International Journal of Chronic Obstructive Pulmonary Disease

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COPD and cognitive impairment: the role of hypoxemia and oxygen therapy
This article was published in the following Dove Press journal: International Journal of Chronic Obstructive Pulmonary Disease 9 August 2010 Number of times this article has been viewed

Neeta Thakur 1 Paul D Blanc 2 Laura J Julian 1 Edward H Yelin 3 Patricia P Katz 3 Stephen Sidney 4 Carlos Iribarren 4 Mark D Eisner 1,2
Department of Medicine, 2Division of Occupational and Environmental Medicine and Division of Pulmonary and Critical Care Medicine, 3Institute for Health Policy Studies, Department of Medicine, University of California, San Francisco, CA, USA, 4Division of Research, Kaiser Permanente, Oakland, CA, USA

Background: Several studies have shown an association between chronic obstructive pulmonary disease (COPD) and cognitive impairment. These studies have been limited by methodological issues such as diagnostic uncertainty, cross-sectional design, small sample size, or lack of appropriate referent group. This study aimed to elucidate the association between COPD and the risk of cognitive impairment compared to referent subjects without COPD. In patients with established COPD, we evaluated the impact of disease severity and impairment of respiratory physiology on cognitive impairment and the potential mitigating role of oxygen therapy. Methods: We used the Function, Living, Outcomes and Work (FLOW) cohort study of adults with COPD (n = 1202) and referent subjects matched by age, sex, and race (n = 302) to study the potential risk factors for cognitive impairment among subjects with COPD. Cognitive impairment was defined as a Mini-Mental State Exam score of ,24 points. Disease severity was using Forced Expiratory Volume in one second (FEV1); the validated COPD Severity Score; and the BMI (Body Mass Index), Obstruction, Dyspnea, Exercise Capacity (BODE) Index. Multivariable analysis was used to control for confounding by age, sex, race, educational attainment, and cigarette smoking. Results: COPD was associated with a substantive risk of cognitive impairment compared to referent subjects (odds ratio [OR] 2.42; 95% confidence interval [CI] 1.043–6.64). Among COPD patients, none of the COPD severity measures were associated with the risk of cognitive impairment (P  . 0.20 in all cases). Low baseline oxygen saturation was related to increased risk of cognitive impairment (OR for oxygen saturation # 88% (OR 5.45; 95% CI 1.014–29.2; P  =  0.048). Conversely, regular use of supplemental oxygen therapy decreased the risk for cognitive impairment (OR 0.14; 95% CI 0.07–0.27; P , 0.0001). Conclusion: COPD is a major risk factor for cognitive impairment. Among patients with COPD, hypoxemia is a major contributor and regular use of home oxygen is protective. Health care providers should consider screening their COPD patients for cognitive impairment. Keywords: chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by the irreversible loss of lung function. Although COPD has been traditionally considered as a disease primarily affecting the lungs, its systemic effects have been increasingly recognized with diverse manifestations involving body systems distant from the lung.1,2 The brain, in particular, may be vulnerable to the systemic effects of COPD.3–8 Several features of the ­ disease may contribute to impaired cognitive function, including hypoxemia and comorbid cardiovascular disease.7–9 In addition, COPD may lead patients to curtail their physical activity which may, in turn, further increase the risk of cognitive impairment.10
International Journal of Chronic Obstructive Pulmonary Disease 2010:5 263–269 © 2010 Thakur et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

Correspondence: Mark D Eisner University of California, 505 Parnassus Ave, M1097, San Francisco, CA 94143-0111, USA Tel + 1 415 476 7351 Fax + 1 415 476 6426 Email

