Abstract
Chronic obstructive pulmonary disease (COPD) is a common disorder with a high prevalence among elderly men and women and an increasing mortality rate. Its diagnosis relies on spirometry, with a diagnostic cut-off value of a forced expiratory volume in 1 second (FEV1)/forced vital capacity ratio of <0.7. This cut-off level has received some criticism because a ratio decline is part of normal advanced aging. Thus, clinicians must be vigilant in applying appropriate diagnostic criteria when managing elderly patients and may choose to use one or more of the alternative diagnostic values that have been created.
It is important to remember that COPD is a systemic disorder with several extrapulmonary manifestations. Elderly patients with COPD are at an increased risk of cardiovascular events, osteoporosis, fractures, peripheral muscle wasting, depression and anxiety. Management of these patients requires a multidisciplinary approach and should begin with stratification of disease severity and prognostic information for each patient.
Traditionally, FEV1 has been used as a marker of COPD severity. However, indices such as the Modified Medical Research Council (MMRC) Dyspnoea Scale; the updated body mass, airflow, obstruction, dyspnoea and exercise (BODE) index; and the new age, dyspnoea, obstruction (ADO) index have been found to be better predictors of mortality in elderly patients.
In addition to smoking cessation, supplemental oxygen and vaccines, management strategies such as patient education programmes — which have been shown to reduce hospital admissions — should not be overlooked. Pulmonary rehabilitation remains an underutilized treatment modality despite its demonstrated association with improvements in quality of life, reduced dyspnoea and increased exercise capacity. Studies have shown no correlation between age and outcomes in pulmonary rehabilitation, suggesting that age should not be an exclusion criterion. Although bronchodilators and corticosteroids remain the cornerstone of pharmaceutical management of COPD, their efficacy relies on correct medication administration. Inhaler technique should be frequently assessed in the elderly population and the choice of inhaler device needs to be tailored to the patients’ needs, situation and preferences. Assessment and management of extrapulmonary co-morbidities of COPD should also be undertaken. Careful attention to the mental health of elderly patients with COPD is also vital, as they have high rates of depression and anxiety. Furthermore, elderly patients with severe COPD receive inadequate palliative care despite the elevated mortality risk associated with this illness. Early discussion about end-of-life care and advanced care planning is recommended.
Similar content being viewed by others
References
O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society recommendations for the management of chronic obstructive pulmonary disease: 2008 update. Can Respir J 2008 Jan–Feb; 15Suppl. A: 1A–8A
Kaplan A, Hernandez P, O’Donnell DE. Less smoke, more fire: what’s new for you in the latest COPD guidelines? Can Fam Physician 2008; 54: 737–9
Statistics Canada. Selected leading causes of death, by sex — Canada [online]. Available from URL: http://www40.statcan.gc.ca/l01/cst01/health36-eng.htm [Accessed 2009 Aug 28]
Bourbeau J, Sebaldt RJ, Day A, et al. Practice patterns in the management of chronic obstructive pulmonary disease in primary practice: the CAGE study. Can Respir J 2008; 15: 13–9
Swanney MP, Ruppel G, Enright PL. Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction. Thorax 2008; 63: 1046–51
Hardie JA, Buist AS, Vollmer WM, et al. Risk of overdiagnosis of COPD in asymptomatic elderly never-smokers. Eur Respir J 2002; 20: 1117–22
Vollmer WM, Gíslason P, Burney P, et al. Comparison of spirometry criteria for the diagnosis of COPD: results from the BOLD study. Eur Respir J 2009; 34(3): 588–97
