Hospice of the Comforter

COPD, or Chronic Obstructive Pulmonary Disease refers to several lung diseases that cause a blockage or narrowing of the airways. This results in a decrease in the flow of air, both in and out of the lungs, resulting in diminished oxygenation for the entire body. The disease has a slow, progressive course and is irreversible. It is the third leading cause of death in the United States.

Throughout the illness, and increasingly in the end stage of the disease, depression, anxiety and panic attacks are very common and debilitating symptoms, occurring at rates of 42%, 50% and 32% respectively. The anxiety and panic associated with COPD has roots in both the physiology of the illness as well as the psycho-emotional response. The graphic above demonstrates the anxiety cycle related to COPD.

Other factors that can increase the feelings of a panic attack are caused by some of the common medications used in COPD, such as steroids and bronchodilators. On an emotional and behavioral level, anticipation of activities that may increase shortness of breath, even temporarily, can lead to a misinterpretation of physical symptoms such as increasing heart rate and trigger the anxiety attack.

For example, a person might avoid exercise because it is leads to increased heart and respiratory rates that are associated with shortness of breath, and makes them feel anxious. However, exercise will actually slow the progression of the illness, because it helps the lungs expand more fully, the circulation work more efficiently and raises the oxygen levels in the blood. Uncontrolled anxiety, then, impacts the person’s physical, emotional, mental and social well-being, since attempts to limit the feelings associated with anxiety can severely diminish the person’s engagement with many activities that improve quality of life.

As with many end-stage illnesses, depression can also be a common reaction to COPD. As life becomes more and more restricted, and symptoms increase, depression is an understandable response. In recent studies, depression has actually been found to be a significant factor in increasing the mortality risk for those with COPD.

Unfortunately, although anxiety and depressive disorders are known to occur in high rates among people with COPD, treatment of these disorders is woefully infrequent. Several studies indicate that among those who have anxiety and/or depression, only about 30% are receiving treatment. Because these conditions can actually lead to a worsening of the disease, it behooves practitioners to screen for these disorders and provide treatment or an appropriate referral. Some simple questions to uncover these conditions were listed in an article by Dr. Robert Griffith entitled “Emotional Aspects of COPD”:

If the symptoms suggest a diagnosis of depression, anxiety, or panic, the patient can be screened by a number of suitable tests. A screening tool called PRIME-MD contains two depression and three anxiety screening questions that have been validated for use in COPD:

1. In the past month, have you been bothered a lot by:

- little interest or pleasure in doing things?

- feeling down, depressed, or hopeless?

2. In the past month, have you been bothered a lot by:

- "nerves", or feeling anxious or on edge?

- worrying about a lot of different things?

3. During the past month:

- have you had an anxiety attack (suddenly feeling fear or panic)?

Every depression screening questionnaire should also contain a question regarding possible suicidal thought processes.

There are many treatments available to help treat these disorders. Anxiety and depression can both respond well to some of the newer anti-depressants, known as Selective Serotonin Reuptake Inhibitors (SSRI), as they are least likely to compromise breathing as some of the older anti-depressants and tranquilizers do.

These disorders can also be treated with a variety of drug-free techniques that are very safe for the patients. Some of these are:

• Breathing Retraining: the patient is taught methods to slow and deepen breathing.

• Relaxation Techniques: the patient is taught methods to trigger the body’s relaxation response which would slow the heart and relax the airways, such as progressive muscle relaxation.

• Cognitive-Behavioral Therapy: may involve teaching the patient to recognize and cope with misperceptions about their bodily functioning. Another technique may be progressive desensitization to those situations that ordinarily trigger anxiety or panic.

• Encouragement to participate in structured activities and social engagement, which may include attending support groups for those with COPD.

• Interpersonal therapy: the patient is encouraged to resolve conflicts and difficulties with the important people in their lives.

For persons with end-stage or terminal COPD, hospice is uniquely situated to address these symptoms as well as the myriad of medical issues caused by the disease. Nurses and doctors monitor any drug treatments prescribed and help control other physical symptoms related to the anxiety or depression.  Hospice of the Comforter has a respiratory therapist available who teaches patients special breathing techniques. Our social workers are highly trained to help with cognitive and behavioral techniques to lessen symptoms. Often, anxiety and depression have a spiritual component that influences the symptoms, and our chaplains help to explore and resolve those challenges. Our Hospice Aides, with their gentle touch and wisdom in providing physical comfort measures, can help promote a relaxation response. Our volunteers, who lend open hearts and ears to both the patient and the family also help alleviate these distressing symptoms.

Depression and anxiety are common in COPD. However, just because they are common, healthcare providers shouldn’t consider them a typical part of the package that simply must be tolerated. Not addressing these conditions can significantly diminish quality of life, and as mentioned, even length of life. As Dr. Cecily Saunders, the founder of the modern hospice movement said,

"You matter to the last moments of your life and we will do all we can not only to help you die peacefully, but to live until you die."

^References:

^{Griffith, R. (2006). Emotional Aspects of COPD. Health and Age.}

^{Schneider, C., Jick, S., Bothner, U., Meier, C. (2010) COPD and the Risk of Depression. Chest: 137 (2): 341-347.}

^{Coen, M. (2008). Coping with Anxiety in COPD: a Therapist’s Perspective. AARC Times: March.}