Correlation between self-management, psychological cognitive impairment, and quality of life in elderly chronic obstructive pulmonary disease patients

Abstract

BACKGROUND

The correlation conclusions between self-management, frailty, and quality of life (QoL) of chronic obstructive pulmonary disease (COPD) patients are inconsistent.

AIM

To comprehensively assess the current status of self-management, psychological cognitive impairment, and QoL in elderly patients with COPD.

METHODS

Convenient sampling was employed to select 312 elderly patients with COPD who were receiving treatment in the respiratory and critical care medicine department of a tertiary grade A hospital from November 2023 to February 2024. The study utilized demographic information and clinical characteristics, self-management behavior, occurrence of psychological cognitive impairment, and QoL as evaluated through general information questionnaires, the COPD patient self-management scale, simple frailty scale, simple mental status scale, clinical dementia assessment scale, and the clinical COPD assessment test questionnaire. This research aims to describe the current status and correlations among self-management behavior, cognitive impairment occurrence, and QoL.

RESULTS

The average score for self-management behavior in elderly COPD patients was 136.00 (119.00, 164.50), indicating a moderate level overall. There were 98 cases of cognitive impairment, accounting for 31.4%, with a mental status score of 3 (2, 3.75). The average QoL score was 24 (19, 28), indicating a low level. Additionally, there was a negative correlation between total self-management behavior score and cognitive impairment occurrence (r = -0.589, P < 0.001), and QoL total score (r = -0.409, P < 0.001). Cognitive impairment occurrence was positively correlated with QoL total score (r = 0.345, P < 0.001). Disease course and self-management behavior score were independent factors affecting the total QoL score in elderly COPD patients (P < 0.05).

CONCLUSION

The self-management behavior of elderly patients with COPD is at a moderate level. However, the occurrence of cognitive impairment is high and significantly influenced by disease course, level of self-management, and mental status. The QoL is low, emphasizing the urgent need to intervene in the self-management behaviors of elderly COPD patients, actively reduce the occurrence of cognitive impairment, and mitigate the impact of the disease on QoL.

Key Words: Elderly; Chronic obstructive pulmonary disease; Self-management behavior; Mental status; Cognitive impairment; Quality of life

Core Tip: This study investigates the relationship between self-management, cognitive impairment, and quality of life (QoL) in elderly chronic obstructive pulmonary disease patients. Findings reveal that self-management behavior is at a moderate level, cognitive impairment is prevalent, and QoL is generally low. A negative correlation exists between self-management and both cognitive impairment and QoL. Additionally, disease duration and self-management are independent factors affecting QoL. Interventions targeting self-management and cognitive health are essential to improve the overall well-being and QoL of elderly chronic obstructive pulmonary disease patients. This study provides valuable insights for personalized disease management strategies.

INTRODUCTION

Chronic obstructive pulmonary disease (COPD), a prevalent and severe chronic respiratory condition, is marked by irreversible and progressive obstructive damage to the airways[1]. In China, the aging population has led to a rapid increase in COPD prevalence, presenting a significant challenge to both the government and the healthcare system[2,3]. Currently, there is no cure for COPD, and its hallmark symptom of breathlessness worsens over time, diminishing patients’ quality of life (QoL)[4]. Self-management behavior refers to a healthy behavior in which patients maintain and improve their own health through their own actions, monitor and manage symptoms and signs of illness, reduce the impact of illness on their social functioning, emotions, and interpersonal relationships, and persist in treating their own illnesses[5]. In China, elderly COPD patients generally exhibit low levels of self-management, often leading to acute exacerbations due to poor disease control. This results in increased hospital admissions and a reduced QoL[6]. Cognitive impairment refers to the heterogeneity of cognitive impairment [clinical dementia rating (CDR) ≤ 0.5] caused by physiological factors (including physical frailty and pre-physical frailty) in elderly individuals, excluding dementia caused by Alzheimer’s disease or other diseases[7,8]. Cognitive decline is associated with higher mortality, disability, and readmission rates, significantly reducing the ability to perform daily activities and severely impacting patients’ QoL[9,10]. This study aims to provide an in-depth analysis of the current status of QoL and its influencing factors among elderly COPD patients. It will also explore the relationship between self-management behaviors, cognitive impairment, and QoL, offering innovative perspectives for improving health management and QoL for this patient group.