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­ frican American. and durability and has been widely used in epidemiologic research.1 Assessment of pulmonary physiology Baseline oxygen saturation was measured at rest in the seated position using the Nellcor N-180 (Covidien-Nellcor.Thakur et al Dovepress Although there is a plausible link between COPD and cognitive impairment. and cognitive testing. The FLOW study is an ongoing prospective cohort study of adult members of an integrated health care delivery system with a physician’s diagnosis of COPD with an accompanying matched control group.19 Race-ethnicity was categorized as white non-Hispanic. 61 subjects had oxygen saturation measured on their prescribed supplemental oxygen (range 1–4 liters/minute). Dyspnea. 264 submit your manuscript | www. or never smoked. We also used the validated BMI (Body Mass Index). systemic corticosteroid use.18 A control group of 302 subjects without COPD were recruited who were matched by age. Living. we conducted spiro­ metry according to American Thoracic Society (ATS) Guidelines.11–14 In a large cohort study of COPD. accuracy. previous hospitalization or intubation for respiratory disease. MA. At baseline assessment. we defined educational attainment as high school or International Journal of Chronic Obstructive Pulmonary Disease 2010:5 Dovepress . The study was approved both by the University of California. Recruitment methods have been previously reported in detail.26. we aimed to elucidate the impact of COPD on the risk of cognitive impairment compared to a matched referent group without disease. congestive heart failure. sex. and home oxygen use. Obstruction.27 Based on survey responses.21 These include a reported physician’s diagnosis of coronary artery disease. past smoking. Most subjects were measured on room air. Methods Recruitment of the cohort and referent subjects The current study is a matched case-referent analysis conducted within the Function. Measurement of COPD severity We used a combined approach to measure COPD severity. the existing literature is limited by methodological issues such as diagnostic uncertainty. Asian/Pacific Islander. small sample size. Possible total scores range from 0 to 35. some college.1. we evaluated the impact of disease severity and impairment of respiratory physiology on cognitive impairment and the potential mitigating role of oxygen therapy. other COPD medication use. or stroke based on our previous work. Exercise Capacity (BODE) Index.19 Cigarette smoking was measured using questions developed for the National Health Interview Survey (NHIS) and was defined as current smoking. Among patients with established COPD. grade of dyspnea (D) assessed by the modified Medical Research Council (MRC) Structured telephone interviews All subjects (COPD subjects and non-COPD referents) underwent 30–40 minute structured telephone interviews that ascertained sociodemographic characteristics. To measure pulmonary function. or college/graduate degree. or lack of appropriate referent group. which is known for its reliability. COPD clinical history. and race to the cohort members. cigarette smoking. Spirometry confirmed that none of the controls met Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for COPD.28 The BODE Index is based on the body-mass index (B).22. which is a multi-modal measure of disease severity.20 We assessed comorbid cardiovascular conditions using survey items modified from the NHIS.202 Kaiser Permanente Medical Care Program (KPMCP) members who were recently treated for COPD using a validated algorithm based both on health care utilization and pharmacy dispensing for COPD. we did not administer bronchodilators for study purposes. USA). CO). Chelmsford.15. Hispanic. Outcomes.1. other physical assessments.23 We used the EasyOne™ Frontline spirometer (ndd Medical Technologies. and Work (FLOW) study of COPD.15–17 We recruited a cohort of 1. We used a disease-specific COPD severity score that we had previously developed and validated for use in epidemiologic and outcomes research. or A other.24.25 Because research clinic examinations were conducted by trained nonmedical personnel. Boulder. and health status. the degree of airflow obstruction (O) measured by Forced Expiratory Volume in one second (FEV1). However. the COPD severity score is comprised of five overall aspects of COPD severity: respiratory symptoms. 90% of subjects had taken their own short-acting bronchodilator within 4 hours of spirometry or had taken a long-acting bronchodilator earlier in the same day. health status. Each item was weighted based on clinical aspects of the ­ disease and its expected contribution to overall COPD severity. crosssectional design.dovepress. we conducted structured telephone interviews that ascertained sociodemographic characteristics. As in our previous studies. and home oxygen use. with higher scores reflecting more severe COPD.16 Research clinic visits included spirometry. San Francisco Committee on Human Research and the Kaiser Foundation Research Institute’s institutional review board and all participants provided written informed consent.

