Caring for the Older Person With Chronic Obstructive Pulmonary Disease

Abstract

Chronic obstructive pulmonary disease (COPD) is a common disease in elderly patients. It is characterized by high symptom burden, healthcare utilization, mortality, and unmet needs of both patients and their caregivers. The treatment of the older patient with COPD is highly challenging. Although COPD is a major cause of respiratory failure and dyspnea in the elderly, multiple other disease entities, including heart failure, pulmonary embolism, and anxiety; medication effects; and other conditions, including deconditioning and malnutrition; may exacerbate COPD symptoms. Randomized controlled trials, which provide the strongest evidence for guideline recommendations, may underestimate the risk of adverse effects of interventions for older patients with COPD. The focus of guidelines on disease-modifying therapies may not address the full spectrum of both patient and caregiver needs engendered by the increasing burdens of advanced disease, particularly the high rates of bothersome symptoms, risk of functional and cognitive decline, and need for end-of-life care planning. Older patients tend to have a substantial disease burden coupled with functional and cognitive decline complicating the successful implementation of COPD treatments. Meeting the many needs of older COPD patients and their families requires that clinicians supplement guideline-recommended care with treatment decision making that takes into account older persons’ comorbid conditions, recognizes the trade-offs engendered by the increased risk of adverse events, focuses on symptom relief and function, and prepares patients and their loved ones for further declines in the patient’s health and their end-of-life care. A case of COPD in an 81 year old man hospitalized with severe dyspnea and respiratory failure is presented. This case highlights both the challenges in managing COPD in the elderly and the limitations in applying guidelines to geriatric patients.

Phenotype of Normal Spirometry in an Aging Population

“…Aging populations also experience increased multimorbidity and adverse events related to polypharmacy (6,7), highlighting the importance of diagnostic accuracy when establishing disease. For example, in the evaluation of dyspnea, if normal lung function as measured by spirometry is misclassified as respiratory impairment, then an overdiagnosis of respiratory disease may occur, leading to inappropriate use of respiratory medications and delays in considering alternative diagnoses.…”

Respiratory Symptoms, Spirometric Respiratory Impairment, and Respiratory Disease in Middle‐Aged and Older Persons

“…Hence, despite its methodological rigor, GLI‐defined spirometric respiratory impairment cannot be presumed to represent symptomatic respiratory disease, and this is especially relevant for older persons. In particular, given their high rate of multimorbidity, a diagnostic approach that prioritizes symptomatic disease is indicated . Conversely, a diagnostic approach that frequently establishes asymptomatic disease may lead to inappropriate and potentially harmful pharmacotherapy, as well as delays in considering other diagnoses …”

“…Although it stratifies severity of disease in established airflow obstruction, FEV1 cannot define normal spirometry (airflow obstruction can occur with a normal FEV1), nor can it identify the type of impairment (obstructive vs restrictive) . The capacity to establish normal spirometry has strong relevance, because it may prompt clinicians to consider alternative causes for the respiratory symptom(s) …”

“…With advancing age, as the prevalence of multimorbidity and polypharmacy increases, it is possible that respiratory symptoms may be attributed incorrectly to misidentified respiratory disease . Because GLI‐defined spirometric respiratory impairment rigorously identifies reduced lung function beyond what normal aging causes, it was postulated that it would be strongly associated with respiratory symptoms and, in turn, frequently establish symptomatic respiratory disease.…”

Using Time-limited Trials to Improve Surgical Care for Frail Older Adults

“…By providing a mechanism by which treatment decisions can be re-evaluated in an iterative fashion using defined criteria for improvement or decline, time-limited trials offer patients near the end of life an alternative to all-or-none commitments to unfamiliar and potentially burdensome and painful interventions. Time-limited trials have been used across a range of clinical contexts—including treatment decisions for the critically ill, 3 post-stroke care, 4 and the management of end-stage renal disease 5 and chronic lung disease 6 —to tailor difficult care decisions to individual priorities and to highlight important considerations that might otherwise be overlooked.…”