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Finding mild cognitive impairment quickly in primary care
Primary care is the ideal setting to screen for mild cognitive impairment. Screening can be performed in under 10 minutes using brief cognitive assessment tools. When it comes to treatment, deprescribing is a priority, as many drug interactions contribute to cognitive disorders. Drugs also influence the value of nondrug therapies.
At the XXIX National Congress of General and Family Medicine of the Spanish Society for General and Family Physicians, Granada, Spain, Alberto Freire, MD, a family doctor and head of the society’s neurology group, presented a way to detect cognitive impairment in a few minutes during a primary care office visit. He also presented a stepwise algorithm for diagnosing and treating the condition, which is highly prevalent and underdiagnosed.
The specialist dismissed the idea that “memory problems are associated with age,” though it is true that in normal aging, “cognitive frailty develops, and some processes will move a little slower. But there won’t be significant functional impairment.” Mild cognitive impairment falls between normal aging and dementia.
“Primary care is essential for screening for mild cognitive impairment due to its high level of accessibility, proximity, and continuity, but most of all due to its longitudinal perspective, which differentiates it from other specialties,” said Dr. Freire. He pointed out that screening is not the same as diagnosis because screening merely indicates probability or well-founded suspicion that can then be confirmed in secondary care.
He also highlighted the need for assessment of cognitive function using brief cognitive tests, as well as the need for functional assessment of activities of daily living. Many cognitive function tests are available, some of which are patient oriented and some caregiver oriented.
“The patient initially comes to see us due to memory loss that he or she, or that some reliable reporter, has detected,” said Dr. Freire. He indicated that 18.5% of consultations for cognitive impairment are prompted by subjective perceptions of memory complaints, which represent the most common subtype of the condition: mild amnestic cognitive impairment.
Quick cognitive tests
Dr. Freire was in favor of picture-based tests, which he strongly recommended. “These are the most-studied tests in Spain for detecting neurocognitive impairment, and they eliminate the reading factor. They’re quick, they’re easy to use and interpret, and are well-accepted by patients. Also, they assess executive function (verbal fluency) and memory.” Dr. Freire stressed the importance of referencing categories when showing the pictures, as well as the fact that the test is available for free online.
He also questioned whether the Mini-Mental State Examination is dead because “there’s an abbreviated version that the author rejects, and the author’s permission is required to use it. It’s very appropriate for Alzheimer’s disease, but not for cognitive impairment.”
Another notable test is the episodic test (a test that avoids interfering with working memory). It has been validated for amnestic mild cognitive impairment and Alzheimer’s disease, but a reliable caregiver is required to verify patient responses.
For caregiver-oriented tests, Dr. Freire pointed to AD8, which, when paired with any brief cognitive test, significantly increases detection of cognitive impairment.
He also recommended a useful website for everyday consultations created by several scientific societies, including the Spanish Society of General and Family Physicians. The site includes the AD8 and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) questionnaires that can be completed online. “It produces a score that indicates the likelihood that the patient has cognitive impairment, and it can be filled out by family members or caregivers to get the result during the consultation,” he said.
Functional assessment
“Functional assessment of the patient’s level of independence for their life in society is what conceptually differentiates mild cognitive impairment from dementia,” explained Dr. Freire. “There are several types of activities of daily living. The instrumental activities (cooking, laundry, talking on the phone, using transportation, managing finances, taking medications, etc.) are the activities that truly distinguish between mild cognitive impairment and dementia. They allow the person to adjust to their environment and retain their independence within the community.”
There are multiple tools for assessing activities of daily living, but Dr. Freire singled out the Mongil test (from Spain), which covers basic, instrumental, and advanced activities. The higher the score, the worse the patient’s condition, so the goal is to lower the score. On the other hand, grouping certain items together helps determine whether there is a risk of falling, sarcopenia, depression, or suicide, among other outcomes. “So, it’s not only useful for diagnosis and treatment but also detects geriatric problems and syndromes. That is, it’s useful for prevention and allows planning of preventive and therapeutic medical interventions,” he explained.
Reversible dementia
Dr. Freire presented a diagnostic and therapeutic algorithm for cognitive impairment to be used when brief cognitive tests are positive. “The first thing is to perform a clinical assessment because although many cases of cognitive impairment go undiagnosed, 10% of the cases of symptomatic dementia are potentially reversible. We shouldn’t overlook these.” These cases of dementia may be brought on by medication use, alcoholism, chronic meningoencephalitis, toxins, normal pressure hydrocephalus, certain brain tumors, hypothyroidism, and nutritional deficits, among other causes. Functional assessment follows, using the scales mentioned above.
Interactions and deprescribing
“As to polypharmacy, there is underuse of good, evidence-backed medications with no major contraindications. But care must also be taken with inappropriate or off-label medications, overtreatment, drug interactions, and adherence,” said Dr. Freire.
“We need to start deprescribing because the chemical basis of cognitive impairment traces back to reduced cholinergic activity, increased dopaminergic activity in the brain, or both. There are many commonly prescribed drugs with anticholinergic interactions that can cause cognitive disorders. These could be psychotropics, hypnotics, analgesics (nonsteroidal anti-inflammatory drugs), first-generation antihistamines, antihypertensives, antiarrhythmics, histamine2 blockers, and even antibiotics like penicillin and quinolones, among many others,” he emphasized.
The next step is to perform comprehensive laboratory testing to rule out vitamin and mineral deficiencies, diabetes, thyroid disorders, kidney failure, liver diseases, urinary infections, and infections of the central nervous system. After that, neuroimaging should be performed. MRI is the preferred method because it allows quantification of atrophy and volumetric measurements.
Strict cardiovascular control
“At this point, treatment can be started, and the patient can be referred to secondary care,” said Dr. Freire, as he proceeded through a therapeutic algorithm following diagnosis of the patient. Regular exercise increases coordination synapses, prevents disease onset, improves executive function, and delays the onset of dementia. “The problem lies in not knowing how much time should be spent daily and weekly on exercise to achieve these goals.
