Respiratory Diseases in the Elderly

The present article includes a short review of the available reference standards for pulmonary function data in elderly people. The review underlines the lack of a standard for many functional data and in many geographical areas, particularly for very old subjects, who are quite often evaluated in clinical physiology laboratories The authors discuss the possible errors deriving from inappropriate use of the predictive models in the elderly and suggest a strategy for reducing diagnostic errors.

Comprehensive geriatric assessment qualifies as the state-of-the-art approach to elderly patients, especially frail ones. Its role in the broad elderly population is summarised herein, and then the available evidence on its efficacy in elderly chronic obstructive pulmonary disease (COPD) populations provided.

Dimensions relevant to the explanation of COPD-related health status are presented, and their interplay in defining health status is discussed. On these bases, multidimensional interventions proven or likely to benefit elderly COPD patients are reported, and then selected assessment instruments suitable for different populations and contexts are suggested. Finally, an overview of current and expected developments in the technology of comprehensive geriatric assessment is provided.

Chronic obstructive pulmonary disease (COPD) among the very old is associated with many hidden realities with relevance for patients, physicians, researchers and public health practitioners regarding the development of COPD, misdiagnosis and multiple determinants of health outcomes. Greater awareness of these hidden realities offers opportunities for prevention and improvement of the health and functional status of the very old with COPD. Although elimination of smoking, regardless of age, is the single most important factor for prevention of COPD, other potential targets for prevention throughout the lifespan include control of prenatal and childhood exposures to tobacco smoke and childhood infections, nutritional exposures and physical activity, post-menopausal hormone replacement, psychological characteristics, and control of exposures to occupational and environmental dusts and fumes.

Underutilisation of spirometry, particularly in the very old, frequently contributes to errors in the diagnosis of COPD, and demonstration of fixed airflow obstruction with spirometry is essential before making the diagnosis. With limited training of staff, spirometry can be successfully performed in the primary-care setting with reasonable accuracy, and is often associated with changes in management.

The available evidence suggests a number of under-recognised factors that deserve special consideration in optimising the management of the very old with COPD. These other factors include multiple comorbid conditions and psychosocial factors. The co-occurrence of multiple chronic illnesses, many mediated through systemic inflammation, presents a number of diagnostic and management challenges. Although recent evidence regarding the detection and management of comorbid conditions and psychosocial factors also offers potential opportunities for further improving the functional performance and health status of patients with COPD, many unanswered questions remain and require further research.

Community-acquired pneumonia (CAP) is traditionally considered a medical disease, and has been managed with intravenous fluids and antibiotics. Recent cost-containment efforts have shifted the provision of care to outpatient settings, and only those with the most severe disease and multiple comorbid illnesses are admitted to hospitals. Therefore, the proportion of hospitalised patients with severe CAP who require intensive care and life support is increasing. Furthermore, the incidence of severe CAP is also rising due to disproportionate growth of the elderly population, which is most vulnerable to this disease. Many of these elderly patients have advanced underlying illness, and CAP might often be a terminal event superimposed upon an underlying chronic debilitating health status. Physicians need to be familiar with this disease and its complications and prognosis in order to provide care in a timely and rational fashion in some patients, and to refrain from life support in others. Just as prior efforts have sought to improve and standardise criteria for hospital admission, future efforts should aim to improve and standardise decisions regarding intensive care and life support in these very sick elderly patients. The future management of CAP needs to focus on the post-discharge period, when most deaths occur. Prevention is another important issue, especially for those at high-risk of CAP.

The presence of restrictive lung disease has, classically, required the measure of total lung capacity to document true restriction, which has limited its detection in large population-based studies. Using spirometric data to classify people with restriction on spirometry has defined a population at risk of common comorbid diseases, along with an increased risk of adverse outcomes. Risk factors for restriction on spirometry include ageing, obesity, diabetes mellitus, metabolic syndrome and cardiovascular disease. People with restriction on spirometry show an increased risk of developing diabetes, higher mortality and an increased risk of lung cancer. Additional research is required in order to better describe the mechanisms that lead to restriction on spirometry and potential interventions.

Pulmonary embolism (PE) is a potentially fatal disease if left untreated. The prevalence of PE increases markedly with age, and its diagnosis in elderly people is difficult since many cardiopulmonary conditions may mimic the clinical presentation of PE and age may unfavourably influence the characteristics of diagnostic tests for PE. The modern approach to PE is based on sequential diagnostic strategies based on clinical probability, D-dimer measurement, lower limb compression ultrasonography, ventilation/perfusion lung scans and helical computed tomography. Pulmonary angiography is rarely necessary as the noninvasive diagnostic work-up is usually conclusive.

Age reduces the clinical usefulness of D-dimer measurement and the ventilation/perfusion lung scan. D-dimer measurement permits PE to be ruled out in only 5% of patients aged >80 yrs, compared with 60% aged <40 yrs. Similarly, the rate of inconclusive ventilation/perfusion lung scans is almost twice as high (58%) in patients aged >70 yrs compared with patients aged <40 yrs (32%). In contrast, the diagnostic accuracy of clinical probability assessment, either empirical or as determined by prediction rules, is unchanged by ageing, and the diagnostic characteristics of helical computed tomography do not to appear to be influenced by advancing age.