Statistical analysis Statistical analysis was conducted using SAS software. cognitive function was measured using the Mini-Mental State Examination. First. recall ability. Figure 1 demonstrates that the risk of cognitive impairment increases with decreasing oxygen saturation. FEV1. race. and smoking history. was not associated with cognitive impairment (Table 3).5% vs 2.1 (SAS Institute. Area under receiver operator characteristic curve for this model was excellent (0. short-term memory.0001).31 The 11-item instrument assesses orientation. We used two approaches to control for confounding. Because oxygen therapy is prescribed to patients with more severe disease.32 It evaluates most of the main domains of cognitive status and has been extensively validated. Risk estimates (ie. We also evaluated the impact of home oxygen use on the risk of cognitive impairment. which reflected matching (P  .0051). Multivariable logistic regression analysis was then used to evaluate the impact of home oxygen use on the risk of cognitive impairment using inverse probability-weighted estimators derived from the propensity scores to control for confounding.Dovepress COPD and cognitive impairment Dyspnea Scale. When oxygen use was added to the multivariable model.2). we used propensity scores to correct for confounding by indication. and educational attainment (OR 2. Second. confounding by indication will likely bias the unadjusted results in the direction of no effect. Each component is assigned a specific score and the total score ranges from 0 to 10 points (higher scores indicate greater severity). This method fitted a flexible smoothed curve that did not impose a linear relationship.20 in all cases) (Table 1). Persons with COPD also had lower educational attainment than referents.46. as measured by FEV1. low oxygen saturation remained associated with a greater risk of cognitive impairment (OR 5. USA) and Stata 10 (College Park.0%. sex. International Journal of Chronic Obstructive Pulmonary Disease 2010:5 submit your manuscript | www. race. sex. COPD was associated with a greater risk of cognitive impairment function even after controlling for age. controlling for age. Bivariate comparisons were carried out using t-test for continuous variables and the chi-square test for categorical variables. We used logistic regression analysis to examine the association between COPD (vs referent) and the risk of cognitive impairment. TX. P = 0. NC.28–30 Cognitive assessment At the time of the research clinic visit. sex. Inc. odds ratios) were expressed per a 0. log odds) of cognitive impairment. sex.  0.014–29.043–6. and smoking history (past smoking and current smoking as indicator variables). and race-ethnicity.45. and exercise capacity (E) measured by the six-minute-walk test. and arithmetic ability. Propensity scores were developed from a multivariable logistic regression model to predict home oxygen use conditional on observed covariates.31–36 We used the recommended cut-point score of .com Dovepress 265 . we used multivariable logistic regression analysis to elucidate the association between COPD severity measures and the risk of cognitive impairment. A small minority of subjects (n = 61) used prescribed supplemental oxygen. In multivariable analysis. smoking history. and desaturation during Six Minute Walk Test ($4%). smoking history. which is the most commonly used screening test for cognitive impairment in North America. 95% CI 1. race. race. educational attainment. BODE Score. USA). 0. Cary. respiratory impairment.40 Results Baseline characteristics of subjects with and without COPD Subjects with and without COPD were similar in age.64) (Table 2). baseline oxygen saturation COPD and the risk of cognitive impairment The prevalence of cognitive impairment was much higher among COPD subjects compared to the matched referent group without COPD (5. In the COPD cohort. Risk factors for cognitive impairment among subjects with COPD Among patients with COPD. an approximation of the minimal clinically important difference.42. The BODE index predicts death and other poor outcomes in COPD.24 points out of the total possible 30 points to indicate cognitive impairment.92). we used standard multivariable logistic regression.39 The LOWESS (locally weighted regression scatter plot smoother) procedure was used to graphically depict the relationship between oxygen saturation and the logit (ie. 95% CI 1.37 (#88%).5 standard deviation of each predictor variable. version 9. Variables included were age.dovepress. sex.38 Multivariable analysis was used to control for age. Low baseline oxygen saturation (#88%) was strongly related to cognitive impairment (adjusted OR 5. but that the relationship is non-linear. The prevalence of lifetime smoking was higher among those with COPD (87%) than in the referent group (48%) (P  . 95% CI 1. educational attainment.007–30).

