Knowledge and Practices Regarding Chronic Obstructive Pulmonary Disease among Elderly Patients
EmanShokryAbd–Allah1, Marwa Mahmoud Abdelsamea2, Ashraf ElsayedElshora3
1Professor of Community Health Nursing and Gerontological Nursing in Faculty of Nursing at Zagazig University, Egypt
2M.Sc. Nursing, Clinical instructor of Gerontological Nursing in Faculty of Nursing at Zagazig University, Egypt
3Professor of chest disease department in Faculty of Medicine at Zagazig University, Egypt Corresponding author: Eman Shokry Abd Allah, Email: [email protected]
Abstract
Study’s purpose: to assess knowledge and practices regarding COPD among elderly patients.
Methodology: A descriptive design was conducted at chest diseases department in cardiothoracic hospital at sednawy in Zagazig Hospitals,a purposive sample of 60 elderly subjects who fulfilled the study inclusion criteria. Data collected by a structured interview questionnaire,Modified Borg Dyspnea Scale and COPD elderly patient’s practices (observational checklist). Major results:
revealed that the majority of studied elderlysample had poor knowledge and practices regarding COPD. Clinical implications: there was lack of knowledge and practices regarding COPD among elderly.Recommendations:applying training program for COPD elderly patients to improve their knowledge and practices and positive impact on health status of elderly patient.
Keywords: Knowledge, Practice,COPD and elderly patients
Introduction
Aging is a method of growing up and growing old during life. At conception, it starts and ends with death. So, we are all ageing from the time of birth in this way. With age, the human body changes in several significant ways, and aging is also followed by a decline in bodily functions. A reduction in function, however, varies from a loss of function due to diseases(Chalise, 2019).Chronic obstructive pulmonary disease (COPD) is a category of progressive lung diseases and not entirely reversible limitations of airflow. Emphysema and chronic bronchitis are the most common. Many COPD individuals have both of these conditions. Emphysema slowly destroys air sacs in the lungs, interfering with the movement of outer air, while bronchitis induces inflammation and bronchial narrowing (Duangrithi et al., 2017). By 2020, 7 percent of all deaths worldwide (4-5 million people annually) will be caused by this COPD. Compared to patients less than 40 years of age, the incidence of COPD increases with age, with a five-fold increased risk identified for those over 65 years of age. The disorder affects an affected older person's well-being and the degree to which this subgroup can be 'physically involved' and engage in social relations (Raherison&Girodet al., 2019).The most widely encountered risk factor for COPD worldwide is cigarette smoking. It has been estimated that in developed and developing countries, 73 and 40 percent of COPD mortality is related to smoking. More than 3 billion people worldwide are exposed to biomass smoke and women are also exposed during household activities to the burning of biomass fuels. Other risk factors for COPD include occupational dust and chemical contamination, repeated childhood respiratory tract infections, outdoor air pollution, poverty and genetic susceptibility (Bahtouee et al., 2018).COPD is frequently under diagnosed, which may be due to a lack of knowledge in the general public about the disease. Patients' level of knowledge about COPD is a significant factor influencing the development of the disease,the overall level of disease knowledge in patients with COPDis low. Most patients appeared to understand their condition and the therapies available, but fewer than half of them truly understood the signs and causes of COPD(Folch-Ayoraet al., 2019).The patients’ knowledge of COPD was poor in several domains including the causes of COPD, the consequences of inadequate therapy and the management of exacerbations. Patient
education is known to improve the levels of disease knowledge and quality of life. However, the lack of knowledge among patients with COPD emphasizes the general lack of patient education (Dhand et al., 2018).The majority of COPD patients are unaware of their condition, the value of drug enforcement, and disease precautions. Patients should be conscious of their condition because unawareness contributes to repeated exacerbations of the disease with symptoms of severe breathlessness, cough, hypoxemia, exhaustion, multiple hospital visits, inadequate or negligible usage of drugs, diminished immunity, and minimal involvement in leisure and social activities, Ultimately, this leads to accelerated disease development and decreased quality of life (Thakrar et al., 2014).The limitation of practice, patients with COPD have an impaired exercise capacity that restricts their ability to perform daily living tasks, engage in social life, have a detrimental effect on their quality of life. Additionally, COPD patients