The Relationship Between Frailty and Psychosocial Adjustment in Older Adults with COPD

Chronic obstructive pulmonary disease (COPD), a progressive yet preventable disease, is the fourth leading cause of death (4.7%), with a global prevalence of 10.3% (1, 2). In Türkiye, respiratory diseases are the third leading cause of death, with COPD being responsible for 61.5% of deaths due to respiratory diseases (1, 3). While there has been a substantial decrease in mortality from other prominent causes of death in recent years, there has been a rise in mortality due to COPD (2, 4). The prevalence of COPD, which is 13.2% at ages 65-69 and 17.9% at ages 75-79, rises with advancing age (5). As the number of risk factors grows and the population continues to age, it is anticipated that the prevalence of COPD will continue to rise in the years ahead (2).

The process of aging often leads to frailty, marked by functional losses in multiple organs or systems and heightened vulnerability to stressors. Frailty involves cognitive, psychological, and social factors (6). According to Buchner and Wagner  (6), a primary sign of frailty is decreased energy metabolism and O₂ levels due to cardiac or pulmonary disease. Individuals with COPD are also prone to frailty due to the condition’s characteristic symptoms of shortness of breath and hypoxia, which are frequently associated with aging (2). Almost one in every three individuals with COPD is frail (32%), which is associated with shortness of breath (7).

Both shortness of breath and comorbidities play a role in the advancement of COPD, rendering the management of the disease more challenging (1). Chronic diseases are stressors that change adaptive capacity (8, 9). Some patients consider COPD a devastating condition because COPD is a progressive disease without an effective cure. Progressive pathophysiological changes, medication requirements, and symptoms, (e.g., breathing difficulties) decrease COPD patients’ quality of life, resulting in psychological issues (9, 10). Research shows that COPD patients often experience death anxiety, which exacerbates their difficulties in adapting socially to the disease and life (9). COPD also leads to frequent hospitalizations and a reduced workforce due to exacerbations, resulting in socioeconomic challenges (1). Older COPD patients with long-term disease and frequent exacerbations exhibit low levels of disease acceptance (11). Therefore, COPD is not only a physical but also a psychosocial condition with biological, psychological, social, familial, and environmental consequences (9, 12). Research has shown that COPD patients have poor psychosocial adaptation (9, 13, 14). Patients with COPD need to adapt to these changes to maintain homeostasis (12).

Psychosocial adjustment is influenced by various factors related to both the disease and its treatment (9, 13). Conversely, changes in psychosocial adjustment-whether improvement or decline-can impact the prognosis. Additionally, frailty is common in older COPD patients (5). Uchmanowicz et al. (11) reported that high levels of physical and social frailty reduced the level of disease acceptance. However, the link between frailty and psychosocial adjustment in older COPD patients is unclear. Healthcare professionals should adopt a holistic approach when dealing with individuals with COPD, regularly monitoring their condition and evaluating any problems or challenges they may face. Determining the relationship between frailty and psychosocial adjustment in older adults with COPD and the factors affecting this relationship will guide a holistic approach in the evaluation of care management and treatment. This study was conducted to determine the relationship between frailty and psychosocial adjustment in older individuals with COPD.

Design and Samples

This descriptive-correlational study population consisted of all patients with COPD admitted to the inpatient and outpatient units of a public hospital in Türkiye between December 2019 and February 2020. The inclusion criteria were 1) aged 65 years and older, 2) having COPD for at least six months, 3) having no mental disorder, 4) having no communication problems, and 5) volunteering. The sample consisted of 137 participants. At the end of the study, a power analysis was performed based on the results of the second regression model. The results indicated a power of 99.9% (a=0.05). The independent variables were age, gender, education, and COPD duration, and stage. The dependent variables were psychosocial adjustment and frailty levels.