Sin DD, Anthonisen NR, Soriano JB, et al. Mortality in COPD: role of comorbidities. Eur Respir J 2006; 28: 1245–57
Mahler DA, Wells CK. Evaluation of clinical methods for rating dyspnea. Chest 1988; 93: 580–6
Celli BR, Cote MD, Marin JM. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004; 350: 1005–12
Puhan MA, Garcia-Aymerich J, Frey M, et al. Expansion of the prognostic assessment of patients with chronic obstructive pulmonary disease: the updated BODE index and the ADO index. Lancet 2009; 374: 704–11
Brooks SM. Task group on surveillance for respiratory hazards in the occupational setting. Surveillance for respiratory hazards. ATS News 1982; 8: 12–6
McIvor RA, Todd DC, Cox G. Approach to chronic obstructive pulmonary disease in primary care. Can Fam Physician 2008; 54: 706–11
Nishimura K, Izumi T, Tsukino M. Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest 2002; 121: 1434–40
Gerardi DA, Lovett L, Benoit-Connors ML, et al. Variables related to increased mortality following out-patient pulmonary rehabilitation. Eur Respir J 1996; 9: 431–5
Landbo C, Prescott E, Lange P, et al. Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160: 1856–61
American Thoracic Society Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166: 111–7
Schunemann H. From BODE to ADO to outcomes in multi-morbid COPD patients. Lancet 2009; 374(9691): 667–8
Calverley PM, Anderson JA, Celli BR, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 2007; 356: 775–89
Sidney S, Sorel M, Quesenberry Jr CP, et al. COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program. Chest 2005; 128: 2068–75
Soriano JB, Visick GT, Muellerova H, et al. Patterns of comorbidities in newly diagnosed COPD and asthma in primary care. Chest 2005; 128: 2099–107
Sin DD, Man JP, Man SF. The risk of osteoporosis in Caucasian men and women with obstructive airways disease. Am J Med 2003; 114: 10–4
Dam TT, Harrison S, Fink HA, et al., for the Osteoporotic Fractures in Men (MrOS) Research Group. Bone mineral densities and fractures in older men with chronic obstructive pulmonary disease or asthma. Osteoporos Int. Epub 2009 Oct 9
Jagoe RT, Englen MP. Muscle wasting and changes in muscle protein metabolism in chronic obstructive pulmonary disease. Eur Respir J 2003; 22Suppl. 46: 52S–63S
Schols AM, Mostert R, Soeters PB, et al. Body composition and exercise performance in patients with chronic obstructive pulmonary disease. Thorax 1991; 46: 695–9
Troosters T, Casaburi R, Gosselink R, et al. Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005; 172: 19–38
Bernard S, Leblanc P, Whittom F, et al. Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998; 158: 629–34
Wilson DO, Rogers RM, Wright EC, et al. Body weight in chronic obstructive pulmonary disease: the National Institutes of Health Intermittent Positive-Pressure Breathing Trial. Am Rev Respir Dis 1989; 139: 1435–8
Vestbo J, Prescott E, Almdal T, et al. Body mass, fat-free body mass, and prognosis in patients with chronic obstructive pulmonary disease from a random population sample: findings from the Copenhagen City Heart Study. Am J Respir Crit Care Med 2006; 173: 79–83
Borst SE. Interventions for sarcopenia and muscle weakness in older people. Age Ageing 2004; 33(6): 548–55
Kunik ME, Roundy K, Veazey C, et al. Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 2005; 127: 1205–11
Maurer J, Rebbapragada V, Borson S, et al. Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest 2008; 134Suppl. 4: 43S–56S
Solano JP, Gomes B, Higginson IJ, et al. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Sympton Manage 2006; 31(1): 58–69
Cully JA, Graham DP, Stanley MA, et al. Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression. Psychosomatics 2006; 47: 312–9
Bosley CM, Corden ZM, Rees PJ, et al. Psychological factors associated with use of home nebulizer therapy for COPD. Eur Respir J 1996; 9: 2346–50