“It is known that a Mediterranean diet and omega-3 fatty acids improve cognitive impairment. However, care should be taken with omega-3s as they are no longer helpful in dementia that has already been established.” The importance of strictly controlling cardiovascular risk factors must also be kept in mind, as backed by validated studies; it has been shown that blood pressure levels below 128 mm Hg make mild cognitive impairment and dementia worse, atrial fibrillation increases the risk of dementia by a factor of 1.4-2.4, diabetes is a risk factor for developing amnestic mild cognitive impairment, tobacco use also leads to cognitive impairment – even in individuals exposed to second-hand smoke – and statins do not change the risk in cases of dyslipidemia.
Nondrug treatment
Dr. Freire also highlighted the importance of multiple nondrug therapies in this field, such as cognitive training and rehabilitation, reminiscence, music therapy, cognitive-behavioral psychotherapy, and sensory interventions, among others. He also recommended patient groups for these individuals.
He added: “In mild cognitive impairment, there is currently no drug that is an improvement over nondrug therapies.”
The drugs aim to improve memory loss, prevent or delay the onset of mild cognitive impairment, and treat initial symptoms of dementia if applicable. The most commonly prescribed drugs are citicoline alone in vascular disease and memory loss, EGb 761 (which is the only approved dose-dependent drug), and others such as phosphatidylserine, nimodipine, and memantine combined with galantamine or piracetam, Dr. Freire concluded.
Dr. Freire had declared receiving funding as a student in training and outreach activities for popular science sponsored by Ferrer, and on the topic of pain by Esteve, Grünenthal Pharma, and Menarini. He has also reported being a consultant for GSK, Lilly, and Pfizer.
A version of this article first appeared on Medscape.com.
Primary care is the ideal setting to screen for mild cognitive impairment. Screening can be performed in under 10 minutes using brief cognitive assessment tools. When it comes to treatment, deprescribing is a priority, as many drug interactions contribute to cognitive disorders. Drugs also influence the value of nondrug therapies.
At the XXIX National Congress of General and Family Medicine of the Spanish Society for General and Family Physicians, Granada, Spain, Alberto Freire, MD, a family doctor and head of the society’s neurology group, presented a way to detect cognitive impairment in a few minutes during a primary care office visit. He also presented a stepwise algorithm for diagnosing and treating the condition, which is highly prevalent and underdiagnosed.
The specialist dismissed the idea that “memory problems are associated with age,” though it is true that in normal aging, “cognitive frailty develops, and some processes will move a little slower. But there won’t be significant functional impairment.” Mild cognitive impairment falls between normal aging and dementia.
“Primary care is essential for screening for mild cognitive impairment due to its high level of accessibility, proximity, and continuity, but most of all due to its longitudinal perspective, which differentiates it from other specialties,” said Dr. Freire. He pointed out that screening is not the same as diagnosis because screening merely indicates probability or well-founded suspicion that can then be confirmed in secondary care.
He also highlighted the need for assessment of cognitive function using brief cognitive tests, as well as the need for functional assessment of activities of daily living. Many cognitive function tests are available, some of which are patient oriented and some caregiver oriented.
“The patient initially comes to see us due to memory loss that he or she, or that some reliable reporter, has detected,” said Dr. Freire. He indicated that 18.5% of consultations for cognitive impairment are prompted by subjective perceptions of memory complaints, which represent the most common subtype of the condition: mild amnestic cognitive impairment.
Quick cognitive tests
Dr. Freire was in favor of picture-based tests, which he strongly recommended. “These are the most-studied tests in Spain for detecting neurocognitive impairment, and they eliminate the reading factor. They’re quick, they’re easy to use and interpret, and are well-accepted by patients. Also, they assess executive function (verbal fluency) and memory.” Dr. Freire stressed the importance of referencing categories when showing the pictures, as well as the fact that the test is available for free online.
He also questioned whether the Mini-Mental State Examination is dead because “there’s an abbreviated version that the author rejects, and the author’s permission is required to use it. It’s very appropriate for Alzheimer’s disease, but not for cognitive impairment.”
Another notable test is the episodic test (a test that avoids interfering with working memory). It has been validated for amnestic mild cognitive impairment and Alzheimer’s disease, but a reliable caregiver is required to verify patient responses.
For caregiver-oriented tests, Dr. Freire pointed to AD8, which, when paired with any brief cognitive test, significantly increases detection of cognitive impairment.
He also recommended a useful website for everyday consultations created by several scientific societies, including the Spanish Society of General and Family Physicians. The site includes the AD8 and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) questionnaires that can be completed online. “It produces a score that indicates the likelihood that the patient has cognitive impairment, and it can be filled out by family members or caregivers to get the result during the consultation,” he said.
Functional assessment
“Functional assessment of the patient’s level of independence for their life in society is what conceptually differentiates mild cognitive impairment from dementia,” explained Dr. Freire. “There are several types of activities of daily living. The instrumental activities (cooking, laundry, talking on the phone, using transportation, managing finances, taking medications, etc.) are the activities that truly distinguish between mild cognitive impairment and dementia. They allow the person to adjust to their environment and retain their independence within the community.”
There are multiple tools for assessing activities of daily living, but Dr. Freire singled out the Mongil test (from Spain), which covers basic, instrumental, and advanced activities. The higher the score, the worse the patient’s condition, so the goal is to lower the score. On the other hand, grouping certain items together helps determine whether there is a risk of falling, sarcopenia, depression, or suicide, among other outcomes. “So, it’s not only useful for diagnosis and treatment but also detects geriatric problems and syndromes. That is, it’s useful for prevention and allows planning of preventive and therapeutic medical interventions,” he explained.
Reversible dementia
Dr. Freire presented a diagnostic and therapeutic algorithm for cognitive impairment to be used when brief cognitive tests are positive. “The first thing is to perform a clinical assessment because although many cases of cognitive impairment go undiagnosed, 10% of the cases of symptomatic dementia are potentially reversible. We shouldn’t overlook these.” These cases of dementia may be brought on by medication use, alcoholism, chronic meningoencephalitis, toxins, normal pressure hydrocephalus, certain brain tumors, hypothyroidism, and nutritional deficits, among other causes. Functional assessment follows, using the scales mentioned above.