MATERIALS AND METHODS

Participants

This study selected elderly COPD patients hospitalized for respiratory and critical care treatment at a certain tertiary grade A hospital between November 2023 and February 2024 through convenience sampling as the survey subjects. Inclusion criteria were: (1) Aged 60 years and above; (2) According to the clinical practice guidelines for elderly COPD[11]. The diagnosis criteria for stable COPD include symptoms such as cough, sputum production, and shortness of breath being stable or mild, and overall condition has basically returned to the state before acute exacerbation; and (3) Informed consent, voluntary participation in this study. Exclusion criteria were: (1) Presence of other diseases that may cause airflow limitation, such as diffuse panbronchiolitis, bronchiectasis, bronchial asthma, etc.; (2) Presence of organic mental disorders or anxiety, depression, and other mental disorders caused by the use of psychoactive substances and non-dependency substances; (3) Severe speech and hearing impairments, poor compliance with medical treatment, intellectual developmental delay, and other issues that prevent cooperation with the study; and (4) Limited by cultural level or other factors, unable to answer relevant questions or provide information.

Research Tools

General information survey: Through a comprehensive review of relevant literature and consultation with field experts, a questionnaire on patients’ general demographics was self-designed. It includes gender, age, body mass index, marital status, education level, living conditions, average monthly family income, smoking behavior, level of participation in daily intellectual activities, frequency of physical activities, nightly sleep duration, history of falls in the past year, polypharmacy usage, comorbidities, duration of illness, frequency of acute exacerbation events within a year, lung function assessment level, dyspnea grading based on the modified Medical Research Council dyspnea scale, blood glucose level, arterial oxygen pressure, arterial carbon dioxide pressure, diagnosis of hypoxemia, and the status of receiving long-term oxygen therapy[12,13].

COPD self-management scale (Chronic Disease Self-Management Study Measures): The chronic disease self-management scale contains 5 dimensions with a total of 51 items[14]. These dimensions include symptom management (8 items), daily life management (14 items), emotional management (12 items), information management (8 items), and self-efficacy (9 items). The scale uses a 5-point Likert scoring system, with a total score ranging from 51 to 255. A higher score indicates stronger self-management abilities in patients.

Frail scale: The Frail scale was designed by experts from the International Association of Nutrition and Aging[15]. There were 5 dimensions, 5 items, including fatigue, increased resistance/decreased endurance, decreased free activity, disease aspects, and body weight loss. The total score is 5 points, and the results can be divided into: Normal, debilitating early, weak, score 3 and above points for weakness, 1-2 are debilitating early, and 0 is normal. When dated in hospitalized elderly patients, the total Cronbach’s α coefficient of this scale was 0.826 with good validity of each construct. This scale is simple and easy and widely used in the elderly.

Minimum Mental State Examination: The Minimum Mental State Examination scale was designed by Folstein et al[16] in 1975, aiming to serve as a preliminary screening tool for assessing cognitive impairment. The scale shows a Cronbach’s α coefficient of 0.833 and is suitable for the initial diagnosis of Alzheimer’s disease. The Minimum Mental State Examination scale covers five main domains: Orientation, memory, attention, calculation, and recall and language skills.

CDR: The CDR was developed by Hughes et al[17]. It is a cognitive psychological assessment tool used to determine whether an individual has dementia and to assess the severity of dementia. The CDR scale includes six assessment domains: Orientation to time and place, recent and remote memory, cognitive and problem-solving abilities related to daily life issues, social affairs handling capacity, household and personal hobbies, and personal self-care abilities.

