Behavioral Adaptation and Response to Pulmonary Rehabilitation in Older Patients with Advanced COPD: Beyond Clinical and Immune Biomarkers

Patients with advanced chronic obstructive pulmonary disease (COPD) respond differently to pulmonary rehabilitation (PR), and respiratory impairment alone might not fully explain this variability. Behavioral adaptation may contribute to differences in rehabilitation response. We studied 102 patients with advanced COPD (GOLD III–IV) who completed a 3-week multidisciplinary PR program. Functional response was assessed by change in six-minute walking distance (6MWD). Clinical, functional, psychological, lifestyle, and immune characteristics were evaluated, including coping strategies measured with the Brief COPE, Torque Teno virus (TTV) viremia, and circulating T-cell subsets. Exploratory mediation analyses examined whether coping strategies contributed to the association between age and rehabilitation response. Greater improvement in 6MWD was associated with higher active coping and planning scores, while self-distraction also differed across response groups. Planning scores were higher in good responders than in non-responders (7.10 ± 1.35 vs. 5.05 ± 1.93, respectively; p < 0.001). Planning was the only coping strategy showing a statistically significant indirect effect in the exploratory mediation analysis. The estimated proportion mediated was approximately 26.5%, although the wide confidence interval indicated substantial uncertainty. These findings should be interpreted cautiously given the observational design and the assessment of multiple coping strategies. Conventional physiological measures, lifestyle characteristics, and immune biomarkers—including TTV viremia and circulating T-cell subsets—did not significantly distinguish rehabilitation response groups. Planning and active coping were associated with response in both sexes. A separate pilot randomized study, IMPROVE (n = 36), was subsequently conducted to investigate whether structured psychological support could influence coping strategies and help maintain the benefits of PR. At six months, patients receiving psychological support showed better maintenance of rehabilitation benefits, alongside improvements in psychological well-being, quality of life, and selected coping strategies. These findings provide preliminary evidence that coping-related characteristics may be modifiable; however, IMPROVE was a separate exploratory intervention study and was not designed to validate the observational findings. Assessment of coping strategies may complement clinical and functional evaluation and help identify patients who could benefit from tailored psychological support. Their clinical utility and the effectiveness of targeted interventions require confirmation in larger prospective studies.