Interactions and deprescribing
“As to polypharmacy, there is underuse of good, evidence-backed medications with no major contraindications. But care must also be taken with inappropriate or off-label medications, overtreatment, drug interactions, and adherence,” said Dr. Freire.
“We need to start deprescribing because the chemical basis of cognitive impairment traces back to reduced cholinergic activity, increased dopaminergic activity in the brain, or both. There are many commonly prescribed drugs with anticholinergic interactions that can cause cognitive disorders. These could be psychotropics, hypnotics, analgesics (nonsteroidal anti-inflammatory drugs), first-generation antihistamines, antihypertensives, antiarrhythmics, histamine2 blockers, and even antibiotics like penicillin and quinolones, among many others,” he emphasized.
The next step is to perform comprehensive laboratory testing to rule out vitamin and mineral deficiencies, diabetes, thyroid disorders, kidney failure, liver diseases, urinary infections, and infections of the central nervous system. After that, neuroimaging should be performed. MRI is the preferred method because it allows quantification of atrophy and volumetric measurements.
Strict cardiovascular control
“At this point, treatment can be started, and the patient can be referred to secondary care,” said Dr. Freire, as he proceeded through a therapeutic algorithm following diagnosis of the patient. Regular exercise increases coordination synapses, prevents disease onset, improves executive function, and delays the onset of dementia. “The problem lies in not knowing how much time should be spent daily and weekly on exercise to achieve these goals.
“It is known that a Mediterranean diet and omega-3 fatty acids improve cognitive impairment. However, care should be taken with omega-3s as they are no longer helpful in dementia that has already been established.” The importance of strictly controlling cardiovascular risk factors must also be kept in mind, as backed by validated studies; it has been shown that blood pressure levels below 128 mm Hg make mild cognitive impairment and dementia worse, atrial fibrillation increases the risk of dementia by a factor of 1.4-2.4, diabetes is a risk factor for developing amnestic mild cognitive impairment, tobacco use also leads to cognitive impairment – even in individuals exposed to second-hand smoke – and statins do not change the risk in cases of dyslipidemia.
Nondrug treatment
Dr. Freire also highlighted the importance of multiple nondrug therapies in this field, such as cognitive training and rehabilitation, reminiscence, music therapy, cognitive-behavioral psychotherapy, and sensory interventions, among others. He also recommended patient groups for these individuals.
He added: “In mild cognitive impairment, there is currently no drug that is an improvement over nondrug therapies.”
The drugs aim to improve memory loss, prevent or delay the onset of mild cognitive impairment, and treat initial symptoms of dementia if applicable. The most commonly prescribed drugs are citicoline alone in vascular disease and memory loss, EGb 761 (which is the only approved dose-dependent drug), and others such as phosphatidylserine, nimodipine, and memantine combined with galantamine or piracetam, Dr. Freire concluded.
Dr. Freire had declared receiving funding as a student in training and outreach activities for popular science sponsored by Ferrer, and on the topic of pain by Esteve, Grünenthal Pharma, and Menarini. He has also reported being a consultant for GSK, Lilly, and Pfizer.
A version of this article first appeared on Medscape.com.
Primary care is the ideal setting to screen for mild cognitive impairment. Screening can be performed in under 10 minutes using brief cognitive assessment tools. When it comes to treatment, deprescribing is a priority, as many drug interactions contribute to cognitive disorders. Drugs also influence the value of nondrug therapies.
At the XXIX National Congress of General and Family Medicine of the Spanish Society for General and Family Physicians, Granada, Spain, Alberto Freire, MD, a family doctor and head of the society’s neurology group, presented a way to detect cognitive impairment in a few minutes during a primary care office visit. He also presented a stepwise algorithm for diagnosing and treating the condition, which is highly prevalent and underdiagnosed.
The specialist dismissed the idea that “memory problems are associated with age,” though it is true that in normal aging, “cognitive frailty develops, and some processes will move a little slower. But there won’t be significant functional impairment.” Mild cognitive impairment falls between normal aging and dementia.
“Primary care is essential for screening for mild cognitive impairment due to its high level of accessibility, proximity, and continuity, but most of all due to its longitudinal perspective, which differentiates it from other specialties,” said Dr. Freire. He pointed out that screening is not the same as diagnosis because screening merely indicates probability or well-founded suspicion that can then be confirmed in secondary care.
He also highlighted the need for assessment of cognitive function using brief cognitive tests, as well as the need for functional assessment of activities of daily living. Many cognitive function tests are available, some of which are patient oriented and some caregiver oriented.
“The patient initially comes to see us due to memory loss that he or she, or that some reliable reporter, has detected,” said Dr. Freire. He indicated that 18.5% of consultations for cognitive impairment are prompted by subjective perceptions of memory complaints, which represent the most common subtype of the condition: mild amnestic cognitive impairment.
Quick cognitive tests
Dr. Freire was in favor of picture-based tests, which he strongly recommended. “These are the most-studied tests in Spain for detecting neurocognitive impairment, and they eliminate the reading factor. They’re quick, they’re easy to use and interpret, and are well-accepted by patients. Also, they assess executive function (verbal fluency) and memory.” Dr. Freire stressed the importance of referencing categories when showing the pictures, as well as the fact that the test is available for free online.
He also questioned whether the Mini-Mental State Examination is dead because “there’s an abbreviated version that the author rejects, and the author’s permission is required to use it. It’s very appropriate for Alzheimer’s disease, but not for cognitive impairment.”
Another notable test is the episodic test (a test that avoids interfering with working memory). It has been validated for amnestic mild cognitive impairment and Alzheimer’s disease, but a reliable caregiver is required to verify patient responses.
For caregiver-oriented tests, Dr. Freire pointed to AD8, which, when paired with any brief cognitive test, significantly increases detection of cognitive impairment.
He also recommended a useful website for everyday consultations created by several scientific societies, including the Spanish Society of General and Family Physicians. The site includes the AD8 and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) questionnaires that can be completed online. “It produces a score that indicates the likelihood that the patient has cognitive impairment, and it can be filled out by family members or caregivers to get the result during the consultation,” he said.