COPD assessment test: The COPD assessment test (CAT) scale was developed by Jones et al[18]developed in 2009, the CAT scale aims to comprehensively assess the QoL of patients with COPD and reflect the severity of the disease. The CAT scale collects various factors that affect QoL, consisting of a total of 8 items, including 2 objective indicators and 6 subjective indicators.

Statistical analysis

Statistical analysis was performed using IBM’s SPSS software version 25.0 and R version 4.2.3. All statistical analyses were deemed significant at P < 0.05. The total score and scores of various dimensions were presented as mean ± SD if they followed a normal distribution, and as median (P25, P75) if they did not. The incidence rate of cognitive impairment was reported in terms of counts and percentages. For continuous variables following a normal distribution, independent samples t-tests were employed for comparisons between two groups and analysis of variance tests were used for comparisons among multiple groups. For variables not following a normal distribution, the Wilcoxon rank-sum test was utilized for comparisons between two groups and the Kruskal-Wallis test was applied for comparisons among multiple groups. Categorical variables were analyzed using χ²-tests, and correlations were analyzed using Spearman’s rank correlation. Generalized linear modeling (GLM) was employed to analyze the independent factors influencing the overall QoL of the subjects. Nonlinear relationships between the independent factors identified in the generalized linear modeling analysis and the overall QoL of the subjects were explored using restricted cubic spline.

RESULTS

Self-management behaviors total score and scores in various dimensions for elderly COPD patients

In this study, the average total score of self-management level for 312 patients was 136.00 (119.00, 164.50). Among the scores in various dimensions, the average scores for emotional management, daily life management, symptom management, self-efficacy, and information management were 34.00 (30.00, 42.00) points, 31.00 (25.00, 41.75) points, 29.00 (26.00, 33.75) points, 25.00 (21.00, 31.00) points, and 16.00 (14.00, 20.00) points, respectively (Table 1).

Table 1 Total scores and scores for each dimension of self-management behaviors in elderly chronic obstructive pulmonary disease patients (n = 312).

Dimension	Entry	Minimum value	Maximum value	Median (P25, P75)
Total score of self-management level	51	92	237	136.00 (119.00, 164.50)
Symptom management	8	18	60	34.00 (30.00, 42.00)
Daily life management	14	18	68	31.00 (25.00, 41.75)
Emotional management	12	10	48	29.00 (26.00, 33.75)
Self-efficacy	9	11	44	25.00 (21.00, 31.00)
Information management	8	10	39	16.00 (14.00, 20.00)

Cognitive impairment scores in elderly COPD patients

In this study, cognitive impairment in elderly COPD patients was assessed based on scores from a simple cognitive impairment scale, mental state scores, and clinical dementia assessment scores. The average scores for the simple cognitive impairment scale, mental state, and clinical dementia assessment were 3.00 (2.00, 3.75), 18.00 (16.00, 27.00), and 0.50 (0.00, 1.00) respectively (Table 2).

Table 2 Status of cognitive frailty in elderly chronic obstructive pulmonary disease patients (n = 312).

Project	Dimension	Minimum value	Maximum value	Median (P25, P75)
Simple scale weakness score	5	0	5	3.00 (2.00, 3.75)
Mental state score	5	5	30	18.00 (16.00, 27.00)
Clinical dementia assessment score	6	0	3	0.50 (0.00, 1.00)

QoL scores for elderly COPD patients

In this study, the current status of QoL was evaluated based on the scores: Among 312 elderly COPD patients, 12 individuals experienced a slight impact on QoL, accounting for 3.80%; 99 individuals experienced a moderate impact, accounting for 31.70%; 159 individuals experienced a severe impact, accounting for 51.00%; and 42 individuals experienced an extremely severe impact, accounting for 13.50%. The lowest QoL score was 8 points, the highest was 38 points, and the average score was 24.00 (19.00, 28.00) points (Table 3).