can experience exacerbations, episodes typically lasting 7-10 days that are associated with increased inflammation of the airway, mucus development and marked gas trapping that may require hospitalization, leading to increased dyspnea and functional decline (Vogelmeier et al., 2017).The center of COPD management is practice (exercise training) which involves many forms of training, such as field walking exercise training, cycling training, strength training, and so on. The sort of preparation that is most appropriate for patients with COPD depends on their physiological requirements and individual requirements. It focuses on the COPD physical pathology, methods of exercise evaluation, and training for COPD patients (McCarthy et al., 2015).Limitations in practice (exercise and activity) are characteristic features of patients with COPD, especially among elderly. Exercise aversion among elderly may result from ventilator restriction, cardiovascular disease, and/or skeletal muscle dysfunction. The recommendations for exercise training suggest that patients with mild to severe COPD be regularly included in their management. It may be undertaken in an inpatient, outpatient, or home-based setting, depending on the individual needs of the patient and available resources. Improper practice may lead to frequent exacerbations of the disease, excessive breathlessness, cough with expectorations (Zeng et al., 2018).It is necessary to recognize knowledge and practice among COPD patients about their condition as it makes them aware of the process of the disease and its characteristics. This helps them deal with their issues, create a positive outlook for the future by engaging in pulmonary rehabilitation services and establishing a partnership for better prognosis with health care professionals (Uzel et al., 2017). Gerontological nurses play a key role in the treatment of elderly patients with COPD, since they are the main health care providers, spending more time than most practitioners with elderly. The primary goals of COPD management nurses are to delay disease progression, improve knowledge toward disease, alleviate symptoms, improving (practice) exercise tolerance, preventing and treating complications, facilitating the engagement of patients in treatment, preventing and treating exacerbations and reducing the risk of mortality. In teaching elderly COPD patients how to breathe properly, the nurse has an important role (Adams, 2010).
Literature review
A previous study carried out in India by Gupta et al. (2019)who founded that there is a lack of knowledge, incorrect attitudes, and flawed behavioral changes which needs to be corrected among the patients with COPD. On the other hand a study in Assiut, Egypt by Labieb etal. (2020) who concluded that the majority of studied elderly had poor knowledge & practice regarding COPD with impaired in respiratory functions. In the study setting, the high prevalence, complexity, and health implications associated with COPD in elderly lead to increase the attention on this topic. Also the research on COPD among elderly patients is totally lacking in the vast majority of countries particularly in Zagazig city. Hence, the aim of this study is to assess the knowledge level and practice among elderly patients’ regarding COPD.
Significance of the study
COPD is the third cause of death and the fifth cause of disability adjusted life years in 2020.The
prevalence of COPD increases with age and affects more than 300 million people worldwide and three million deaths per year especially in low and middle income countries (Roberto et al., 2020) In Egypt, COPD is a rising significant health problem and the prevalence of COPD among high- risk individuals and was estimated to be about 10% as per GOLD (Said et al., 2015).
AIM OF THE STUDY: The aim of this study was to assess the knowledge and practices regarding COPD among elderly patients.
This aim has been achieved through the following objectives 1. Assess the knowledge level of elderly patients’ regarding COPD.
2. Evaluate the skills / practices of elderly patients’ regarding COPD.
Research questions:
1. What is the knowledge level among elderly patients’ regarding COPD?
2. What are the skills / practices among elderly patients’ regarding COPD?
SUBJECTS AND METHODS Research design
A descriptive cross-sectional research design Study setting
The study was conducted at chest diseases department in cardiothoracic hospital at sednawy Hospital in Zagazig city.
Study subjects
A Purposive sampling technique was used in therecruitment of 60elderly patients for this study according to the followinginclusion criteria for patient:
1- Diagnosed with COPD for one year or more.
2- Free from any other respiratory or associated disorders as heart failure, coronary artery diseases and asthma.
3- Free from psychiatric disorders and dementia (reported by elderly).
Exclusion criteria: any communication problems as (speech and hearing problems).
