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279

Letter to the Editor

Diminished Cognitive Function Among Chronic Obstructive Pulmonary
Disease Patients During Periods of Acute Illness Exacerbation

Alex D. Federman,1 Michael S. Wolf,2 Tiffany Sheng,1 Rachel O’Conor,2 Melissa Martynenko,1
and Juan Wisnivesky1,3

1Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York. 2Division of General Internal
Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. 3Division of Pulmonary, Critical Care and Sleep
Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.

Address correspondence to Alex D. Federman, MD, MPH, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, One
Gustave Levy Place, Box 1087, New York, NY 10029. Email: alex.federman@mssm.edu

Decision Editor: Stephen Kritchevsky, PhD

Dear Editor,
Adults with chronic obstructive pulmonary disease (COPD) are
known to experience more rapid declines in cognitive function over
time than adults without the disease (1). It is not known, however,
how their cognitive functioning changes in the context of acute
COPD exacerbations, when they may be exposed to conditions
that often disrupt cognitive processes, like hypoxemia, high dose
steroids, and altered sleep-wake cycles. In this study, we evalu-
ated change in cognitive function during and after COPD-related
hospitalizations.

Methods

Data were from a prospective longitudinal cohort study of adults,
aged 55 years or older with COPD in New York City and Chicago
(n = 403) (2). The institutional review boards at each site approved
the study and participants provided written informed consent.
Patients were excluded if they had dementia or a neuropsychiatric
condition that affects cognition. This analysis focused on the 65
(16.1%) participants who were hospitalized for a COPD exacer-
bation during the study. Cognitive assessments were performed by
trained research assistants. Assessments performed in the hospital
were conducted with the permission of the attending hospitalist
and only when patients were comfortable and in no distress, typi-
cally near the end of their hospital stay. We compared cognitive
performance during hospitalization with performance during a
period of disease stability, either preceding or following the hospi-
talization. Post-hospitalization assessments were performed at the
next regularly scheduled in-person interview, which could occur
1–12  months following the hospital discharge. We evaluated gen-
eral cognition with the Mini-Mental State Examination (MMSE),
processing speed (Trail Making Test A), executive functioning (Trail

Making Test B), immediate and delayed recall (New York University
Paragraph Recall test), and word fluency (Animal Naming test). We
used generalized estimating equation models to evaluate changes in
test scores, incorporating the correlation structure of the data aris-
ing from repeated measures within individuals, and controlling for
age, education, comorbidities (diabetes, hypertension, depression),
and whether hospitalization occurred prior to or after the scheduled
evaluation.

Results

Of the 65 patients in our evaluation, 17 (4.2%) were recruited
during a hospital admission for COPD exacerbation. Overall, the
mean (SD) age was 66.8 (8.3) years, 69% were female, 15% were
white, 54% black, and 28% were Hispanic. The mean score on the
MMSE during periods of COPD stability was 23.2 (4.0) (Table 1),
and 47% scored 1 SD below the age and education-adjusted norm.
Statistically significant declines (mean change [SD]) in function were
observed between periods of COPD stability and hospitalization
for general cognition (MMSE: −1.6 (2.4) units; adjusted p = .001),
immediate recall (−1.0 [3.0] units; adjusted p  =  .01), and delayed
recall (−1.5 [2.9] units; adjusted p = .0003). In contrast, there were
nonsignificant declines in processing speed (Trails A: −4.1 [34.3]
units; adjusted p = .08), executive functioning (Trails B: −11.4 [87.3]
units; adjusted p  =  .10), and word fluency (animal naming: −1.3
[4.1] units; adjusted p = .21).

Discussion

This evaluation is limited by a small sample size and inclusion of
individuals who were recruited during hospitalization rather than
a homogenous sample of individuals with baseline evaluation and

Journals of Gerontology: Medical Sciences
cite as: J Gerontol A Biol Sci Med Sci, 2016, Vol. 71, No. 2, 279–280

doi:10.1093/gerona/glv200
Advance Access publication November 2, 2015

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subsequent COPD hospitalization. Those recruited during hospitali-
zation tended to have poorer cognitive performance during scheduled
interviews, though the magnitude of the changes in cognitive func-
tion between stable and acute periods was similar to that for patients
whose hospitalization occurred subsequent to a scheduled interview.

Acute COPD exacerbations requiring hospitalization are associated
with significant declines in cognitive function, specifically in memory.
A diminished ability to recall information provided during hospitaliza-
tions may put patients at risk for poor adherence to post-hospitali-
zation self-care and follow-up instructions, and might contribute to
the high rate of hospital readmissions observed among adults with
COPD (3). This observation highlights the importance of, and indeed
validates, hospital discharge strategies like Coleman’s Care Transitions
Model, that emphasize clear communication about discharge instruc-
tions, inclusion of low health literacy-appropriate printed instructions,
and rapid follow-up with a health care provider (4).

Funding

This work was supported by a grant from the National Heart, Lung,
and Blood Institute (grant number R01HL105385).

Acknowledgments

Financial/nonfinancial disclosures: J.W. is a member of the research board of
EHE International, has received consulting honorarium from Quintiles, BMS,
and Merck, and research grants from Aventis and Quorum. All other authors
report no potential conflicts of interest.

References
1. Dodd JW, Getov SV, Jones PW. Cognitive function in COPD. Eur Respir J.

2010;35:913–922.
2. Kale MS, Federman AD, Krauskopf K, et  al. The association

of health literacy with illness and medication beliefs among
patients with chronic obstructive pulmonary disease. PLoS One.
2015;10(4):e0123937.

3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients
in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–
1428.

4. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions inter-
vention: results of a randomized controlled trial. Arch Intern Med.
2006;166:1822–1828.

Table 1. Differences in Cognitive Function Scores Between Periods of COPD Stability and Exacerbation

Measure During Period of
COPD Stability
Mean (SD)

During COPD
Hospitalization
Mean (SD)

Difference p Adjusted p

MMSE 23.7 (3.7) 22.2 (4.1) 1.6 (2.4) .001 .001
Trail Making Test A 72.9 (40.8) 78.2 (43.1) .14 .10
Trail Making Test B 209.0 (110.6) 229.9 (88.6) .11 .08
NYU Paragraph Immediate Recall 5.3 (3.2) 4.2 (3.0) .004 .01
NYU Paragraph Delayed Recall 5.1 (3.8) 3.7 (3.3) .0001 .0003
Word Fluency 13.8 (5.4) 13.1 (5.7) .15 .21

Notes: COPD = chronic obstructive pulmonary disease; MMSE = Mini-Mental State Exam; NYU = New York University.

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