Functional assessment
“Functional assessment of the patient’s level of independence for their life in society is what conceptually differentiates mild cognitive impairment from dementia,” explained Dr. Freire. “There are several types of activities of daily living. The instrumental activities (cooking, laundry, talking on the phone, using transportation, managing finances, taking medications, etc.) are the activities that truly distinguish between mild cognitive impairment and dementia. They allow the person to adjust to their environment and retain their independence within the community.”
There are multiple tools for assessing activities of daily living, but Dr. Freire singled out the Mongil test (from Spain), which covers basic, instrumental, and advanced activities. The higher the score, the worse the patient’s condition, so the goal is to lower the score. On the other hand, grouping certain items together helps determine whether there is a risk of falling, sarcopenia, depression, or suicide, among other outcomes. “So, it’s not only useful for diagnosis and treatment but also detects geriatric problems and syndromes. That is, it’s useful for prevention and allows planning of preventive and therapeutic medical interventions,” he explained.
Reversible dementia
Dr. Freire presented a diagnostic and therapeutic algorithm for cognitive impairment to be used when brief cognitive tests are positive. “The first thing is to perform a clinical assessment because although many cases of cognitive impairment go undiagnosed, 10% of the cases of symptomatic dementia are potentially reversible. We shouldn’t overlook these.” These cases of dementia may be brought on by medication use, alcoholism, chronic meningoencephalitis, toxins, normal pressure hydrocephalus, certain brain tumors, hypothyroidism, and nutritional deficits, among other causes. Functional assessment follows, using the scales mentioned above.
Interactions and deprescribing
“As to polypharmacy, there is underuse of good, evidence-backed medications with no major contraindications. But care must also be taken with inappropriate or off-label medications, overtreatment, drug interactions, and adherence,” said Dr. Freire.
“We need to start deprescribing because the chemical basis of cognitive impairment traces back to reduced cholinergic activity, increased dopaminergic activity in the brain, or both. There are many commonly prescribed drugs with anticholinergic interactions that can cause cognitive disorders. These could be psychotropics, hypnotics, analgesics (nonsteroidal anti-inflammatory drugs), first-generation antihistamines, antihypertensives, antiarrhythmics, histamine2 blockers, and even antibiotics like penicillin and quinolones, among many others,” he emphasized.
The next step is to perform comprehensive laboratory testing to rule out vitamin and mineral deficiencies, diabetes, thyroid disorders, kidney failure, liver diseases, urinary infections, and infections of the central nervous system. After that, neuroimaging should be performed. MRI is the preferred method because it allows quantification of atrophy and volumetric measurements.
Strict cardiovascular control
“At this point, treatment can be started, and the patient can be referred to secondary care,” said Dr. Freire, as he proceeded through a therapeutic algorithm following diagnosis of the patient. Regular exercise increases coordination synapses, prevents disease onset, improves executive function, and delays the onset of dementia. “The problem lies in not knowing how much time should be spent daily and weekly on exercise to achieve these goals.
“It is known that a Mediterranean diet and omega-3 fatty acids improve cognitive impairment. However, care should be taken with omega-3s as they are no longer helpful in dementia that has already been established.” The importance of strictly controlling cardiovascular risk factors must also be kept in mind, as backed by validated studies; it has been shown that blood pressure levels below 128 mm Hg make mild cognitive impairment and dementia worse, atrial fibrillation increases the risk of dementia by a factor of 1.4-2.4, diabetes is a risk factor for developing amnestic mild cognitive impairment, tobacco use also leads to cognitive impairment – even in individuals exposed to second-hand smoke – and statins do not change the risk in cases of dyslipidemia.
Nondrug treatment
Dr. Freire also highlighted the importance of multiple nondrug therapies in this field, such as cognitive training and rehabilitation, reminiscence, music therapy, cognitive-behavioral psychotherapy, and sensory interventions, among others. He also recommended patient groups for these individuals.
He added: “In mild cognitive impairment, there is currently no drug that is an improvement over nondrug therapies.”
The drugs aim to improve memory loss, prevent or delay the onset of mild cognitive impairment, and treat initial symptoms of dementia if applicable. The most commonly prescribed drugs are citicoline alone in vascular disease and memory loss, EGb 761 (which is the only approved dose-dependent drug), and others such as phosphatidylserine, nimodipine, and memantine combined with galantamine or piracetam, Dr. Freire concluded.
Dr. Freire had declared receiving funding as a student in training and outreach activities for popular science sponsored by Ferrer, and on the topic of pain by Esteve, Grünenthal Pharma, and Menarini. He has also reported being a consultant for GSK, Lilly, and Pfizer.
A version of this article first appeared on Medscape.com.
Comorbidities and the prognosis of chronic obstructive pulmonary disease
Strict control of comorbidities in patients with chronic obstructive pulmonary disease decreases exacerbations and morbimortality, and avoids readmissions. An increasing number of women have the disease, which progresses differently in women than in men and even has different comorbidities.
said Belén Alonso, MD, PhD, coordinator of the COPD Working Group of the Spanish Society of Internal Medicine. Up to 73 comorbidities associated with chronic obstructive pulmonary disease have been described. Dr. Alonso made these remarks during her presentation at the Comorbidities in Chronic Obstructive Pulmonary Disease Panel, which took place during the 43rd Conference of the Spanish Society of Internal Medicine (SEMI), in Gijón, Spain.
According to the scientific society’s press release, moderator María Gómez Antúnez, MD, stated, “The correct approach and treatment of these comorbidities is fundamental to improve the quality of life of the patient, decrease exacerbations, avoid readmissions, and decrease morbimortality in people with chronic obstructive pulmonary disease.”
The different works published, two of them by the SEMI COPD Working Group (ECCO and ESMI studies), indicate that the main comorbidities of patients with that pneumopathy are arterial hypertension, dyslipidemia, diabetes, heart failure, atrial fibrillation, ischemic heart disease, chronic kidney disease, peripheral arterial disease, and osteoporosis. Chronic hepatopathy, pulmonary neoplasm, depression, and cerebrovascular disease are less common.