Tool of data collection
Three tools were used to collect necessary data. Tool I: A structured interview questionnaire that was developed by the researcher based on the literature review. It consisted of four parts; Part one was used to assess the demographic characteristics which included age, sex, marital status, educational level, residence, occupation before retirement, income, and income source. Part two to collect the medical history of the COPD as; duration of disease, complaints, date of admission, previous hospital admission and medication used. Part three smoking habits among elderly patients involved data about history of smoking, when did stop smoking, the reason for stopping smoking and negative smoker for him. Part four; the elderly patients’ knowledge regarding COPD included questions about (respiratory system nature, COPD nature, COPD medication, how to deal with oxygen, nutrition, fluids, exercise, measures to reduce risk of dyspnea & airway irritants, periodic examination and questions about source of their knowledge.Tool II: Modified Borg Dyspnea Scale (Borg, 1982): This scale was used to detect the difficulty rate of elderly patients breathing. It begins at 0 where breathing is not difficult for elderly patients and progresses to 10 where breathing difficulty is maximal for elderly patients. This scale is divided into two stages which consider the starting need for breathing exercises; the first stage is medium difficulty breathing (3-4) score and somewhat serious difficulty breathing (5-7) score. This means the lower score, the lower difficulty breathing and the higher score, the higher difficulty breathing, it’s Cronbach α was 0.72.Tool III:
COPD elderly Patient’s practices observational checklists: This tool was developed by the researcher based on the literature review to assess the elderly performance of the following skills:
inspiratory muscle training technique, breathing retraining exercise, upper and lower extremities exercises, and airway clearance techniques and using inhaler. It was consisted of steps evaluated on a three point Likert scale ranging from completely done the step with score two, incompletely done
with score one and score zero (0) for not done the step at all. The total grades were summed to grades and performance was considered adequate if the percentage was 50% or more and inadequate if less than 50% it’s Cronbach α was 0.83.
Results
The current studyreveals very low percentages of adequate knowledge about anatomy of respiratory system, diet& fluid for COPD patient, dealing with &causes of dyspnea exacerbation and exercise for COPD among the studied elderly.(Table 1). Table 2: reveals that, almost of the studied COPD elderly patients were unable to manage incentives spirometry procedure (98.3%), 96.7% of them were unable to manage pursed lip breathing procedure, 98.3% of them were unable to manage diaphragmatic breathing procedure,100% of them were able to manage stretching exercise, and 98.3% of them were able to manage strengthen exercise procedure, almost of them were unable to manage deep breathing & coughing procedure (88.3%), 100% of them were unable to manage percussion & vibration procedure, 88.3% of them were unable to manage using a metered dose inhaler procedure,33% of them were able to manage using a dry powder inhaler procedure.Concerning the relation between demographic characteristics of the studied elderly and COPD knowledge score, Table 3 demonstrates statistically significant relations between Elderly’s educational level, occupation before retirement and COPD knowledge score (p<0.05).It is evident that the COPD knowledge score was low/ inadequate among illiterate, read &write and free workers.As regard the relation between demographic characteristics of the studied elderly patients and COPD practice (observational checklist), Table 4 explains statistically significant relations between Elderly’s aged group and COPD practice (p<0.05). It is evident that the COPD practice score was higher among those aged 60-69 yearsRegarding to COPD elderly patients’ knowledge, this score had statistically significant positive correlation with practice Table 5(observational checklist).
