https://orcid.org/0000-0002-0348-3664
Abstract
Since the outbreak of the SARS-CoV-2 pandemic in 2020, many governments have been imposing confinement and physical distancing measures. No data exist on the effects of lockdowns on the health status of patients affected by chronic pathologies, specifically those with Chronic Obstructive Pulmonary Disease (COPD). Our study aims to establish variations across the psychological and cognitive profile of patients during the isolation period in Italy, in a cohort of patients affected by COPD, between February and May 2020. Forty patients with established COPD were comprehensively evaluated by geriatric multidimensional assessment before the spread of the epidemic in Italy, and submitted to a second evaluation during the subsequent lockdown. We assessed functional ability, basic and instrumental Activities of Daily Living (ADL and IADL), cognition and mood status. We compared the scores obtained at baseline against those obtained during the pandemic, and used mean differences for correlation with major clinical and functional indexes. The score differences from MMSE, ADL and IADL were statistically significant. Such differences were correlated to the presence of a caregiver and to the total number of family members living together. Remarkably, the loneliness dimension, more than the restrictions themselves, seemed to represent the major determinant of altered health status and depressed psycho-cognitive profile in our population. Also remarkably, we detected no correlation between the score variation and the respiratory function indexes of disease severity. The isolation measures adopted during the SARS-CoV-2 pandemic have triggered the classic clinical string associated to geriatric isolation, which leads to a deterioration of cognitive functions, independence and frailty levels in a population affected by a chronic degenerative disease, such as COPD. If considered from a multidimensional geriatric point of view, the individual benefit of isolation measures could be small or non-existent.
Introduction
In January 2020, Italy, then Europe and the entire world were hit by a SARS-Cov-2 outbreak, the first widespread pandemic on records since the Spanish flu, which ravaged populations worldwide between 1918 and 1920.
Considering the infection high virulence, the lack of treatments and the necessity to contain the saturation risk for hospitals and national health services, many governments decided to impose confinement and physical distancing measures. On one side [Citation1], these helped to lower the virus transmission rate, and contain the impact on hospital bed saturation. However, on the other side, the isolation measures proved challenging and depleting for those obliged to stay at home, especially among the elderly [Citation2].
Social isolation is a well known geriatric condition, associated to a significant worsening of quality of life (QoL) and independence levels, compromising cognitive functions, mood and generally worsening the health and life expectancy of frequently chronically ill older patients [Citation3].
At the moment, we do not have reliable data on the effects that the lockdown had on the general health of patients affected by chronic pathologies, especially on those affected with Chronic Obstructive Pulmonary Disease (COPD) [Citation4], a condition known to act as an independent risk factor for hospitalization and mortality within the COVID-19 [Citation5] pandemic and a clinical determinant of frailty [Citation6].
Changes in health status and quality of life induced by physical isolation in COPD patients might have an impact on needs of care and on relevant clinical outcomes [Citation7], such as more frequent and longer hospital, or other healthcare facility, admissions, but also survival [Citation8], increased dependence and need for assistance and caregivers. Exploring the burden of COVID-19 restrictions on the main domains of a geriatric multidimensional assessment would be of practical usefulness in subjects with COPD.
Our study, therefore, aims at establishing and describing variations across the psychological and cognitive profiles, and the general health determinants occurred during the isolation measures undertaken in Italy, in a cohort of patients affected by COPD and residing in the municipality of Rome, between February and May 2020.
Methods and materials
All study participants attending the Campus Bio Medico respiratory outpatient clinic had been previously diagnosed with COPD, according to internationally recognized recommendations, but, taking into account the advanced age profile of participants, functional age-related evaluations were also included. During the initial phone call, participants gave their verbal informed consent to participate in the survey. This was converted to a written informed consent when all subjects were re-admitted at the respiratory outpatient clinic, once the physical isolation measures were lifted. Considering the observational nature of this work, no request for ethical approval was made.