73 comorbidities described
Dr. Alonso told this news organization, “Of those 73 comorbidities, some of the lesser known or less attention grabbing, according to a paper that we brought to the panel, include sleep disorders that encompass insomnia, nightmares, night terrors, sleep apneas, or hypopneas. Other lesser-known comorbidities related to cognitive decline, with patterns that reflect that up to 60% [of patients] may have some degree of deterioration, involve the disease phase, hypoxemia, or degree of inflammation. On the other hand, it has also been associated with Parkinson’s disease and gastroesophageal reflux, among many more that arise from the cardiovascular sphere.”
One paper reveals that more than 78% of patients with chronic obstructive pulmonary disease have one associated comorbidity, almost 69% have two, and 47.9% have three.
“Based on gender, comorbidities are different. In women, it is well observed that anxiety, depression, and osteoporosis are more common. However, hypertension, ischemic heart disease, and diabetes are more common in men with chronic obstructive pulmonary disease,” she stated.
“The pulmonary disease in question also progresses differently in men and women. In women, onset is at younger ages – between 40 and 50 years – and in men, after 50. Likewise, it appears that the disease progresses more quickly, which coincides with a worse quality of life (since dyspnea is tolerated less) and exceeds the anatomical differences, where hormonal influences play a dominant role,” Dr. Alonso stressed.
Reciprocal prognosis
Dr. Alonso stated, “The prognostic importance of comorbidities in the disease is reciprocal. In other words, if there are comorbidities that we do not look for or treat, they are going to have a negative influence on the chronic obstructive pulmonary disease. The disease will progress more and elevate the risk of exacerbations (the most important prognostic factor of that disease). In turn, if we are not treating the disease well, not only pharmacologically, it will have negative repercussions on the comorbidities. It will progress and have negative connotations, such as diabetes or ischemic heart disease.”
The aforementioned ECCO and ESMI studies include patients in internal medicine with exacerbations where the most common comorbidities have been mapped out, although there is also extensive research on comorbidities in patients who are admitted to departments other than internal medicine. “With regard to prognostic implications, our working group very clearly observed the comorbidities and the comorbidome, that solar system that appears so much in medical conferences and forums, which implies that proximity to the center of that solar system is related more to mortality, anxiety, depression, and breast cancer. Other pathologies, such as ischemic heart disease or dyslipidemia, are outside of that territory of greater risk, in which we have been more pioneering than other groups,” said Dr. Alonso.
The current trend is that the age of these patients is increasing, and there are more and more women with this pathology. According to the latest report from the Ministry of Health on respiratory diseases, the prevalence of chronic obstructive pulmonary disease among the population 40 years and older is around 33.9 cases per 1,000 inhabitants, more than twice as common in men than in women (47.7 vs. 21.3). Prevalence increases with age after 40 years progressively until reaching the greatest frequency in the 80- to 84-year-old age group.
In 2019, the number of deaths due to chronic obstructive pulmonary disease in Spain was 13,808 (9,907 men and 3,901 women), with a crude mortality rate of 29.3 deaths per 100,000 inhabitants. This toll decreased in comparison with that of 2018. Chronic obstructive pulmonary disease causes 2.5 times more deaths in men than in women. From 2001 to 2019, mortality due to that pathology declined by 43% in men and women. The decrease was almost 50% in men and 33% in women.
Overlap syndrome prevalent
Javier Sánchez Lora, MD, of the internal medicine department of the Virgen de la Victoria de Málaga University Clinical Hospital, discussed chronic obstructive pulmonary disease and sleep disorders. More concretely, he spoke about overlap syndrome: chronic obstructive pulmonary disease plus obstructive sleep apnea. According to the international consensus document on obstructive sleep apnea, the diagnosis requires an apnea-hypopnea index (AHI) equal to or greater than 15 per hour or equal to or greater than 5. The patient must also have one or more of the following factors: excessive daytime sleepiness, sleep that is not restful, excessive fatigue, and deterioration in quality of life related to sleep and not justified by other causes.
“The overlap syndrome affects 3%-66% of chronic obstructive pulmonary diseases and 7%-55% of obstructive sleep apnea,” said Dr. Sánchez Lora. This syndrome has important effects on different systems: at the cardiovascular level (arterial and pulmonary hypertension, heart failure, stroke, arrhythmias, ischemic heart disease, pulmonary thromboembolism), metabolic (insulin resistance, diabetes, metabolic syndrome), neurocognitive (dementia, depression), and neoplastic (lung, pancreas, esophagus) effects.
“These patients have a worse prognosis than those that have these pathologies alone. During sleep, they experience more frequent episodes of oxygen desaturation and they have a longer total period of sleep with hypoxemia and hypercapnia than those with obstructive apnea alone without chronic obstructive pulmonary disease,” said Dr. Sánchez Lora.
The apneic events of patients with the syndrome have a more profound hypoxemia and more arrhythmias, in addition to them being more susceptible to developing pulmonary hypertension than those with chronic obstructive pulmonary disease or sleep apnea alone. “The good news is that in patients with overlap, the use of ventilation with positive pressure reduces all causes of hospitalization and the visits to the emergency room, as well as the moderate and severe exacerbations of the disease.”
Dr. Sánchez Lora referred to a series of recommendations in clinical practice for the diagnosis and treatment of overlap syndrome: screening, combined therapy of hygienic-dietary measures, and the use of continuous positive respiratory pressure. Oxygen therapy to correct isolated nocturnal desaturations has not shown benefits in survival, although a benefit trial of symptoms attributed to nocturnal hypoxemia in patients with significant comorbidity can be conducted.
Underdiagnosis
“During the panel, we also spoke about the importance that as part of internal medicine we need to make an effort to reduce the underdiagnosis of chronic pulmonary disease and its comorbidities. Specialists in internal medicine need to become aware that this pathology is not only pulmonary, but also multisystemic, complex, heterogenous, and very variable even in the same patient,” said Dr. Sánchez Lora.
Dr. Alonso said, “Regarding the importance of diagnosis of this disease, we continue with an underdiagnosis greater than 70% for men and 80% for women. Secondly, we need to actively seek out the comorbidities associated with chronic obstructive pulmonary disease, even taking advantage of the admission of these patients with exacerbations, which are undesired and common.