Table (1): COPD Knowledge among the studied elderly COPD Knowledge Items
(n=60) No % Anatomy of respiratory
system
Adequate
Inadequate 0 60
0.0 100.0 Causes & symptoms of
COPD
Adequate
Inadequate 9 51
15.0 85.0
COPD treatment
compliance & periodic checkup :
Adequate
Inadequate 4 56
6.7 93.3 Diet & fluid for COPD
patient:
Adequate Inadequate
0 60
0 100.0 O2 therapy Precautions Adequate
Inadequate
13 47
21.7 78.3 Dealing with & causes of
dyspnea exacerbation :
Adequate Inadequate
0 60
0.0 100.0 Exercise for COPD & its
benefits:
Adequate Inadequate
0 60
0.0 100.0
Table (2): COPD elderly patients’ practices among the studied elderly patients COPD elderly patients’ practices Pre(n=60)
No %
1- Incentives spirometer
Not done
Incompletely done Completely done
59 1 0
98.3 1.7 0 2- Breathing
retraining exercise:
a. Pursed lip breathing:
Not done
Incompletely done Completely done
58 2 0
96.7 3.3 0.0 b. Diaphragmatic
breathing:
Not done
Incompletely done Completely done
59 1 0
98.3 1.7 0.0 3- Upper& lower
extremities exercise:
a. Stretching exercise:
Not done
Incompletely done Completely done
60 0 0
100.0 0.0 0.0 b. Strengthen
exercise:
Not done
Incompletely done Completely done
59 1 0
98.3 1.7 0.0 4- Airway
clearance techniques:
a. Deep breathing
& coughing:
Not done
Incompletely done Completely done
53 7 0
88.3 11.7 0.0 b. Percussion &
vibration:
Not done
Incompletely done Completely done
60 0 0
100.0 0.0 0.0 5- Using inhaler:
a. Using a
metered- dose inhaler:
Not done
Incompletely done Completely done
53 7 0
88.3 11.7 0.0 b. Using a dry
powder inhaler:
Not done
Incompletely done Completely done
20 40 0
33.3 66.7 0.0
Table (3): Relation between demographic characteristics of the studied elderly patients and COPD knowledge post the program
Demographic characteristics COPD Knowledge score
Adequate(n=41) Inadequate(n=19) χ2 P No % No %
1.172 .557 Age group
(years)
60 – 69 70 – 79 80 +
14 25 2
34.1 61.0 4.9
8 11 0
42.1 57.9 0.0
Gender: Male 37 90.2 18 94.7
.343 .558
Female 4 9.8 1 5.3
Marital status:
Single Married
1 40
2.4 97.6
0 19
0.0 100.0
.471 .492
Residence Rural 20 48.8 13 68.4 2.024 .155
Urban 21 51.2 6 31.6
Education Illiterate 1 2.4 8 42.1
18.003 .001*
Read and write 7 17.1 5 26.3
Intermediate 20 48.8 6 31.6
University 13 31.7 0 0.0
Occupation before retirement:
House wife Employee Free work (crafts man)
3 18 20
7.3 43.9 48.8
0 2 17
0.0 10.5
89.5 9.216 .010*
Income Sufficient insufficient
12 29
29.3 70.7
5 14
26.3
73.7 .056 .813
Table (4): Relation between demographic characteristics of the studied elderly patients and COPD practice (observation checklist) score post the program
Demographic characteristics COPD practice (observation checklist)
Fair (n=34) Good (n=26) χ2 P
No % No %
7.234
.027*
Age group (years)
60 – 69 70 – 79 80 +
9 25 0
26.5 73.5 0.0
13 11 2
50.0 42.3 7.7
Gender: Male 32 94.1 23 88.5
.617 .432
Female 2 5.9 3 11.5
Marital
status: Single Married
0 34
0.0 100.0
1 25
3.8
96.2 1.330 .249
Residence Rural 21 61.8 12 46.2
1. 451 .228
Urban 13 38.2 14 53.8
Education Illiterate 15 44.1 11 42.4
7.798 .099
Read and write 7 20.6 5 19.2
Intermediate 8 23.5 1 3.8
University 4 11.8 9 34.6
Occupation before retirement:
House wife Employee Free work
1 10 23
2.9 29.5 67.6
2 10 14
7.7 38.5 53.8
1.482 .477 Income Sufficient
insufficient
9 25
26.5 73.5
8 18
30.8
69.2 .134 .777 Table 5: Relation between COPD knowledge and practice among studied elderly patients
Scores
Spearman's rank correlation coefficient COPD
knowledge
practice (observational check list)
COPD knowledge .411**
practices .411**
Discussion
This study revealed that very low percentages of adequate knowledge about COPD. The deficient
pre-program knowledge depicted among the elderly in the present study might be attributed to the low level of education among some of them, lack of health literacy about causes and symptoms of COPD and inadequate health services in rural areas that provide them with inaccurate knowledge.