Forty patients with established COPD were comprehensively evaluated by geriatric multidimensional assessment before the pandemic happened, and then submitted to a second evaluation during the lockdown. Functional ability, basic and instrumental Activities of Daily Living (ADL and IADL), cognition and mood status were assessed. All subjects had been attending our respiratory facilities in the six months preceding the lockdown, and, at the time of recruitment, none had ever been identified as having accelerated cognitive decline. The inclusion criteria considered for our study were: absence of acute infectious, inflammatory and cerebrovascular event or any potential major event influencing autonomy and cognitive profiles, as well as no current or recent acute exacerbation of COPD (assessed through the Anthonisen’s clinical criteria) at the time of the enrollment, taking place during the lockdown. Functional ability was assessed using the Katz index for basic Activities of Daily Living (ADL) [Citation9] and the Lawton scale for Instrumental Activities of Daily Living (IADL) [Citation10]. Cognition was assessed using the Folstein Mini Mental State Examination (MMSE) [Citation11], while depression was screened using the 15 item Geriatric Depression Scale (GDS) [Citation12].
We compared the scores obtained at baseline against those obtained during the pandemic, and used mean differences for correlation with major clinical and functional indexes. All the evaluations taken under the lockdown were administered remotely, by telephone or video call, and when necessary, supervised by the caregiver.
COPD diagnosis and comprehensive geriatric assessment
All the patients included in the study were previously diagnosed with COPD according to current international GOLD recommendations. We performed respiratory function tests, the 6-minute walk test and blood gas analysis on patients, who had not smoked any cigarettes for at least 12 h. Using a water-sealed bell spirometer (Biomedin, Padua, Italy), we measured forced exhalation volumes following the acceptability and reproducibility criteria proposed by the American Thoracic Society and by the European Respiratory Society (ATS/ERS) [Citation13]. We repeated the test after the inhalation of salbutamol, and used post-bronchodilator data to characterize COPD patients [Citation14]. We obtained the Total Lung Capacity (TLC) and the Residual Volume (RV) using the helium-rebreathing technique [Citation15], with predicted values expressed as percentage of predicted, calculated through standardized reference equations.
In order to provide a more comprehensive assessment and take into account the many age-related issues linked with the diagnosis of COPD, we also considered specific clinical and functional features of COPD in the elderly (Eur J Intern Med).
Considering that the recommended FEV1/FVC threshold of 0.7 overestimates airway obstruction in elderly people, we based the diagnosis of COPD on a lower post-bronchodilator FEV1/FVC ratio (below the lower limit of normalCitation16], and used two different GOLD classifications (2011 and 2007) to address the severity of the obstruction and COPD clinical impact [Citation17]. In six cases displaying a relevant amount of hyperinflation (RV >130% of predicted), the diagnosis of COPD was made despite a FEV1/FVC ratio above the lower limit of normal [Citation18]. Frequent exacerbators were defined as having ≥ 2 exacerbations/year, while dyspnoeic patients were defined as having a ≥ 2 on the modified Medical Research Council dyspnea scale [Citation19] (mMRC).
ADLs (Activities of Daily Living) are basic self-care tasks. The six basic ADLs are eating, bathing, dressing, toileting, ambulating, and grooming [Citation9]. IADLs (Instrumental Activities of Daily Living) are slightly more complex skills. They represent key life tasks that people need to manage in order to live at home and be fully independent. The ADL and IADL scales take 10 to 15 min to administer and contain several items, with a summary score reflecting the degree of self-functioning [Citation9,Citation10].
The Mini–Mental State Examination (MMSE), or Folstein test, is a 30-point questionnaire used extensively in clinical and research settings to measure cognitive impairment. It is commonly used in medicine and allied health to screen for dementia or mild cognitive impairment [Citation11].
Finally, the short geriatric depression scale (GDS) is a brief 15-item questionnaire, in which participants are asked to respond by answering Yes or No in reference to how they felt over the past week. Of the 15 items, 10 indicate the presence of depression when answered positively, while the rest (questions number 1, 5, 7, 11, 13) indicate depression when answered negatively. Scores of 0-4 are considered normal, depending on age, education, and complaints; 5-8 indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe depression [Citation12].