Data Collection

The data were collected face-to-face using a patient identification form, the Psychosocial Adjustment to Illness Scale-self report (PAIS-SR), and the Edmonton Frail Scale (EFS). Outpatients were interviewed in the meeting room, while inpatients were interviewed in the patient rooms. Each interview lasted about 25 minutes.

The Identification Form

Consisted of 20 questions on sociodemographic (age, gender, education, income, etc.) and disease-related factors (alcohol/tobacco use, COPD duration, comorbidities, medications, hospitalizations, etc.). It was developed by the researchers (13, 15).

Psychosocial Adjustment to Illness Scale-Self Report

The instrument consists of seven subscales: 1) healthcare orientation, 2) vocational environment, 3) domestic environment, 4) sexual relationships, 5) extended family relationships, 6) social environment, and psychological distress. The total score ranges from 0 to 138, with lower scores indicating good psychosocial adjustment. The scores below 35 indicate good psychosocial adjustment. The scores between 35 and 51 refer to moderate psychosocial adjustment. The scores above 51 are associated with poor psychosocial adjustment (16, 17). Cronbach’s alpha score was 0.81 in the present study.

EFS was developed in 2006 (18) and adapted to Turkish by Aygör et al. (19) in 2013. The scale consists of 11 items that assess nine subscales: 1) cognition, 2) general health status, 3) functional independence, 4) social support, 5) medication use, 6) nutrition, 7) mood, 8) continence, and 9) functional performance. The total score ranges from 0 to 17. The degree of frailty is scored as follows: 0-4 points indicate no frailty, while the degree of frailty increases with every 2-point increase. Cronbach’s alpha score was 0.74 in the study.

Statistics

The data were analyzed using the Statistical Package for Social Sciences (SPSS, version 25) at a significance level of 0.05. Descriptive statistical methods, comparison tests, correlation, and reg ression tests were used for analysis. The results showed that the data were non-normally distributed. Therefore, the Mann-Whitney U test and the Kruskal-Walli’s test were used for analysis. Tamhane’s test was used for post-hoc comparisons. Spearman’s correlation coefficients were employed to assess the relationship between numerical variables. Backward analysis was used for regression testing.

Ethical Considerations

The study was approved by the ethics committee of Düzce University (approval number: 2019/119, date: 25.06.2019). Permission was obtained from the Provincial Directorate of Health (61518654-619). Written consent was obtained from all participants. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Participants had a mean age of 70.51±5.18 years. More than half of the patients were 65-69 years of age (52.6%), and 65% were men. 36.5% of the older patients had primary school degrees; 48.2% of them were retired. Almost a quarter of the participants were smokers, (23.4%) (19.69±10.47 cigarettes a day. Participants were diagnosed with COPD more than 14 years ago (14±9.16). Fewer than half of the participants had stage II COPD (45.3%). All participants experienced dyspnea, with 54.4% reporting symptoms twice a day. More than 59.1% of the participants had been previously hospitalized for COPD. Additionally, 59.1% of participants had been hospitalized for COPD. Most participants were on respiratory support (75.2%).

Participants had a mean PAIS-SR score of 54.37±12.91. They had mean PAIS-SR “social environment” and “extended family relationships” subscale scores of 6.93±3.1 and 3.32±2.87, respectively. 53.3% of the participants had poor psychosocial adjustment (Table 1). Age (χ²=7.32, p=0.026) and COPD stages (χ²=9.71, p=0.021) affected participants’ median PAIS-SR scores (p<0.05). Participants over 76 years of age had a higher median PAIS-SR score than those aged 65-69 years (p<0.05). Moreover, participants with stage III COPD had a significantly higher median PAIS-SR score than those with stage I COPD (p<0.05) (Table 2).

The participants’ EFS mean score was 6.79±3.83 (Table 1). Almost half of the participants were frail (49.6%), while nearly a quarter of them were severely frail (21.9%) (Table 1).