In agreement with this result, Sharma et al (2016) &Fromer (2014) in India who reported that the most of the COPD patients had low knowledge regarding COPD. Also, Egyptian study confirmed this point by Labieb et al (2020)who mentioned that the majority of study sample had poor knowledge. On the same line a study done in Italy by Ivziku (2018) who showed that patients possess limited knowledge about COPD, especially on chest infections and exacerbations related to low education level of elderly patients. RegardingCOPD practices among the studied elderly patients, the current study clarified that there was poor level of all practices among COPD elderly patients. The inadequate pre-program practices was shown among the elderly in the present study might be attributed to that the majority of elderly had more than three chronic disease which take the priority in care rather than the breathing exercises regarding COPD. Additionally, the low level of education, insufficient income among some of them as well as their inadequate knowledge regarding the importance of breathing exercises for COPD management. These findings were in accordance with an Egyptian study by Amer et al., (2018) and Labieb et al., (2020) who reported that the majority of the COPD patients had poor practices regarding COPD.The recent study showed that there were statistically significant relations between Elderly’s educational level, occupation before retirement and COPD knowledge score (p<0.05). It is evident that the COPD knowledge score was inadequate among illiterate and craftsman elderly patients confirmed by multivariate analysis that clarified education was positive predictor and occupation was negative predictor of knowledge score. On the same line, a study in China by Yang et al. (2019) who demonstrated that there was a significant positive correlation between the level of knowledge of COPD and level of education.
Another study by Kraïm-Leleu et al. (2016) who demonstrates that occupational exposure increases the risk of COPD related to limited knowledge.The current study explains statistically significant relations between Elderly’s aged group and COPD practice (p<0.05). It is evident that the COPD practice score was higher among those aged 60-69 years. It is can be explained through that COPD is disease causing severe disability in advanced stages. Along with old age, these patients become very fragile. Even a minor exacerbation may lead to a deterioration of the disease, which loss ability to engagement in any exercises. Thus, there is a statistically significant relation between Elderly’s aged group and COPD practice. Similarly, a study done inSweden by Persson et al.
(2019) clarified that patients aged ≥65 years were better in breathing exercises and they have ability to engage in any practices. The current study founded that, there were significant positive correlation between the total score of knowledge and practice. This may be explained by that when the level of knowledge improved the practices level improved also. These findings were in consistent with Labieb et al (2020) in Assiut (Egypt) and Fouad et al (2016) who mentioned that there was relation between knowledge and practice about COPD with a significant value.
References
1. Amer F, Eldakhakhny A, Ahmed A, &Taha N. (2018).Effect of Nursing Intervention Program on Patients knowledge and Practice regarding Breathlessness in patients with Chronic Obstructive Pulmonary Disease, Zagazig Nursing Journal;14(1):76-92.
2. Fouad A, Shafik S, &Belal S. (2016): Effect of Nursing intervention on Activities of Daily Living of Elderlys with Chronic Respiratory Impairment, American Journal of Nursing Science;5(4):129-140.
3. Kraïm-Leleu M, Lesage FX, Drame M, Lebargy F, &Deschamps F. (2016). Occupational Risk Factors for COPD: A Case-Control Study. PloS one, 11(8), e0158719.https://doi.org/10.1371/journal.pone.0158719.
4. Persson HL, Lyth J, Wiréhn AB, Lind L. (2019).Elderly patients with COPD require more health care than elderly heart failure patients do in a hospital-based home care setting. Int J Chron Obstruct Pulmon Dis; 14:1569-1581.
5. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, LacasseY(2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev;
(2):CD003793.
6. Zeng Y, Jiang F, Chen Y, Chen P, &Cai S. (2018). Exercise assessments and trainings of pulmonary rehabilitation in COPD: a literature review. International journal of chronic obstructive pulmonary disease, 13, 2013–2023. https://doi.org/10.2147/COPD.S167098 7. Chalise H N. (2019).Aging: Basic Concept. Am J Biomed Sci& Res; 1(1).