“Regarding ongoing trials, we have a study that started during the COVID-19 pandemic, ADEG-EPOC, that involves the adaptation to and impact of severe and very severe exacerbations in patients admitted to our departments,” the specialist indicated.
“In the group, we are also planning to publish an updated agreement, which we already made in 2014, on the most common and important comorbidities associated with chronic obstructive pulmonary disease.” The agreement discusses the 20 most important comorbidities. In addition, the 2023 Gold Guide, which appeared in November 2022, includes a new chapter on updated treatment and the latest developments.
In the last 5 years, Dr. Alonso has collaborated with Abbott, AstraZeneca, Boehringer Ingelheim, Chiesi, FAES, Ferrer, Fresenius Kabi, GSK, Nestlé, Novo Nordisk, Nutricia, and Menarini. Dr. Sánchez Lora has collaborated with AstraZeneca, Boehringer Ingelheim, Chiesi, FAES, GSK, and Menarini.
This article was translated from the Medscape Spanish edition. A version of this article appeared on Medscape.com.
Strict control of comorbidities in patients with chronic obstructive pulmonary disease decreases exacerbations and morbimortality, and avoids readmissions. An increasing number of women have the disease, which progresses differently in women than in men and even has different comorbidities.
said Belén Alonso, MD, PhD, coordinator of the COPD Working Group of the Spanish Society of Internal Medicine. Up to 73 comorbidities associated with chronic obstructive pulmonary disease have been described. Dr. Alonso made these remarks during her presentation at the Comorbidities in Chronic Obstructive Pulmonary Disease Panel, which took place during the 43rd Conference of the Spanish Society of Internal Medicine (SEMI), in Gijón, Spain.
According to the scientific society’s press release, moderator María Gómez Antúnez, MD, stated, “The correct approach and treatment of these comorbidities is fundamental to improve the quality of life of the patient, decrease exacerbations, avoid readmissions, and decrease morbimortality in people with chronic obstructive pulmonary disease.”
The different works published, two of them by the SEMI COPD Working Group (ECCO and ESMI studies), indicate that the main comorbidities of patients with that pneumopathy are arterial hypertension, dyslipidemia, diabetes, heart failure, atrial fibrillation, ischemic heart disease, chronic kidney disease, peripheral arterial disease, and osteoporosis. Chronic hepatopathy, pulmonary neoplasm, depression, and cerebrovascular disease are less common.
73 comorbidities described
Dr. Alonso told this news organization, “Of those 73 comorbidities, some of the lesser known or less attention grabbing, according to a paper that we brought to the panel, include sleep disorders that encompass insomnia, nightmares, night terrors, sleep apneas, or hypopneas. Other lesser-known comorbidities related to cognitive decline, with patterns that reflect that up to 60% [of patients] may have some degree of deterioration, involve the disease phase, hypoxemia, or degree of inflammation. On the other hand, it has also been associated with Parkinson’s disease and gastroesophageal reflux, among many more that arise from the cardiovascular sphere.”
One paper reveals that more than 78% of patients with chronic obstructive pulmonary disease have one associated comorbidity, almost 69% have two, and 47.9% have three.
“Based on gender, comorbidities are different. In women, it is well observed that anxiety, depression, and osteoporosis are more common. However, hypertension, ischemic heart disease, and diabetes are more common in men with chronic obstructive pulmonary disease,” she stated.
“The pulmonary disease in question also progresses differently in men and women. In women, onset is at younger ages – between 40 and 50 years – and in men, after 50. Likewise, it appears that the disease progresses more quickly, which coincides with a worse quality of life (since dyspnea is tolerated less) and exceeds the anatomical differences, where hormonal influences play a dominant role,” Dr. Alonso stressed.
Reciprocal prognosis
Dr. Alonso stated, “The prognostic importance of comorbidities in the disease is reciprocal. In other words, if there are comorbidities that we do not look for or treat, they are going to have a negative influence on the chronic obstructive pulmonary disease. The disease will progress more and elevate the risk of exacerbations (the most important prognostic factor of that disease). In turn, if we are not treating the disease well, not only pharmacologically, it will have negative repercussions on the comorbidities. It will progress and have negative connotations, such as diabetes or ischemic heart disease.”
The aforementioned ECCO and ESMI studies include patients in internal medicine with exacerbations where the most common comorbidities have been mapped out, although there is also extensive research on comorbidities in patients who are admitted to departments other than internal medicine. “With regard to prognostic implications, our working group very clearly observed the comorbidities and the comorbidome, that solar system that appears so much in medical conferences and forums, which implies that proximity to the center of that solar system is related more to mortality, anxiety, depression, and breast cancer. Other pathologies, such as ischemic heart disease or dyslipidemia, are outside of that territory of greater risk, in which we have been more pioneering than other groups,” said Dr. Alonso.
The current trend is that the age of these patients is increasing, and there are more and more women with this pathology. According to the latest report from the Ministry of Health on respiratory diseases, the prevalence of chronic obstructive pulmonary disease among the population 40 years and older is around 33.9 cases per 1,000 inhabitants, more than twice as common in men than in women (47.7 vs. 21.3). Prevalence increases with age after 40 years progressively until reaching the greatest frequency in the 80- to 84-year-old age group.
In 2019, the number of deaths due to chronic obstructive pulmonary disease in Spain was 13,808 (9,907 men and 3,901 women), with a crude mortality rate of 29.3 deaths per 100,000 inhabitants. This toll decreased in comparison with that of 2018. Chronic obstructive pulmonary disease causes 2.5 times more deaths in men than in women. From 2001 to 2019, mortality due to that pathology declined by 43% in men and women. The decrease was almost 50% in men and 33% in women.
Overlap syndrome prevalent
Javier Sánchez Lora, MD, of the internal medicine department of the Virgen de la Victoria de Málaga University Clinical Hospital, discussed chronic obstructive pulmonary disease and sleep disorders. More concretely, he spoke about overlap syndrome: chronic obstructive pulmonary disease plus obstructive sleep apnea. According to the international consensus document on obstructive sleep apnea, the diagnosis requires an apnea-hypopnea index (AHI) equal to or greater than 15 per hour or equal to or greater than 5. The patient must also have one or more of the following factors: excessive daytime sleepiness, sleep that is not restful, excessive fatigue, and deterioration in quality of life related to sleep and not justified by other causes.