Compression ultrasonography was mandatory when using single-slice computed tomography. However, recent studies suggest that compression ultrasonography is no longer mandatory when using multi-slice computed tomography (MSCT). In outpatients, a strategy based on assessment of clinical probability, D-dimer measurement and MSCT has been shown to be cost-effective, even in elderly patients. In in-patients D-dimer measurement is probably useless. Compression ultrasonography remains useful in patients with contraindications to MSCT, as an attempt to avoid further imaging.

Lung diseases are a major cause of illness, disability and death among those aged ≥65 yrs. As ageing occurs, human beings are more prone to suffering other nonrespiratory chronic diseases; more than half of elderly people have at least three chronic medical conditions.

Different indices have been validated to measure the impact of these comorbidities upon the most common respiratory diseases in the elderly, namely, respiratory infections, lung cancer, sleep apnoea and chronic obstructive pulmonary disease.

The present chapter analyses the impact of comorbidities upon the health outcomes of elderly patients with common respiratory diseases, and their implication for management, as well as the pathogenic mechanisms that may link these respiratory diseases (with special emphasis in chronic obstructive pulmonary disease) with the comorbid conditions frequently present in these patients.

Physiological changes in functional and metabolic pathways are present in normal ageing, and often result in a decreased amount of skeletal muscle mass over the years, a process known as sarcopenia.

Changes in body composition are also recognised in chronic diseases, of which chronic obstructive pulmonary disease (COPD) is one of the most common in the elderly population. In the literature, most attention is drawn to muscle wasting in COPD, and qualitative intramuscular changes, such as fibre-type shifting and an imbalance in protein metabolism, have been demonstrated.

Various disease-specific factors, e.g. physical inactivity, experience of exacerbations, chronic low-grade inflammation, the presence of continuous or intermittent hypoxia and endocrine disturbances, all contribute to skeletal muscle wasting. As well as skeletal muscle wasting, disturbances in bone metabolism are also documented as another extrapulmonary effect of COPD.

Recent reports argue that fat mass contributes to systemic inflammation in chronic obstructive pulmonary disease, but this hypothesis contrasts with the finding of a lower mortality rate in chronic obstructive pulmonary disease patients with a high body mass index compared with those with a low body mass index, called the obesity paradox. Nutritional management of chronic obstructive pulmonary disease should focus on treating muscle wasting with a combined therapy of nutritional supplements and physical activity.

Elderly patients present particular challenges when deciding upon the most appropriate management for asthma or chronic obstructive pulmonary disease (COPD).

In the current chapter, the authors argue that the special case of the elderly patient has not been sufficiently taken into account by major treatment guidelines for asthma and COPD. Their emphasis is on drug therapy, and especially the adverse effects of such therapy. Specific concerns are as follows: 1) the effects of drug interactions that result from the existence of common pathways for the metabolism of most drugs and the large number of drugs often prescribed to elderly patients; and 2) the effects of inhaled corticosteroids on the eyes and on the risk of fractures, as well as the excess of severe pneumonias seen among patients with COPD treated with this class of medication, either alone or in combination with long-acting β-agonists. The authors also point to the need for further studies of the occurrence of cardiac arrhythmias in relation to the use of bronchodilators, especially the newer longer-acting agents.

These adverse effects are particularly troubling in the treatment of chronic obstructive pulmonary disease, since methodological errors have greatly exaggerated the potential benefits of these medications, especially inhaled corticosteroids, in the treatment of chronic obstructive pulmonary disease further shifting the balance from benefit to harm.

Elderly patients often have comorbidities and other characteristics that make the selection of treatment daunting. In the past, elderly patients with early stage nonsmall cell lung cancer (NSCLC) were often excluded from surgical treatment. However, it is now clear that, since surgical treatment in fit elderly patients has similar benefits and toxicity to those in nonelderly patients, age per se is not a contraindication for resection.

The beneficial results achieved with adjuvant chemotherapy in the general population with early NSCLC cannot be automatically extrapolated to elderly subjects, who are at higher risk of toxicity. However, a recent retrospective analysis of the BR-10 trial, which investigated adjuvant chemotherapy in resected NSCLC and established the therapeutic advantage for vinorelbine–cisplatin versus observation, demonstrated that this benefit extended those aged up to 75 yrs. Retrospective analyses of combined chemo-radiotherapy in locally advanced NSCLC patients suggest an equivalent benefit for both younger and older patients, despite heightened toxicity. There have been no elderly-specific phase III trials for locally advanced NSCLC. For advanced NSCLC, although single-agent chemotherapy is the standard of care for nonselected elderly patients, recent phase II trials suggest that cisplatin-based chemotherapy, with cisplatin administered at attenuated doses, may be a promising option for fit elderly patients.

In limited-disease small cell lung cancer (SCLC), sequential chemo-radiotherapy is less toxic compared with a standard concurrent approach; however, the current authors’ assessment of treatment is hindered by the absence of prospective elderly-specific trials. While prophylactic cranial irradiation has emerged as a standard strategy, it should be omitted in patients with cognitive impairment. In extensive SCLC, etoposide combined with either cis- or carbo-platin is the standard treatment also for elderly patients. However, haematopoietic support is necessary, especially in those at heightened risk for myelosuppression.

With the exception of advanced nonsmall cell lung cancer, prospective elderly-specific studies are lacking. Virtually all of the data presented herein are retrospective in nature and limited by patient selection.