Statistical analysis
We expressed all data as mean and standard deviation (SD) or median and inter-quartile range for continuous variables, and frequency and percentage for categorical variables. Differences among scores, expressed as mean and 95% confidence intervals, were assessed using unpaired or paired t-test.
In order to evaluate the correlation between variables, we adopted the Spearman analysis, considering differences as significant at p < 0.05.
Results
shows all general characteristics from the studied population. The mean age was 77.7 (SD 7). Males represented the 65% of the whole sample. Participants mostly showed a mild to moderate airway obstruction (mean FEV1 of 73% -SD 21.5 - of predicted), were poorly symptomatic (60% belonging to GOLD stage A), physically fit (6MWD = 375.3 -SD 110.8 mt) and well nourished (BMI = 28.2 -SD 5.4). The multidimensional scores at baseline did not reveal any significant limitation in daily living activities (ADL = 5.8 ± 0.6 and IADL = 7.6 ± 1.2) and cognitive performance (MMSE = 28.4 ± 2.6), while a border line depressive mood (GDS = 9.9-SD 3.0) was seen in our population. When compared against the scores obtained under lockdown, the differences from MMSE, ADL and IADL were statistically significant (ΔMMSE = 4.6 ± 3.3, ΔADL = 1.8 ± 2.7, ΔIADL = 2.1 ± 3.5; p < 0.001), an indication of worsened cognition and independence levels both for simple and instrumental ADLs during the lockdown period. Despite the GDS score worsening during the physical distancing period, indicating a more severe depressive attitude, the amplitude of this change was not found to be statistically significant (ΔGDS = 2.1 ± 2.5, p = 0.09) (see ). Conversely, we found statistically significant differences in ΔGDS, ΔADL and ΔIADL according to the presence/absence of a caregiver and the number of relatives cohabiting in the same house, for ΔGDS and ΔIADL (Spearman’s correlation index of −0.293 and −0.320, respectively; p < 0.05) (see ). Remarkably, there was no correlation between the score variation level and the respiratory function indexes measured at spirometry (see ).
Table 1. General characteristics of the population included in the study.
Table 2. Paired t-test comparing means of multidimensional tests before and during the lockdown period.
Table 3. Paired t-test and Spearman’s correlation index between the differential (Δ) of multidimensional tests and social factors.
Table 4. Spearman’s correlation index between the differential (Δ) of multidimensional tests and indexes of respiratory function.
Discussion
This preliminary report confirms that the isolation measures adopted during the SARS-CoV-2 pandemic have triggered the classic clinical string associated to geriatric isolation, which leads to a deterioration of cognitive functions, independence and frailty levels in a population affected by a chronic degenerative disease such as COPD. This decline, apart from being statistically significant, appears to display also a clinical relevance.
The mean MMSE score, in fact, dropped from 28 to 23.8, a value below the threshold considered suggestive of cognitive impairment [Citation11]. Similarly, ADL and IADL scores observed during the lockdown are typically associated with a higher level of dependence for basic and instrumental activities of daily living [Citation20].
Notably, the GDS depression score did not result significantly increased during the lockdown.
This apparently counterintuitive finding might be due to at least a couple of reasons: firstly, the mean GDS score at baseline was already high, indicating an attitude of the subjects toward a depressive mood. This was not the case for ADL, IADL and MMSE; these scores at baseline were indeed within the limits of normality. In this perspective, the impact of the lockdown over a preserved function could have been more relevant. Secondly, it is likely that, during the lockdown, our study population had to spend much more time than usual with their cohabitants or relatives sharing the same house, since they also had to observe the restrictions. Supporting this hypothesis is the fact that, after stratifying according to the presence of the caregiver, we found the ΔGDS turning statistically significant.
Similarly, a positive inverse correlation was found between the ΔGDS and the number of subjects living in the same house during the lockdown. It is therefore likely that, not physical isolation itself, but loneliness, provided the strongest contribution to psycho-cognitive distress in elderly COPD patients.
