Psychosomatics 46:41-46, February 2005
© 2005 The Academy of Psychosomatic Medicine
Psychological Status and Quality of Life in Elderly Patients With Asthma
Ömer O uztürk, Ph.D.,
Aydanur Ekici, M.D.,
Murat Kara, M.D.,
Mehmet Ekici, M.D.,
Mesut Arslan, M.D.,
Ahmet  teginli, M.D.,
Türkan Kara, M.D., and
Ercan Kurtipek, M.D.
Received Nov. 5, 2003; revision received March 17, 2004; accepted April 29, 2004. From the Departments of Psychiatry, Chest Diseases, and Thoracic Surgery, Faculty of Medicine, Kirikkale University. Address correspondence and reprint requests to Prof. Dr. Ekici, Atatürk Bulvari 9.sok. Haci Mustafa Bey Ap. No. 2/2, Kirikkale, 07100 TURKEY; mehmetekici_{at}hotmail.com (e-mail).
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ABSTRACT
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The psychological status and quality of life of 70 stable patients with asthma age  60 years and 40 age-matched comparison subjects were examined. The patients with long-standing asthma (duration 8 years) had lower quality-of-life scores than those with recent-onset asthma (duration < 8 years). In multivariate linear regression analysis with adjustment for age, gender, duration of disease, and level of bronchial hyperreactivity, worse quality of life was predicted by anxiety, depression, and asthma severity scores. In elderly patients with long-standing asthma, disease severity significantly impairs quality of life. Impaired quality of life in these patients may be partly related to psychological status indicators.
Key Words: elderly • asthma • depression • anxiety
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INTRODUCTION
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Previous research suggests that anxiety and depression are more common in patients with asthma than in the general population.1 Patients with moderate to severe asthma treated at community health facilities may have high rates of often untreated depressive and anxiety disorders.2 Depression may be a risk factor for asthma-related morbidity and mortality.3 In addition, psychological factors have been implicated as potentially contributing to asthma severity.4 The comorbidity of severe asthma and depression is frequent and complicates the patient’s comprehensive medical management. Asthma and depression are thought to interact to worsen both conditions, particularly in patients with severe asthma.5 Recognition and treatment of psychological disturbances in these patients could significantly reduce asthma-related morbidity.6,7 Indeed, patients with chronic asthma spend their lifetime coping with the symptoms of their disease, and a reduction in these symptoms may lead to a perceived improvement in physical, emotional, and social areas of daily life.8
One of the main objectives of health care for patients with asthma is to preserve a satisfactory quality of life, a goal that has become an essential part of health outcome measurement in chronic disorders.9 Previous research supports the recommendation that health-related quality of life should be measured in addition to conventional clinical parameters in patients with asthma.10,11 Asthma in younger subjects is recognized to be a cause of poorer quality of life.12–15 However, few data exist regarding the effect of asthma on quality of life in elderly patients. Numerous factors might lead to poorer quality of life in lung diseases. The clinically relevant question remains whether psychopathology in elderly patients with asthma is a risk factor for worse quality of life.
Although the majority of patients with asthma have disease onset as children or young adults, onset of asthma may occur at any age, even very late in life. The symptoms of patients with onset of asthma at an advanced age are similar to those typically found in young adults, but medication requirements to maintain normal functioning may be higher in elderly patients.16 Numerous studies have been carried out to clarify the contribution of psychological factors to the severity of asthma. However, we are not aware of any research comparing the psychological status and quality of life of patients with long-standing asthma and those with recent-onset asthma. We conducted a study to examine the relationship of psychological status and quality of life with other disease characteristics in elderly patients with asthma, including those with long-standing and recent-onset disease.
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METHOD
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Patients
Of 108 nonsmoking patients with asthma who were followed up regularly for a period of 5 years in the Respiratory Disease Clinics of Kirikkale University Hospital, a total of 70 (64.8%) elderly patients were included in this study. The comparison group was composed of 40 age-matched healthy nonsmokers who attended local mosques. Asthma diagnosis was made according to the American Thoracic Society criteria, which included symptoms of episodic wheezing, cough and shortness of breath responding to bronchodilators, and reversible airflow obstruction documented in at least one previous pulmonary function study.17 The patient group included 54 women and 16 men with a mean age of 66.9 years (SD=0.4, range=60–79). All patients in the study and all comparison subjects were nonsmokers. Informed consent was obtained from all subjects. Atopy was determined by skin-prick tests for common inhalant allergens (Center Laboratories, Port Washington, N.Y.).