“The overlap syndrome affects 3%-66% of chronic obstructive pulmonary diseases and 7%-55% of obstructive sleep apnea,” said Dr. Sánchez Lora. This syndrome has important effects on different systems: at the cardiovascular level (arterial and pulmonary hypertension, heart failure, stroke, arrhythmias, ischemic heart disease, pulmonary thromboembolism), metabolic (insulin resistance, diabetes, metabolic syndrome), neurocognitive (dementia, depression), and neoplastic (lung, pancreas, esophagus) effects.
“These patients have a worse prognosis than those that have these pathologies alone. During sleep, they experience more frequent episodes of oxygen desaturation and they have a longer total period of sleep with hypoxemia and hypercapnia than those with obstructive apnea alone without chronic obstructive pulmonary disease,” said Dr. Sánchez Lora.
The apneic events of patients with the syndrome have a more profound hypoxemia and more arrhythmias, in addition to them being more susceptible to developing pulmonary hypertension than those with chronic obstructive pulmonary disease or sleep apnea alone. “The good news is that in patients with overlap, the use of ventilation with positive pressure reduces all causes of hospitalization and the visits to the emergency room, as well as the moderate and severe exacerbations of the disease.”
Dr. Sánchez Lora referred to a series of recommendations in clinical practice for the diagnosis and treatment of overlap syndrome: screening, combined therapy of hygienic-dietary measures, and the use of continuous positive respiratory pressure. Oxygen therapy to correct isolated nocturnal desaturations has not shown benefits in survival, although a benefit trial of symptoms attributed to nocturnal hypoxemia in patients with significant comorbidity can be conducted.
Underdiagnosis
“During the panel, we also spoke about the importance that as part of internal medicine we need to make an effort to reduce the underdiagnosis of chronic pulmonary disease and its comorbidities. Specialists in internal medicine need to become aware that this pathology is not only pulmonary, but also multisystemic, complex, heterogenous, and very variable even in the same patient,” said Dr. Sánchez Lora.
Dr. Alonso said, “Regarding the importance of diagnosis of this disease, we continue with an underdiagnosis greater than 70% for men and 80% for women. Secondly, we need to actively seek out the comorbidities associated with chronic obstructive pulmonary disease, even taking advantage of the admission of these patients with exacerbations, which are undesired and common.
“Regarding ongoing trials, we have a study that started during the COVID-19 pandemic, ADEG-EPOC, that involves the adaptation to and impact of severe and very severe exacerbations in patients admitted to our departments,” the specialist indicated.
“In the group, we are also planning to publish an updated agreement, which we already made in 2014, on the most common and important comorbidities associated with chronic obstructive pulmonary disease.” The agreement discusses the 20 most important comorbidities. In addition, the 2023 Gold Guide, which appeared in November 2022, includes a new chapter on updated treatment and the latest developments.
In the last 5 years, Dr. Alonso has collaborated with Abbott, AstraZeneca, Boehringer Ingelheim, Chiesi, FAES, Ferrer, Fresenius Kabi, GSK, Nestlé, Novo Nordisk, Nutricia, and Menarini. Dr. Sánchez Lora has collaborated with AstraZeneca, Boehringer Ingelheim, Chiesi, FAES, GSK, and Menarini.
This article was translated from the Medscape Spanish edition. A version of this article appeared on Medscape.com.
Strict control of comorbidities in patients with chronic obstructive pulmonary disease decreases exacerbations and morbimortality, and avoids readmissions. An increasing number of women have the disease, which progresses differently in women than in men and even has different comorbidities.
said Belén Alonso, MD, PhD, coordinator of the COPD Working Group of the Spanish Society of Internal Medicine. Up to 73 comorbidities associated with chronic obstructive pulmonary disease have been described. Dr. Alonso made these remarks during her presentation at the Comorbidities in Chronic Obstructive Pulmonary Disease Panel, which took place during the 43rd Conference of the Spanish Society of Internal Medicine (SEMI), in Gijón, Spain.
According to the scientific society’s press release, moderator María Gómez Antúnez, MD, stated, “The correct approach and treatment of these comorbidities is fundamental to improve the quality of life of the patient, decrease exacerbations, avoid readmissions, and decrease morbimortality in people with chronic obstructive pulmonary disease.”
The different works published, two of them by the SEMI COPD Working Group (ECCO and ESMI studies), indicate that the main comorbidities of patients with that pneumopathy are arterial hypertension, dyslipidemia, diabetes, heart failure, atrial fibrillation, ischemic heart disease, chronic kidney disease, peripheral arterial disease, and osteoporosis. Chronic hepatopathy, pulmonary neoplasm, depression, and cerebrovascular disease are less common.
73 comorbidities described
Dr. Alonso told this news organization, “Of those 73 comorbidities, some of the lesser known or less attention grabbing, according to a paper that we brought to the panel, include sleep disorders that encompass insomnia, nightmares, night terrors, sleep apneas, or hypopneas. Other lesser-known comorbidities related to cognitive decline, with patterns that reflect that up to 60% [of patients] may have some degree of deterioration, involve the disease phase, hypoxemia, or degree of inflammation. On the other hand, it has also been associated with Parkinson’s disease and gastroesophageal reflux, among many more that arise from the cardiovascular sphere.”
One paper reveals that more than 78% of patients with chronic obstructive pulmonary disease have one associated comorbidity, almost 69% have two, and 47.9% have three.
“Based on gender, comorbidities are different. In women, it is well observed that anxiety, depression, and osteoporosis are more common. However, hypertension, ischemic heart disease, and diabetes are more common in men with chronic obstructive pulmonary disease,” she stated.
“The pulmonary disease in question also progresses differently in men and women. In women, onset is at younger ages – between 40 and 50 years – and in men, after 50. Likewise, it appears that the disease progresses more quickly, which coincides with a worse quality of life (since dyspnea is tolerated less) and exceeds the anatomical differences, where hormonal influences play a dominant role,” Dr. Alonso stressed.
