) and -10.3 points (95% CI, -19.1 to -1.6), respectively. Arthrosis symptoms behaved in a similar way.

CONCLUSIONS

The most common pathologies or symptoms causing primary care consultations in the over-65s affect significantly the quality-of-life dimensions relating to the pursuit of normal daily life.

Multimorbidity and quality of life in primary care: a systematic review

Background

Many patients with several concurrent medical conditions (multimorbidity) are seen in the primary care setting. A thorough understanding of outcomes associated with multimorbidity would benefit primary care workers of all disciplines. The purpose of this systematic review was to clarify the relationship between the presence of multimorbidity and the quality of life (QOL) or health-related quality of life (HRQOL) of patients seen, or likely to be seen, in the primary care setting.

Methods

Medline and Embase electronic databases were screened using the following search terms for the reference period 1990 to 2003: multimorbidity, comorbidity, chronic disease, and their spelling variations, along with quality of life and health-related quality of life. Only descriptive studies relevant to primary care were selected.

Results

Of 753 articles screened, 108 were critically assessed for compliance with study inclusion and exclusion criteria. Thirty of these studies were ultimately selected for this review, including 7 in which the relationship between multimorbidity or comorbidity and QOL or HRQOL was the main outcome measure. Major limitations of these studies include the lack of a uniform definition for multimorbidity or comorbidity and the absence of assessment of disease severity. The use of self-reported diagnoses may also be a weakness. The frequent exclusion of psychiatric diagnoses and presence of potential confounding variables are other limitations. Nonetheless, we did find an inverse relationship between the number of medical conditions and QOL related to physical domains. For social and psychological dimensions of QOL, some studies reveal a similar inverse relationship in patients with 4 or more diagnoses.

Conclusions

Our findings confirm the existence of an inverse relationship between multimorbidity or comorbidy and QOL. However, additional studies are needed to clarify this relationship, including the various dimensions of QOL affected. Those studies must employ a clear definition of multimorbidity or comorbidity and valid ways to measure these concepts in a primary care setting. Pursuit of this research will help to better understand the impact of chronic diseases on patients.

Sleep and chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Sleep disorders are pervasive in patients with chronic obstructive pulmonary disease (COPD). The patient with COPD is especially vulnerable to sleep-induced gas exchange aberrations. Most sleep disturbances affect the quality of life and some potentially affect survival in these patients. These issues impact treatment of these patients.

RECENT FINDINGS

Insomnia is very common in COPD but might respond to inhaled anticholinergic agents. The use of hypnotics in the hypercapnic patient with severe COPD might be dangerous. The incidence of sleep apnea in COPD patients is allegedly very high, but recent studies suggest this association to be artifactual. Nocturnal oxygen desaturation, which is common in these patients, occurs even in mild COPD. This clinical complication might reflect sleep-disordered breathing or REM sleep-related hypoventilation. We need cost-effective and reliable methods to help distinguish between these causes without routinely resorting to formal polysomnography.

SUMMARY

Development of sound clinical algorithms to address this clinical dilemma is indeed a focus for future research. Some of these patients might require continuous positive pressure therapy, whereas others might need long-term oxygen therapy. Although oxygen therapy in COPD patients with only mild hypoxemia and nocturnal desaturation has not uniformly been shown to be beneficial, it is perhaps too soon to abandon this important clinical intervention in these patients.

The influence of co-morbidity on health-related quality of life in asthma and COPD patients

This study examines the association between somatic co-morbidity and both general and disease-specific health-related quality of life (HRQoL) in patients with asthma and chronic obstructive pulmonary disease (COPD). A cross-sectional analysis was done among 161 COPD patients and 395 asthma patients, aged 40-75 years, recruited from general practice. In the total study population, 47% had no, 32% had one, and 21% had two or more somatic co-morbid conditions, with no significant differences between asthma and COPD patients. Co-morbidity appeared to be associated with poor disease-specific HRQoL in asthma [odds ratio (OR) = 2.08 (1.37-3.18)] and with poor general HRQoL in asthma [OR = 2.96 (1.93-4.53)] and COPD [1.81 (0.91-3.60)] patients. Poorest HRQoL was found in patients with more than one co-morbid condition. Cardiac disease and hypertension were associated with poor disease-specific HRQoL in asthma. Of all co-morbid conditions, musculoskeletal disorders were most strongly associated with poor general HRQoL. Cardiac disease was found to be associated with general and disease-specific HRQoL in asthma but not in COPD. In studies on patients with asthma or COPD aged 40-75 years, co-morbidity should be treated as a determinant of HRQoL.

Management of insomnia in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common medical disorder, which causes considerable morbidity and mortality. Given the chronic and symptomatic nature of the disease, the patient is often seen in the physician's office with complaints of dyspnea. However, more than 50% of COPD patients also have sleep complaints characterised by longer latency to falling asleep, more frequent arousals and awakenings, and/or generalised insomnia. Sleep disturbance tends to be more severe with advancing disease and substantially reduces the COPD patients' quality of life. In approaching the COPD patient who complains of insomnia it is important to take a complete sleep history. Having characterised the degree and duration of the problem, medical management of the underlying COPD must first optimise oxygen saturation while minimising the effects of many of the medications used for COPD. While aerosol therapies may be systemically absorbed and contribute to sleep disruption, anticholinergics, such as ipratropium bromide, are the least likely to do so and indeed have been shown to improve sleep quality in this population. Many of the traditional sedatives and hypnotics have been used in the COPD population including benzodiazepines, imidazopyridines, pyrazolopyrimidines and, less commonly, antidepressants and phenothiazines. Clinical trials support the role of numerous agents in treating insomnia in this population but do not always provide reassurance that these therapies can be used safely, particularly in the patient with severe COPD with hypercarbia. Benzodiazepines are among the most commonly employed agents, but case reports and series continue to describe adverse pulmonary events. Although the newer pyridine derivatives also have the potential to worsen pulmonary function, they appear less likely to do so. Data to date are limited with the tricyclic antidepressants and phenothiazines, although they appear to be very well tolerated from a respiratory point of view. Since sleep disturbances are often long-standing and associated with maladaptive behaviours towards sleep, cognitive/behavioural approaches are often useful and are more effective in the long-term than are hypnotics. When prescription of a sedative is to be made, extra caution is required for those patients at increased risk of adverse respiratory effects, such as those with advanced disease and hypercarbia in whom pharmacological therapy is often best avoided. Selection of the various options will depend upon the degree of underlying disease and the patient's specific complaints of insomnia. Finally, it is important to remember that while most hypnotics work in an acute setting, the long-term management will require an integrated approach.