Table 3 Total scores and scores for each dimension of quality of life in elderly chronic obstructive pulmonary disease patients (n = 312).

Dimension	Minimum value	Maximum value	Median (P25, P75)
Total score of quality of life	8	38	24.00 (19.00, 28.00)
Degree of breathlessness when climbing stairs	1	5	5.00 (3.00, 5.00)
Tolerance for daily household activities	0	5	3.00 (3.00, 5.00)
Confidence level in outdoor activities	0	5	3.00 (3.00, 5.00)
Vitality	0	5	3.00 (3.00, 3.00)
Severity of coughing	0	5	3.00 (2.25, 3.00)
Total amount of phlegm coughed up	0	5	3.00 (2.00, 3.00)
Sleep condition	0	5	1.00 (0.00, 5.00)
Degree of chest tightness	0	4	0.00 (0.00, 2.00)

Analysis of the correlation between self-management, cognitive impairment, and QoL in elderly COPD patients

The total score of self-management in elderly COPD patients is negatively correlated with the occurrence of cognitive impairment (r = -0.589, P < 0.001) and the total score of QoL (r = -0.409, P < 0.001), while the occurrence of cognitive impairment is positively correlated with the total score of QoL (r = 0.345, P < 0.001) (Table 4).

Table 4 Correlation between self-management level, cognitive frailty and total score of quality-of-life level in elderly chronic obstructive pulmonary disease patients.

Variable	Total score of self-management	Onset of cognitive impairment	Simplified Weakness Score	Simplified Mental State Rating	Clinical Dementia Rating Scale Score	Total score of quality-of-life level
Total score of self-management level	1
Onset of cognitive impairment	-0.589c	1
Simplified Weakness Score	-0.373c	0.540c	1
Simplified Mental State Rating	0.247c	-0.126a	-0.254c	1
Clinical Dementia Rating Scale Score	-0.116a	-0.077	0.165b	-0.860c	1
Total score of quality-of-life level	-0.410c	0.345c	0.404c	-0.609c	0.592c	1

^aP< 0.05.

^bP< 0.01.

^cP< 0.001.

Univariate analysis of factors affecting the QoL of elderly COPD patients

The total score of QoL in elderly COPD patients with different demographic characteristics was compared. There was a statistically significant difference (P < 0.05) in the total score of QoL among patients with different educational levels (P = 0.032), frequency of physical exercise (P < 0.001), duration of sleep per night (P < 0.001), daily intellectual activity (P < 0.001), different disease courses (P < 0.001), pulmonary function grading (P < 0.001), respiratory distress grading (P < 0.001), as well as a history of falls in the past year (P = 0.018), coexistence of multiple diseases (P = 0.002), occurrence of hypoxemia (P < 0.001), adherence to inhaled medication (P < 0.001), and long-term oxygen therapy (P < 0.001) (Table 5).

Table 5 Comparison of total scores of qualities of elderly chronic obstructive pulmonary disease patients with different demographic characteristics (n = 312).

