Recognition and Management of Cognitive Impairment in Chronic Obstructive Pulmonary Disease (COPD): Implications of Clinical Confidence

Cognitive impairment is a serious comorbidity in chronic obstructive pulmonary disease (COPD), consistently associated with adverse clinical outcomes, including impaired self-management, poor treatment adherence, reduced participation in pulmonary rehabilitation, and increased risk of mortality. Despite this, it remains inconsistently recognised and insufficiently addressed during routine COPD assessment. This narrative review synthesises current evidence on the recognition and management of cognitive impairment in COPD, with a particular focus on understanding why it continues to be under-recognised and inadequately managed in clinical practice. Across care settings, cognitive concerns are commonly identified informally, assessed selectively, or deferred altogether, even when clinicians acknowledge their relevance to respiratory assessment, treatment implementation, and patient engagement. This persistent evidence-practice gap suggests the influence of factors extending beyond disease- or patient-related explanations alone. Emerging evidence indicates that clinician-level determinants, particularly clinical confidence, play a central role in shaping cognitive care practices. Limited clinical confidence appears to mediate the translation of existing knowledge and competence into clinical action, influencing decisions to initiate assessment, communicate cognitive concerns, assume clinical ownership, and pursue follow-up or referral. These confidence-related barriers are further reinforced by educational limitations, time constraints, diagnostic ambiguity, particularly in the early cognitive impairment stage, and the absence of clear operational guidance within COPD-specific frameworks. Conceptualising cognitive care through the lens of clinical confidence provides a coherent explanation for the underrecognition of cognitive impairment in COPD. It also helps account for observed variability in clinical decision-making, highlighting clinical confidence as a modifiable intermediary between knowledge, competence, and practice and a potential target for strengthening integrated, patient-centred COPD care.