Age (χ²=35.96, p<0.001), education (χ²=32.24, p<0.001), occupation (χ²=12.62, p=0.013), and hospitalization history (z=-4.06, p<0.001) affected participants’ median EFS scores. Participants over 76 years of age had a significantly higher median EFS score than those aged 65-69 years. Participants with bachelor’s or higher degrees had a significantly lower median EFS score than those with high school or lower degrees. Illiterate participants had a significantly higher median EFS score than those with primary school or higher degrees. Participants with a history of hospitalization had a significantly higher median EFS score than those without a history of hospitalization (p<0.05) (Table 2).

There was a weak positive correlation between total EFS and PAIS-SR scores (rs=0.337, p<0.05). A weak positive correlation existed between total EFS and PAIS-SR “vocational environment” (rs=0.314), “domestic environment” (rs=0.323), “extended family relationships” (rs=0.206), “social environment” (rs=0.204), and “psychological distress” (rs=0.248) subscale scores. The results showed that the more severe the frailty, the poorer the psychosocial adjustment (Table 3).

Table 4 shows the effect of sociodemographic characteristics and frailty on psychosocial adjustment. The model using backward elimination was significant (F=13.22, p<0.001). COPD stages and EFS explained 15.2% of the model. The effect of frailty on PAIS-SR was greater than the effect of COPD stages [beta (b)=-0.341].

Two models were developed using backward elimination to assess the effect of sociodemographic characteristics and psychosocial adjustment on frailty (Table 5). Model 1 was significant (F=18.654, p<0.001). Hospitalization history and psychosocial adjustment accounted for 20.6% of the variance in the model. Psychosocial adjustment had a greater effect on frailty than hospitalization history (b=0.319). Model 2 was significant (F=24.501, p<0.001). Age, education, hospitalization history, and psychosocial adjustment accounted for 40.9% of the model. A one-unit increase in the PAIS-SR score led to an average increase of 0.073 units in the EFS score. Age had a greater effect on frailty than the other variables (b=0.318).

The study explored the relationship between psychosocial adjustment and frailty in older COPD patients. The participants had poor psychosocial adjustment and were frail to varying degrees. The study results also indicated a negative correlation between psychosocial adjustment and frailty. It was concluded that the psychosocial adjustment of older patients with advanced COPD and those who are frail may be poor.

COPD has adverse effects on an individual’s healthcare, psychological well-being, sexual life, relationships, and social surroundings. Because of the systemic impacts of COPD, patients’ ability to adapt to psychosocial domains may be affected (14). The participants had poor psychosocial adjustment. Çelik and Özkan (13) found that patients with COPD had poor psychosocial adjustment, mostly affecting their adjustment to healthcare orientation and vocational environment. Yuet et al. (20) documented those patients with COPD had poor psychosocial adjustment, mostly affecting their adjustment to sexual relationships and domestic, vocational, and social environments. Research shows that patients with COPD have poor psychosocial adjustment, mostly affecting their adjustment to sexual relationships, healthcare orientation, and vocational, social, and domestic environments (9, 13, 20, 21). In this study, COPD mostly affected the participants’ healthcare orientation, sexual relationships, and vocational and domestic environments, which is consistent with the literature (9, 13, 20, 22). Limitations in daily activities, functional reliance, and decreased physical activity could have influenced their healthcare orientation.

The stages of COPD, the frequency and duration of symptoms, comorbidities, and the loss of physical strength all have a negative impact on psychosocial adjustment (13, 20). With an increase in the severity of COPD, there is a corresponding increase in respiratory difficulty and fatigue, leading to a decrease in activity status. This situation, in turn, results in a decrease in psychosocial adjustment (20). The results showed that COPD stage was a predictor of psychosocial adjustment and that participants with stage III COPD had poorer psychosocial adjustment than those with stage I COPD.