Variable	Total score of quality of life, median (P25, P75)	Z/H value	P value
Age, years
60-69	23.00 (18.00, 28.00)	4.456	0.108
70-79	22.00 (18.00, 27.00)
80 and above	25.00 (20.75, 29.00)
Body mass index, kg/m2
< 18.5	24.00 (19.00, 29.00)	2.077	0.354
18.5-23.9	24.00 (18.00, 28.00)
≥ 24	22.00 (18.00, 27.00)
Gender
Male	24.00 (19.00, 28.00)	0.720	0.472
Female	22.50 (18.00, 28.75)
Degree of education
Elementary school and below	25.00 (19.00, 29.00)	7.370	0.025
Junior high school and vocational school, high school, and vocational college	22.00 (18.00, 27.00)
College degree, undergraduate degree or above	20.00 (16.25, 24.50)
Living
To live alone	22.00 (19.00, 27.00)	0.314	0.754
Not living alone	24.00 (18.00, 28.00)
Per capita household income, yuan
< 2842.5	24.00 (20.25, 28.00)	0.960	0.337
≥ 2842.5	24.00 (18.00, 28.00)
Smoking situation
Never smoking situation	22.00 (17.75, 26.25)	5.699	0.058
Swear off smoking	25.00 (19.00, 28.50)
Smoking situation	21.00 (18.00, 27.50)
Engage in intellectual activities every day
Correct	20.50 (16.00, 26.25)	3.821	< 0.001
Deny	25.00 (19.75, 29.00)
Frequency of physical exercise
0 time/week	25.50 (21.00, 30.00)	30.767	< 0.001
Approximately 1 time/week	22.00 (17.00, 26.00)
≥ 3 times/week	20.00 (16.00, 25.00)
Sleep duration per night
≤ 6 hours	26.00 (22.00, 30.00)	5.667	< 0.001
> 6 hours	21.00 (16.00, 26.00)
Disease duration, years
< 5	22.00 (17.00, 26.00)	15.703	< 0.001
5-10	25.00 (19.00, 29.00)
> 10	25.00 (21.00, 30.00)
Fall history in the past year
No	23.50 (18.00, 28.00)	2.349	0.019
Yes	26.50 (22.50, 30.50)
Polypharmacy
No	24.00 (19.00, 28.00)	1.189	0.235
Yes	22.00 (18.00, 28.00)
Coexistence of multiple illnesses
No	21.00 (16.00, 26.50)	3.024	0.002
Yes	24.00 (19.00, 28.00)
Random blood glucose
Normal	23.00 (18.00, 28.00)	0.932	0.628
Above normal	24.00 (20.00, 28.00)
Below normal	24.00 (21.00, 27.50)
Pulmonary function classification, grade
I	19.00 (13.75, 24.00)	59.504	< 0.001
II	21.00 (16.00, 26.00)
III	25.00 (21.00, 29.75)
IV	27.50 (22.25, 31.00)
Dyspnea classification, level
0	19.00 (12.00, 24.25)	69.582	< 0.001
1	19.00 (14.00, 24.00)
2	21.00 (18.00, 26.00)
3	26.00 (22.00, 29.00)
4	29.00 (22.00, 33.00)
Hypoxemia
No	21.00 (17.00, 26.00)	6.696	< 0.001
Yes	26.00 (22.00, 30.00)
Persist in using inhaled medication
No	25.00 (20.00, 28.00)	3.987	< 0.001
Yes	20.00 (16.00, 27.00)
Long term oxygen therapy status
No	22.00 (18.00, 27.00)	5.18	< 0.001
Yes	28.00 (22.00, 31.00)

Multi factor analysis of factors affecting the QoL of elderly COPD patients

Using the education level, daily intellectual activity, frequency of physical exercise, duration of sleep per night, disease course, history of falls in the past year, coexistence of multiple diseases, pulmonary function grading, dyspnea grading, hypoxemia, adherence to inhaled medication, long-term oxygen therapy, number of acute attacks in the past year, and Spearman related self-management level total score and cognitive decline occurrence with P < 0.05 as independent variables, a generalized linear model was constructed with the total score of QoL of elderly COPD patients as the dependent variable. The assignment table is shown in Table 6. The results of the generalized linear model analysis showed that disease duration and self-management score were independent influencing factors on the total score of QoL in elderly COPD patients (P < 0.05). The total score of QoL for patients with a disease course of more than 10 years was higher than that for patients with a disease course of less than 5 years (β = 1.665, 95%CI: 0.072-3.259, P = 0.041). The higher the self-management score, the lower the total score of QoL for patients (β = -0.058, 95%CI: -0.089 to -0.026, P < 0.001) (Table 7).

Table 6 Assignments for the variables included in the generalized linear model.