14.0. did not exclude the ‘no effect’ level.42 (1. Living. however.2) 691 (57. standard deviation.42 Our results reveal a disconnect between global measures of COPD severity. OR. The risk of cognitive impairment was not associated with COPD severity as defined by either the COPD severity score or BODE score (Table 3).0001 42 (14%) 95 (31%) 165 (55%) . however. Function. The specific role of cardiovascular comorbidities as a risk factor for cognitive impairment in COPD is difficult to ascertain as both conditions share risk factors (eg. race.50 0. and cardiovascular disease did not appear to explain the development of cognitive impairment in COPD. its extrapulmonary effects are profound and disabling.4%) 810 (67%) 206 (17%) 35 (3%) 111 (9%) 40 (3%) 352 (29%) 524 (44%) 326 (27%) 165 (13%) 393 (33%) 644 (54%) Referents (n = 302) 58. mean (SD) Female. Stroke and other cardiovascular disease were also not related to cognitive impairment (Table 4). Our study indicates that COPD is strongly associated with cognitive impairment in a large cohort of patients with a broad range of COPD severity.Thakur et al Dovepress Table 1 Baseline characteristics of FLOW cohort of COPD vs referent subjects Characteristic Age in years. sex. educational attainment. confidence interval. The unadjusted estimate. in the unadjusted analysis. n (%)   White. COPD severity. home oxygen use was strongly associated with a decreased risk of cognitive impairment (OR 0. chronic obstructive pulmonary disease.0. Resting hypoxemia was the single most important risk factor for cognitive impairment. SD. which was strongly associated with decreased cognitive function. FLOW. The point estimate for cardiovascular disease was elevated. we found no impact of these indicators of disease severity on the risk of cognitive impairment. and decreased resting oxygenation.0 2. no association was found among the COPD cohort. odds ratio.64) Abbreviations: CI.dovepress. smoking) and COPD patients may be predisposed to cardiovascular events. which was likely confounded by indication.86 (1. We used a rigorous and multifaceted approach to measuring COPD severity (lung function. and BODE Index). n (%)  Never smoked   Current smoker  Ex-smoker COPD (n = 1.2 (6.46) Controlling for age.23 0. n (%)  High school or less  Some college   College/graduate degree Smoking status.202) 58. so lack of statistical power may be one explanation Table 2 COPD and the risk of cognitive impairment Comparison Referent Group COPD Unadjusted OR (95% CI) 1. Despite this approach.5 (6. Discussion COPD is often considered a disease that solely affects the lungs. treatment with supplemental oxygen markedly decreased the risk. Lung function impairment.043–6.0 2. COPD Severity Score. using inverse probabilityweighted estimators derived from the propensity scores to control for confounding. In the most adjusted model. 266 submit your manuscript | www.34–7. non-Hispanic   African-American   Asian/Pacific Islander  Hispanic   Other Educational attainment.0001 158 (52%) 12 (4%) 132 (44%) P-value International Journal of Chronic Obstructive Pulmonary Disease 2010:5 Dovepress . Outcomes and Work.2) 185 (61%) 200 (66%) 57 (19%) 8 (3%) 28 (9%) 9 (3%) . This differs from some previous work. n (%) Race/ethnicity.18 When cardiovascular comorbidities were evaluated as a risk factor for cognitive impairment.27). which were not related to cognitive impairment. 95% CI 0.96 Abbreviations: COPD. Home oxygen therapy and cognitive impairment in COPD Home oxygen therapy was associated with a decreased risk of cognitive impairment among persons with COPD (Table 5). and smoking history OR (95% CI) 1.01–0.41 but is similar to other studies that found no association between disease severity and cognitive impairment.