Half of the participants were frail to varying degrees. Researchers also show that the prevalence of frailty ranges from 35% to 50.2% (23-25). The underlying mechanisms linked to COPD, including factors like inflammation and muscle weakness, which contribute to the pathophysiology of frailty can increase the prevalence of frailty by at least twofold in individuals with COPD (15, 24, 26). Frailty is also a risk factor for COPD exacerbations and progression (15).

Age is also a risk for frailty (24). COPD is also associated with frailty. Aging, chronic inflammation, endocrine dysfunction, and smoking are shared risk factors for both COPD and frailty (11, 27). The result showed that age was a critical predictor of frailty. The literature also shows that age is an important variable for frailty in COPD patients (11, 23, 27). The findings align with the existing literature.

The results showed that education was a significant variable associated with frailty. There was a negative correlation between education and frailty. Education can mitigate frailty as educated individuals often have better access to information sources, are more adaptable to treatment, and tend to age more actively, which decreases the risk factors for frailty (23, 28).

COPD causes repeated hospitalizations in frail patients. Kennedy et al. (29) highlighted a link between frailty and extended hospital stays in COPD patients, while Bernabeu et al. (30) noted that severely frail individuals were about five times more likely to be hospitalized. Frailty was an important risk for rehospitalization in patients with acute exacerbations. Shortness of breath and reduced physical activity resulting from COPD exacerbations as well as the loss of muscle strength due to frailty can contribute to multiple hospitalizations in older adults (11, 29, 30). Consistent with earlier studies, the findings emphasize that hospitalization is a significant determinant of frailty.

The results indicated a negative correlation between frailty and psychosocial adjustment. The results also showed that frailty was significantly associated with psychosocial adjustment. Frailty has a greater impact on psychosocial adjustment than COPD stages. Since both COPD and frailty lead to diminished oxygen capacity and share similar risk factors like dyspnea, these factors collectively have adverse effects on adjustment. In line with these findings, Uchmanowicz et al. (11) found that older patients with severe COPD were more prone to frailty and exhibited lower acceptance of their illness. The same study concluded that low disease acceptance was linked to higher levels of frailty, particularly in the physical and social domains. Frailty, coupled with decreased muscle strength resulting from COPD, frequent hospitalizations, reduced mobility, high levels of anxiety, and the fear of death, may collectively impact various aspects of life and hinder psychosocial adjustment (9, 20, 24, 27, 30). Zhao et al. (31) found that frailty and depression in individuals with COPD were associated with low disease self-management and limited social support. Low self-management impedes adaptation to healthcare orientation, while inadequate social support can lead to poor adaptation in extended family relationships and social environment areas.

Study Limitations

This is the first study to unveil the relationship between frailty and psychosocial adjustment and related predictors in older patients with COPD. However, the results are sample-specific and cannot be generalized to all older patients with COPD. Researchers should conduct studies in different centers and different cultures to better understand the link between frailty and psychosocial adaptation.

The participants had poor psychosocial adjustment. More than half of the participants were frail to varying degrees. Age, education, hospitalization, and psychosocial adjustment were predictors of frailty. The results showed a negative correlation between frailty and psychosocial adjustment. The results also suggested that COPD stages and frailty were associated with psychosocial adjustment. If healthcare professionals implement interventions to promote psychosocial adjustment and reduce frailty, the patients receiving these interventions experience the disease less severely and are hospitalized less frequently. In this context, it is advisable to conduct regular assessments of COPD patients, particularly those who are older, have lower education levels, are in advanced COPD stages, and experience frequent hospitalizations, with a focus on evaluating their psychosocial adjustment and frailty. The assessment will enable healthcare professionals to identify frail patients with low adjustment levels early and meet their follow-up and care needs in the early period. Furthermore, it is essential to expand psychosocial support services for older adults on both clinical and community levels, with the aim of enhancing psychosocial adjustment. Educational and intervention initiatives are strongly recommended as effective strategies for mitigating frailty and enhancing psychosocial adjustment in older individuals with COPD.