Stapleton RD, Nielsen EL, Engelberg RA, et al. Association of depression and life-sustaining treatment preferences in patients with COPD. Chest 2005 Jan; 127(1): 328–34
Light RW, Merrill EJ, Despars JA, et al. Prevalence of depression and anxiety in patients with COPD: relationship to functional capacity. Chest 1985; 87(1): 35–8
Fan VS, Ramsey SD, Giardino ND, et al. Sex, depression, and risk of hospitalization and mortality in chronic obstructive pulmonary disease. Arch Intern Med 2007; 167(21): 2345–53
Kunik ME, Azzam PN, Souchek J, et al. A practical screening tool for anxiety and depression in patients with chronic breathing disorders. Psychosomatics 2007; 48: 16–21
Bourbeau J, Julien M, Maltais F, et al. Reduction ofhospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Arch Intern Med 2003; 163: 585–91
Brooks D, Sottana R, Bell B, et al. Characterization of pulmonary rehabilitation programs in Canada in 2005. Can Resp J 2007; 14: 87–92
Bendstrup KE, Ingemann JJ, Holm S, et al. Outpatient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary disease. Eur Respir J 1997; 10: 2801–16
Troosters T, Gosselink R, Decramer M, et al. Exercise training in COPD: how to distinguish responders from nonresponders. J Cardiopulm Rehabil 2001; 21: 10–7
Baltzan MA, Kamel H, Alter A, et al. Pulmonary rehabilitation improves functional capacity in patients 80 years of age or older. Can Respir J 2004; 11: 407–13
Di Meo F, Pedone C, Lubich S, et al. Age does not hamper the response to pulmonary rehabilitation of COPD patients. Age Ageing 2008; 37: 530–5
Ferguson GT, Peter MA, Calverley MD, et al. Prevalence and progression of osteoporosis in patients with COPD: results from TORCH. Chest 2009; 136(6): 1456–65
Remillard AJ. A pharmacoepidemiological evaluation of anticholinergic prescribing patterns in the elderly. Pharmacoepidemiol Drug Saf 1996 May; 5(3): 155–64
Feinberg M. The problems of anticholinergic adverse effects in older patients. Drugs Aging 1993; 3(4): 335–48
Melani AS. Inhalatory therapy training: a priority challenge for the physicians. Acta Biomed 2007; 78(3): 233–45
Dow L, Fowler L, Lamb H. Elderly people’s technique in using dry powder inhalers: new inhaler devices are rarely used by older people in the community [letter]. BMJ 2001; 323: 49–50
Quinet P, Young CA, Héritier F. The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmonary disease. Ann Phys Rehabil Med Epub 2009 Dec 1
Armitage JM, Williams SJ. Inhaler technique in the elderly. Age Ageing 1988; 17: 275–8
Jarvis S, Ind PW, Shiner RJ. Inhaled therapy in elderly COPD patients: time for re-evaluation? Age Ageing 2007; 36: 213–8
Goodridge DM, Marciniuk DD, Brooks D, et al. End-of-life care for persons with advanced chronic obstructive pulmonary disease: report of a national interdisciplinary consensus meeting. Can Respir J 2009; 16(5): e51–3
Curtis JR. Palliative and end-of-life care for patients with severe COPD. Eur Respir J 2008; 32: 796–803
Knauft ME, Nielsen EL, Engelberg RA, et al. Barriers and facilitators to communication about end-of-life care for patients with COPD. Chest 2005; 127: 2188–96
Acknowledgements
No sources of funding were used to assist in the preparation of this review. Andrew McIvor has received honoraria from AstraZeneca, GlaxoSmithKline, Boehringer Ingelheim and Pfizer for attending advisory board meetings and providing continuing medical education on COPD, and has received grants for phase II and III clinical trials from the same companies. Jacob Gelberg has no conflicts of interest that are directly relevant to the content of this review.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Gelberg, J., McIvor, R.A. Overcoming Gaps in the Management of Chronic Obstructive Pulmonary Disease in Older Patients. Drugs Aging 27, 367–375 (2010). https://doi.org/10.2165/11535220-000000000-00000
Published:
Issue Date:
DOI: https://doi.org/10.2165/11535220-000000000-00000