Factor	Variable	Assignment
Degree of education	X1	1 = “Elementary school and below”, 2 = “Junior high school and vocational school, high school and vocational college”, 3 = “College, undergraduate and above”
Engage in intellectual activities every day	X2	1 = Yes, 2 = No
Frequency of physical exercise	X3	1 = “0 time/week”, 2 = “Approximately 1 time/week”, 3 = “≥ 3 times/week”
Sleep duration per night	X4	1 = “≤ 6 hours”, 2 = “> 6 hours”
Course of disease	X5	1 = “< 5 years”, 2 = “5-10 years”, 3 = “> 10 years”
Fall history in the past year	X6	0 = None, 1 = Yes
Coexistence of multiple illnesses	X7	0 = None, 1 = Yes
Pulmonary function classification	X8	1 = “Level I”, 2 = “Level II”, 3 = “Level III”, 4 = “Level IV”
Dyspnea classification	X9	0 = “Level 0”, 1 = “Level 1”, 2 = “Level 2”, 3 = “Level 3”, 4 = “Level 4”
Hypoxemia	X10	0 = None, 1 = Yes
Persist in using inhaled medication	X11	0 = None, 1 = Yes
Long-term oxygen therapy	X12	0 = None, 1 = Yes
The number of acute attacks in the past year	X13	Continuous variable, no assignment required
Total score of self-management	X14	Continuous variable, no assignment required
Cognitive decline	X15	0 = Did not occur, 1 = Occurred
Total score of quality of life	Y	Continuous variable, no assignment required

Table 7 Multivariate analysis of total quality of life scores in elderly chronic obstructive pulmonary disease patients.

Variable	Regression coefficient	SE	95% confidence interval of regression coefficient	χ2-tests	P value
Degree of education
Elementary school and below	Reference
Junior high school and vocational school, high school, and vocational college	-0.478	0.658	-1.767-0.811	0.528	0.467
College degree, undergraduate degree or above	-2.222	1.814	-5.777-1.333	1.501	0.221
Engage in intellectual activities every day
Yes	Reference
No	0.791	0.717	-0.613-2.195	1.219	0.270
Frequency of physical exercise
0 time/week	Reference
Approximately 1 time/week	-1.295	0.798	-2.859-0.270	2.632	0.105
≥ 3 times/week	-1.522	0.932	-3.348-0.305	2.666	0.102
Sleep duration per night
≤ 6 hours	Reference
> 6 hours	-0.990	0.734	-2.429-0.450	1.817	0.178
Course of disease
< 5 years	Reference
5-10 years	0.973	0.766	-0.529-2.475	1.612	0.204
> 10 years	1.665	0.813	0.072-3.259	4.196	0.041
Fall history in the past year
No	Reference
Yes	0.096	1.367	-2.582-2.774	0.005	0.944
Coexistence of multiple illnesses
No	Reference
Yes	-0.731	0.741	-2.183-0.721	0.973	0.324
Pulmonary function classification, grade
I	Reference
II	0.218	1.086	-1.909-2.346	0.041	0.841
III	1.333	1.185	-0.989-3.654	1.266	0.261
IV	0.575	1.611	-2.583-3.733	0.127	0.721
Dyspnea classification, level
0	Reference
1	-0.292	1.445	-3.123-2.540	0.041	0.840
2	1.353	1.548	-1.681-4.387	0.764	0.382
3	2.133	1.683	-1.166-5.432	1.606	0.205
4	3.575	1.908	-0.164-7.315	3.512	0.061
Hypoxemia
No	Reference
Yes	1.924	1.343	-0.709-4.557	2.051	0.152
Persist in using inhaled medication
No	Reference
Yes	1.073	0.976	-0.839-2.985	1.211	0.271
Long term oxygen therapy status
No	Reference
Yes	1.406	0.866	-0.291-3.102	2.637	0.104
The number of acute attacks in the past year	0.319	0.300	-0.269-0.907	1.132	0.287
Self-management rating	-0.058	0.016	-0.089-(-0.026)	12.836	< 0.001
Cognitive decline
No occurrence	Reference
Occur	-1.613	1.379	-4.315-1.089	1.369	0.242