Patients with cardiac disorder, cognitive impairment, or respiratory tract infection in the previous 4 weeks and those who received systemic corticosteroids were excluded from the study. All patients received inhaled ß2 agonist and inhaled steroids. Detailed physical examination and spirometric measurements were obtained from each patient. The median duration of asthma among the elderly patients was 8 years. The median duration of symptoms was used to dichotomize patients as having long-standing asthma (8 years) or recent-onset asthma (<8 years).
Bronchial Provocation Test
Patients were assessed with a histamine inhalation test to determine their level of bronchial hyperreactivity. Before testing, inhaled and oral bronchodilators were withheld for at least 12 hours. Inhaled corticosteroids were not withheld. Histamine solution (diphosphate salt, Sigma, Diesenhofen, Germany) was prepared in sterile isotonic saline. The histamine challenge test was performed according to a standardized procedure.18 Pulmonary functions were measured with a flow-sensing spirometer connected to a computer. LAB, version 4.3 software (Jeager, Wurzburg, Germany) was used for the analysis. Each subject inhaled increasing concentrations of histamine (0.03–16 mg/ml), nebulized by a dosimeter with a mean output of 0.9 ml/puff (SD=0.3) (Dosimeter APS Pro, Jeager, Wurzburg, Germany), until forced expiratory volume in 1 second (FEV1) was reduced by 20% from baseline values. Bronchial response to histamine was expressed as the provocative dose (in mg/ml) causing a 20% reduction in FEV1 (PD20) and was calculated by using LAB, version 4.3 software (Jeager, Wurzburg, Germany).
Assessment of Cognitive Functioning
The Mini Mental Status Examination (MMSE)19 was administered to assess cognitive functioning. This test explores six cognitive domains (temporal and spatial orientation, short-term memory, computation, secondary memory, verbal attainment, and constructive ability). Healthy subjects have scores > 23.19
Assessment of Quality of Life and Asthma Severity
Quality of life was assessed by means of the Mini Asthma Quality of Life Questionnaire.20 The asthma severity score was defined according to the National Asthma Education Program (NAEP) guidelines, which take into account frequency of symptoms, degree of airflow obstruction, and frequency of use of oral glucocorticoids.21
Assessment of Psychological Status
The patients were asked to complete the self-reported Hospital Anxiety and Depression Scale.22 The scale consists of 14 questions in which the overall severity of anxiety and depression is rated on a 4-point scale (0 to 3). Seven questions were related to anxiety, and seven to depression.
Statistical Analysis
The differences between groups were assessed with Student’s t test and the Mann-Whitney U test, as appropriate. Multiple linear regression analysis was performed with the Mini Asthma Quality of Life Questionnaire score as the dependent variable and the following predictor variables: anxiety score, depression score, gender, age, asthma severity score, and PD20 value. The predictor variables were entered into the multivariate model by using a stepwise procedure. Clinical data were expressed as means and standard deviations. A p value less than 0.05 was considered statistically significant.
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RESULTS
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Table 1 summarizes the characteristics of the study subjects. No significant differences in mean age were found between the elderly patients with long-standing asthma and the patients with recent-onset asthma and between the patients with long-standing asthma and the comparison group. The mean anxiety score of the patients with long-standing asthma was significantly greater than that of patients with recent-onset asthma and that of the comparison subjects. Similarly, the depression score of the patients with long-standing asthma was significantly greater than that of the patients with recent-onset asthma and that of the comparison subjects. However, the MMSE scores of the patients with long-standing asthma did not differ from that of the patients with recent-onset asthma (mean=27.2 [SD=1.9]) versus mean=27.7 [SD=1.6], p=0.54), although the MMSE scores of the patients with recent-onset asthma differed significantly from those of the comparison subjects (28.3 [SD=1.4], p<0.02).
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TABLE 1. Characteristics of Elderly Patients With Long-Standing and Recent-Onset Asthma and Age-Matched Healthy Comparison Subjects
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As Table 1 shows, the mean total score on the Mini Asthma Quality of Life Questionnaire of the patients with long-standing asthma was significantly lower than that of the patients with recent-onset asthma. Likewise, the asthma severity score of the patients with long-standing asthma was significantly greater than that of the patients with recent-onset asthma. The mean FEV1 and PD20 values of the patients with long-standing asthma were significantly different from those of the patients with recent-onset asthma.
A high degree of correlation was found between the anxiety and depression scores. These variables were entered into separate multiple regression models to avoid collinearity (Table 2).