flow = 0 liters/minute) was added to the multivariable model with minimal impact on the results (OR 5. and smoking history.78 (0.35 5.73 1. ‡ 61 subjects had oxygen saturation measured on supplemental oxygen (range 1–4 liters/minute).74 (0.23) P = 0.049). educational attainment.07–0. race. coronary artery disease. especially those that involve memory or complex reasoning.23–2.28 Multivariable OR (95% CI)† 0.11 0. COPD. Consequently. our methods could have missed cases of mild cognitive impairment.43 It is likely that cognitive impairment has major effects on many aspects of patient functioning and health status. race.36 Forced expiratory volume in 1 second* Baseline oxygen saturation #88%‡ BODE Score* COPD Severity Score* Stroke (n = 68.13 (1. Area under receiver operator characteristic curve for model was 0. and baseline oxygen saturation (#88%). FEV1.17) P = 0. race. therefore. sex.85–1. Dyspnea.41 (0. The MMSE is a widely used measure of cognitive impairment but it is not sensitive for mild cognitive dysfunction.049). sex. Because our primary study focus was development of disability in COPD. we enrolled younger patients (45–65 years). Dyspnea. low oxygen saturation remained associated with a greater risk of cognitive impairment (OR 5. chronic obstructive pulmonary disease.46. confidence interval. Abbreviations: BODE. P = 0. Propensity scores were developed from a separate multivariable logistic regression model to predict home oxygen use. † Separate multivariable logistic regression analysis for each severity measure plus age.93 (0.95–1.dovepress. FEV1. and perform other aspects of self-management.008–29. that COPD severity could predict milder degrees of cognitive dysfunction. CI. confidence interval.27) P = 0.10 Multivariable OR (95% CI)† 0. This method fitted a flexible smoothed curve that did not impose a linear relationship.92–2. 0. reduced the effect estimate.2) P = 0. oxygen flow rate (no oxygen.40 (0.68 1. Exercise Capacity.23) P = 0.08 (0. Our study is subject to several other limitations. such as smoking. or congestive heart failure. P = Dovepress 267 .11–1. odds ratio. Given that many of the medications for COPD are self-activated. so that any association between cardiovascular disease and cognitive impairment may be mediated by smoking and other factors. Obstruction. confidence interval.69) P = 0.71) P = 0.81 (0.25 1.44.30 (0. COPD. even mild degrees of cognitive impairment could have significant effects on 1 ­ isease management. OR. † Multivariable logistic regression analysis including age. log odds) of cognitive impairment. *odds ratio per ½ standard deviation decrement.66) P = 0. odds ratio.03 (0. which were derived from propensity scores. 95% CI 1. OR.61) P = 0. COPD Severity Score. sex.79–1.63 4. smoking history. CI.007–30. educational attainment.31) P = 0.92–21) P = 0. † Multivariable model including inverse probability-weighted estimators.002–1. CI.17) P = 0. Cognitive impairment may interfere with patients’ ability to adhere to their medication regimen. More broadly. race.5%) Other cardiovascular disease (n = 841.046 1.14 (0.45 Consequently. 95% CI 1. adjust their medications in response to respiratory symptoms.014–29. 56%)* *hypertension. our study may underestimate the impact of COPD on cognitive impairment in older patients. sex.94–1. and smoking history.97 (0. BODE Score.25–2.92. *Multivariable logistic regression analysis including home oxygen use plus age. Obstruction.26–1.064 1.Dovepress COPD and cognitive impairment Table 3 Relationship between COPD severity and cognitive impairment Disease severity measure Risk of cognitive impairment Unadjusted OR (95% CI) 0. Abbreviations: CI.0001 −1 0 Multivariable model* −2 Multivariable model (propensity score adjusted)† 80 85 90 95 100 Resting oxygen saturation (%) Figure 1 Relationship between resting oxygen saturation and the risk of cognitive impairment.57 (0.66 Table 4 Cardiovascular disease and the risk of cognitive impair-ment in COPD Cardiovascular disease Risk of cognitive impairment Unadjusted OR (95% CI) 0.048 1. Controlling for covariates. Exercise Capacity. Forced Expiratory Volume in one second. In additional analysis.27) P . Variables included were age.90–1. Misclassification Logit of cognitive impairment Table 5 Home oxygen use and the risk of cognitive impairment in COPD Statistical model Unadjusted Risk of cognitive impairment OR (95% CI) 0. educational attainment. When oxygen use was added to the multivariable model.44.53 0. BMI (Body Mass Index). chronic obstructive pulmonary disease. The LOWESS (locally weighted regression scatter plot smoother) procedure was used to graphically depict the relationship between oxygen saturation and the logit (ie. BODE Score. Abbreviations: BODE. baseline oxygen saturation.08 (0. 4.45 (1. Oxygen saturation was measured using pulse oximetry. odds ratio. and height. OR. See Methods for more details. BMI (Body Mass Index). It remains possible.11) P = 0. cognitive impairment d may create difficulties with performing daily activities. −3 International Journal of Chronic Obstructive Pulmonary Disease 2010:5 submit your manuscript | www. confidence interval. A future analysis of cognitive impairment using a detailed neuropsychologic battery of tests is required to evaluate milder cognitive impairment in COPD.74–2. FEV1. for this lack of effect.09) P = 0. smoking history.

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