Restricted cubic spline model adjusts for education level, daily intellectual activity, frequency of physical exercise, duration of sleep per night, disease course, history of falls in the past year, comorbidity of multiple diseases, pulmonary function grading, dyspnea grading, hypoxemia, adherence to inhaled medication, long-term oxygen therapy, number of acute attacks in the past year, and cognitive impairment.

Nonlinear relationship analysis between self-management behavior and QoL in elderly COPD patients

This study showed that there was no non-linear correlation between the total score of self-management and the total score of QoL in elderly COPD patients, but there was a dose-response relationship (P overall = 0.003, P nonlinear = 0.582). The higher the total score of self-management, the lower the total score of QoL (Figure 1).

Figure 1 Restrictive cubic spline analysis of the dose-response relationship between self-management total score and quality of life total scores in elderly chronic obstructive pulmonary disease patients.

DISCUSSION

The results of this study showed that the self-management score of elderly COPD patients was 136.00 (119.00, 164.50) points, indicating a moderate level of self-management behavior, which differs from previous studies. Therefore, compared with previous studies, there is a certain difference in the scores of patients’ self-management level in this study, which may be due to the more severe condition of elderly COPD patients involved in this study, regional differences, and age distribution, which have a significant impact on the research results[19,20]. In addition, among the 312 elderly COPD patients involved in this study, it was found that 98 patients were accompanied by cognitive impairment, with an incidence rate of 31.4%. This data directly shows that the current situation of cognitive impairment in elderly COPD patients is quite severe[21]. The lowest and highest QoL scores for elderly COPD patients in this study were 8 points and 38 points, with an overall median score of 24 (19, 28) points. The higher the score on the QoL scale, the more severe the impact of COPD disease on the patient’s QoL, and the lower the level of QoL[22]. Therefore, healthcare workers should give sufficient attention to the cognitive decline and QoL issues that may accompany elderly COPD patients.