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TABLE 2. Multiple Linear Regression Analysis of Predictors of Quality of Life in Elderly Patients With Asthma and Age-Matched Healthy Comparison Subjects
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Multiple linear regression analysis indicated that the asthma severity score and the anxiety score were significant predictors of the total Mini Asthma Quality of Life Questionnaire score, after adjustment for other independent variables (age, gender, duration of disease, and PD20 value) (Table 2).
In addition, multiple linear regression analysis clarified that the asthma severity score and the depression score were significant predictors of the total Mini Asthma Quality of Life Questionnaire score, after adjustment for other independent variables (age, gender, duration of disease, and PD20 value) (Table 2).
The asthma severity score accounted for 59% of the variance in the total quality of life score, the anxiety score accounted for 49%, and the depression score accounted for 41%. The asthma severity score combined with the anxiety score accounted for 68% of the variance in the total quality of life score, after adjustment for other independent variables. Asthma severity score, combined with depression score and gender, accounted for 67% of the variance in the total quality of life score, after adjustment for other independent variables.
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DISCUSSION
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The literature includes numerous reports on the psychological status of patients with asthma. Previous studies showed that either younger1,7,23 or elderly24 patients with asthma were more anxious and more depressed, relative to comparison subjects without asthma. However, Janson et al.25 were unable to find significant associations of asthma with anxiety or depression in a general population sample. In our study, we found that the depression and anxiety scores of patients with long-standing asthma significantly differed from those of the patients with recent-onset asthma and from those of a healthy comparison group. Furthermore, studies have been carried out to define the relationship between the severity of asthma and patients’ psychological status. Nouwen et al.26 found no differences in anxiety or depression levels between patients who had two or more emergency room visits during the last 2 years and patients who had no emergency room visits in the same period. Similarly, Rocco et al.27 reported that psychiatric symptoms had no significant relationship with the presence of asthma or near fatal asthma. However, Ten Brinke et al.4 showed that asthmatic patients with psychiatric dysfunction had significantly more frequent visits to general practitioners and emergency departments and significantly more exacerbations and hospitalizations, compared with nonpsychiatric patients; the findings suggest that the severity of asthma is strongly correlated with psychiatric dysfunction. Garden and Ayres28 found that patients with "brittle" asthma had greater psychiatric morbidity than those with less severe asthma. Chetta et al.29 also suggested that severity of disease might be related to psychological disturbances in outpatients. Our data showed that although the asthma severity score was a significant predictor of depression, it was a strong, but nonsignificant predictor of anxiety. The latter finding might be attributed to the small number of patients with anxiety in our study.
Although we analyzed the possible predictors of both overall quality of life and specific aspects of quality of life with respect to depression and anxiety scores, we mainly examined results for the total Mini Asthma Quality of Life Questionnaire score. Given that one of the main objectives of health care should be to preserve a satisfactory quality of life in patients with asthma, the presence and seriousness of anxiety or depression and their effects on quality of life should be taken into account as part of the clinical evaluation. Although numerous studies have examined psychological factors in asthma, differences in the psychological status and quality of life of patients with long-standing asthma and those with recent-onset asthma remain unclear. Our data from multiple linear regression analysis showed that anxiety, depression, and asthma severity were independent risk factors for worse quality of life in patients with asthma. These findings indicate that worse quality of life in elderly patients with asthma is not only the result of disease severity but also might be related to psychological status indicators. Similar studies by Dyer et al.7 and Incalzi et al.30 showed that elderly people with asthma have an impaired quality of life and that depression is an important determinant of their worse quality of life. Enright et al.31 found that asthma in elderly patients was associated with a lower quality of life, although depression was not the major cause of this result in a comparison with nonasthmatic comparison subjects. In studies of younger patients with asthma, Rimington et al.8 and Mancuso et al.32 found that depression scores showed a negative correlation with quality of life. Renwick and Connolly33 showed that obstructive airways disease significantly impaired quality of life in adults and that the reduction in quality of life in these patients was related to both baseline pulmonary function and nonspecific bronchial responsiveness. Different results in these studies may be attributed to differences in the asthma severity, age, and gender of the subjects and to differences in the measurements used.
In conclusion, we found that disease severity in elderly patients with long-standing asthma significantly impairs quality of life and that the impairment in quality of life may be related to psychological status indicators. Thus, the presence and seriousness of anxiety and depression should be taken into consideration as part of the clinical evaluation of elderly patients with asthma. Treatment of the symptoms of asthma and of unfavorable psychological status in these patients may help improve their quality of life.
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ABSTRACT
INTRODUCTION