AJBSR.MS.ID.000503.
8. Duangrithi D, Saiprom K, Tew JS, Sa-u Y. (2017). Impact of exacerbation on the errors of inhaler techniques in COPD patients. J App PharmSci; 7 (05): 084-089.
9. Brandsma CA, de Vries M, Costa R, Woldhuis RR, Königshoff M, Timens W. (2017).
Lung ageing and COPD: is there a role for ageing in abnormal tissue repair? European Respiratory Review; 26 (146): 170073.
10. Bahtouee M, Maleki N, Nekouee F. (2018).The prevalence of chronic obstructive pulmonary disease in hookah smokers.ChronRespir Dis.;15(2):165–72.
11. Gupta A, Ravaliya V, Mishra D, Dani V, Sodawala C, Shah H, & Patel D. (2019).
Assessment of knowledge, attitude, and behavior about the disease process and physiotherapy management in patients with chronic obstructive pulmonary disease: A qualitative study. Journal of education and health promotion; 8 (15):209_18.
12. Folch-Ayora A, Orts-Cortes MI, Macia-Soler L, Andreu-Guillamon MV, Moncho J. (2019).
Patient education during hospital admission due to exacerbation of chronic obstructive pulmonary disease: effects on quality of life-controlled and randomized experimental study. Patient EducCouns; 102(3):511–519.
13. Dhand R, Mahler DA, Carlin BW, et al. (2018).Results of a patient survey regarding COPD knowledge, treatment experiences, and practices with inhalation devices. RespirCare
;63(7):833–839.
14. Raherison C, Girodet P-O. (2019). Epidemiology of COPD.EurRespir Rev; 18(114):213–
221.
15. Said A, Ewisb A, Omran A,Magdya M, &Saleeb M. (2015).Prevalence and predictors of chronic obstructive pulmonary disease among high-risk Egyptians, Egyptian Journal of Bronchology; 9 (1): 27-33.
16. Roberto B, Beatriz A, & Megan D. (2016).Self-Management and Quality of Life in Chronic Obstructive Pulmonary Disease (COPD): The Mediating Effects of Positive Affect, Journal of Patient Education and Counseling; 99 (4), 617– 623.
17. Sharma M, Kumar A, &Venkateshan M. (2016): Effectiveness of self-instructional model on knowledge of self-care management of Chronic Obstructive Pulmonary Disease among patients with chronic obstructive e pulmonary disease. International Journal of Research in Medical Sciences, 4(5),1604-1608.
18. Fromer L. (2014): Diagnosis and treating COPD: understanding the challenges and finding solutions, International Journal of General Medicine:4(2):729-739.
19. Labieb MM, Mohamed SA, Abd El-Aziz NM, Hassan AA, &Fahmy HM.
(2020).Assessment of Respiratory Functions among the Elderly with Chronic Obstructive Pulmonary Disease on their knowledge and practice at the Main University Hospital in Assuit city.Assuit Scientific Nursing Journal; 21(8): pp 34-45.
20. Ivziku D, Clari M, Grazia M, Marinis D, Matarese M.(2018). Patients and caregivers' knowledge of chronic obstructive pulmonary disease Professioniinfermieristiche 71(1):49- 57.
21. Yang H, Wang H, Du L, Wang Y, Wang X, & Zhang R. (2019).Disease knowledge and self-management behavior of COPD patients in China. Medicine, 98(8), e14460.
22. Thakrar R, Alaparthi GK, Kumar SK, Vaishali K, Zulfeequer CP, Aanad R. (2014).
Awareness in patients with COPD about the disease and pulmonary rehabilitation: A
survey. Lung India; 31:134-8.
23. Uzel FI, Karadağ P, Önür ST, Turan D, Yentürk E, Tuncay E. (2017). Abasic question: Are patients with chronic obstructive pulmonary disease aware of their disease? Turk Thorac J;
18:114–8.
24. Adams R. (2010).Improving health outcomes with better patient understanding and education.Risk Management and Healthcare Policy; 3: 61-72. PMid:22312219 http://dx.doi.org/2147/ RMHP.57500