Reciprocal prognosis
Dr. Alonso stated, “The prognostic importance of comorbidities in the disease is reciprocal. In other words, if there are comorbidities that we do not look for or treat, they are going to have a negative influence on the chronic obstructive pulmonary disease. The disease will progress more and elevate the risk of exacerbations (the most important prognostic factor of that disease). In turn, if we are not treating the disease well, not only pharmacologically, it will have negative repercussions on the comorbidities. It will progress and have negative connotations, such as diabetes or ischemic heart disease.”
The aforementioned ECCO and ESMI studies include patients in internal medicine with exacerbations where the most common comorbidities have been mapped out, although there is also extensive research on comorbidities in patients who are admitted to departments other than internal medicine. “With regard to prognostic implications, our working group very clearly observed the comorbidities and the comorbidome, that solar system that appears so much in medical conferences and forums, which implies that proximity to the center of that solar system is related more to mortality, anxiety, depression, and breast cancer. Other pathologies, such as ischemic heart disease or dyslipidemia, are outside of that territory of greater risk, in which we have been more pioneering than other groups,” said Dr. Alonso.
The current trend is that the age of these patients is increasing, and there are more and more women with this pathology. According to the latest report from the Ministry of Health on respiratory diseases, the prevalence of chronic obstructive pulmonary disease among the population 40 years and older is around 33.9 cases per 1,000 inhabitants, more than twice as common in men than in women (47.7 vs. 21.3). Prevalence increases with age after 40 years progressively until reaching the greatest frequency in the 80- to 84-year-old age group.
In 2019, the number of deaths due to chronic obstructive pulmonary disease in Spain was 13,808 (9,907 men and 3,901 women), with a crude mortality rate of 29.3 deaths per 100,000 inhabitants. This toll decreased in comparison with that of 2018. Chronic obstructive pulmonary disease causes 2.5 times more deaths in men than in women. From 2001 to 2019, mortality due to that pathology declined by 43% in men and women. The decrease was almost 50% in men and 33% in women.
Overlap syndrome prevalent
Javier Sánchez Lora, MD, of the internal medicine department of the Virgen de la Victoria de Málaga University Clinical Hospital, discussed chronic obstructive pulmonary disease and sleep disorders. More concretely, he spoke about overlap syndrome: chronic obstructive pulmonary disease plus obstructive sleep apnea. According to the international consensus document on obstructive sleep apnea, the diagnosis requires an apnea-hypopnea index (AHI) equal to or greater than 15 per hour or equal to or greater than 5. The patient must also have one or more of the following factors: excessive daytime sleepiness, sleep that is not restful, excessive fatigue, and deterioration in quality of life related to sleep and not justified by other causes.
“The overlap syndrome affects 3%-66% of chronic obstructive pulmonary diseases and 7%-55% of obstructive sleep apnea,” said Dr. Sánchez Lora. This syndrome has important effects on different systems: at the cardiovascular level (arterial and pulmonary hypertension, heart failure, stroke, arrhythmias, ischemic heart disease, pulmonary thromboembolism), metabolic (insulin resistance, diabetes, metabolic syndrome), neurocognitive (dementia, depression), and neoplastic (lung, pancreas, esophagus) effects.
“These patients have a worse prognosis than those that have these pathologies alone. During sleep, they experience more frequent episodes of oxygen desaturation and they have a longer total period of sleep with hypoxemia and hypercapnia than those with obstructive apnea alone without chronic obstructive pulmonary disease,” said Dr. Sánchez Lora.
The apneic events of patients with the syndrome have a more profound hypoxemia and more arrhythmias, in addition to them being more susceptible to developing pulmonary hypertension than those with chronic obstructive pulmonary disease or sleep apnea alone. “The good news is that in patients with overlap, the use of ventilation with positive pressure reduces all causes of hospitalization and the visits to the emergency room, as well as the moderate and severe exacerbations of the disease.”
Dr. Sánchez Lora referred to a series of recommendations in clinical practice for the diagnosis and treatment of overlap syndrome: screening, combined therapy of hygienic-dietary measures, and the use of continuous positive respiratory pressure. Oxygen therapy to correct isolated nocturnal desaturations has not shown benefits in survival, although a benefit trial of symptoms attributed to nocturnal hypoxemia in patients with significant comorbidity can be conducted.
Underdiagnosis
“During the panel, we also spoke about the importance that as part of internal medicine we need to make an effort to reduce the underdiagnosis of chronic pulmonary disease and its comorbidities. Specialists in internal medicine need to become aware that this pathology is not only pulmonary, but also multisystemic, complex, heterogenous, and very variable even in the same patient,” said Dr. Sánchez Lora.
Dr. Alonso said, “Regarding the importance of diagnosis of this disease, we continue with an underdiagnosis greater than 70% for men and 80% for women. Secondly, we need to actively seek out the comorbidities associated with chronic obstructive pulmonary disease, even taking advantage of the admission of these patients with exacerbations, which are undesired and common.
“Regarding ongoing trials, we have a study that started during the COVID-19 pandemic, ADEG-EPOC, that involves the adaptation to and impact of severe and very severe exacerbations in patients admitted to our departments,” the specialist indicated.
“In the group, we are also planning to publish an updated agreement, which we already made in 2014, on the most common and important comorbidities associated with chronic obstructive pulmonary disease.” The agreement discusses the 20 most important comorbidities. In addition, the 2023 Gold Guide, which appeared in November 2022, includes a new chapter on updated treatment and the latest developments.
In the last 5 years, Dr. Alonso has collaborated with Abbott, AstraZeneca, Boehringer Ingelheim, Chiesi, FAES, Ferrer, Fresenius Kabi, GSK, Nestlé, Novo Nordisk, Nutricia, and Menarini. Dr. Sánchez Lora has collaborated with AstraZeneca, Boehringer Ingelheim, Chiesi, FAES, GSK, and Menarini.
This article was translated from the Medscape Spanish edition. A version of this article appeared on Medscape.com.