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COPD on the Psych Rotation

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COPD on the Psych Rotation

  1. 1. COPD on the CL GAZI RASHID 17 AUG 2017
  2. 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. 3. Emphysema Chronic Bronchitis ↓ ↓FEV1 ↓ FVC Ratio
  4. 4. ↑CO2 ↓O2 ↑CO2 ↓O2
  5. 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. 6. Treatment & Management
  7. 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. 8. Mental Illness & COPD
  9. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. Managing Depression & COPD SSRIs are first line compared to TCAs Mirtazapine – stimulates appetite Steroid-induced psychosis: most commonly presents as depression
  22. 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. 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. 24. Barriers <1/3 with comorbid anxiety or depression get appropriate treatments
  25. 25. Physician Patient - No standardized test - Poor confidence - Time limited to COPD - Masking - Lack of knowledge - Stigma - Reluctance - Masking
  26. 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. 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. 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. 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. 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

Editor's Notes

  • Impact - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293292/
    VA population - http://www.veteransenterprise.com/index.php/articles-online-magazine/articles/general/423-the-burden-of-copd-on-veterans-and-the-va-healthcare-system
  • Makes it difficult to breath out
  • Theopylline – increases mucoiliary clearance and central respiratory drive; refractory COPD
    O2 can be given continuously or at night time

    Education -
    Exercise – improves exercise tolerance
    PT
  • 1-2 symptoms worsening for 1-2 days from previous state
  • https://www.ncbi.nlm.nih.gov/pubmed/21907063
    50-80% of ppl w/ schizo are smokers; 55% of bipolar d/o

    In different conditions, you’ll see that
    COPD  problems
    Vs.
    See reverse as well
    Probably 2 way street on all
  • Nearets hospital is 50 miles away
    https://www.nature.com/articles/npjpcrm201523#case-study-2-a-74-year-old-man-with-very-severe-copd-living-alone-in-a-remote-community
  • Estimated 1.3 million have both COPD and cognitive impairment

    Various RF and various mechanisms proposed
    Generally focused on hypoxemia
    Unproven that they entirely account for cognitive deficits

    https://www.ncbi.nlm.nih.gov/pubmed/18842932
  • Smaller studies have shown some efficacy
    No specific Rx associated with improved cognition
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181154/
  • Not a lot of literature found
    Some case reports

    Hypercapnia without hypoxia
    http://onlinelibrary.wiley.com/doi/10.1111/crj.12008/full

    NIPPV
    NIPPV – study 2016 of NIPPV unit: 32% of 153 pt had delirium; Delirium was a predictor of early mortality within 1 year

    Multiple studies have shown no difference btwn high and low doses of ICS
    http://journals.sagepub.com/doi/abs/10.1177/0897190017703504
    Study of pt. on MV
    >< 300 mg/d of maintenance prednisone  no diff in length of stay on MV or in ICU; high rates of infection

    http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2013.187.1_MeetingAbstracts.A1578
    Initial high dose of SCS showed no increased risk of delirium, but had longer stays


  • COPD: how to manage dep and anxiety
  • JFP easing burden
  • Theophylline – tachycardia, arrhythmias , irritability, insomnia, headache,
  • - Four interventions including hypnosis and relaxation, patient education and information sharing, music therapy, and supportive touch have been investigated in the literature and may be helpful in reducing patient stress.
    http://acc.aacnjournals.org/content/14/1/73.short

    Less common due to anticholinergic and sedating side effects

    Risks of addiction

    In our pt, weaned off lorazepam and started gabapentin
  • JFP easing burden

    Pt. on chronic O2 have prevalence of ~60%

    Breathlessness or depression
    Fatigue or depression
    Loss of interest and withdrawal? Or just no energy?


    Impact of COPD on depression more limited



  • Good if pt. is anorexic or interferenes with eating

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2706604/
  • Breathing, hypnoses, meditation, etc
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2849676/pdf/nihms101564.pdf

    I want to take a look at what’s barreirs are stopping them from finding the depression or anxiety
    BC if you don’t realize something is a barrier, you won’t know what you’re missing
  • Systemic – lack of communication, universal EMR, time, insurance
  • 3To rates of someone who has never smoked
    https://www.copdfoundation.org/Praxis/Community/Blog/Article/598/Dr-Robert-Benzo-Changing-Outcomes-in-COPD-through-Motivational-Interviewing.aspx

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