Several prospective findings link high levels of loneliness with a decline in gait speed [Citation21] or mobility [Citation22], and increased difficulties with activities of daily life or upper extremity tasks. This would suggest that loneliness may increase the likelihood of sarcopenia, an age related syndrome characterized by the loss of skeletal muscle mass and strength [Citation23]. Sarcopenia is a major contributor to the risk of functional decline and physical frailty [Citation24].
Primarily, no statistically significant correlation was observed between the amplitude of the change in the multidimensional indexes and any of the spirometric parameters. This would confirm that the functional dimension alone cannot detect COPD effects on the general health of patients, or predict their frailty levels.
The high disease heterogeneity of COPD phenotypes, in fact, cannot be simply expressed by the severity of airway obstruction, since the impact of the disease on the health status is independently determined by several factors other than the classical functional parameters at spirometry, such as dyspnea, physical limitation, isolation, hypoxia-related mental deterioration and sarcopenia [Citation25]. In this perspective, the multidimensional assessment has demonstrated a good performance in predicting COPD severity and association with clinical outcomes [Citation8].
In particular, we found that loneliness, more than physical distancing alone, was likely to play a major role.
Under this perspective, the findings of this study are not surprising, since the roles of loneliness, physical distancing and reduced social interactions have been already associated with reduced autonomy and accelerated mental decline in the elderly COPD population, and geriatricians are already aware of the need to prevent this problem [Citation4,Citation26]. Clearly, the sudden outbreak of a worldwide pandemic has posed new challenges.
If instructing elderly people to remain at home, have groceries and medications delivered at home, and minimize contact with relatives and loved ones may positively impact viral dissemination and pandemic consequences on frailer segments of the population, urgent action is needed to mitigate the mental and physical implications derived from keeping a physical distance from other people [Citation27].
Both conventional and online technologies should be implemented and tailored in order to develop new, original models for home care which integrate monitoring and following up, and are capable of reducing the emotional distance between charities or social care services, geriatricians or general practitioners and a lonely, isolated or secluded frail person [Citation28]. Far from considering telemedicine and telehealth care as a surrogate for the traditional medical approach, we believe that efforts should be made in order to integrate new complementary tools. Interventions could simply involve more frequent telephone calls, but also more articulated community-based projects, providing medical, social or simply peer support. Cognitive behavioral therapies, for example, could be delivered online to reduce loneliness and ameliorate mental wellbeing [Citation29].
Several limitations of the present study deserve consideration: specifically, the lack of a control group of elderly patients not suffering from COPD does not allow us to exclude that the impact of physical distancing might be associated to many other chronic diseases and not be peculiar to the COPD population. Indeed, the descriptive design of this study does not permit to clarify this issue, but confirms the high susceptibility of COPD subjects to experience an accelerated decline of psycho-cognitive abilities as response to adverse social triggers.
Further research is needed to make comparisons between COPD and other chronic diseases. Furthermore, the sample size of this study is small and this, although allowing a longitudinal analysis, did not permit to search for further correlations or inferential statistics. Adequately dimensioned studies should be performed with this aim. Finally, we cannot be sure that our assumption about the equivalence between geriatric assessments administrated in different ways (in presence vs remotely, telephone or video calls) is correct.
However, although we cannot exclude that the small study sample and the different approach used to deliver the multidimensional assessment between the baseline and the lockdown might have affected the strength of our finding, we feel that the impact of physical distancing on the different domains of senior COPD health status is not negligible nor hidden.
In conclusion, we have observed an impressive worsening of most multidimensional geriatric domains involving functionality, cognition and mental health likely due to the direct and indirect effects of the physical restrictions applied during the SARS-CoV-2 pandemic. The main detrimental trigger seems to be associated with loneliness, more than with physical isolation itself.
As in the case of the debated struggle between health and economic needs, the SARS-CoV-2 pandemic has raised multiple issues, with the challenge of balancing community versus individual rights. Healthcare providers and politicians are today venturing on this impervious ridge with no simple solution.
If considered from a geriatric and multidimensional point of view, the individual benefit of isolation measures could in fact be small or non-existent.
Declaration of interest
The authors have no real nor perceived conflict of interest to declare.
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