Study: Anxiety May Increase Acute Exacerbation Risk for Older Patients With COPD

Older patients with chronic obstructive pulmonary disease (COPD) and anxiety exhibited exacerbated symptoms, increased comorbidities, and frequent acute exacerbations of COPD (AECOPD), emphasizing the need for routine psychiatric screening in COPD management.

Older patients with chronic obstructive pulmonary disease (COPD) and anxiety had worsening symptoms, more comorbidities, and frequent acute exacerbations of COPD (AEOPD), according to a study published in Frontiers in Medicine.1

The researchers explained that anxiety is a common comorbidity among patients with COPD. For example, a past study found that, among patients with COPD, the prevalence of anxiety ranged from 10% to 55% for inpatients and 13% to 46% for outpatients.2

Also, many patients with COPD experience poor mental health; older patients with COPD are more likely to develop a mental health condition, especially anxiety.1 As age increases and COPD progresses, one study noted that patients experience decreased physical function, limited physical and social activities, and increased dyspnea, leading to more severe anxiety symptoms.3

However, the researchers noted that limited clinical trials have been conducted among older patients with COPD.1 Consequently, they conducted a study to identify the risk factors of anxiety in older patients with COPD, as well as the impact of anxiety on future AECOPD.

Patient with anxiety | Image Credit: Kittiphan -

Patient with anxiety | Image Credit: Kittiphan -

To do so, they analyzed patients aged 60 years or older with COPD who visited a pulmonary outpatient clinic at 15 hospitals in Shanghai between June 2017 to December 2020. All eligible patients were required to complete a structured questionnaire and go through a physical examination.

AECOPD frequency and severity in the previous year were recorded at the first visit, and the patients were followed up for 1 year. The researchers classified each AECOPD as mild (treated with short-acting bronchodilators [SABDs] only), moderate (relieved by SABDs plus antibiotics), or severe (required hospitalization, emergency admission, or intensive care unit transferring).

Also, the researchers used the Hamilton Anxiety Rating Scale (HAM-A) to evaluate anxiety in patients. It included 14 items that covered 2 types of symptom factors: psychic anxiety factors and somatic anxiety factors. All items were scored on a scale of 0 to 4 points, and patients with a score of 14 or greater were considered to have COPD with anxiety.

Additionally, they used various tests to assess each patient's COPD severity and health-related quality of life (HRQL). This included the BODE index, which is based on the patient's body mass index, degree of airflow obstruction evaluated by forced expiratory volume in the first second (FEV1), grade of dyspnea according to the modified Medical Research Council (mMRC) dyspnea score, and exercise capacity assessed by the 6-minute walking distance test (6MWD).

The BODE index predicted death and other poor outcomes in patients with COPD; total scores ranged from 0 to 10 points, with higher scores indicating higher COPD severity. Lastly, the researchers used both the COPD assessment test (CAT) and St. George’s respiratory questionnaire (SGRQ) to evaluate the patient's HRQL.

The researchers included 424 eligible patients in their study population. The study population had a median age of 70 years, and it consisted of 380 (89.60%) male patients and 44 (10.40%) female patients. Also, of the study population, 86.79% had 1 or more comorbidities, and 56.13% had at least 1 exacerbation in the previous year.

After determining their study population, the researchers divided them into 2 groups; Group 1 consisted of older patients with both COPD and anxiety, while Group 2 consisted of older patients with only COPD. Group 1 consisted of 84 patients, which included 76 (90.48%) male patients and 8 (9.52%) female patients. Conversely, Group 2 consisted of 340 patients, which included 304 (89.41%) male patients and 36 (10.59%) female patients. The researchers noted that the mean (SD) age of Group 1 was 68 (63-77) years, while the mean age of Group 2 was 70 (65-78) years.

Compared to Group 2, the researchers found increased pack-years, previous AECOPD, and comorbidities among those in Group 1 (P < .05). They also discovered that patients in Group 1 had higher mMRC and CAT scores, as well as a shorter 6MWD (P < .05).

Based on the BODE index, the researchers determined that higher COPD severity was associated with a higher risk of anxiety in older patients with COPD. Overall, the researchers determined that older patients with COPD and more than 1 comorbidity (OR, 5.671; 95% CI, 3.193-10.07), along with those who experienced AECOPD in the previous year (OR, 4.004; 95% CI, 2.204-2.273), were at a greater risk of developing anxiety. Lastly, they noted that anxiety increases the risk of AECOPD in older patients with COPD (OR, 4.250; 95% CI, 2.369-7.626) within 1 year, including both moderate (OR, 2.653; 95% CI, 1.526-4.611) and severe (OR, 2.006; 95% CI, 1.221-3.297) AECOPD.

The researchers acknowledged their study’s limitations, one being that they obtained AECOPD data from each patient's medical records. Therefore, there may be a possibility that AECOPD frequency was underreported if patients sought treatment elsewhere. Despite the study's limitations, the researchers made treatment suggestions based on their findings.

“In COPD management, routine screening for psychiatric symptoms should be an integral part of clinical work to reduce the risk of anxiety in older COPD patients at an early stage,” the authors concluded.


  1. Mou Y, Shan L, Liu Y, et al. Risk factors for anxiety and its impacts on acute exacerbation in older patients with chronic obstructive pulmonary disease. Front Med (Lausanne). 2024;11:1340182. doi:10.3389/fmed.2024.1340182
  2. CavaillèsA,Brinchault-RabinG,DixmierA,GoupilF,Gut-GobertC,Marchand-AdamS,etal.ComorbiditiesofCOPD.Eur Respir Rev.(2013)22:454–75. doi: 10.1183/09059180.00008612
  3. Cleland JA, Lee AJ, Hall S. Associations of depression and anxiety with gender, age, health-related quality of life and symptoms in primary care COPD patients. Fam Pract. 2007;24(3):217-223. doi:10.1093/fampra/cmm009
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