The results of this study showed a negative correlation between self-management behavior scores and QoL scores (r = -0.41, P < 0.001). The higher the QoL score, the more severe the impact of COPD on patients’ QoL, and the worse their QoL, which is consistent with previous research results[23]. Research has found that elderly COPD patients can maintain and promote their own health, manage the disease, reduce the severity of their illness, alleviate the impact of the disease on their social function, emotions, and interpersonal relationships, and improve their QoL by improving their behavioral habits[24]. The results of this study showed that the self-management behavior score of elderly COPD patients was negatively correlated with the occurrence of cognitive decline (r = -0.59, P < 0.001), that is, the higher the self-management behavior score, the lower the degree of cognitive decline, indicating that elderly COPD patients with good self-management behavior have a lower degree of cognitive decline. Similar to the study by Cramm et al[25], it points out that COPD is a chronic disease characterized by the persistence of its course and the frequency of its attacks. Therefore, possessing effective self-management skills can significantly improve patients’ ability to combat diseases[26]. The results of this study showed a positive correlation between cognitive impairment and QoL scores in elderly COPD patients (r = 0.383, P < 0.01), indicating that the higher the degree of cognitive impairment, the higher the QoL score. The pathological process of COPD involves multiple aspects, including persistent inflammation, inadequate oxygen supply (hypoxemia), and carbon dioxide accumulation (hypercapnia). These factors work together to make elderly patients more prone to developing cognitive impairment[27]. Therefore, while paying attention to the QoL of elderly patients with chronic COPD, medical staff should also pay attention to the issue of cognitive decline in these patients, conduct timely assessments of cognitive decline, and develop personalized health education plans based on the assessment results to prevent the occurrence and slow down the progression of cognitive decline, thereby improving the QoL of elderly COPD patients. Related studies abroad have shown a negative correlation between self-management and frailty, with older adults with poor self-management abilities scoring higher in physical frailty. Zaslavsky et al[28] believed that the better the self-management level of diabetes patients, the fewer their weaknesses. Diabetes is a metabolic disease. High or low blood sugar levels will lead to increased risk of weakness. Therefore, improving patients’ self-management level plays a crucial role in reducing the occurrence and development of weakness. Nakhjiri et al[29] conducted a questionnaire survey on 125 elderly patients with heart failure, and the study showed a significant negative correlation between self-management and frailty. This study conducted regression analysis and found that self-management score and duration of illness were independent factors affecting the total score of QoL in elderly COPD patients (P < 0.05). In this study, self-management score was an independent influencing factor on the total score of QoL in elderly COPD patients. A non-linear relationship analysis was conducted between the total score of self-management and QoL in elderly COPD patients, showing a dose-response relationship (P overall = 0.003, P nonlinear = 0.579). The higher the total score of self-management, the lower the total score of QoL, and the better the QoL. Based on social cognition theory, self-efficacy theory, and self-determination theory, self-management behavior is influenced by self-determination, self-awareness, and self-efficacy levels. When the levels of these three factors are high, patients are in a positive state[30-34]. Therefore, active self-management in elderly COPD patients can effectively control disease progression and improve their QoL[35]. Therefore, medical staff should do a good job in patient chronic disease management, popularize knowledge of patient self-management, motivate patients to engage in self-management, and improve their QoL. In addition, this study suggests that disease duration is an independent factor affecting the QoL of elderly COPD patients. Specifically, compared to elderly COPD patients with shorter disease duration, elderly COPD patients with a disease duration exceeding 10 years often face lower QoL, which may be closely related to the progression characteristics of the disease and accompanying complications. On a psychological level, they may also encounter problems such as anxiety and depression[36]. With the long-term development and frequent acute exacerbations of COPD, the number of comorbidities in patients increases. These health problems accumulate at multiple levels, including physical, psychological, and social, leading to a decrease in physiological reserves. As a result, patients develop multidimensional health defects that affect their daily living abilities, ultimately resulting in a decrease in the QoL of elderly COPD patients. Therefore, healthcare workers should pay special attention to elderly COPD patients with a longer course of illness and form a professional team composed of experts from multiple disciplines to provide guidance.

Due to time and budget constraints, this study only included relevant factors that are easily accessible, which may limit the breadth and completeness of data collection. In addition, this study is a cross-sectional study, and the temporal order of variables is not clear. The association between factors cannot be determined, and the causal relationship between variables cannot be clarified. In the future, further intervention measures and self-management behavior training programs can be carried out for cognitive impairment, and prevention and treatment plans for cognitive impairment in elderly COPD patients can be constructed to reduce the occurrence of cognitive impairment in elderly COPD patients, improve their cognitive level and self-management ability, and thus improve their QoL. In addition, in future studies, more rigorous research designs can be adopted and elderly COPD patients from primary and secondary hospitals can be included as research subjects to validate the conclusions of this study.

CONCLUSION

In summary, this study collected relevant data on self-management behavior, cognitive decline, and QoL of the research subjects, conducted statistical analysis, and studied the current status and influencing factors of self-management behavior, cognitive decline, and QoL in elderly COPD patients. The study also investigated the relationship between self-management behavior, cognitive decline, and QoL in elderly COPD patients. The self-management behavior, cognitive decline status, and QoL of elderly COPD patients are closely related. It is necessary to pay attention to patients’ self-management behavior and cognitive decline status, and develop personalized chronic disease management plans for different types of patients to help elderly COPD patients develop good self-management behavior and ultimately improve their QoL.

ACKNOWLEDGEMENTS

We would like to express our gratitude to the researchers who generously participated in this study, as well as the institutions that provided financial support.